Primary Care Based Disease Management

VISN 4 MIRECC

VA Philadelphia

University of Pennsylvania

MIRECC – VISN 4

Delivering Quality MH Care in Primary Care

Epidemiology

Chronic Disease Model

Barriers to quality care

Tools / models to improve quality

MIRECC – VISN 4

Psychiatric Disorders in Primary Care

Diagnoses» Depressive disorders» Anxiety Disorders (PTSD in the VA)» Problem Drinking» Illicit Drugs (VA)» Cognitive Disorders (elderly)

Clinical Features» Common» Often milder than cases seen in behavioral health» Associated with significant suffering, morbidity, disability,

excess utilization, and mortality

MIRECC – VISN 4

Barriers to Quality MH Care

Beliefs, experience, and expectations of patients and providers

Silos of care Competing demands for providers and

patientsDisincentives for the implementation of

chronic care model

MIRECC – VISN 4

Performance Past Screening

FY 04 FY05

Screened for Depression 94 95

Screened for Alcohol Misuse 92 93

Screened for PTSD 58 41

Follow-up on positive screens

Depression 58 56

Alcohol misuse 42 49

PTSD 40 44

Depression Guideline care 12 14

Brief Interventions 10*

MIRECC – VISN 4

Tools / Models of Care

Education of providers on best practice» Guidelines, CMEs, seminars, etc.

Enhancing referral mechanismsProvider Adjuncts

» Disease management specialist» Technological assists

MIRECC – VISN 4

Three Examples of Research to Enhance Treatment Outcomes

PRISME Study

NIMH PROSPECT Study

Telephone Disease Management

Behavioral Health Laboratory

MIRECC – VISN 4

Timeline of activity in Primary and Specialty Care

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MIRECC – VISN 4

MIRECC – VISN 4

Study Design

Randomized trial comparing integrated (collaborative) care to referral care

Target conditions»Depression»Anxiety»At-risk Drinking

Study Phases»Screening»Baseline assessment»Follow-up assessments at 3 and 6 months

MIRECC – VISN 4

Treatment Arms

Referral Care» Direct referral to specialty psychiatry (most programs used

geriatric specialty mental health programs for all subjects)» Enhancements were made at many sites including

appointments within 2 weeks, transportation, reduced or no patient costs

» Sites were encouraged to deliver guideline adherent care but no specific treatment was mandated

Integrated (collaborative care)» All sites had staff trained in Brief Alcohol Interventions» Some sites used standardized depression protocols others

were optimal clinical care

Levkoff S., et. al. (2004)

MIRECC – VISN 4

Engagement in treatment by condition

Integrated Care

Referral Care

Odds Ratio

Depression 75 % 52 % 2.86 [2.26,3.61]

Anxiety 71 % 56 % 1.93 [0.69, 5.40]

At-risk Drinking 61 % 34 % 3.09 [2.07, 4.63]

Overall 71 % 48 % 2.84 [2.35, 3.43]

Engagement = at least one contact with the mental health specialist.

MIRECC – VISN 4

Figure 2: Unadjusted Mean (S.E.) CES-D Scores

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18

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32

Baseline 3 Months 6 Months

CE

SD S

core MD-Refer

MD-IntegOD-ReferOD-Integ

Major Depression (MD)

All Other Depression (OD)

*

* Paired t-test of crude mean difference in CESD change BL to 6 months significant at 0.003 level (integrated -7.49, referral -10.24; difference= referral had 2.75 point steeper decline). Decline in CESD score indicates improvement (reduced depression severity)

MIRECC – VISN 4

Preliminary Findings fromPreliminary Findings from

PROSPECTPROSPECTAn NIMH supported study onAn NIMH supported study on

Prevention of Suicide in Prevention of Suicide in Primary Care Elderly: Primary Care Elderly:

Collaborative TrialCollaborative Trial

MIRECC – VISN 4

THE TWO PREMISES OF THE TWO PREMISES OF PROSPECT’S INTERVENTIONPROSPECT’S INTERVENTION

2. Guidelines alone do not ensure both correct physician decisions and patient adherence to treatment.

PROSPECT has added a “depression specialistdepression specialist” to:

• assist the physician by providing timely and targetedtimely and targeted patient-specific clinical strategies • encourage patient adherence to treatment through education and support.

1. Effective treatments for depression exist:

PROSPECT has operationalized AHCPR guidelines for use in primary care with the elderly

MIRECC – VISN 4

PROSPECTPROSPECT

Percent with > 50% reduction in HDRS/24 Scores Among Patients with MDD

0.0

10.0

20.0

30.0

40.0

50.0

60.0

4 Months 8 Months 1 Year

% 5

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edu

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ControlIntervention

P=.001 P=0.01 P=0.2

MIRECC – VISN 4

Telephone Based Interventions

Telephone Disease Management is algorithm driven care delivered by a Behavioral Health Specialist.

Enhanced Usual care. The PCP can monitor, treat, and/or refer. The PCP is provided a diagnosis and references for treatment options.

MIRECC – VISN 4

Baseline Characteristics

Usual Care Subjects

TDM Subjects p

(n=51) (n=46)

Age 61.9 (11.3) 61.3 (10.3) 0.775

Gender (% Male) 96.1 95.7 0.916

Race (% Caucasian) 41.2 58.7 0.085

Marital Status (% married) 49.0 39.1 0.328

Currently smokes (%) 45.1 39.1 0.552

Cases of depression (%) 84.3 73.9 0.206

Cases of at-risk drinking (%) 29.4 34.8 0.571

Cases from Primary Care (%) 60.8 58.7 0.834

MIRECC – VISN 4

Improvements with TDM

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TDM Usual Care

Depression Remission

Alcohol Remission

Overall Remission

Oslin, et. al. 2003

MIRECC – VISN 4

VA Performance Measures for 2004

Mental Health Performance Measures for 2004» VA Measures are modeled after HEDIS measures» Apply to patients with

• New diagnosis of depression• New treatment with antidepressant medication

» Measures probe the quality of acute phase (12 wk) tx• % with > 3 clinical follow-up visits

– Only 1 visit can be by telephone– At least 1 must be with the prescribing MD

• % who receive adequate medication for 84 days

MIRECC – VISN 4

Depression Care Monitoring

Diagnosis and decision to treat Baseline assessment (from BHL) Prescription of antidepressant Follow-up assessment in 1-2 weeks

» With provider or designate• Educational• Check on adherence• Check on side effects

Follow-up assessments at 6 and 10 weeks by BHL Follow-up in-person assessments with MD at the conclusion of an

episode of care » If remission, discuss continuation treatment» If no response by 6 weeks, modify treatment» If residual symptoms at 12 weeks, modify treatment.

MIRECC – VISN 4

Care Management

Motivational based brief intervention for enhancing adherence and retention

» Pilot of 20 patients – 70% treatment engagement

Telephone Disease Management

VISN 4 MIRECC

VA Philadelphia

University of Pennsylvania

MIRECC – VISN 4

Purpose

To develop a method for delivering high quality depression and alcoholism treatment in Primary Care, CBOCs, and other clinics in which there are significant transportation, staff resource, or other impediments to the delivery of face-to-face MH/SA care.

To develop methods for translating effects demonstrated in randomized clinical trials to clinic populations.

MIRECC – VISN 4

Who is Appropriate?

Inclusion criteria» DSM-IV Major

Depression» Age 18-85» MMSE > 18» Hearing and language

adequate for participation

Exclusion criteria» Alcohol dependence» Other substance abuse» Current psychosis» Suicidal ideation» History of primary

psychosis» History of (hypo)mania

MIRECC – VISN 4

The Role of the Behavioral Health Specialist

The role of Behavioral Health Specialist (BHS) is to influence adherence to guidelines by providing "on- time, on‑target" information to primary care physicians and collaboratively make appropriate care decisions.

MIRECC – VISN 4

Integration of Care with the Supervising Psychiatrist

MIRECC – VISN 4

Initial Assessment

1. Review of physician progress notes

2. History of psychiatric and medical conditions

3. List of current medications

4. History of use of psychotropic medications

5. Recent laboratory and neuroimaging reports

6. Record information on initial progress note

MIRECC – VISN 4

Initial contact - Goals Begin to establish rapport in order to build a supportive and therapeutic

relationship. Review the purpose of the phone call and the reasons for the referral. Conduct a semi-structured clinical interview in order to learn the patient’s

perception of his or her problem and the clinician’s assessment of the presenting problem. (PHQ-9, Beck Anxiety Scale (if warranted), alcohol/substance use and the UKU for side effects)

Begin to develop a hypothesis of the patient’s diagnosis Complete a Choose a treatment algorithm based on the outcome of the

interview Consult with the primary physician regarding the proposed treatment plan. Consult with the psychiatrist if needed. Discuss the proposed treatment plan with the patient, using motivational

techniques Educate the patient regarding medications, if any, that are ordered. Set up a follow-up phone call with the patient and the BHS for one week later. Schedule a follow-up visit Complete a baseline progress note.

MIRECC – VISN 4

Motivating the Patient for Treatment

Assist the individual in recognizing their symptoms and developing an interest in addressing the symptoms.

Motivational Interviewing helps to resolve ambivalence so that the patient can make a decision to accept and adhere to treatment suggestions.

It is a supportive, respectful approach

MIRECC – VISN 4

Roadblocks

Religious

Self-Change

Denial

MIRECC – VISN 4

Key Points

Avoid arguments with the PatientExpress EmpathySupport Self-Efficacy Roll with ResistanceDevelop Discrepancy (help the patient identify

where they are now and where they want to be in the future)

MIRECC – VISN 4

Determining a Treatment Plan

1. Monitoring (but not treating) some patients.2. Treatment by the physician and BHS within protocol

guidelines.3. Delay initiation of treatment algorithms pending

further medical stabilization, patient/family approval, or further diagnostic assessment or consultation.

4. Referral for a consultation and/or treatment of patients with complicated diagnostic presentations, chronic benzodiazepine use, severe cognitive impairment, need for hospitalization, or primary psychotic illnesses.

MIRECC – VISN 4

Acute Phase of Treatment for Depressive Disorders

Baseline Week 1 Week 3 Week 6 Week 9 Week 12

PHQ-9 X X X X X X

UKU X X X X X X

Medication profile

X X X X X X

Clinical Note X X X X X X

Substance abuse X X X

MIRECC – VISN 4

Maintenance Phase

Asymptomatic or minimally symptomatic (PHQ-9 score of 10 or less) - continuing pharmacotherapy of six months duration.

During maintenance therapy, meet once a month to obtain clinical ratings.

During the maintenance phase, if a patient scores 10 or greater on the PHQ-9, s/he should be reassessed one week later. If the PHQ-9 score remains at 10 or greater, the patient may be relapsing; therefore, the BHS should consult with the physician and/or supervising psychiatrist. The patient may need to restart the acute phase of the study.

MIRECC – VISN 4

End of Treatment Procedure for Maintenance Therapy

Siscuss with the patient her/his interest in continuing to take medication for relapse prevention.

Patients who continue taking it are less likely to have a relapse than those who discontinue it.

MIRECC – VISN 4

Adverse Event Documentation

During each phone contact, the BHS will initially ask patients if they are having any problems with their medication in an open-ended fashion.

The BHS will proceed with administration of the UKU Side Effects Rating Scale.

CNS Gastrointestintinal Other

Somnolence Nausea Sweating

Insomnia Dry mouth Abnormal Ejaculation

Tremor Diarrhea

MIRECC – VISN 4

Key Decision Points

**Week 6If PHQ-9 score is >10,

» and NOT reduced 25% from baseline evaluation» or if patient is actively suicidal

***Week 12If PHQ score is >5,

» And NOT reduced 30% from baseline evaluation » or if patient is actively suicidal

MIRECC – VISN 4

Psychopharmacologic Algorithms

MIRECC – VISN 4

General Principles Substitution, rather than augmentation Psychotherapy may be used as alternative to pharmacotherapy

(Psychotherapy alone) or be combined with antidepressants (augmentation).

Drugs that are simpler to implement in primary care are favored over drugs of known efficacy, but which require special procedures,

Treatments that are often poorly tolerated are given lower priority than treatments that are more likely to be tolerated, even when the efficacy of the latter treatments may be less well-established, e.g., bupropion augmentation of SSRI's was favored over lithium augmentation of SSRI's,

Venlafaxine/Bupropion will be the preferred treatment for patients who appear to be refractory.

When following each algorithm, clinical judgment can override the algorithm.

BHS clinicians are encouraged to discuss these cases with the supervising psychiatrist.

MIRECC – VISN 4

6 Week Responsechange in PHQ

Optimize (max. dose) dose

Venlafaxine XR 200 mg/d

Buproprion SR150 mg BID

< 30 % change

Continue

12 Week Response

Maintenance Treatment

Physician Choice

> 50 %30 - 50 %

Skip to 12 week response box

PHQ > 5 and < 50 % change in PHQ

PHQ < 5PHQ > 5 and 50 + % change in PHQ

6 Week Responsechange in PHQ

Optimize (max. dose) dose

< 30 % change

Maintenance Treatment

> 50 %30 - 50 %

Skip to 12 week response box

6 Week Response

12 Week Response

PHQ < 5PHQ > 5

D/C Bupropion and Augment with nortriptyline plasma levels 80 -120 ng/ml X 6 weeks

6 Week Response

Continue

Augment with BupropionSR 150 mg BIDX 6 weeks

Maintenance Treatment

PHQ < 5PHQ > 5

unspecified

MIRECC – VISN 4

High Risk Management Protocol

Be very attentiveRemain calm and non-threatenedGive the patient some space and time to

vent Stress a team approach to the problemBe willing to say the word “suicide”

without flinching