CMs, MDs collaborate on depression care
CMs, MDs collaborate on depression care
Patients also improve their physical health
A collaborative approach in which primary care physicians and nurse case managers work with patients with depression has resulted in a 50% improvement of scores on a depression questionnaire among patients who were part of a pilot project at UC Davis Family Medicine in Sacramento.
The initiative was piloted in the academic primary care office, staffed mostly by residents at UC Davis Medical School, then rolled out to UC Davis Family Medicine's 11 primary care offices, according to Angela Gandolfo, MBA, advisor for performance improvement in clinical operations at UC Davis, who worked with Jaesu Han, MD, assistant clinical professor and program director for the combined medicine/psychiatry resident training program at UC Davis Medical School. About 16% of patients treated by UC Davis Family Medicine have a diagnosis of major depressive disorder in addition to a physical diagnosis.
"Mental health benefits are declining in California, especially from MediCal," Gandolfo says. "More and more primary care providers have to deal with psychosocial issues and depression. We recognize that patients' underlying mental health issues have a lot to do with their physical health. Our pilot study showed that a collaborative effort between physicians and case managers can help patient manage their behavioral health problems and improve their physical health by becoming more compliant with their treatment plan."
Every patient seen by UC Davis Family Practice is offered the Patient Health Questionnaire (PHQ-9) depression screen. The tool is available in multiple languages, and patients are offered interpreters if necessary. When patient scores meet the minimum criteria for major depression, they are offered the opportunity to enroll in the collaborative care program.
"Many patients, particularly those with chronic diseases such as diabetes, hypertension, and heart failure, were grateful that we brought up the subject of depression. They were struggling and didn't know how to ask for help," Gandolfo says.
Interventions are based on the patient's score on the depression screen. For most patients, the primary care provider conducts the initial intervention and prescribes medication to help with depression, then refers the patient for case management. The physician practices have a psychologist or social worker on site who also can provide interventions when appropriate. In some instances, patients may see their primary care provider and a psychiatrist at the same time.
The nurse case managers are nurses with backgrounds in case management and behavioral medicine and work in the UC Davis managed care and utilization department in a site near the hospital. The case management interventions are customized for each individual patient. The case managers call patients at intervals that depend on patient needs. Patients can call their case manager at any time if they have questions or concerns. The case managers document their encounters in the electronic medical record and send the notes to the primary care provider and Han, who oversees the program.
"The key to this program is collaboration between the case manager and the physician," Gandolfo says. "When patients have problems with adhering to their treatment plan or experience side effects, the case managers often pick it up in between visits to the physician. The physician can change the medication or take other action to prevent the patient's condition from exacerbating."
Often, patients with depression start to feel good and stop taking their medication or they stop taking it because of the side effects. The most typical side effect is that patients feel sick until their body adjusts to the medication, Gandolfo says. The case managers educate them to understand the side effects and how to manage them until they stabilize. If the patients continue to have progressive symptoms, the case managers coordinate with the primary care physician and the psychiatrist about whether the medication should be changed.
In every conversation, the case managers educate the patients about depression and teach them how to manage their symptoms at home. They work with the patients on exercise and good nutrition and help them adhere to their treatment plan. If the patient isn't taking medication, the case managers work through why they aren't taking them and educate them about the necessity to continue the medication.
The case managers help patients with everything from basic social needs to medical management and refer them to resources that can meet their needs. They may refer them to their health plan for help in managing a chronic disease, arrange for durable medical equipment or orthotics, or help them access community programs to help with their transportation needs.
Right now, the program is strictly telephonic. "The long-term plan is to have the nurse case managers do onsite visits with the primary care provider with certain patients so the patients can meet them face to face and they can be part of the care team," Gandolfo says.
A collaborative approach in which primary care physicians and nurse case managers work with patients with depression has resulted in a 50% improvement of scores on a depression questionnaire among patients who were part of a pilot project at UC Davis Family Medicine in Sacramento.Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.