A Health Care Home Model proven to work for depression care and beyond

An Innovative Collaborative Approach to Depression Care in Primary Care

Nancy Jaeckels, Vice President, Member Relations and Strategic Initiatives

Institute for Clinical Systems Improvement (ICSI)Ken Joslyn,MD, MPH Consultant

“The American health care system is in need of fundamental change. The current care systems cannot do the job. Trying harder will not work. Changing systems of care will.”

--Crossing the Quality Chasm, 2001

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• Transforms Health Care through facilitation of collaborative work by bringing together providers, payers, patients, and purchasers to improve care based on evidence and innovation.

• 60 member organizations• 9,000 physicians• 7 sponsoring health plans

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DIAMOND: Transforming Health Care

Best Practice program = care practice redesign

Fair Payment for new services = care payment redesign

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Collaboration from Multiple Stakeholders

• Primary Care providers• Behavioral Health providers• Health plans• MN Department of Human Services• Purchasers/Employers• Patients• NIMH Research Study team• External expert - Jurgen Unutzer, MD• ICSI

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DIAMOND Guiding Structure

• DIAMOND Steering Committee• Subgroups:

– Funding/Coverage Operations– Care Delivery Operations– Measurement– Clinical Flow– Primary Care Physicians– Mental Health– Measurement Analysis & Reporting

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DIAMOND Clinic Participation Requirements (certification)

• Provisional training series (8 months)– Team attendance and participation

required• Care management training (2 days)

– Care manager and consulting psychiatrist part of team

• Final review with ICSI – System and staff ready to

operationalize by implementation date

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Post-Implementation

• Collect & submit monthly data specified in measurement plan

• Implementation Strategy calls• Care Manager Networking calls• Site visits• Steering Committee data review

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Care Delivery

Redesign

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The DIAMOND Model*Four Processes:

1. Consistent method for assessment/monitoring (PHQ-9)

2. Presence of tracking system (registry)3. Stepped care approach to intensify/modify

treatment4. Relapse prevention

Two Roles:5. Care manager for follow up, support, coordination6. Consulting psychiatrist for caseload review

*Based on the Collaborative Care Model for depression by Wayne Katon, MD and the IMPACT study by Jurgen Unutzer, MD as well as numerous other controlled trials.

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1. Assessment and Monitoring

• PHQ-9 for depression• What is the evidence based

equivalent for other medical conditions

• Systems and processes in place automatic use of these assessments and monitoring for each chronic disease

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2. Tracking System

• The main tool for the care manager– Track progress– Make follow-up contacts– Data collection

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3. Stepped Care Approach - appropriate treatment

• Treatment adjustments based on clinical outcomes (PHQ-9 scores)

• ICSI Depression guideline

• Again what is the evidence-based equivalent for other medical conditions

• How to embed evidence based GL’s and decision support into the care team approach

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4. Relapse Prevention

• Care plan• After patient is in remission and need

maintenance• Patient & care manager create together

– Risk factors– Continuing treatment– Warning signs

• This applies not only to depression but what is the care plan for each patient with chronic disease(s)

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5. Care Manager Role

• Uses the registry and follows up with patients for:– Education– Supporting self management goals– Liason for appropriate treatment – Coordination of care– Relapse prevention/care plans

• Background of Diamond care managers have been medical assistants, nurses, behavioral health.

QuickTime™ and a decompressor

are needed to see this picture.

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6. Consulting Psychiatrist

• Two hrs/wk caseload review with care manager

• Focus on new patients and those not improving

• Build relationship with primary care team• Treatment recommendations based on

evidence-based guidelines

• Bring in other specialist in this same team care approach

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Care PaymentRedesign

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DIAMOND Standardized…

How medical groups become certified to participate in DIAMONDServices covered under the care mgmt paymentEligibility criteria for enrolling patients in the programLength of time for patients to be enrolled in the care mgmt program

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New Payment

• Health plan payment to the participating DIAMOND clinics for the bundled set of care management services

• Initial payment for delivery of service, eventually to be linked to clinical outcomes

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DIAMOND Services Covered

• Coverage include the following bundle of services:• Care manager tracking and use of the registry• Care manager contacts with patients active in the

program • Care manager use and administration of the PHQ-9• Care manager relapse prevention visit with the patient• Psychiatrist weekly consultation and caseload review with

care manager• Ongoing communication to the PCP• PHQ-9 at 6 months and 12 months - even if patient is no

longer in the care mgmt program

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Not Included in the Bundle

• Services billed separately • (fee for service):

• Patient visits with the primary care physician

• Direct care by mental health providers

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Eligibility and length of program• Patients 18 years and older• Any one of the diagnosis codes, 292.2, 292.3,

300.4• PHQ-9 >9

• Program is covered for 12 consecutive months active

• Can apply for an extension if needed• If patient relapses and meets eligibility criteria

again, they may re-enter the program (and payment/coverage)

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Need to have a WIIFM for every stakeholder

• Medical groups - sustaining program is cost neutral for covered patients (still not all covered)

• Health plans - total health care cost savings over time

• Employers - higher productivity, less absenteeism, total health care cost savings

• Patients - better care, quality of life back to normal faster

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Value - Quality Improvement and Cost Savings

• Clinical outcome data are significantly improved from usual care

• IMPACT HealthCare Cost per year per patient– Start up costs the first year– Second year is close to cost neutral– Third and fourth year savings of about $1000 per year

per patient• DIAMOND is starting to collect data for total costs of care

and project same if not better cost savings• And the DIAMOND study is collecting productivity data as

well

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Hours missed from work in past 7 days due to health problems

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7-9 10-14 15-19 20+

Study baseline PHQ9 scoreHours of productivity at work affected due to health problems

02468

10121416

7-9 10-14 15-19 20+

Study baseline PHQ9 score

Work Productivity

Preliminary data from the DIAMOND study - Confidential, not for citation or publication

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MN State HCH payment work groups• Patient complexity tiers• Clinic and payer communication

processes• Consumer/patient payment considerations

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Measurement

Four types of measurement:• Care delivery process (patient

enrollment, PHQ-9s administered)• Care delivery outcome (response

and remission)• Patient satisfaction and productivity

(from NIH study)• Cost effectiveness (from NIH study)

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DIAMOND Monthly Cummulative

EnrollmentMarch 08-September 09

0

500

1000

1500

2000

2500

3000

3500

4000

Mar-08

Apr-08

May-08

Jun-08

Jul-08 Aug-08

Sep-08

Oct-08

Nov-08

Dec-08

Jan-09

Feb-09

Mar-09

Apr-09

May-09

Jun-09

Jul-09 Aug-09

Sep-09

Oct-09

Num

ber o

f Pat

ient

s

Total Number of Patients Enrolled during this Period=3104

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DIAMOND ProgramPrimary Care Provider PHQ-9 UsageInstitute for Clinical Systems Improvement

Bloomington, Minnesota, United States

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55

60

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100

Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09

Perc

enta

ge o

f pat

ient

s w

ith d

epre

ssio

n di

agno

sis

(exc

ludi

ng 3

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ho h

ave

PHQ

-9

Overall=69%

DIAMOND Implementation starts

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The Numbers (as of 12/31/09)

• Patients enrolled: 3746 • Clinics participating: 58• DCM (FTEs) (fill in closer)• Physicians 346

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DIAMOND Outcomes (as of 12/31/09)

Remains Initially CommunityAt Six Months Active Activated (MNCM)

n 1264 2127

PHQ9 Re-measured 69% 59%

ResponseResponse 60%60% 36% (PHQ 50%)

Remission Remission 45%45% 27% 4.3% (PHQ <5)

Activation Activation 22%22% 22%

At 12 month n=396 n=869

Response 73% 33%Remission 56% 25%

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Keys to Success - Thus Far

1. Usual care data and lack of existing success created urgency for change

2. Engaging multiple stakeholders in productive environment– ICSI as neutral convener

3. Identification of evidence based model, and national expert

4. Focus on “fair process”5. Selection process for dissemination critical

– Leadership, ability to commit resources, PHQ-9 and registry experience

6. Measures align with state reporting requirements

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2008 MN HCH legislation - standards must meet the following criteria:

– Use of primary care– Focus on high-quality efficient and effective health care services– Encourage patient-centered care– Provide consistent, ongoing contact with a personal clinician or

team of clinical professionals– Ensure appropriate comprehensive care plans for their patients

with complex or chronic conditions– Measure quality, resource use, cost of care, and patient

experience– Use of scientifically based health care, patient decision-making

aids– Use of health information technology and systematic follow-up,

including the use of patient registries

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Summary of MN legislation for HCH criteria

• Access and communication• Tracking and Registry• Care coordination• Care plan• Performance improvement

– Outcome Measurement

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MN State HCH Care Coordination Fee

• State steering committee and work groups formed to create a proposal that is now being reviewed and finalized by the Commissioners

• Fees vary by patient complexity• Non-medical complexity considered• CC fee to certified HCHs by 1/1/10 and

implemented in all public programs by 7/1/10• Health plans include HCH in their network by

1/1/10 and payment by 7/1/10 and payment conditions consistent with the state system

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Next Steps

• Spreading care delivery success• Sustaining funding• Moving to pay for outcomes model• Integrate with health care home/medical

home models - innovation pilots starting in Jan 2010 - spreading specifically to disease clusters - diabetes, HTN, lipids

Questions?

Contact Information:Nancy JaeckelsEmail: Nancy.Jaeckels@icsi.orgTelephone: 952-814-7070

www.icsi.org

Ken JoslynEmail: Ken.Joslyn@gmail.comTelephone: 763-226-6217