Creating value in depression management.

BACKGROUND: in the current healthcare system in the USA, common mental health conditions are frequently undertreated. As a result, unacceptable disability, morbidity and mortality rates occur. Various stakeholders define, provide, monitor and may reward providers of mental health care, but based on differing interests and agendas. Examples of the implementation of evidence-based practice in general care, accompanied by changes in fiscal incentives, are rare outside of research endeavours. METHODS: we review as a case study a Minnesota state-wide effort to introduce collaborative care into 80 primary care clinics in order to improve the outcomes of depressed patients. This effort has been named the DIAMOND project (Depression Initiative Across Minnesota, Offering a New Direction) and it may illustrate several key steps towards creating value at the interface between primary care and specialty mental health care. Outcomes were defined and will be examined for a three-year period from when the initiative began in March 2008. RESULTS: to date the results are encouraging. All 80 clinics have introduced a new measurement tool into their practices, trained and hired care managers, and have developed an ongoing relationship with a psychiatrist. Over 4800 patients have been screened for depression, have received treatment and have been followed to ensure compliance and better outcomes. Remission rates (averaging 27%) are at levels comparable to research studies which have more stringent inclusion and exclusion criteria. Challenges including the loss of eligible patients are described. CONCLUSION: to create value in depression management, not only was a viable model required, but also a process for implementation and a structure for ongoing support of the model. The case study presented offers lessons that might be applied elsewhere toward creating value at the mental health and primary care interface.

Outcomes, health status, and medical resource utilization after bariatric surgery.

Surgical results, economic consequences, and shortterm health of obese patients were evaluated before and after bariatric surgery. Of 35 patients in Mayo Health Plan Arizona eligible for bariatric surgery and scheduled for gastric restriction with Roux-en-Y gastrojejunostomy, 22 (7 men, 15 women) completed pre- and postoperative (6- and 12-mo) short form (SF)-12 Health Surveys. Nineteen patients had open bariatric procedures and 3 had laparoscopic procedures. Comorbid conditions, hospital course, weight loss, and complications were examined. Health care utilization (actual dollars paid by plan) for the preceding year and at 1- and 2-yr follow-up were compared. Major comorbid conditions included diabetes mellitus or impaired fasting glucose, hyperlipidemia, sleep apnea, and hypertension. Mean length of hospital stay was 4.8 d after open procedures and 2 d after laparoscopic procedures. No serious operative or postoperative complications occurred. From a baseline average body mass index (BMI) of 51.9, the 6- and 12-mo BMI averages were 39.6 (23.7% decrease) and 35.3 (32% decrease), respectively. Both physical and mental status improved. From baseline, physical health changed 18 and 21.2 points at 6 and 12 mo, respectively (p < 0.001), and mental health changed 9.3 points at each interval (p =0.003). Each postoperative year, resource utilization decreased (mean= $1300 per patient). Our findings of good surgical outcomes, significant weight loss, improved health status, and potential financial savings in this small sample may help patients, insurers, and self-funded employer groups evaluate the appropriateness of bariatric procedures.

Primary care perspective on bariatric surgery.

The role of primary care physicians in identifying potential candidates for bariatric surgery and providing them with long-term postoperative care is gaining rapidly in importance. With the increased use of surgical procedures as treatment options for obesity, a knowledge of bariatric surgery is essential for providing optimal care. During the past decade, the number of bariatric procedures has increased, and refinements of these procedures have made them safer and more effective. Primary care physicians should know how to Identify appropriate surgical candidates and be familiar with available procedures, aware of potential complications and benefits, and able to provide lifelong monitoring and follow-up care. Thus, the primary care physician must be informed about surgical criteria, types of procedures, outcomes, complications, and the long-term monitoring needs of these patients.

Teaching disease management care: a senior resident seminar and team project model.

To address the six general competencies outlined by the Accreditation Councilfor Graduate Medical Education, family practice residency programs will need to enhance their future curriculum. This paper describes one approach to teaching three of these core competencies (practice-based learning and improvement, interpersonal and communication skills, and systems-based practice), while enhancing the quality of patient care within the model family practice center Resident involvement in and feedback on this pilot curriculum was positive, and the residents were confident in the skills they developed.

Designing a disease management program: a collaboration.

Designing a disease management program is a complex process that can involve a variety of clinical, professional, and research skills. This paper describes a collaborative effort by Mayo Health Plan Arizona and the Mayo Clinic Scottsdale Family Medicine Residency program. Using an evidence-based approach to hypertension management, resident physicians acquired skills in three of the six core competency areas required for future physicians as defined by the Accreditation Council for Graduate Medical Education, Chicago. Resident involvement and feedback for this pilot curriculum were positive and the residents were confident in the skills they developed.

The 'Collaborative Care' curriculum: an educational model addressing key ACGME core competencies in primary care residency training.

AIM: The 'Collaborative Care' curriculum is a 12-month senior resident class project in which one evidence-based clinical guideline is designed, implemented and evaluated in our residency practice. This curriculum specifically addresses three of the six Accreditation Council for Graduate Medical Education (ACGME) core competencies: Practice-Based Learning and Improvement, Interpersonal and Communication Skills and System-Based Practices. Additionally, the project enhances the quality of patient care within the model family practice centre in a family practice residency. METHODS: During the project, the third-year residency class selects the disease, develops the clinical guideline, leads its implementation and guides the evaluation process. Select faculty members serve as mentors and coach the resident class through each phase of the project. Specific educational objectives are developed for each content area: evidence-based medicine, clinical guideline development, continuous quality improvement and team leadership. A series of seminars are presented during the project year to provide 'just-in-time' learning for the key content and skills required for each step in the project. By working together to develop the practice guideline, then working with nurses and allied health staff to implement the guideline and review its effectiveness, the resident team gains competence in the areas of practice-based learning and improvement, interpersonal and communication skills and system-based practices. RESULTS: The self-reported level of resident confidence in skill acquisition for each content area was measured for each resident at the time of graduation from the residency programme. Results from the first 2 years of this curriculum are reported (resident n = 12), and demonstrate a high level of physician confidence in the skills addressed and their utility for future practice. CONCLUSIONS: The senior resident seminar and team project model reported here creates learning experiences that appear to address at least three of the ACGME general competency expectations: practice-based learning and improvement, interpersonal communication skills, and systems-based practice. From the initial resident feedback, this educational model seems to establish a high level of physician confidence in the skills addressed and their utility for future practice.