Program targets members treated in primary care
Program targets members treated in primary care
Coaches' help members comply with plan
Members who seek treatment for depression and anxiety from a primary care physician are getting help managing their condition through a new program from CIGNA HealthCare.
The program targets the 83% of people who have symptoms of depression and anxiety but who do not go to a mental health specialist, says Peg Audley, LICSW, assistant director of operations for CIGNA's disease management program.
"Our program fills a gap. The people we serve have never accessed their mental health benefit. Many are not therapy candidates, but they do benefit from the support and information the behavioral health coaches provide. We want to impact the kind of care that people receive in the primary care setting," Audley says.
Just giving people medication for depression doesn't change their behavior, Audley points out.
"We have to find a hook, something that is so important that members will want to change and become compliant. We guide them in finding what will work for them," she says.
The health plan identifies members from medical claims and pharmacy claims and excludes those members who are already seeing a behavioral health specialist. For instance, the database identifies people who have filled a prescription for an antidepressant medication but who do not have behavioral health claims.
Members whose claims from a primary care office include a diagnosis for depression but who have not filled a prescription for an anti-depressant are also flagged for inclusion.
"We also include anxiety in our program, which makes us unique in the industry. In the primary care setting, it can be difficult to differentiate between anxiety and depression, and people who are diagnosed with depression also have a high incidence of anxiety as a comorbidity," she says.
The program is staffed by master's level behavioral clinicians who act as coaches to help the members comply with their treatment plan.
Members who are identified receive a welcome letter telling them about the program, which is free to them, along with a workbook reference guide about depression.
If the members have comorbid chronic conditions, such as cardiac conditions, chronic obstructive pulmonary disease, low back pain, asthma, or diabetes, the health plan notifies them that a health coach will be contacting them by telephone to determine if they want to take part in the program.
If members do not have a comorbid condition, the health plan's letter offers them the same program but asks members to call the health coach if they are interested.
"Our claims data shows that 50% of people with medical conditions have comorbidities that include anxiety or depression. Those with medical conditions typically have health care costs that are 2.5 time higher than the rest of our population. We focus most of our energy on people with comorbid conditions who are at higher risk for medical costs," she says.
The program is essentially the same for both groups. If a member has a medical condition in addition to depression and is in a case management or disease management program, the health coach collaborates with the case manager who is coordinating the medical care.
"They work closely together to make sure that we get the best outcome," she says.
The first contact between the coach and the member is an hourlong session that includes several assessments that determine how depressed the member is, the type of symptoms he or she is experiencing, and the effect on the member's level of function and ability to continue working.
The health plan also screens for alcohol use, because that cuts the effectiveness of antidepressants by 50% and because people with depression are at a higher risk for abusing alcohol than the general public, Audley says. If the problem is severe enough, the members are referred to an alcohol treatment program.
The coaches work with the members to set goals and follow up with a half-hour appointment a week later.
"All contact is by set appointments. This ensures that we reach the member at a convenient time. Members receive a reminder call the day before to make sure they will still be available," she says.
The coaches make phone calls from 7 a.m. to 10 p.m. CST Monday through Friday and 7 a.m. to 5 p.m. CST on Saturdays.
"Our hours of operation are designed to cover the country. We want to be accessible to our members. If they need to call us in between sessions, we are available as well," she says.
"As people progress, we focus on their understanding of their illness and their medication and how it works," she says.
Medication compliance is one of the top focuses, Audley says. The goal is for all members to be at an 80% or higher compliance rate.
"People don't like to think of depression as a chronic condition. Some people will need to stay at a therapeutic dose of an antidepressant for six to eight months. It's hard for them," Audley says.
The coaches work with members on what lifestyle choices they need to make to ensure that they will be compliant with their medication.
"People who have side effects may end up feeling worse physically, and the chance that they will discontinue the medication is very high. It's very common for people to stop taking their medication and continue to get worse," she says.
The coaches help the members come up with plans for self care and lifestyle changes that can improve their functioning, such as nutrition, exercise, and handling stress.
"A lot of people who are depressed are easily overwhelmed and can't think of where they want to go with their lives. A coach will help them take a step at a time," Audley says.
The coaches don't provide therapy, she emphasizes. Rather, they encourage the members to look at what is happening today and what will happen in the future.
"A lot of times, people who are depressed look at the past. We are working on improving their day-to-day level of functioning," she says.
In urgent cases, the health coaches or a CIGNA medical director will contact the physician's office directly, but in most cases, the coaches work to empower the members to take charge of their own health.
Once someone has agreed to work with a coach, with the member's permission, the health plan sends a letter to the member's physician telling him or her about the program and sends progress reports that include scores on a depression scale, medication compliance, and the problems that the member is working on with the coach.
When members are severely depressed, the coaches urge them to seek ongoing, face-to-face therapy.
"It takes a combination of antidepressants and therapy to treat depression effectively. If they aren't open to the idea of therapy, we can at least help them manage their depression," she says.
The program began January 1, 2006.
"We're still gathering data on the outcomes, but there are a lot of anecdotal outcomes that show the positive effect of the program," she says.
For instance, a 42-year old worker had been on a subtherapeutic level of an antidepressant for two years and had decided that he was never going to feel any better. He was hopeless and withdrawn from his coworkers and his family.
The member and the coach worked together on listing symptoms and documenting them. They rehearsed what the member was going to say to his physician. The doctor increased the medication and the member began to feel better.
"As a result the man has his life back. He's engaged at work and at home and has a new hobby. He says he never wants to come off his medication because it makes him feel so good," Audley says.
The coaches work to find out what might motivate people to change, Audley says.
For instance, when Audley was a coach, she worked with a 50-year-old woman who was tired of trying medications that didn't work and, because of her irritability, was in danger of losing her job.
"She couldn't tell me anything that was giving her pleasure. To her, everything was dark and dismal, but after about two weeks, she started talking about her 18-month-old granddaughter and her tone of voice changed. I asked her to picture what she and her granddaughter could do together if she was feeling like her old self," Audley says.
Eventually, the woman agreed to see a psychiatrist, who worked with her until she started feeling better.
"You have to find out what will move people to take their medicine and to make changes in their lives. They don't have time for that in the primary care physician's office, but when we take the time to work with these members, it makes a tremendous difference," she says.
Members who seek treatment for depression and anxiety from a primary care physician are getting help managing their condition through a new program from CIGNA HealthCare.Subscribe Now for Access
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