MCO updates successful depression program

A disease management program is a work in progress. Even the most carefully designed program should be monitored and evaluated continually. If you implement a program and fail to gather feedback on what works and what doesn’t, you will fail to meet your goals.

A randomized controlled study of patients enrolled as members of Group Health Cooperative of Puget Sound in Seattle conducted by independent researchers in the Seattle area prompted the managed care organization to develop and implement its Depression Roadmap in 1998. The study found that 70% of depression management occurred in the primary care setting. This meant that 30% of all patients who presented with depression either sought help in specialty clinics or received no help at all.

The challenge for Group Health was to provide consistent and appropriate diagnosis and treatment for the 70% of depressed patients who sought treatment in its primary care clinics. (For a profile of the roadmap, see Case Management Advisor, October 1998, pp. 168, 173-174.)

The Depression Roadmap has been in place for more than a year, and Marvin Rosenberg, ACSW, BCD, Depression Roadmap team coordinator with the clinical planning and improvement division of Group Health, has hit the road — revisiting each clinic to provide educational updates and gather feedback from providers about the tools and the guidelines. "We’re also in the process of making decisions about which components of the program to keep, which to revise, which to eliminate, and which to add based on provider feedback."

Group Health has been measuring the success of its Depression Roadmap using chart reviews to determine the effectiveness of various elements of its depression guidelines, including follow-up, and encouraging treatment compliance and plans to publish the results soon. "Our initial findings and feedback from providers indicate that the diagnostic tools are particularly useful," notes Rosenberg. "As we’ve toured our delivery system and visited clinics, our findings have been very positive overall. However, we have made some changes."

• Preserved: depression diagnostic tool/ symptom severity scale. To facilitate an open dialog between providers and patients, Group Health developed a simple two-page depression screening tool and a five-question depression severity scale for use in the primary care setting based on the DSM IV checklist for depression, Rosenberg says.

"The depression scale can be explained by office staff and completed by the patient. The tools help confirm the diagnosis and also help track the patient’s progress when used to reassess the patient at regular intervals," he says. "Our treatment goals call for at least a 50% reduction in the severity scale score or significant improvement based on the provider’s clinical judgment within four to eight weeks of initial treatment."

Primary care physicians have reported that the diagnostic tools are among the best aides they have used as part of a quality improvement initiative, he notes. "Providers have told us that the diagnostic tools give them a common language to talk about depression with their patients. The patient reads the form and completes it. The provider can then say, Because you answered that question in this way, it means this.’ The tools provide a ready form of discussion for what is often a very difficult thing for patients to accept. People are very reluctant to accept they are depressed. We simply haven’t made significant gains culturally to make a behavioral health diagnosis acceptable to most patients."

Providers often have an algorithm in mind when they assess their patients, he notes. "If I am a provider, I might ask a patient a series of questions in an informal interview. I have a checklist in my mind that the patient can’t see. The patient doesn’t know I have an algorithm for diagnosis in my head. It has less meaning for the patient than a tool filled out by the patient that the provider can actually show the patient and use to discuss symptoms and treatment."

• Eliminated: preprinted prescription pads. Early on, Group Health provided clinicians with bright yellow preprinted prescription pads that were placed in exam rooms in one of its primary care clinics. The pads referenced the diagnostic tools and listed the drugs used to treat depression and the recommended dosages.

"The pads provided a visual reminder of certain things the provider should do when diagnosing and treating depression," says Rosenberg. The prescription pads included boxes for the most commonly used antidepressants and boxes to indicate whether patients received educational materials and scheduled a follow-up appointment.

"Our initial goal in introducing the prescription pads was to provide a visual reminder to raise clinician consciousness about the recommended treatments for depression. If providers had liked them, we would have continued them, but providers told us they didn’t like hunting around for the right prescription pad, he says. "Providers reported that it was too cumbersome to carry or locate multiple pads."

• Eliminated: pharmacy reminders. When the program was first initiated, pharmacy reminders were sent to primary care clinics every two weeks with a list of patients who required follow-up. "From the beginning, we knew the pharmacy reminders were only a preliminary stop-gap measure until we could get a more sophisticated system in place," Rosenberg says, adding that the pharmacy reminders have been replaced with a full-service population registry.

• Added: full-service population registry. "Patients diagnosed with depression are automatically entered into the registry and placed into one of two categories — medication track if they are given a prescription for an antidepressant or "active support and watchful waiting" if they either have a diagnosis of mild depression or are reluctant to initiate treatment."

Once patients are placed on either of these two tracks, the registry clocking system automatically sends clinical reminders and decision support tips to providers that track the schedule for follow-up visits and reassessment.

The medication treatment track has three phases — acute, continuation, and maintenance — each with its own timed reminders. Any patient who has received a prescription for an antidepressant and a diagnosis of depression is placed on this track. "It’s important that there be a diagnosis of depression. Antidepressants are sometimes prescribed for other conditions," Rosenberg explains.

The reminders are sent via the clinical workstations all providers in the Group Health system have in their clinics. "The registry allows the entire delivery system to have access to patient information regardless of the delivery setting," he says. "For example, a patient comes to Clinic A and sees a provider and is diagnosed with depression. The patient then comes back for an unrelated complaint, such as a sinus infection, and the patient’s regular provider is on vacation. The treating provider could look on the registry to identify any necessary assessment or treatment needs. Any provider in the system, even if the patient goes to another clinic other than the clinic where the initial treating provider practices, has access to the registry and can ask the right questions and do the right procedure and the patient doesn’t fall through the cracks."

It’s often assumed that once patients start an antidepressant, their symptoms will improve, but that’s not always the case, Rosenberg points out. "The guidelines call for reassessment using the severity scale within the first four to eight weeks of treatment."

For patients with mild depression who are placed in the "active support and watchful waiting" track, the registry sends reminders to have them reassessed. "It’s a way of capturing a whole population of patients who are often lost to treatment in primary care. Most primary care structures are built to provide acute care. But patients with mild depression may be getting worse and require additional treatment down the road."

• Added: patient education pamphlet. This year, Group Health introduced a patient education pamphlet written in-house that provides basic information on the spiral of depression, available treatments, and answers to the most commonly asked questions about diagnosis and treatment of depression. In addition, the pamphlet includes a self-care section that focuses on behavioral changes.

"Any clinician who treats depression knows that refocusing patients on pleasurable events, encouraging them to make time in their lives for activities they enjoy, and emphasizing the importance of spending time with supportive people helps balance distorted or negative thoughts," says Rosenberg. "We also emphasize the importance of staying physically active and learning relaxation and stress reduction techniques."

The Roadmap team reviewed commercially available materials on depression before writing its own pamphlet. "We found that although many were very good, they were missing one piece or another. They weren’t integrated with the algorithm we use to systematically treat depression. We wanted a piece that fit with our organizational commitment to doing this work and linked all the elements of our Depression Roadmap together."