When considering practice change it can be helpful to hear about the experiences of clinicians and organizations that have already been down that road.
A Clinician’s Experience with Integrated Care
“I think there are certain things we don’t talk about in this society, and depression has been one of them. In the past, a lot of patients would mostly talk about their physical problems and then, near the end of the interview, would say oh by the way I’m not sleeping or I’m depressed or my husband or wife think I’m depressed. Now, when patients come in, the nurses are more attuned to depression, and we give them this survey questionnaire to fill out so it’s on the agenda rather than part of the hidden agenda….The patients who have been treated for depression complain of physical symptoms less, I need to see them less, and I can address their physical issues more directly when I do.” - Donald E. Potter, MD, primary care physician at Group Health Cooperative in Seattle*Statewide Integrated Mental Health Program in Minnesota
DIAMOND is a statewide quality improvement initiative in the state of Minnesota focused on improving the recognition and treatment of depression in primary care through a redesign of clinical practice and payment for that care. This effort is led by the Institute for Clinical Systems Improvement with guidance from a steering committee comprised of representatives from the nine largest health insurance plans in the state, two county-based purchasers/plans, the state Medicaid plan, healthcare providers and patients. A white paper provides additional details about the process and design of DIAMOND.
Over the course of several years, DIAMOND has been rolled out in over 80 medical practices throughout the state. These include small, rural practices and large, urban ones. The program is being evaluated with a $3 million, five-year grant from the National Institute for Mental Health to Healthcare Partners. This Minneapolis local news segment provides a brief summary of the program.
Practice Change in a Large Healthcare Organization
Below is a story about Kaiser Permanente of Southern California, which has practiced integrated mental health care in many of their clinics since 2004. They got started with integrated care when a few of their primary care clinics participated in a research study looking at the effectiveness of an integrated care approach for depression called IMPACT.The program and its patients earn an “A”
Patients who participated in the IMPACT study were twice as likely as patients treated in the usual manner to have a significant improvement in their depression. They also showed considerable improvements in their physical functioning, chronic pain, and quality of life. Primary care providers who participated in the project were uniformly enthusiastic about the value of the IMPACT program.
Kaiser’s Primary Care Administrator, Walter Borschel, LSCW, CHE, was very encouraged by the results. “Some of our successes were with patients who had been seen in our psychiatry department for long periods of time and hadn’t gotten better. They had chronic, disabling depression. They not only got better but also maintained their gains. That was extremely impressive and surprised me,” said Borschel.
These very positive study results demonstrated the value of a more personalized, comprehensive approach to helping older adults with depression. Based on these dramatic results, Kaiser decided to investigate how they might adapt IMPACT to fit their particular health care culture so that they could continue to offer integrated care and make the program available to adults of all ages, after the research study ended.
Inspired commitment
These heartening results changed the way Kaiser looks at caring for depressed patients. Borschel says, “It’s made me more committed to Kaiser’s doing a better job of treating depression within primary care. For three reasons: First, it increased my knowledge and understanding of how many depressed patients we see within primary care. Second, we can do something to make it better. And third, it looks like some of these things we could do by using our existing resources differently. Those are all things I feel very good about.”
Adapting the program to the reality of a large health care system
To insure long-term sustainability, Kaiser staff worked closely with the IMPACT Implementation Center to make several adaptations to the treatment model to fit it into the Kaiser delivery system. These adaptations included:
- Expanding the program to all adult patients, not only those 60 and over
- Adding an optional group education class about depression offered by the Member Health Education Department
- Tailoring the number and frequency of visits according to each patient’s need (instead of providing every patient with a pre-determined number of visits, as was done in the research study).
- Adding a medical assistant to perform some of a care manager’s tasks, such as routine follow-up phone calls to patients to measure their symptoms of depression.
Sustainable change and return on investment
Does the adapted version of IMPACT work as well as the research study version? To answer that question, Kaiser staff conducted a program evaluation with the first 284 patients enrolled in the Kaiser version of IMPACT.
Their findings were very encouraging. Patients seen with the adapted version of IMPACT averaged half the number of clinic visits and one-third the number of phone contacts as the patients enrolled in the formal research study. Despite this, these patients showed the same dramatic benefits after six months of treatment that were seen in the original research study. Participants in the pilot also had lower health care costs per year when compared to patients receiving usual care or patients who had received IMPACT care in the original study.
Graphs adapted from: L. Grypma et al. General Hospital Psychiatry 28 (2006) 101–107.
Expanding practice innovation
A big ship doesn’t make sudden turns on the high seas. Its captain calculates the best and safest course and maneuvers the vessel slowly and deliberately. So it is with implementing healthcare innovation in a delivery system as large as Kaiser Permanente Southern California. Thoughtfully and deliberately, Kaiser made a big decision. They considered the results of the original IMPACT study, the post-study program evaluation, and several other efforts to improve care for depressed members. Based on their findings, they made integrated care available in all 12 of their regional medical centers.
Since then, Kaiser has trained over 75 staff from all 12 medical centers to provide integrated mental health care to depressed members. This region, which serves over three million people, is also educating their primary practice physicians in using the PHQ-9 as a tool to help diagnose depression and monitor treatment outcomes.
How is it working?
Andrew Golden, MD, former Chief of the Department of Family Practice and a long-time Kaiser physician sums it up well.” The exciting part is the cooperation, integration, and acceptance between psychiatry, primary care, and patients. We felt it could happen, we just hadn’t found a way to do it.” Giving integrated care an enthusiastic thumbs up, he adds, “This is one model that’s really done well.”
“This could revolutionize the way depression is treated in medical settings,” says Dr. Richard Della Penna, head of Kaiser Permanente’s Aging Network (KPAN) and an investigator with the original IMPACT trial. “The strong results of this important study and our experiences with the IMPACT program have clearly shown the value of the team care model for depression.”
* based on content originally published in the 2002 John A. Hartford Foundation annual report. Used with permission.