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The American Journal of Managed Care November 2014
The Correlation of Family Physician Work With Submitted Codes and Fees
Richard Young, MD, and Tiffany L. Overton, MPH
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Population Targeting and Durability of Multimorbidity Collaborative Care Management
Elizabeth H.B. Lin, MD, MPH; Michael Von Korff, ScD; Do Peterson, MS; Evette J. Ludman, PhD; Paul Ciechanowski, MD, MPH; and Wayne Katon, MD
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Lauren Hersch Nicholas, PhD, MPP
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Emily Carrier, MD, and Peter Cunningham, PhD
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William H. Shrank, MD, MSHS; Andrew Sussman, MD; and Troyen A. Brennan, MD, JD
Care Coordination Measures of a Family Medicine Residency as a Model for Hospital Readmission Reduction
Wayne A. Mathews, MS, PA-C
Medication Adherence and Readmission After Myocardial Infarction in the Medicare Population
Yuting Zhang, PhD; Cameron M. Kaplan, PhD; Seo Hyon Baik, PhD; Chung-Chou H. Chang, PhD; and Judith R. Lave, PhD
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Kelly M. Doran, MD, MHS; Ashley C. Colucci, BS; Stephen P. Wall, MD, MS, MAEd; Nick D. Williams, MA, PhD; Robert A. Hessler, MD, PhD; Lewis R. Goldfrank, MD; and Maria C. Raven, MD, MPH
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Guy David, PhD; Max Gill, MBA, Candace Gunnarsson, EdD; Jeff Shafiroff, PhD; and Steven Edelman, MD
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Kali S. Thomas, PhD; Momotazur Rahman, PhD; Vincent Mor, PhD; and Orna Intrator, PhD

Population Targeting and Durability of Multimorbidity Collaborative Care Management

Elizabeth H.B. Lin, MD, MPH; Michael Von Korff, ScD; Do Peterson, MS; Evette J. Ludman, PhD; Paul Ciechanowski, MD, MPH; and Wayne Katon, MD
Benefits of a patient-centered multimorbidity care management program occurred early, and were evident only among patients with depression and unfavorable medical control of diabetes and heart disease.


A patient-centered collaborative care program for depression and uncontrolled diabetes and/or coronary heart disease (CHD) demonstrated improved clinical outcomes relative to usual care. We report clinically stratified analyses of patient outcomes to inform the duration and targeting of care management services for complex patients with multimorbidity.


A 12-month randomized controlled trial of a multimorbidity collaborative care program followed patients at 6, 12, 18, and 24 months for diabetes (glycated hemoglobin [A1C]), blood pressure (systolic; SBP), low-density lipoprotein (LDL) cholester- ol, and depression (Symptoms Check List-20 score). Depressed patients with less favorable medical control (Patient Health Questionnaire-9 score >10, A1C >8.0 %, SBP >140 mm Hg, and LDL cholesterol >120 mg/dL) were compared with depressed patients with more favorable medical control to describe differential intervention benefits over time.


In contrast to patients with more favorable baseline control, patients with depression and unfavorable control of A1C, SBP, and LDL at baseline showed improved outcomes as early as the 6-month follow-up assessment. Clinical benefits in the intervention group were largely sustained over the 24-month follow-up, except for some deterioration of glycemic control in intervention patients and trends toward improvement among controls over time. Among patients with depression and more favorable medical control at baseline, there were minimal between-group differences in medical disease outcomes.


Clinical benefits of a multimorbidity collaborative care management program occurred early, and were only found among patients with poor control of baseline diabetes and CHD risk factors. Targeting may maximize reach and improve affordability of complex care management.

Am J Manag Care. 2014;20(11):887-895

This paper addresses targeting and duration of care management among complex patients with multimorbidity. A patient-centered multimorbidity collaborative care program demonstrated better outcomes in depression, coexisting diabetes, and cardiovascular risk factors only among the subgroup of patients with unfavorable medical control at baseline (Patient Health Questionnaire-9 score >10, glycated hemoglobin >8.0%, systolic blood pressure >140 mm Hg, and low-density lipoprotein cholesterol >120 mg/dL). Improvements occurred early and continued over 2 years. In contrast, patients with depression and more favorable medical control showed no clinical benefit beyond reduced depression.

Implications for complex care management:

  • Target patients with unfavorable medical outcomes at baseline.
  • Targeting may maximize reach and improve affordability.
Patients with multiple chronic conditions are prevalent in primary care.1-3 The high prevalence of depression and psychological distress accompanying common physical conditions such as diabetes and coronary heart disease (CHD) magnifies the complexity of care and instensifies resource utilization.4-6 About two-thirds of total healthcare spending in the United States is directed toward the one-fourth of patients with multimorbidity (defined as having more than 1 chronic condition).7 To better serve patients with complex healthcare needs, the Agency for Health Care Research and Quality recommend reorganizing primary care to include care managers, clinical decision support, and other resources.8 However, a comparative effectiveness review of care/case management found limited improvement in outcomes and quality of care, and little change in resource utilization among patients receiving complex care management.9

A recent randomized trial of a collaborative care intervention for patients with depression as well as uncontrolled diabetes and/or CHD demonstrated improved outcomes for diabetes, hypertension, hyperlipidemia, and depression relative to patients receiving enhanced usual care (UC).10 In addition to better clinical outcomes, intervention patients reported higher functioning, quality of life, patient satisfaction, and self-efficacy in disease management after the 12-month intervention.11,12 Improved outcomes were achieved through a team-based, patient-centered, collaborative chronic care program targeting both physical and mental health goals.13 At the 2-year follow-up, cost-effectiveness analyses suggested outpatient cost savings; depression continued to be significantly improved in the intervention relative to enhanced UC.14 Benefit for control of hyperglycemia, hypertension, and hyperlipidemia had diminished between intervention and UC groups in the year after intervention cessation.14

We report analyses from this trial stratified by baseline status of disease-control parameters [glycated hemoglobin (A1C), systolic blood pressure (SBP), and low-density lipoprotein (LDL)] to shed light on ways this innovative and integrated intervention can be refined to achieve the “triple aim” of better care experience and outcomes at a lower cost.15 Specifically, this paper addresses the following questions: 1) Which patients should be targeted for care management? and 2) How long should care management be sustained?9,16 Analyses describe clinical outcomes over a 24-month period for the following subgroups: 1) depressed patients with less favorable medical control of diabetes, hypertension, or hyperlipidemia; versus 2) depressed patients with more favorable medical control of diabetes, hypertension, or hyperlipidemia.


Setting and Participants

Participants with depression and uncontrolled diabetes and/or CHD were recruited from 14 Group Health primary care clinics from May 2007 to October 2009. An epidemiologic study at Group Health found a 12% prevalence of major depression among a large cohort of patients with diabetes.17 Electronic medical records identified patients with poor glycemic control (A1C ≥8.5%), systolic blood pressure (SBP ≥140/90 mm Hg), or lipid control (LDL >120 mg/dL) for a 2-stage depression screen. Eligibility also required a depression score >10 on the 9-item Patient Health Questionnaire (PHQ-9).18 Exclusion criteria included terminal illness; pregnancy; planned disenrollment; limited English proficiency; bipolar disorder or schizophrenia; and mental confusion suggesting dementia.

Randomization and Intervention

Patients were assigned to treatment groups using a permuted block design with randomly selected block sizes of 4, 6, and 8 patients. After randomization, a study nurse contacted patients assigned to the intervention to initiate treatment. UC patients received enhanced routine care as they were advised to consult with their primary care physician (PCP) to receive care for depression, diabetes, and/or CHD. Their PCPs also received baseline 6-, 12-, 18-, and 24-month assessments of depression and blood pressure, as well as laboratory test results. Please see prior publications for additional method details.13,19 Based on sample distribution that was confirmed by clinical consensus, patients with depression (overall sample) were divided into the following subgroups: more versus less favorable glycemic control (baseline A1C >8.0%); more versus less favorable blood pressure (BP) control (SBP >140 mm Hg); and more versus less favorable lipid control (LDL >120 mg/dL). There were no patients with more favorable control of depression at baseline, as a PHQ-9 score >10 was an inclusion criterion.

Intervention: Multimorbidity Collaborative Care (TEAMcare)

This intervention distilled elements from collabora- tive care for depression,20,21 the chronic care model,22,23 and treat-to-target strategies initially developed for diabetes.24 This integrated program was applied systematically across 3 chronic illnesses (diabetes, depression, and CHD) for 12 months.13 Figure 1 illustrates core elements of a patient-centered, collaborative care program for patients with multiple chronic illnesses (Treatment, Enhancement, Activation, and Motivation care [TEAMcare]). The team consisted of our patients, the TEAMcare nurse care managers, the patient’s PCP and care team, and the medical and psychiatric consultants. Nurse care managers conducted in-person and telephone follow-up visits in a structured manner, and met the patient at their primary care clinic for the in-person visits.

Intervention began with a comprehensive face-to-face biopsychosocial assessment and included goal-setting and formulating “my health plan,” self-management support, monitoring of disease indicators, and pharmacotherapy with frequent treatment adjustments to control depression, hyperglycemia, hypertension, and hyperlipidemia. Patients collaborated with nurse care managers and PCPs to create individualized clinical and self-management goals and care plans. Nurses followed patients proactively to monitor clinical progress, and used motivational and problem-solving approaches to support medication adherence, healthy eating, and physical activity.25 An electronic registry supported tracking of PHQ-9 scores and A1C, LDL, and BP levels, and flagged patients who were not making good progress. Weekly case reviews were conducted as face-to-face interdisciplinary meetings with nurse care manager presentations on the new patients and focused updates on patients who were not making adequate progress. Care managers received medical and psychiatric consultation with a family medicine or internal medicine physician (EHBL or BY) and a psychiatrist (WK or PC) and psychologist (EJL). Treatment protocols employing commonly used medicines guided consultant recommendations, and medication changes were tailored to patient history and clinical response. The nurse communicated treatment change recommendations to the patient’s PCP, who was responsible for medication management. Once patients achieved targeted levels for relevant measures, the nurse and patient developed a relapse prevention and maintenance plan. Patients whose disease control had worsened were offered follow-up and protocol-based intensification of treatment regimens.13,25

Outcomes and Follow-up

At baseline and at 6, 12, 18, and 24 months, telephone interviewers assessed depression symptoms, according to the Symptoms Check List-20 score (37). Blood pressure and A1C were measured in person at baseline, 6 months, and 12 months; fasting LDL was measured at baseline and 12 months.

Study Oversight

The TEAMcare Data Safety Monitoring Board reviewed methods initially and outcomes every 6 months thereafter. The trial was approved by the Institutional Review Boards of Group Health and the University of Washington.

Statistical Analyses

We compared intervention versus UC trends over the 24-month follow-up period for subgroups with more versus less favorable control at baseline for glycemic control, BP control, and lipid control. We describe glycemic, BP, and lipid control differences with means and confidence intervals. Since these post hoc comparisons have substantially smaller sample size than the unstratified analyses originally reported for the randomized controlled trial, the contrasts are necessarily underpowered to detect potentially clinically meaningful differences. The intent of these analyses is to describe the baseline clinical characteristics of patients who benefitted from TEAMcare, and the duration of observed benefits. Analyses adjusting for baseline levels were conducted using linear regression. All analyses were performed on those with complete follow-up data and were carried out using STATA 12.0 (Stata-Corp, College Station, Texas).


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