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Effective Implementation of Collaborative Care for Depression: What Is Needed?
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Effective Implementation of Collaborative Care for Depression: What Is Needed?

Robin R. Whitebird, PhD, MSW; Leif I. Solberg, MD; Nancy A. Jaeckels, BS; Pamela B. Pietruszewski, MA; Senka Hadzic, MPH; Jürgen Unützer, MD, MPH, MA; Kris A. Ohnsorg, MPH, RN; Rebecca C. Rossom, MD
Factors most important for successful implementation of collaborative care for depression differ for patient activation versus achieving remission; both are critical to program success.
Objectives
To identify the care model factors that were key for successful implementation of collaborative depression care in a statewide Minnesota primary care initiative.

Study Design
We used a mixed-methods design incorporating both qualitative data from clinic site visits and quantitative measures of patient activation and 6-month remission rates.

Methods
Care model factors identified from the site visits were tested for association with rates of activation into the program and remission rates.

Results
Nine factors were identified as important for successful implementation of collaborative care by the consultants who had trained and interviewed participating clinic teams, and rated according to a Likert Scale. Factors correlated with higher patient activation rates were: strong leadership support (0.63), well-defined and -implemented care manager roles (0.62), a strong primary care physician champion (0.60), and an on-site and accessible care manager (0.59). However, remission rates at 6 months were correlated with: an engaged psychiatrist (0.62), not seeing operating costs as a barrier to participation (0.56), and face-to-face communication (warm handoffs) between the care manager and primary care physician for new patients (0.54).

Conclusions
Care model factors most important for successful program implementation differ for patient activation into the program versus remission at 6 months. Knowing which implementation factors are most important for successful activation will be useful for those interested in adopting this evidence-based approach to improving primary care for patients with depression.

Am J Manag Care. 2014;20(9):699-707
Nine implementation factors were most important for the success of the collaborative care model for depression and differed for patient activation into the program versus achieving remission at 6 months.

• Strong leadership support and a strong physician champion are essential for patient activation into the program.

• The more well defined and implemented the care manager role, the higher the rate of patient activation.

• The more engaged a psychiatrist was and the more often in-person communication occurred, the more frequently patients experienced remission from their depression.

• The less likely a group experienced operating costs as a barrier, the more likely their patients were to experience remission.
There is extensive evidence from randomized controlled trials that collaborative care for depressed adults in primary care improves patient outcomes.1-5 Key elements in evidence-based collaborative care programs include consistent measurement and monitoring of depression severity, close proactive follow-up by a clinic-based care manager, and regular psychiatric consultation focused on treatment changes for patients who are not improving with initial treatment. Based on these studies, the US Preventive Services Task Force recommends that routine screening of adults for depression is justified only when systems for collaborative depression care are in place.6,7 Not only can collaborative care produce better patient outcomes (with rates of remission and response that are approximately twice those of usual care), but it can also produce net cost savings over 4 years.8-10

Despite these findings, however, little is known about which implementation factors are most important for achieving these outcomes. For example, prior studies of collaborative care have employed care managers with wide varieties of education and experience without providing information about comparative benefits on outcomes.1,4 It is also unclear what supports a care manager needs to function most effectively or whether it is important for the psychiatrist to be onsite to provide consultation and supervision. Similarly, it is unknown whether an effective local primary care champion or face-to-face communication between the primary care provider (PCP) and care manager are important.

Between 2008 and 2012, an initiative led by a regional quality improvement collaborative, the Institute for Clinical Systems Improvement (ICSI), systematically provided standardized training in implementing collaborative depression care and consultative support for primary care clinics throughout Minnesota and western Wisconsin. The initiative, Depression Improvement Across Minnesota – Offering a New Direction (DIAMOND), included payment redesign through a partnership with nearly all commercial health plans in the state.11,12 While maintaining fidelity to the core aspects of the model was required, local tailoring was considered important, so there were significant variations in implementation. The initiative also collected standardized process and outcomes data as part of the quality improvement support system, as well as information about each clinic’s approach to the care model. This quantitative information was supplemented with a round of site visits to all participating groups, providing a unique opportunity to document differences in care processes and implementation strategies. This information allowed examination of which approaches to implementation might be important for high levels of enrollment and good patient outcomes.

METHOD

Background

The DIAMOND initiative was created in 2006 by a diverse stakeholder group convened by ICSI that included health plans, medical clinics, patients, and employers, with the goal of planning a new approach to depression care. After extensive reviews and discussions, it became clear that both the collaborative care model and payment redesign were needed. The group recommended that payers provide a monthly fee to DIAMOND-certified sites for eligible patient-members enrolled in the care model.

The structure of the initiative was based largely on the collaborative care model as it was tested in the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) study.10,13-17 It focused on 6 components: 1) use of the Patient Health Questionnaire-9 (PHQ-9)18 for assessment and ongoing monitoring; 2) use of a registry for systematic tracking of patients; 3) use of evidence-based guidelines to provide stepped care treatment modification/ intensification; 4) relapse prevention education; 5) a care manager located in the clinic to provide education, care coordination, behavioral activation, and support of medication management; and 6) a consulting psychiatrist to meet with the care manager for weekly case review and treatment change recommendations.

ICSI conducted training for 5 sequences of clinics participating in the new model over the course of 2 years; every 6 months a new sequence started the 6-month training and implementation program, beginning in September 2007 and continuing until the final sequence started implementation in March 2010. Each sequence consisted of 10 to 26 clinics. In Minnesota nearly all PCPs are organized into single or multispecialty organizations termed “medical groups” that include a number of clinics or practice sites; small, independent practices are rare. A total of 99 clinics representing 21 different medical groups implemented the program.

Design

Each clinic provided standardized monthly data reports through a common Internet portal about the number of patients seen by the care coordinator, the number enrolled in DIAMOND (activation rate), and the PHQ-9 scores (needed to calculate response [change in PHQ-9] and remission [PHQ-9 <5] rates at 6 and 12 months). These quantitative data were supplemented with interview data from a round of site visits in 2009-2010 to all medical groups. For this analysis, we focused on medical groups who had completed all site visits and had at least 50 patients in their DIAMOND program (7 had <50) for a total of 42 clinics from 14 medical groups. The local Institutional Review Board reviewed and approved this study.

Activation and Remission Data

Activation rate was defined as the number of eligible patients (PHQ-9 >10) who entered DIAMOND per PCP full-time equivalent per month (PCP FTE/M). Remission rates (defined as PHQ-9 <5) were calculated at 6 months post activation. To calculate the overall activation and remission rates for each medical group, the monthly rates were averaged for the period of March 2008 to September 2010.

Qualitative Data Collection

At least 2 ICSI staff attended each site visit, and all clinics were provided with materials prior to the site visit meeting. Materials included sequence-specific outcomes data; an overall DIAMOND data report strategies each group used in implementation; and a discussion guide focused on barriers and facilitators. The latter included questions about practice culture; team approach; care manager role and duties; medical/psychiatric complexities of patients; psychiatry consults; care coordination; registry use; and approach to financial issues (see eAppendix available at www.ajmc.com). Site visit meetings included the core team participating in training and implementation, which included the project lead, care manager, and PCP champion. Other staff encouraged to attend were other physicians, the consulting psychiatrist, and the quality improvement lead. Following each site visit, ICSI staff completed a structured qualitative narrative to document their assessment of factors affecting implementation. This narrative focused on their perceptions of the implementation strategies, barriers, and facilitators, noting information about team dynamics, staff concerns, clinic staff response to the program, and their overall impression of program implementation at the site. Summaries were then prepared by the ICSI site-visit teams and were reviewed by the entire study team.

Implementation Factors

Twenty-three factors were initially identified in the structured qualitative narratives. The analysis team and ICSI staff (n = 8) then used a modified Delphi method to identify, multi-vote, and rank factors believed to be most related to successful implementation of DIAMOND (see Table 1).

Following identification of these factors, a Likert scale rating system was used to determine the extent to which each factor was present in each medical group, from 0 (absent implementation) to 4 (full implementation). ICSI staff rated each medical group on each of the 9 top implementation factors.

Data Analysis

To assess the association between implementation factors and activation and remission rates, we calculated Pearson correlation coefficients between each implementation factor and activation and remission rates. Scatter plots were used to understand the form of the relationship for all associations. Simple linear regression was used to estimate the effect of each 1-point increase (on a scale of 0-4) in implementation on activation and remission rates at 6 months. All reported P values are 2-sided and considered significant at P <.05.

RESULTS

This analysis focuses on the 14 medical groups implementing DIAMOND that had 50 or more patients in their program. The majority were multispecialty medical groups (79%) located in the Twin Cities metropolitan area (57%). The number of clinics implementing the program in each group, the PCP FTE/M count of each, and activation and remission rates are shown in Table 2. On average, about 1 patient was activated per PCP FTE/M, and 23% of patients activated into the program were in remission at 6 months. In keeping with the approach of allowing local tailoring, features of the care manager role varied across program sites. Of the 32 care managers in these medical groups, there were registered nurses (n = 15, 47%), licensed practical nurses/certified medical assistants (n = 11, 34%), and licensed social workers/bachelor’s- level psychologists (n = 6, 19%). The majority (72%) had their DIAMOND care manager role as their primary duty, while 28% had other shared clinical duties. Most care managers (59%) worked with patients from a single clinic, with the remaining (41%) working with patients from several clinics.

Implementation Factors and Patient Activation and Remission. Correlation analysis showed statistically significant and moderately strong positive correlations for 5 of the implementation factors with patient activation into the program: strong leadership support, strong care manager, care manager role well defined and implemented, care manager on-site and accessible, and strong PCP champion (see Table 3). We conducted simple linear regression of significant correlations to estimate the effect of increases in scale rating (rating scale 0-4) of implementation factors. Each of these factors was associated with about a 0.4 increase in activation rate.

Correlation analysis also showed statistically significant and moderately strong positive correlations between 3 implementation factors and patient remission rates at 6 months: engaged psychiatrist, warm handoffs (meaning referrals from clinicians to the care manager are usually conducted face-to-face rather than though indirect means), and operating costs not seen as a barrier (see Table 4). Simple linear regression to estimate the effect of an additional increase in scale rating (rating scale 0-4) on remission showed that the less often a medical group experienced operating costs as a barrier, the more likely their patients were to experience remission. Similarly, the more engaged a psychiatrist was and the more often warm handoffs occurred, the more likely patients experienced remission from their depression.

DISCUSSION

 
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