“The Effect of Patient Complexity on Treatment Outcomes for Patients Enrolled

in an Integrated Depression Treatment Program- a Pilot Study”

Ryan Miller, M.A., PsyD, L.P. -Co InvestigatorDana Brandenburg, PsyD, L.P. –Principal Investigator

Rebekah Pratt PhD- Co Investigator

Collaborative Family Healthcare Association 13th Annual ConferenceOctober 27-29, 2011 Philadelphia, Pennsylvania U.S.A.

Session #F4October 29, 201110:30 AM

Faculty Disclosure

We have not had any relevant financial relationships during the past 12 months.

This study was funded by the UCare Foundation

Need/Practice Gap & Supporting Resources

Recent literature has begun to explore the concept of patient complexity as observed in the primary care setting.

Despite the early attempts to conceptualize complexity, no widespread validated instrument to measure patient complexity has surfaced.

Objectives

Describe the association of patient complexity with outcomes in an integrated depression care program

Familiarize yourself with the complexity assessment form

Identify possible future areas of research regarding patient complexity

Expected Outcome

Explore how complexity can impact patient outcomes in your own practice setting.

Become familiar with a possible tool for assessing patient complexity

Background In underserved patient populations, many of the

patients have very complex lives and health care needs which create challenges for primary care providers.

We know a complex patient when we see one, but we do not always know how to identify how they are complex

Mental health issues add another layer of complexity to patients

Mental health issues can lead to poorer outcomes with an individual’s physical illness as well

DIAMOND

The DIAMOND (Depression Improvement Across Minnesota, Offering New Directions) program was developed by the Institute for Clinical Systems Improvement (ICSI) based on research of the IMPACT trials (Unützer J, et al.).

The DIAMOND is a team approach to help eligible patients understand and manage their depression.

Care in DIAMOND is co-managed by the patient’s primary care provider (PCP), the care manager (CM) and a consulting psychiatrist.

Patients are referred by their PCP’s

DIAMOND Eligibility

• Eligibility requirements for the DIAMOND program include a diagnosis of Major Depressive or Dysthymic Disorder, age 18 or older, with a PHQ-9 score of 10 or greater at the time of referral. Participants can speak any language. An interpreter is used to provide services for non-English speaking patients.

DIAMOND Care: How it works

Progress is tracked with the Patient Health Questionnaire-9 (PHQ-9), a screener for depression which is administered at each contact by the CM.

New DIAMOND program patients must complete an initial intake with the CM. Following the initial intake interview, the CM at each clinic will complete all forms.

MCAM form based on the information they obtained during the intake.

Background Our health system outcomes in DIAMOND were less

robust than other enrolled health systems Using the PHQ9 to define positive outcomes in

DIAMOND only looks at the dimension of symptom severity

It does not help us to identify reasons the scores are not changing

Identification of highly complex patients may assist in identifying factors that could impede treatment, so that these factors could be addressed and assist the four UMP clinics in moving closer to reaching the ICSI goals

Research Question:

Is level of patient complexity at the beginning of a patient’s involvement in DIAMOND associated with success (or lack of improvement) after enrollment in the program for 6 months. Success in the DIAMOND program will be defined in two ways: 1) as response (50% reduction in PHQ-9 score) or 2) remission (PHQ-9 score of 5 or less).

Method

Patient is referred and enrolled in DIAMONDPatient is administered a MCAM and PHQ9 at

initial intake, 3 months, and 6 monthsPHQ9 is completed based on pt responsesMCAM is completed based on information

care manager received as part of the initial program intake

PHQ-9

Data Analysis

Descriptive statistics were calculated for demographics and baseline characteristics (number of diagnoses and number of chronic conditions)

Simple and multiple logistic regression models were used to analyze the relationship between the MCAM total score, as well each of the MCAM sub-score domains and the success outcome

P-values < 0.05 were deemed statistically significant

Results: DemographicsVariable N (%)

Female 16 (89%)

Not partnered 12 (67%)

Unemployed 11 (61.1%)

Homeless 6 (33%)

Receiving MH counseling 10 (56%)

Taking Antidepressant 16 (89%)

ResultsBaseline 3 month 6 month

MCAM Score 11.1 8.4 7.1

PHQ9 Score 18.1 12.8 8.7

Relationship between baseline MCAM and treatment responders as measured by PHQ9

Responder Time

Odds Ratio95% Confidence Interval

P-Value

3 month 1.101 (0.751, 1.613) 0.623

6 month 0.838 (0.593, 1.183) 0.315

Implications

• Higher complexity scores at the outset did not impinge on patient’s ability to improve depression symptoms in this study

• More research is needed to better understand how patient complexity and depression improvement interact

Limitations

Collector of information was aware of the studySmall sample sizeOur clinic population may not generalize to

other clinicsIssues related to complications of

implementation with both the MCAM and DIAMOND

Future Directions Additional systematic explorations on a large scale of

complexity and depression.

Further analysis of the multi-factorial nature of decreasing complexity

There is continued work on the complexity scale.

Questions?

Time for Q & A

Session Evaluation

• Please complete and return theevaluation form to the classroom monitor before leaving this session.

•Thank you!

Recommendations

• Consider use of the recently validated Minnesota- Edinburgh Complexity Assessment Model (MECAM) to measure patient complexity.

• For more MECAM information, including details about the newly developed structured staff training presentation, please e-mail Rebecca Pratt at rjpratt@umn.edu.