Members stay on their medication longer
A depression management program has resulted in better scores on Health Plan Employer Data Information Set (HEDIS) measures and a reduction in depression screening scores for Fallon Community Health Plan, with headquarters in Worcester, MA.
Over the last three years, the six-month continuation of treatment among Fallon Community Health Plan members has increased from 37% to 59%, placing the health plan above the 90th percentile nationally.
Members who are in the depression program have showed a 76% reduction in scores on the Beck Depression Inventory (BDI), a 21-item questionnaire that gauges how depressed an individual is. The average BDI score has dropped from 15 to 4.
Favorable satisfaction noted
Member satisfaction with the program is high. Members enrolled in the program gave their interactions with the care managers a score of 91%, compared with average scores in the mid-80th percentile among all practitioners in the system.
"We’ve seen a positive impact in a number of areas. Our HEDIS scores show that we are on the right track," says Wally Mlynaryk, MHA, director of disease management for the health plan.
Here are Fallon Community Health Plan’s HEDIS scores:
- optimal practitioner follow-up contacts (three visits within 90 days): 45%;
- acute-phase medication treatment (continued at least 90 days): 79%;
- continuation treatment (at least six months of medication): 59%.
"We saw the opportunity in terms of our HEDIS scores and the fact that our inpatient utilization rate for depression was pretty high," Mlynaryk says.
The plan began by surveying its primary care physicians to find out how they viewed depression management and what kind of clinical support and patient resources they would prefer.
The physicians reported that they were interested in receiving treatment guidelines and diagnostic tools.
A survey of patients who had discontinued their antidepressant medications prematurely showed that the majority stopped taking the medication because they didn’t understand the need for prolonged treatment.
"Patients often have difficulty with the medications for depression. If they had a side effect, they would stop taking it because they didn’t know what was going on. So the depression would continue," says Jane Palermo, RN, care manager for the depression program.
The health plan developed clinical guidelines for depression and distributed them to the primary care physicians along with copies of the Patient Health Questionnaire or PHQ-9, a short screening tool for depression and a one-page educational flyer on depression.
The PHQ-9 forms and fliers are displayed in the examining rooms.
"If the doctor feels someone is depressed, they go through the survey. Sometimes, patients who are waiting for the doctor to come in look at the survey wonder if they have depression and start a discussion with the doctor," Palermo says.
Physicians make the majority of referrals from the program, although some come from Fallon’s disease management programs.
Palermo follows up with the patients as soon as she gets the referral. She screens the members using the BDI to establish a baseline score and follows up with the tool at intervals to track the outcomes.
Many of the members referred to Palermo, particularly those in their late teens and early 20s, have concerns about taking medication.
Palermo follows up with them and tries to build a rapport. The fact that she is calling them on the telephone makes the interventions less threatening, she says.
In many cases, these members eventually start taking their medication and tell Palermo they wish they had done so sooner.
"So many people don’t understand that depression is genetic. They see a stigma attached to the diagnosis of depression. They’ve lived with depression all their lives, and once they take their medication, they are amazed that it’s treatable and that they don’t have to feel so bad," Palermo says.
In a typical case, she follows up with members about two weeks after they start their medication, and then calls them monthly.
"I always tell them not to wait for me to call if they have a question or a concern. They do call, particularly in the winter months, when they sometimes think they need more medication. Others call just to check in," Palermo adds.
One challenge with patients taking antidepressants for the first time is to help them cope with the side effects, most of which subside after a while. Some members get extreme headaches from their medication. In these cases, Palermo checks with them frequently and, if the headaches continue, calls the physician for a new medication.
"It usually takes three to four weeks before we see any major results. Sometimes patients call in a couple of weeks and think the medication is already starting to work. They feel better just knowing something is going to help them," she says.
There is no particular cutoff time for the program. Palermo follows the members until she and they both feel that they can manage on their own.
Some of the members are in the program only for a short time, such as the man who became depressed after his wife died and stayed in the program only a few months.
"I told him to call me if he ever needed me and we’d reactivate him," Palermo says.
Because of her relationship with the physician offices, Palermo is able to find out answers for the members in a hurry. "A lot of times, patients get frustrated calling the physician and waiting on hold or waiting for the call to be returned. I have a direct link to the physician offices," she says.
For instance, if a patient reports starting to go into a slump, Palermo calls the physician and asks if the medication can be increased. She calls the patient back when the new prescription has been called in to the pharmacy.
In some instances, Palermo recommends that patients get outside help from a psychiatrist to keep their depression in control. She gives them names of psychiatrists to consider and will help them set up appointments if they have difficulties.
"Sometimes, they need more than just the medication and follow up. They need somebody to tie them into the resources they need," she says.
Before the program started, Palermo visited the physician offices to let them know about the program and how they can make referrals.
"It helps increase the rapport when we meet face-to-face. It’s not like I’m a stranger to the doctors. I work closely with the primary care providers. They work with me and I work with the patients," she says.