Depression program focuses on PCPs
Depression program focuses on PCPs
Plan aims to identify disease, help patients manage
Recognizing that more than half the population with depression is treated in the primary care setting, MercyCare Health Plans developed a depression disease management program focusing on giving primary care physicians the tools they need to be able to recognize and treat depression.
"Despite a high prevalence of the disease, depression remains undiagnosed and undertreated, says Linda I. Hanson, RN, CCM, who helped develop the depression program and works with patients who are identified with depression. "If people have chronic conditions such as asthma, diabetes, or heart conditions, the probability of depression is high. We started the program to make sure our health plan isn't missing opportunities to help people feel better and stay well."
MercyCare Health Plans is a subsidiary of Mercy Health System serving about 32,000 members in Southern Wisconsin and Northern Illinois. The health plan has a network of more than 600 credentialed practitioners and six hospitals.
"According to the NCQA [National Committee for Quality Assurance], between 40% and 50% of primary care patients being treated for depression stop taking their medication within three months of diagnosis. Patients who discontinue their depression medication within six months incur an average of $400 more in medical costs per year than patients who are adherent to their depression treatment plan," she adds.
The goal of the program is to identify patients with depression and work with them and their physicians to promote adherence to medication management and improve health outcomes in keeping with the latest standard of care, she adds.
The depression program was developed by a multidisciplinary team of network practitioners including a pharmacist, a data analyst, and a quality coordinator. Hanson facilitates quarterly meetings of the team during which they continue to review and refine the program.
The team started by identifying a depression screening tool, the Patient Health Questionnaire-9 (PHQ-9), to use to evaluate patients and their progress. They created a way to get information from claims data when people fill prescriptions for antidepressants.
"One of the challenges in identifying members with depression is that analyzing claims data is like throwing out a big net. Antidepressants are sometimes used for smoking cessation and other conditions, and those people show up in our data as well," she says.
Another challenge is getting members to buy in to the program because of the stigma connected with mental health disorders, she adds.
"This is an opt-in program, which means people have to agree to be a part of it. Some patients don't like the idea of being recognized as having depression," she adds.
When Hanson gets a list of patients who have filled a prescription for an antidepressant, she sends them a letter that says their records show that they are taking a medication that may have been prescribed to treat depression, and that if depression is why they are taking the medication, the health plan can help.
When members receive the letter, they have two options: They can use the self-addressed stamped envelope asking for more information or they can call Hanson directly.
After she gets the member's consent to participate in the program, she introduces the program and what it hopes to accomplish.
She conducts a detailed assessment that includes information on the patient's social support, financial status, other medical conditions and concerns, and other stressors in their lives, as well as the PHQ-9 depression severity screen.
When Hanson talks with patients, she spends most of her time listening and assessing the patients' readiness to change their behavior to become more adherent to their treatment plan.
"The patients need to be ready to change. I could talk to them every day for two hours and if they're not ready to change, no intervention will help them," she says.
She addresses barriers to compliance and helps the patients work to overcome them.
"By the end of the conversation, we've figured out what we need to work on. I take it in small steps and pick one thing to concentrate on. We come up with a plan to help the patient meet his or her goal," she says.
Hanson and the patient work together to formulate self-management goals and agree on the frequency of telephone visits.
"I let them know that I will be calling their provider and that the three of us will work as a team," she says.
In the beginning, Hanson talks to most of the patients weekly, and some every day if needed. She works with the patients to take small steps toward meeting their goals.
For instance, one patient who had multiple comorbidities wanted to start meditating but felt overwhelmed about starting it.
"By the end of the conversation, she had talked herself into closing her door and looking at a picture of the ocean. It's simple things like that. Patients with depression get so easily overwhelmed that they don't take the time to try things," she says.
She works with the patients on the importance of staying on their antidepressant, exercise and nutrition, as well as coping and learning how to relax.
"It's teaching and talking on the phone that's most effective in changing behavior. I can send them hard copies of the resources available to them but they aren't likely to use them," she says.
When she sends them information, she tells them to put it by the telephone so they can refer to it during the next conversation.
She typically works with patients who have depression for nine months to a year until they are ready to self-manage their conditions.
"I let them know right away that I won't be working with them forever, and I tell them in advance when I'm moving them toward self-management," she says.
She sends the provider a letter notifying him or her that the patient opted in to the program and includes her business card, depression guidelines, and refers the physician to the health plan's web site.
"Most of the time when I call, I talk to the nurse or the medical assistant. I'm always willing to talk to the providers when they have time. Many of them don't know this program is available," she says.
Hanson has spent a lot of time reaching out to the primary care physicians in the network, informing them about the program and the information that is available to help them manage their patients.
"The majority of patients are not recognized as having depression. We let them know that there is a tool that they can use to screen their patients," she says.
One of the team's achievements was getting the PHQ-9 screening tool available to the primary care physicians in the electronic medical record for Mercy Health Systems.
"We want to have it as a pop-up for them to help them remember that if they ask the first two questions on the tool and patients answer positively that they should screen them for depression," she says.
The tool asks patients: Over the last two weeks, how often have you been bothered by any of the following? The first two topics are: little interest or pleasure in doing things and feeling down, depressed, or hopeless.
As part of her outreach program, Hanson visits the primary care clinics in the area to get to know the staff and the physicians.
"I work to build professional relationships with the physicians and nurses. If they don't have the name and know the face of a case manager, they aren't as likely to refer patients," she says.
Hanson is working on integrating the depression program with the health plan's complex case management program.
"People with complex medical needs benefit from the same type of interventions as patients with depression. Unlike in other disease management programs, these conversations can be a minimum of 30 minutes, and some last nearly two hours," she says.
(For more information, contact: Linda I. Hanson, RN, CCM, depression case manager, MercyCare Health Plans, e-mail: [email protected].)
Recognizing that more than half the population with depression is treated in the primary care setting, MercyCare Health Plans developed a depression disease management program focusing on giving primary care physicians the tools they need to be able to recognize and treat depression.Subscribe Now for Access
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