MCOs chart course to treat depression
MCOs chart course to treat depression
Evidence-based guidelines gain MD support
The National Committee for Quality Assurance in Washington, DC, requires managed care organizations seeking accreditation to implement a quality initiative for behavioral health. With 10% of patients in ambulatory care presenting with some level of depression, and dropout rates for treatment compliance as high as 30% in the first month, depression was an obvious behavioral health disorder for Group Health Cooper ative of Puget Sound in Seattle to target.
"Nationally, diagnosing depression in pri - mary care settings is a challenge," says Marvin Rosenberg, ACSW, BCD, Depression Roadmap team coordinator with the clinical planning and improve ment division of Group Health. "Depression is often an illusive disorder which masquerades in the form of physical problems like back pain or sleep problems. Patients are reluctant to accept a diagnosis of depression, especially when it is manifest in physical symptoms. This poses a challenge to physicians to openly discuss depression with patients."
Also, the cost of the new antidepressant medications is escalating, he says. "And direct consumer marketing of antidepressants by pharmaceutical companies in popular magazines places an additional burden on physicians to more accurately diagnose depression as consumers come in requesting medications. It is very important to get the right people into a treatment regimen and take steps to maximize their likelihood of complying and completing treatment successfully."
A randomized controlled study of Group Health patients carried out by independent researchers in the Seattle area found that 70% of depression management occurs in the primary care setting. The challenge for Group Health was to provide consistent and appropriate diagnosis and treatment of depression in its primary care clinics. One preliminary step was to organize a focus group of consumers who had been treated for depression to identify current practices within Group Health. "We asked patients to describe their experiences of diagnosis and treatment of this disorder and found that they had widely different experiences," Rosenberg says. In fact, it seemed no two patients followed the same course of treatment. Patients related these anecdotes:
o A patient went to her primary care physician, who prescribed an antidepressant, which she discontinued after a short time because of side effects without consulting the physician. Eight months later, still experiencing symptoms of depression, the patient went to a behavioral health specialty center and was successfully treated.
o A patient went to see his primary care physician, who had known him and his family for years. The physician prescribed an antidepressant. The patient took the prescription as directed, followed up regularly with the physicians, and improved.
o A patient saw a master's-level therapist, began cognitive behavioral therapy, and discontinued treatment after four sessions with no marked improvement in depression symptoms.
"We learned quickly from our focus groups that most programs in behavioral health are different, depending on which professionals you interface with," Rosenberg says. "We realized that we were going to have to implement a behavioral health initiative that focused on telling each patient the same information, including discussing the options for treatment and also including follow-up to encourage compliance."
Case managers are in a unique position to advocate for patients who have been using the mental health systems unsuccessfully for many years, he notes. "As a profession, case management is in a good position to help organizations develop quality initiatives for behavioral health. There is an opportunity for case managers to initiate these discussions with their organizations and identify areas for improvement."
Drawing the map
Group Health already had developed successful clinical guidelines for treating diabetes, heart disease, and other chronic illnesses, and the formula it followed for the Depression Roadmap was the same one that had proven successful for previous guidelines. The managed care organization (MCO) formed an evidence review team of psychiatrists, psychologists, social workers, pharmacists, primary care physicians, a clinical epidemiologist, and staff from the provider education and guideline development departments. The team met two hours a week for more than a year creating evidence tables from depression studies to help develop the guideline.
"We had primary care physicians in our system who felt they did a good job diagnosing and treating depression," says Rosenberg. "Physicians would tell they could look into the eyes of long-time patients and determine whether patients were depressed."
Developing evidence-based algorithms rather than relying on guidelines based solely on expert opinion helps reduce physician resistance, he notes. "Health care providers are scientifically trained and carry thousands of algorithms in their heads for the diagnosis and treatment of disease. They are highly motivated to provide the best possible care. Evidence-based guidelines, care algorithms, and tools to assist with diagnosis and symptom monitoring help this process," he says. At Group Health, clinical guidelines are not intended to substitute for clinical experience and sound medical judgment but rather to inform the process of decision making by incorporating the scientific evidence.
"Developing guidelines based on scientific evidence rather than relying on expert opinion helps improve not only clinical outcomes but physician acceptance," he says.
The depression guideline organized and structured clinical information in the way practitioners are trained to think about and treat physical disorders, Rosenberg says. For example, the literature review revealed that targeting major depression was likely to produce the best outcomes. "From the research, it's clear that patients suffering from moderate to severe forms of major depression are most likely to get better when treated with a guidelines-based approach which includes consistent follow-up and patient education. Evidence that patients suffering from forms of minor depression or situational adjustment disorders get better with similar treatment was less clear."
Group Health's Depression Roadmap team developed several tools designed to help primary care physicians do just that and is now testing them to determine their effectiveness to meet its behavioral health initiative goals, Rosenberg says. Those tools include:
o Depression diagnostic tool/symptom severity scale. Group Health developed a two-page depression screening tool and a five-question depression severity tool. The depression scale can be explained by office staff and completed by the patient. The tools help confirm the diagnosis and help track patient's progress, Rosenberg says. "Our treatment goal calls for at least a 50% reduction in severity score within four to eight weeks."
o Required training sessions. Group Health held sessions to educate clinicians on the proper use of the depression diagnostic tool and severity scale. "It's the first time we've ever had a non-optional continuing education organized around population management that included providers from all disciplines," he says. "We made sure physicians, nurses, and therapists throughout the system, including primary care and the behavioral health specialty clinics, knew how to diagnose, how to score, how to measure symptom severity. We familiarized everyone with the algorithm. It took us six weeks to complete all the training. If someone absolutely couldn't attend a training session, they had to watch a training video."
o Depression algorithm with shorthand cards in each examination room. "The algorithm makes it easy for providers to determine where the patient falls and determine what the next step in treatment should be," Rosenberg says. "We provided shorthand versions of the algorithm in each exam room. If a practitioner is in the room with a patient and can't remember what that next step should be, they can refer to the card. The algorithms are also on our computer system, but this way, the provider doesn't have to leave the exam room to find the information."
In addition to the algorithm with all the decision points, the exam room cards include the scoring scales for the diagnostic tool and the severity scale, and a list of all the antidepressant medications with dosages and side effect profiles. "It's a quick reference tool to help physicians. Physicians can't possibly remember all this information. Group Health currently has more than 30 of these clinical guidelines."
o Pharmacy reminders. "A pharmacy read out comes every two weeks with a list of patients who require follow-up," he says. "Members of the primary care team make sure that patients who haven't had follow-up visits get called. We're hoping that this improves medication compliance."
o Prescription pads. Group Health is testing bright yellow preprinted prescription pads placed in exam rooms in its primary care offices. "The pad provides a visual reminder of certain things the provider must do," he notes. "For example, every time they write a prescription for antidepressants, they must document a diagnostic determination and a severity score."
The prescription pad includes boxes for the most commonly used antidepressants. It also includes boxes to indicate whether patients received the information pamphlet for depression and for scheduling follow-up appointments.
o Follow-up to encourage compliance. Each primary care team is given the authority to assign patient follow-up in the most appropriate way for its practice and patient population. "Follow-up visits don't always require the physician.
"If a patient indicates there are no barriers to continued treatment compliance, there's no need for the physician to intervene. It's when the patient indicates a problem that the patient must be triaged to the appropriate discipline or the specialty service."
At this time, Group Health provides each team with a list of patients due for follow-up every two weeks and allows each team to delegate follow-up calls. "If a patient has been severely depressed and suicidal, the physician may choose to handle the follow-up. If the patient has been a real challenge in terms of compliance and has a good relationship with a nurse on the team, the nurse may do the follow-up for that patient. It's about getting the right person to make the right contacts with the physician overseeing the process.
"We know that 30% of patients are noncompliant with antidepressant medications at one month, and 44% are noncompliant at three months. That's a lot of people falling out of treatment," notes Rosenberg. "It seems the first month is very important. It seems reasonable that encouraging them to continue their medication with two to three contacts in the first month until blood levels have time to build up and their symptoms improve makes sense. However, what makes sense, may not make a difference. We don't have scientific evidence to prove exactly what will improve treatment adherence."
Group Health plans to begin measuring its success later this year using chart reviews to determine whether the elements of its depression guideline, including follow-up, encourage compliance with depression treatment. The MCO also wants to determine if providers are using the screening tools and guideline consistently.
If the Depression Roadmap team finds after completing its chart reviews that it has succeeded in impacting provider practice, it will be because its depression algorithm is based on sound scientific evidence, he emphasizes. "If you develop initiatives based on good evidence, physicians are more likely to follow them, and you are more likely to succeed in improving outcomes."
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