Prevention-Research Centers Health Aging Research Network (PRC-HAN) Webinar Series Evidence-Based...
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Transcript of Prevention-Research Centers Health Aging Research Network (PRC-HAN) Webinar Series Evidence-Based...
Prevention-Research Centers Health Aging Research Network (PRC-HAN)Webinar Series
Evidence-Based Depression Care Management:
Improving Mood-Promoting Access to Collaborative
Treatment (IMPACT)
Tuesday, October 16th 2008
2-3:30 PM EST
Moderated by: Cate Clegg
Jürgen Unützer, MD, MPH, MA Virna Little, PsyD, LCSW-R
2
Sponsors:
Prevention Research Centers-Healthy Aging Research Network
http://www.prc-han.org/
Retirement Research Foundationhttp://www.rrf.org/
National Council on Aginghttp://ncoa.org/index.cfm
3
IMPACT Primary Care Based
Team Care for
Late-Life Depression
Jürgen Unützer, MD, MPH, MAProfessor & Vice Chair
Psychiatry & Behavioral SciencesUniversity of Washington
Virna Little, PsyD, LCSW-RVice President for Psychosocial Services and
Community AffairsInstitute for Family Health
4
Common 10% in primary care
Disabling #2 cause of disability (WHO)
Deadly Over 30,000 suicides / year
Expensive 50-100% higher health care costs
Depression
5
Depression is deadlyOlder men have the highest rate of suicide.
6
Depression is often notthe only health problem
DepressionNeurologicDisorders
Geriatric Syndromes
Diabetes
20-40%
10-20%
10-20%
Heart Disease
20-40%
Chronic Pain
40-60%
10-20%
Cancer
7
Efficacious treatments for depression
Antidepressant Medications– Over 20 FDA approved
Psychotherapy– CBT, IPT, PST, brief dynamic, etc.
Other somatic treatments– ECT
Physical activity / exerciseUnutzer et al, NEJM 2008.
8
But: few older adults get effective treatment
Only half are ‘recognized’ a particular problem for older men & minorities
– “I didn’t know what hit me …”– “I am not crazy” – “Isn’t depression just a part of ‘normal aging?”
Fewer than 10 % seek care from a mentalhealth specialist. Most prefer their primary care physician.
9
Depression Treatment in Primary Care
50 % are recognized and started on treatment or referred
Limited access to evidence-based psychosocial treatments (psychotherapy)
Increasing use of antidepressants • PCPs prescribe 70 – 90 % of antidepressants
• 10 - 30 % of older adults are on antidepressants
• MAJOR OPPORTUNITIES for Quality Improvement – even for nonprescribing providers
But treatment is often not effective– Only 20 – 40 % improve substantially over 12
months
10
Why integrate care?
Primary Care
Community Mental Health
Center
PC
CM
HC
Home & Community based social
services?
Alcohol & substance
abuse care?
11
Depression Care Management in Primary Care
Limited access to / use of mental health specialists
Treat mental health disorders where the patients are
- Established provider-patient relationship
- Less stigma
- Better coordination with medical care
12
Components of evidencebased integrated care programs
Screening / case finding
Patient education / self-management support
Support medication treatment prescribed in primary care– Monitor adherence, side effects, effectiveness
[Nonprescribing providers function as the ‘eyes and ears of the doctor’]
Proactive outcome measurement / tracking– e.g., PHQ-9, GDS, CES-D
Brief counseling (e.g., Behavioral Activation, PST-PC, IPT, CBT)
Stepped care (initial treatments often are not enough)– increase treatment intensity as needed
– mental health consultation to help guide or provide care for patients not responding as expected
13
IMPACT Study
Funded by
John A. Hartford Foundation California Healthcare Foundation
Robert Wood Johnson FoundationHogg Foundation
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IMPACT Team“None of us is as smart as all of us”
Study coordinating center Jürgen Unützer (PI), Sabine Oishi, Diane Powers, Michael Schoenbaum, Tom Belin, Linqui Tang, Ian Cook. PST-PC experts: Patricia Arean, Mark Hegel
Study sitesUniversity of Washington / Group Health CooperativeWayne Katon (PI), Elizabeth Lin (Co-PI), Paul Ciechanowski Duke University Linda Harpole (PI), Eugene Oddone (Co-PI), David SteffensKaiser Permanente, Southern CA (La Mesa, CA)Richard Della Penna (Co-PI), Lydia Grypma (Co-PI), Mark Zweifach, MD, Rita Haverkamp, RN, MSN, CNSIndiana UniversityChristopher Callahan (PI), Kurt. Kroenke, Hugh. Hendrie (Co-PI)UT Health Sciences Center at San AntonioJohn Williams (PI), Polly Hitchcock-Noel (Co-PI), Jason WorchelKaiser Permanente, Northern CAEnid Hunkeler (PI), Patricia Arean (Co-PI)Desert Medical GroupMarc Hoffing (PI); Stuart Levine (Co-PI)
Study advisory boardLisa Goodale (NDMDA), Rick Birkel (NAMI), Thomas Oxman, Kenneth Wells, Cathy Sherbourne, Lisa Rubenstein, Howard Goldman
15
Study Methods
1998 – 2003
Randomized controlled trial
8 health care organizations in 5 states– 18 primary care clinics
1,801 older adults with major depression or chronic depression– 450 primary care providers– Patients randomly assigned to IMPACT or usual care– Usual care = antidepressant Rx in primary care (~ 70
%) and / or referral to mental health specialists (20 %)– All followed with independent assessments for 2 years
16
IMPACT Team Care Model
Practice Support
Prepared, Pro-active Practice Team
Photo: Courtesy D. Battershall & John A. Hartford Foundation
Effective Collaboration
Informed, Activated Patient
Photo credit: J. Lott, Seattle Times
17
Evidence-based ‘team care’ for depression
TWO PROCESSESTWO NEW ‘TEAM MEMBERS’Care Manager Consulting
Psychiatrist
1. Systematic diagnosis and outcomes tracking
e.g., PHQ-9 to facilitate diagnosis and track depression outcomes
- Patient education / self management support
- Close follow-up to make sure pts don’t ‘fall through the cracks’
- Caseload consultation for care manager and PCP (population-based)
- Diagnostic consultation on difficult cases
2. Stepped Care
a) Change treatment according to evidence-based algorithm if patient is not improving
b) Relapse prevention once patient is improved
- Support anti-depressant Rx by PCP
- Brief counseling (behavioral activation, PST-PC, CBT, IPT)
- Facilitate treatment change / referral to mental health
- Relapse prevention
- Consultation focused on patients not improving as expected
- Recommendations for additional treatment / referral according to evidence-based guidelines
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Treatment Protocol
Assessment and education, Behavioral Activation / Pleasant Events Scheduling
AND(3) a) Antidepressant medication
usually an SSRI or other newer antidepressant
OR
b) Problem Solving Treatment in Primary Care (PST-PC)
6-8 individual sessions followed by monthly group maintenance sessions
(4) Maintenance and Relapse Prevention Plan for patients in remission
19
Stepped Care
Systematic follow-up & outcomes tracking
Patient Health Questionnaire (PHQ-9)
The “cheap suit”
Treatment adjustment as needed - based on clinical outcomes
- according to evidence-based algorithm
- in consultation with team psychiatrist
Relapse prevention
20
21
Greater Satisfaction with Depression Care
0
20
40
60
80
100
0 3 12
month
perc
ent
Usual Care Intervention
P<.0001 P<.0001P=.2375
Unützer et al. JAMA. 2002; 288: 2836-2845.
(% Excellent, Very Good)
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IMPACT Doubles Effectiveness of Depression Care
0
10
20
30
40
50
60
70
1 2 3 4 5 6 7 8
Usual Care IMPACT
%
Participating Organizations
50 % or greater improvement in depression at 12 months
23
43%
54%
42%
19%23%
14%
0%
10%
20%
30%
40%
50%
60%
White Black Latino
IMPACT Care
Care as Usual
Evidence-based Care BenefitsDisadvantaged Populations
Areán et al. Medical Care, 2005
50 % or greater improvement in depression at 12 months
24
Improved Physical Functioning
38
38.5
39
39.5
40
40.5
41
Baseline 3 mos 6 mos 12 mos
Usual Care
IMPACT
SF-12 Physical Function Component Summary Score (PCS-12)
P<0.01P<0.01 P<0.01
P=0.35
Callahan et al. JAGS. 2005; 53:367-373.
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Fewer thoughts of suicide
0
2
4
6
8
10
12
14
16
18
Baseline 6 months 12 months
IMPACTUsual Care
% p
ati
ents
wit
h s
uic
idal
th
ou
gh
ts
Unützer et al, JAGS 2006
26
IMPACT Saves Money
Cost Category
4-year costs in
$
Intervention group cost
in $
Usual care group cost in
$Difference in
$
IMPACT program cost 522 0 522
Outpatient mental health costs 661 558 767 -210
Pharmacy costs 7,284 6,942 7,636 -694
Other outpatient costs 14,306 14,160 14,456 -296
Inpatient medical costs 8,452 7,179 9,757 -2578
Inpatient mental health / substance abuse costs
114 61 169 -108
Total health care cost 31,082 29,422 32,785 -$3363
Unutzer et al. Am J Managed Care 2008.
Savings
27
IMPACT Summary
“I got my life back”
Photo credit: J. Lott, Seattle Times
- Less depressionIMPACT doubles effectiveness of usual care
- Less physical pain
- Better functioning
- Higher quality of life
- Greater patient and provider satisfaction
- More cost-effective
28
IMPACT Endorsements
–President’s New Freedom Commission on Mental Health
–National Business Group on Health
–Institute of Medicine (Retooling for An Aging America)
–POGOe–CDC Consensus Panel–Annapolis Coalition–Partnership to Fight
Chronic Disease–SAMHSA NREPP–Commonwealth Fund–Integrated Behavioral
Health Partnership
29
Taking IMPACT from Research to Practice
Support from JAHF (2004-2009)Over 170 clinics have implemented core
components of the program to date– DIAMOND program in Minnesota implementing
the program state-wide in partnership with 25 medical groups and 9 health plans
Several large health plans and disease management organizations are incorporating core components of IMPACT
30
IMPACT Implementation
Trained over 3000 Providers in over 150 practices to date
2004 2005 2006 2007 2008
Over 3,000 clinicians trained
31
Kaiser Permanente of Southern California
Pilot Study- Compare 284 clients in ‘adapted program’ with 140
usual care patients and 140 intervention patients in the IMPACT study (Grypma et al, 2006)
Dissemination- Implemented core components of program in 10
regional medical centers
32
KPSC – San Diego‘After IMPACT’
Fewer care manager contacts
18.9
10.28.77.9
5.12.8
Total contacts Clinic visits Phone calls
IMPACT Study
Post-Study
Grypma et al, General Hospital Psychiatry, 2006.
33
IMPACT Remains Effective
66% 68%64% 68%
At 3 months At 6 months
IMPACT Post-Study
>= 50 % drop in PHQ-9 depression scores
Grypma et al, General Hospital Psychiatry, 2006.
34
Lower Total Health Care Costs
$7,949
$7,471
$6,800
$7,200
$7,600
$8,000
$8,400
$8,800
Study UsualCare
StudyIMPACT
Post StudyIMPACT
$ / year
Grypma, et al; General Hospital Psychiatry, 2006
35
Institute for Urban Family Health
Number Percent
Age at enrollment:Mean
Range
71.6 years60 – 99 years
Gender:Female
Male
16574
69.0%31.0%
Ethnicity:Hispanic
African AmericanCaucasian
Other
90705623
37.7%29.3%23.4%9.6%
Marital Status:Married
Single, Widowed, Divorced/separated
4448
47.8%52.2%
36
IMPACT Effective for Depression
Mean PHQ-9 Depression Scores
0
2
4
6
8
10
12
14
16
18
20
Time
Mea
n D
epre
ssio
n S
core
s
Initial 3 Months 6 months
14.03
8.14 7.91
37
Change in DepressionInitial to 6 months
6 Month PHQ-9 Depression Scores(Mean Score of 7.91)
0
20
40
60
80
100
120
140
160
PHQ-9 Sore
Nu
mb
er
of
Pa
tie
nts
Initial PHQ-9 Depression Scores
0
20
40
60
80
100
120
140
160
PHQ-9 Score
Nu
mb
er
of
Pa
tie
nts
Under 10:Mild
10-14:Moderate
15-19:Mod.
Severe
20+:Severe
28%
9%
63%
Under 10:Mild
10-14:Moderate
15-19:Mod.
Severe
20+:Severe
65%
24% 5% 6%
38
A word from providers…
“It is good to see that mental health is once again becoming part of the medical Interview, as so much of our patient's health depends on their mental well being.”
- Dr. Eric Gayle
“Project IMPACT has allowed me to incorporate a new tool (PHQ-9)into my primary care practice,
which has improved the accuracy of my diagnosis while increasing my efficiency and productivity as well.
It helped me identify patients I initially overlooked.”-Dr. Joseph Lurio (68th Street)
38.4 35
62.5 61.3
0102030405060708090
100
Non Depressed Depressed
Depression Is Associated With a Higher
Number of Cardiac Risk Factors
Diabetic Patients With CVDN=3010
Diabetic Patients Without CVDN=1215
> 3
Car
diac
Ris
k Fa
ctor
s (%
)
Katon et al, J Gen Intern Med, 2004
Depression Increases Mortality Rate in Patients With Diabetes by 2-Fold
Katon et al. Diabetes Care, 2005Katon et al. Diabetes Care, 2005Katon et al. Diabetes Care, 2005Katon et al. Diabetes Care, 2005
Depression and Diabetes: More
Depression Free Days over 2 Years
Inc
rem
en
t
Inc
rem
en
t0
100
200
300
400
500
Day
s
Pathways IMPACT
Intervention
Usual Care
Increment
412
359331
215.5
53
115.5
Two Collaborative Care Trials Demonstrate
Improved Depression Care in Diabetes Lowers Total Health Care Costs Over 2 Years
Usu
al C
are
Inte
rven
tio
n
Sav
ing
s
Usu
al C
are
Inte
rven
tio
n
Sav
ing
s$0
$5,000
$10,000
$15,000
$20,000
$25,000
Pathways IMPACT
$22,258
$21,148 $18,932
$18,035
$1,110$897
Katon et al. Diabetes Care 2006, Simon et al Arch Gen Psychiatry 2007
43
Project Dulce + IMPACTPrincipal Investigator: Todd Gilmer, UCSD
Combined diabetes and depression care management program targeting low-income and primarily Spanish speaking Latinos in San Diego community clinics
Added a depression care manager to an existing diabetes team (RN/CDE, promotoras)
Translation for Cultural Competency
– DCM bilingual with experience serving Latino pop.
– PST-PC adapted to low-literacy population
44
Project Dulce + IMPACT Results
Screened 499 patients with PHQ9
31% with scores of 10+
75% Latino, 70% Spanish speaking
65% had depressive symptoms for 2+ years
26% interested in pharmacological treatment
74% interested in psychological treatment
48% reported financial stressors
45
Depressive Symptoms at Baseline and Six-Month Follow-Up As Measure with PHQ-9
.
Gilmer et al. Diabetes Care 2008
Inter-Quartile Range (box)Highest and Lowest (whiskers)Outlier (dots)
Median
Collaborative Care for Alzheimer’s Disease
Christopher M. Callahan, MD
Cornelius and Yvonne Pettinga ProfessorDirector, Indiana University Center for Aging Research
Research Scientist, Regenstrief Institute, Inc.
Collaborative Care for Alzheimer’s Disease
IU Center for Aging Research
Improvement in Dementia-related Problem Behaviors
0
5
10
15
20
baseline 6 months 12 months 18 months
Augmented Usual Care Intervention
Pati
en
t N
PI
Score
Callahan et al. JAMA 2006
IU Center for Aging Research
0
5
10
baseline 6 months 12 months 18 months
Augmented Usual Care Intervention
Improvement in Caregiver StressC
are
giv
er
NP
I S
core
Callahan et al. JAMA 2006
49
Shared vision– How will we know success?
– Shared, measurable outcomes
• (e.g., # and % of population screened, treated, improved)
Engaged leaders & stakeholders– Clinic leaders & administration
– PCPs, care managers, psychiatry, other mental health providers
Clinical & operational integration– Functioning teams, communication, and handoffs
– Clear about ‘shared workflow’ & roles of various team members
Adequate resources• Personnel, IT support, funding
Proactive problem solving re barriers & competing demands• Minimize complexity, PDCA
Implementing Collaborative Care
50
http://impact-uw.org