Impact of A National Collaborative Care Initiative for Patients With Depression and Diabetes or Cardiovascular Disease

There is ample evidence of large gaps between usual and evidence-based care for patients with comorbid chronic conditions, yet few examples of successful implementation of innovative care models are able to narrow this gap [1]. Evidence-driven collaborative care for patients with multiple conditions could be used as a model for the implementation of care for complex patients. To date, despite strong evidence demonstrating that the collaborative care model is effective for depression [2–4] and a growing body of evidence that it is also effective for other chronic diseases [4,5], collaborative care based on research outcomes is not routinely implemented outside of clinical trials.

For depression, the evidence supporting the effectiveness of collaborative care is robust, with over 80 randomized clinic trials demonstrating its value [6]. Collaborative care has been shown to increase antidepressant adherence, improve depression outcomes for 2 to 5 years, and increase patient and clinician satisfaction [2]. Some studies have also found collaborative care to be cost-saving, including Improving Mood-Promoting Access to Collaborative Treatment (IMPACT), which demonstrated a reduction of 10% in total healthcare costs over 4 years, despite the intervention lasting only 1 year [7].

For management of chronic diseases other than depression, the evidence supporting the effectiveness of collaborative care is growing. Most notably, TEAMcare demonstrated the feasibility and effectiveness of collaborative care for patients with either diabetes or heart disease in addition to depression [4]. In TEAMcare, collaborative care reduced glycolated hemoglobin (HbA1c), systolic blood pressure (SBP), low-density lipoprotein (LDL) and depression scores and disability levels while improving quality of life measures. Additional studies further support the effectiveness of collaborative care in improving diabetes [8,9] and heart disease outcomes [10].

Despite this evidence, collaborative care for multiple chronic conditions is seldom employed outside of clinical trials, in part because key components of this care are not reimbursable. Consequently, the ability to successfully implement collaborative care in a variety of healthcare systems and improve outcomes among diverse patient populations is largely unknown. To address this knowledge gap, 10 organizations across the US collaborated in a Center for Medicare and Medicaid Health Care Innovation Award-funded project to determine if collaborative care for patients with active depression plus comorbid diabetes and/or cardiovascular disease could be spread across diverse states, healthcare systems and patient populations. The Care of Mental, Physical and Substance use Syndromes (COMPASS) initiative implemented the collaborative care model in 172 clinics representing 18 healthcare systems across eight states. The goals of COMPASS were to improve clinical outcomes (namely depression as measured by the PHQ9, diabetes as measured by HbA1c and hypertension), as well as patient and clinician satisfaction. This paper reports the main findings of the COMPASS initiative.

This large collaborative care initiative for complex patients with multiple chronic diseases was able to successfully spread a new care model to diverse care systems across the United States that was associated with improved disease outcomes in patients with poorly controlled depression and comorbid diabetes, cardiovascular disease or both. All 18 medical groups remained engaged in COMPASS throughout the project, but as is true with any such initiative, there was significant variation in approach to implementation as well as in outcomes achieved. Overall, of patients who had not been at goal at enrollment, 40% achieved depression remission or response, while 23% achieved HbA1c goals and 58% achieved blood pressure goals within a mean enrollment of 11 months. Patients rated their care highly, and clinicians were satisfied with COMPASS resources.

Comparing COMPASS results to randomized clinical trials of collaborative care is challenging, not only given differences in study design but also differences in outcome measures. While most studies report mean changes in depression scores or SBP or HbA1c levels, we instead report what we consider to be a more clinically meaningful outcome for clinicians and patients: the percent of patients who achieved disease outcome goals. An exception to this clinical trial reporting is found in TEAMcare, which reported that at 1 year, 37% of intervention patients were at goal for a combined primary outcome (HbA1c<7.0% or decrease ≥0.5%; SBP<130 or decrease ≥10 mmHg; and LDL<100 or decrease ≥15%), compared to 22% of usual care patients (P=.024) [4]. In addition, 60% of patients in TEAMcare achieved depression response (defined as a ≥50% decrease in Symptom Checklist-20 score [21]) at 12 months, compared to 30% of patients receiving usual care (P<.001). In COMPASS, 23% of patients achieved HbA1c goals (HgA1c<8.0%), and 58% achieved blood pressure goals (SBP<140 and DBP<90 mmHg) during an average follow-up of 11 months. In addition, 40% of COMPASS patients achieved either depression remission (PHQ9<5) or response (PHQ9 decrease of at least 50%). Although we acknowledge that (a) we do not present a similar composite score; (b) our HbA1c and BP outcomes differ somewhat from TEAMcare; and (c) our average patient follow-up is a month shorter, our results are highly encouraging, particularly given that this initiative was implemented outside of a randomized clinical trial and involved patients who had largely failed treatment as usual.

As COMPASS involved 18 medical groups and 172 clinics, it required flexibility in putting the model into practice while also making substantial efforts to maintain the fidelity to the collaborative care model necessary to achieve desired patient outcomes. As a result, there were notable differences in implementation between medical groups and often even between different clinics within the same medical group. Given this, it is not unexpected that there were significant differences in outcomes between medical groups. When examining medical groups that enrolled at least 10 patients with the outcome of interest (Table 4), the best:worst ratios by medical group were 3:1 in hypertension outcomes (76% in medical group 14 vs. 27% in medical group 13), over 4:1 in HbA1c outcomes (33% in medical group 16 vs. 7% in medical group 10) and depression response (26% in medical group 4 vs. 6% in medical group 17), and 8:1 in depression remission (41% in medical group 14 vs. 5% in medical group 6). Moreover, there was often greater variation in outcomes across clinics within medical groups than between the medical groups themselves (clinic-level results not shown). Notably, the highest-and lowest-performing clinics were not consistently in the same medical groups across outcomes, and some clinics did well with one disease outcome while poorly with another.

These variations in approach to implementation and outcomes across medical groups provide a unique opportunity to learn how they might be associated. This is particularly germane because previous research has shown that the greater the fidelity to the collaborative care model, the better patient outcomes, at least when considering depression [22,23]. Although systematic case review teams were encouraged and expected to meet weekly, one medical group met infrequently, and this group had the lowest depression remission and response rates of all 18 medical groups. Regarding CMTS use, two medical groups used private vendors to build custom electronic CMTS, and these groups had poor depression outcomes, and one had poor diabetes outcomes as well. In contrast, there were no clear correlations between disease outcomes and method of systematic case review meetings or location of care managers. It is of course possible that many of these implementation variations reflected unmeasured organizational characteristics such as leadership support or organizational culture that ultimately contributed to the implementation and effectiveness of COMPASS. Some of these variations in implementation and engagement are reflected in the widely varying numbers of patients enrolled by each medical group, ranging from only 51 patients in one medical group to 684 patients in another. In the end, having a systematic case review meet infrequently was associated with the poorest depression remission rates for one medical group, and using a custom electronic CMTS was associated with poor depression and diabetes outcomes for two medical groups, but otherwise, there were few medical group variations that were consistently associated with outcomes. Some medical groups were in the top three of 18 for more than one medical outcome, and some were in the bottom three for more than one medical outcome, but it was much more common for a medical group to perform well or poorly on one measure and in the middle of the pack on the rest.

An important finding of COMPASS is that patient outcomes did not vary according to care manager degree or background. This has important implications for future implementations of this evidence-based collaborative care model, as it has direct bearing on workforce availability and the potential costs of providing this care model. Our preliminary data indicate that the frequency of care manager contact with patients is a strong predictor of patient outcomes, and we will explore this in a subsequent paper. Other COMPASS data suggest that when care managers had been employed longer or had more contact with consulting physicians outside of the scheduled systematic case reviews, their patients had better diabetes outcomes, while when care managers had larger panel sizes, more time allocated to COMPASS or a higher comfort level treating depression, their patients had better depression outcomes [24].

Patients expressed satisfaction with COMPASS care in general and with depression care specifically. These are important findings, as it has been established that satisfaction with care predicts greater adherence and improved outcomes in patients with chronic disease [25]. Satisfaction is also important for achieving what has now been called the quadruple aim (improving quality, patient experience, healthcare costs and clinician satisfaction). In COMPASS, multiple resources were in place to provide increased support to patients and primary care clinicians, including care managers to monitor patients and disease parameters, care registries to prompt care manager attention for patients not achieving goals and systematic case reviews to facilitate discussions of patients not progressing as expected. All of this culminated in increased outreach to patients with chronic disease, likely leading to increased patient satisfaction with care and increased clinician satisfaction with these additional resources. Interestingly, patient and clinician satisfaction did not consistently correlate with chronic disease outcomes. For example, one medical group had some of the best patient depression, diabetes and hypertension outcomes but one of the lowest patient satisfaction ratings. Conversely, one medical group had some of the poorest patient depression, diabetes and hypertension outcomes but one of the highest rates of patient and clinician satisfaction. There were no apparent correlations between patient satisfaction with primary care and the ability to get appointments or answers to questions, areas where we would have expected to see some improvement given the nature of the collaborative care model, which should have provided access to care managers to help facilitate patient appointments or answer patient questions. It is possible that this finding reflects a misunderstanding by patients about the role of the care managers, or it may truly reflect less accessibility to care managers than the COMPASS model should have allowed.

One limitation of this initiative was that data were collected as part of a demonstration project, not as a randomized controlled trial, so there were neither control groups nor detailed measures of the degree of implementation at partner sites. Data were collected by care managers as part of ongoing patient care, rather than a more scheduled collection that might have occurred within a randomized trial. There were many unmeasured factors that may have contributed to patient outcomes, including changes in diet, exercise or social supports or engagement in psychotherapy for which we cannot account. Patients enrolled in COMPASS had largely failed usual care, which may have biased our results towards the null, and these results therefore may not be generalizable to the larger primary care population. There may have been selection bias present, with patients more motivated to address their depression, diabetes or cardiovascular disease more likely to enroll in COMPASS, which may have biased our results away from the null. While some may view the patient and clinician survey rates as some-what low, potentially limiting the validity and generalizability of these data, we submit that the survey rates are reasonably high for a nonresearch real-life evaluation, particularly for one where local operational personnel were recruiting patients and clinicians for the survey. Overall, we believe that any potential limitations of COMPASS are balanced by the rich opportunity to examine a collaborative care initiative for complex patients with multiple chronic conditions in a real-world setting in diverse populations across the country.

COMPASS demonstrates that a complex initiative can be successfully implemented and executed by a wide range of care systems and serve as a model for spreading improved care for medically complex patients. Large-scale spread projects should expect variation in implementation and preemptively create robust processes to identify and reduce this variation and assure that desired care is consistently provided to further improve patient outcomes.