Diagnose depression early to improve outcomes, reduce costs
Diagnose depression early to improve outcomes, reduce costs
Study shows increased costs due to undiagnosed depression
Home health nurses know that depression affects every aspect of a patient's health care and potential outcome, but according to a recent study, depression also affects the total cost of health care services for the depressed patient.1
A study of 14,902 Medicare patients with diabetes mellitus, congestive heart failure, or both, identified 3,289 patients with a diagnosis of depression or possible depression. Health care costs for the patients with depression or possible depression were compared to the other 11,713 patients.
"Older adults with depression had substantially higher total health care costs than those without depression," says Júrgen Unútzer, MD, MPH, MA, co-author of the study and chief of psychiatry at the University of Washington in Seattle. "These high costs persisted even after we adjusted for differences in other factors associated with health care costs," he says.
"The findings were consistent with earlier findings, but we were surprised by the magnitude of the effect of depression on costs," says Unútzer. Study participants with depression had an average of $20,046 annual health care costs, compared to participants without depression who had $11,956 per year, he points out. "We were also surprised to learn that even in 2008, only a small proportion, less than 1%, of the increased costs was spent on mental health specialty care," he adds.
There are many reasons that depression can increase an older home health care patient's costs, says Lisa Sioufas, LCSW-R, ACSW, manager of the mental health program at Visiting Nurse Services (VNS) in Westchester in White Plains, NY. Not only will a depressed patient be less likely to take medications as directed, but the patient also will be less likely to follow exercise and dietary recommendations, as well as follow up with physician visits as directed, she points out. For patients with chronic conditions, such as diabetes and congestive heart failure, non-compliance can mean additional hospitalizations and trips to the emergency department. "Although we are just beginning to research the topic, we also believe that there is a correlation between depression and increased falls," she says.
"Older patients are twice as likely to be depressed as other home care patients, and they are also likely to go undiagnosed and untreated for a long time," says Sioufas. Certain medications, chronic illnesses, pain, and loss of independence by being homebound are all issues that increase an older patient's risk for depression, she says.
Mental health is an area in which the home care nurses at the Westchester VNS have extensive resources to draw upon, because the agency has an in-home mental health program. The nurses within the mental health program all have psychiatric nursing experience or special certifications, so they can serve as resources for the medical home care staff, says Sioufas.
Entire staff knows symptoms
Even with the resources of the mental health program, the key to identifying patients with possible depression or anxiety is to make sure all home care nurses and therapists recognize the symptoms, says Sioufas. To help nurses, the agency has developed a card that lists the OASIS codes related to mental health issues, such as hopelessness, depressed feelings, or thoughts of suicide. The business card-sized tip sheet also includes some questions that the staff member can ask the patient to start a conversation about depression, she says. All home care staff members also are taught the different signs and symptoms of potential depression, she adds. If the staff member suspects depression, anxiety, or a need to learn some coping skills, a mental health program nurse or social worker is asked to visit the patient.
Don't expect an older home health patient to easily admit to depression or any other mental illness, warns Sioufas. "Older patients don't want to admit to depression, because there is a stigma attached to mental problems," she says. "They don't understand that it is just another illness," she explains. In fact, many older patients may have been hiding symptoms of depression, anxiety, or other mental illness for years, she says. "Sometimes, it's a case of not wanting to take another medication when they are already taking so many medications, and sometimes, it's a case of not wanting to be more of a burden on family members," she points out. "Sometimes, older people assume that depression is a normal part of the aging process, but it's not," she adds.
Even if a home health patient is diagnosed with depression or other mental health illness and is taking medication for it, staff members still need to be alert to signs and symptoms of depression, says Sioufas. "If they don't have the right medication or the right dose, the medication won't work," she says. A patient may be reluctant to take the medication, so he or she might just take half the dose for the day, she says. The first thing the nurse needs to check is how the medication is being taken, she recommends. If the medication is being taken appropriately, but the patient still experiences symptoms of depression, a physician may need to evaluate the patient for a different medication, she adds.
Helping a patient manage depression and other mental illnesses early on in his or her home care episode can improve the patient's overall outcome, points out Unútzer. "Older adults, especially those who are frail or who have chronic medical disorders, should be screened and treated for depression," he says. Several programs, including one practice model in which primary care doctors and psychiatrists collaborate on care for patients identified with depression, have been shown effective to treat depression in this population.2
"[These programs have also resulted in] lower total health care costs than care as usual, suggesting that treating depression in this population may not only improve their health and functioning, but also decrease overall health care costs," Unútzer says.
References
1. Unútzer J, Schoenbaum M, Katon W, et al. Health care costs associated with depression in medically ill fee-for-service Medicare participants. Journal of the American Geriatric Society. 2009; 57:506-509.
2. Unútzer J, Katon WJ, Fan M, et al. Long-term cost effects of collaborative care for late-life depression. Am J Manag Care. 2008;14:95-100.
Sources
Júrgen Unútzer, MD, MPH, MA, Professor and Vice Chair, Department of Psychiatry and Behavioral Sciences, Chief of Psychiatry, University of Washington Medical Center 1959 NE Pacific Street, BB-1661A, Seattle, Washington 98195-6560. Telephone: (206) 543-3128. Fax: (206) 221-5414. E-mail: [email protected].
Lisa Sioufas, LCSW-R, ACSW, Manager, Mental Health Program, Visiting Nurse Services in Westchester, 360 Mamaroneck Avenue, White Plains, NY 10605. Telephone: (914)682-1480, ext. 648. E-mail: [email protected].
Home health nurses know that depression affects every aspect of a patient's health care and potential outcome, but according to a recent study, depression also affects the total cost of health care services for the depressed patient.Subscribe Now for Access
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