DM should include psych component for best results

Depression can affect outcomes in ill patients

If your disease management treatment doesn’t take psychological factors into consideration, your results could be less than optimal.

"If a patient has undiagnosed depression, a case manager can be fighting an uphill battle when trying to get the best response possible for a treatment plan," says Sam D. Toney, MD, founder of CMS Healthcare Integrated Inc. in Tampa, FL.

That’s why CMS Healthcare Integrated has developed an integrated care program that combines case management and disease management of both medical and behavioral conditions.

"If a disease management program is treating only the disease and not the entire person, you lost the opportunity for an increased impact," Toney says.

CMS Healthcare provides comprehensive and integrative medical and behavioral health utilization management, case management, and disease management for health plans, physician organizations, government entities, large self-insured employers, and other clients.

The company offers a turnkey program on an outsource basis, or it will train companies to conduct the program internally.

"We can share the responsibility if the company wants to provide the services during the day and have our staff provide the telephone support after hours," adds Cheri Lattimer, RN, vice president, medical management.

One point of contact

The program is unique in that it combines the mental and medical case management aspects into one comprehensive disease management program.

"We believe that having one point of contact is best for the patient. It’s more user-friendly than if they had to deal with several different nurse care managers. We are trying to integrate the process," Lattimer says.

For instance, congestive heart failure may be a priority of treatment when the patient is first diagnosed, but as the disease progresses and takes a toll on quality of life and interpersonal relationships, depression can become the primary disease that needs to be treated, Toney says.

"Our experience has been that these comorbidities and how they are related are dependent on what is primary in the member’s life at that time," Toney says.

When patients are more severely depressed, they may be seeing a psychiatrist who focuses on the depression but doesn’t coordinate with the medical side. That’s why a coordinated approach is essential, he adds.

Program has member education

There are more than 120 million Americans with chronic conditions such as diabetes, asthma, heart disease, and arthritis.

This population is responsible for 75% of all medical spending. Their medical costs are 16 times greater than people without chronic conditions. They are 10 times more likely to be hospitalized, Lattimer says.

They are likely to see eight or more providers in a year, Toney adds.

More than 19 million people have clinical depression at a cost of $30.4 billion a year in medication, benefits, and lost working days.

When a patient has a chronic disease and suffers from depression, the cost of the illness is likely to soar, and the chance for good outcomes becomes less likely.

"A depressive illness with significant symptoms could interfere with the treatment plan on the medical side," Toney says.

For instance, with diabetics, depression can affect the appetite and eating habits in either direction. Depression often causes craving for carbohydrates, which can affect the glucose balance.

Depression causes decreased levels of concentration, decreased energy levels, and can have a physiological effect on the immune system.

"It’s not just the mere fact of being able to remember how to take one’s insulin. It’s the whole physiological balance. Depression can really wreak havoc on a treatment plan," Toney adds.

CMS Healthcare Integrated’s goal is to coordinate programs that will serve the chronically ill people at risk for adverse outcomes and expensive care. They identify the medical, functional, social, and emotional needs that increase the risk of adverse health events, address the disease comorbidities, and integrate care that often is fragmented by setting, condition, or provider.

"We want to integrate disease management for the chronically ill and case management targeted at high-risk patients," Lattimer says.

Case managers with both behavioral and medical case management experience staff the program.

Program components include member education to teach patients about the overall management of depression and their chronic disease, and to help them manage the disease and improve their quality of life. 

The program is new, but early data show a reduction in costs and improvement in quality of life for the patient. For example, a congestive heart failure patient with clinical depression was diagnosed with diabetes and facing a limb amputation.

"He didn’t feel like there was any point in going forward," Lattimer recalls.

Because of the depression, the patient had been missing office visits and was refilling but not taking his medication.

"The depression was keeping him from being motivated to follow through with what he was supposed to do," she adds.

The case manager worked closely with the patient, encouraged him to actively participate in his care and helped him organize his daily life. She worked with the various providers to coordinate the care he was receiving.

As a result, the patient began seeing his physicians more regularly and reported an improvement in quality of life.