A Roadmap for Institutionalizing Collaborative Care for Depression in a Large Integrated Healthcare System.

BACKGROUND: Collaborative models for depression have not been widely adopted throughout the USA, possibly because there are no successful roadmaps for implementing these types of models. OBJECTIVE: To provide such a roadmap through a case study of the institutionalization of a depression care management (DCM) initiative for adult depression in a large healthcare system serving over 300,000 adults with depression. DESIGN: A retrospective observational program evaluation. Program evaluation results are presented for those patients enrolled in the initiative from January 1, 2015, to December 31, 2018. PARTICIPANTS: Over a 4-year period, 17,052 patients were treated in the DCM program. In general, participants were women (76%), were Hispanic (47%), spoke English (84%), and were 51.1 ± 18.3 years old, the majority of whom were 30-64 years old (57%). INTERVENTION: The collaborative care portion of the DCM initiative (DCM program) was implemented by a collaborative care team containing a treatment specialist, an assessment specialist, administrative staff, a primary care physician, and a psychiatry physician. MAIN MEASURES: The main outcome measures were total score on the 9-item Patient Health Questionnaire (PHQ-9). Outcomes were improvement (defined as at least 50% reduction in symptoms) and remission (defined as a PHQ-9 less than 5) of depression symptoms. Follow-up of depression symptoms was also collected at 6 months following discharge. KEY RESULTS: The average course of treatment in 2018, after full implementation, was 4.6 ± 3.0 months; 62% of patients experienced improvement in symptoms, and 45% experienced remission of their depression at the time of discharge. These rates were maintained at the 6-month follow-up. CONCLUSIONS: Collaborative care for depression can be institutionalized in large healthcare systems and be sustained with a specific, detailed roadmap that includes workflows, training, treatment guidelines, and clear documentation standards that are linked to performance metrics. Extensive stakeholder engagement at every level is also critical for success.

Refining the Definition of Polypharmacy and Its Link to Disability in Older Adults: Conceptualizing Necessary Polypharmacy, Unnecessary Polypharmacy, and Polypharmacy of Unclear Benefit.

The term polypharmacy in older adults is generally used in a pejorative context in the medical literature. Because of its link to geriatric syndromes and disability, the avoidance of polypharmacy is usually recommended in older adults as a strategy to optimize functional status. However, there are many polypharmacy regimens based on high-quality trials that clearly reduce the risk of disability in older adults. Other guidelines for older adults recommend the use of additional medications that may or may not be evidence based and that may or may not reduce disability. Therefore, we propose that, in the geriatric literature, polypharmacy now be categorized as "necessary polypharmacy," "unnecessary polypharmacy," or "polypharmacy of unclear benefit." In this article, we discuss the 3 categories of polypharmacy and give examples on each polypharmacy regimen and its potential relationship to disability in older adults.

Potentially Preventable Hospital and Emergency Department Events: Lessons from a Large Innovation Project.

INTRODUCTION: There are few proven strategies to reduce the frequency of potentially preventable hospitalizations and Emergency Department (ED) visits. To facilitate strategy development, we documented these events among complex patients and the factors that contribute to them in a large care-improvement initiative. METHODS: Observational study with retrospective audits and selective interviews by the patients' care managers among 12 diverse medical groups in California, Minnesota, Pennsylvania, and Washington that participated in an initiative to implement collaborative care for patients with both depression and either uncontrolled diabetes, uncontrolled hypertension, or both. We reviewed information about 373 adult patients with the required conditions who belonged to these medical groups and had experienced 389 hospitalizations or ED visits during the 12-month study period from March 30, 2014, through March 29, 2015. The main outcome measures were potentially preventable hospitalizations or ED visit events. RESULTS: Of the studied events, 28% were considered to be potentially preventable (39% of ED visits and 14% of hospitalizations) and 4.6% of patients had 40% of events. Only type of insurance coverage; patient lack of resources, caretakers, or understanding of care; and inability to access clinic care were more frequent in those with potentially preventable events. Neither disease control nor ambulatory care-sensitive conditions were associated with potentially preventable events. CONCLUSION: Among these complex patients, patient characteristics, disease control, and the presence of ambulatory care-sensitive conditions were not associated with likelihood of ED visits or hospital admissions, including those considered to be potentially preventable. The current focus on using ambulatory care-sensitive conditions as a proxy for potentially preventable events needs further evaluation.

Clinician burnout and satisfaction with resources in caring for complex patients.

OBJECTIVE: To describe primary care clinicians' self-reported satisfaction, burnout and barriers for treating complex patients. METHODS: We conducted a survey of 1554 primary care clinicians in 172 primary care clinics in 18 health care systems across 8 states prior to the implementation of a collaborative model of care for patients with depression and diabetes and/or cardiovascular disease. RESULTS: Of the clinicians who responded to the survey (n=709; 46%), we found that a substantial minority (31%) were experiencing burnout that was associated with lower career satisfaction (P<.0001) and lower satisfaction with resources to treat complex patients (P<.0001). Less than 50% of clinicians rated their ability to treat complex patients as very good to excellent with 21% rating their ability as fair to poor. The majority of clinicians (72%) thought that a collaborative model of care would be very helpful for treating complex patients. CONCLUSIONS: Burnout remains a problem for primary care clinicians and is associated with low job satisfaction and low satisfaction with resources to treat complex patients. A collaborative care model for patients with mental and physical health problems may provide the resources needed to improve the quality of care for these patients.