Depression Care Manager Key to Integrated Care Success

In a collaborative care model, a care manager educates patients about depression, coordinates referrals, promotes behavior changes that decrease depression symptoms, supports adherence to treatment regimens, administers serial depression symptom questionnaires, and notifies primary care providers when responses to those questionnaires indicate inadequate improvement and a possible need to revise the treatment plan. Psychiatrists work as consultants to primary care physicians and to the care managers and more directly manage the care of the most severely ill patients.

From 2008 to 2012, the Institute for Clinical Systems Improvement (ICSI) helped 87 primary care clinics implement collaborative care through the Depression Improvement Across Minnesota, Offering a New Direction (DIAMOND) initiative. Brown and colleagues at ICSI and the Department of Family Medicine at the University of Wisconsin School of Medicine and Public Health collected data from depression-care registries at 63 primary care clinics that participated in the initiative through early 2012.

They also surveyed project leaders at the 12 medical groups that operate the clinics about the background of care managers and clinic characteristics.

A total of 9,179 patients enrolled in DIAMOND as of early 2012. Enrollment rates varied from 1 percent to 55 percent across the participating clinics. Clinics with a dedicated care manager had higher enrollment rates than clinics in which the care manager had multiple roles, they found.

There were no significant differences in enrollment based on whether care managers were registered nurses, certified medical assistants, or licensed practical nurses.

Across the clinic sites, 7,438 enrolled patients were eligible for six-month PHQ-9 follow-up. Of these patients, 2,323 attained remission at six months. There was a trend for sites with a dedicated care manager to have higher remission rates, and again remission rates did not differ significantly based on the training level of the care manager.

“It’s important for care managers to see patients face to face on the day of their initial assessment and evaluation,” Brown told Psychiatric News. “If you are trying to bring patients back to the clinic by phone, you don’t get a very good enrollment yield.”

He said care managers need to invest a significant amount of time providing feedback, education, and emotional support for depressed patients. “They help make referrals for psychotherapy or pharmacotherapy or both, and that sometimes involves being on the phone for long periods,” he said. “They also help engage patients in behaviors that by themselves can lift depression—exercise, scheduling enjoyable activities, establishing healthier sleep hygiene, eating healthier.”

Psychiatrist Lori Raney, M.D., a leader in integrated care who reviewed the report, said the finding that outcomes do not differ depending on the training level of the care manager is welcome news to collaborative care leaders seeking to save costs. “Not everyone can have a psychologist or a social worker, and it’s good to know that a medical assistant or nurse can deliver these services,” she said. “You may not need to hire the most expensive people in the field to get a good outcome.”

Brown said he believes a fundamental barrier to adoption of collaborative care is cultural. “The idea of team care runs counter to the culture of health care and physician education,” he said. “Physicians are trained to believe they need to need to personally deliver these services.”

But he said the realities of the demand for mental health treatment in primary care mean psychiatrists and primary care physicians will need to rely on collaborative care team members to extend the reach of clinicians.

Beyond that, he said reimbursement continues to be a barrier. “There is no billing code to support reimbursement for collaborative care,” he said. “And if we did have a code, which individuals could be reimbursed? My fear is that reimbursement will be so low that it will not provide adequate incentive to make sure these services are provided consistently. Ultimately what we need are rigorous quality measures and strong financial incentives to excel on those measures.” ■