Prevalence of practice system tools for improving depression care among primary care clinics: the DIAMOND initiative.

BACKGROUND: Practice system tools improve chronic disease care, but are generally lacking for the care of depression in most primary care settings. OBJECTIVE: To describe the frequency of various depression-related practice system tools among Minnesota primary care clinics interested in improving depression care. DESIGN: Cross-sectional survey. PARTICIPANTS: Physician leaders of 82 clinics in Minnesota. MAIN MEASURES: A survey including practice systems recommended for care of depression and chronic conditions, each scored on a 100-point scale, and the clinic's priority for improving depression care on a 10-point scale. KEY RESULTS: Fewer practice systems tools were present and functioning well for depression care (score = 24.4 [SD 1.6]) than for the care of chronic conditions in general (score = 43.9 [SD 1.6]), p < 0.001. The average priority for improving depression care was 5.8 (SD 2.3). There was not a significant correlation between the presence of practice systems for depression or chronic disease care and the priority for depression care except for a modest correlation with the depression Decision Support subscale (r = 0.29, p = 0.008). Certain staffing patterns, a metropolitan-area clinic location, and the presence of a fully functional electronic medical record were associated with the presence of more practice system tools. CONCLUSIONS: Few practice system tools are in place for improving depression care in Minnesota primary care clinics, and these are less well-developed than general chronic disease practice systems. Future research should focus on demonstrating whether implementing these tools for depression care results in much-needed improvements in care for patients with depression.

Partnership research: a practical trial design for evaluation of a natural experiment to improve depression care.

BACKGROUND: Translational research is increasingly important as academic health centers transform themselves to meet new requirements of National Institutes of Health funding. Most attention has focused on T1 translation studies (bench to bedside) with considerable uncertainty about how to enhance T2 (effectiveness trials) and especially T3 (implementation studies). OBJECTIVE: To describe an innovative example of a T3 study, conducted as partnership research with the leaders of a major natural experiment in Minnesota to improve the primary care of depression. METHODS: All health plans in the state have agreed on a new payment model to support clinics that implement the well-evidenced collaborative care model for depression in the Depression Improvement Across Minnesota: Offering a New Direction initiative. The Depression Improvement Across Minnesota: Offering a New Direction study was developed in an ongoing partnership with the Initiative leaders from 7 health plans, 85 clinics, and a regional quality improvement collaborative to evaluate the implementation and its impacts on patients and other stakeholders. We agreed on a staggered implementation, multiple baseline research design, using the concepts of practical clinical trials and engaged scholarship and have collaborated on all aspects of conducting the study, including joint identification of patient and clinic survey recipients. RESULTS: Complex study methods have worked well through 20 months because of the commitment of all stakeholders to both the Initiative and the Study. Over 1500 subjects have been recruited from health plan information delivered weekly, and 99.7% of 316 physicians and administrators from all participating clinical organizations have completed the Study surveys. CONCLUSIONS: Partnership research can greatly facilitate translational research studies.

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.

Effective Implementation of collaborative care for depression: what is needed?

OBJECTIVES: To identify the care model factors that were key for successful implementation of collaborative depression care in a statewide Minnesota primary care initiative. STUDY DESIGN: We used a mixed-methods design incorporating both qualitative data from clinic site visits and quantitative measures of patient activation and 6-month remission rates. METHODS: Care model factors identified from the site visits were tested for association with rates of activation into the program and remission rates. RESULTS: Nine factors were identified as important for successful implementation of collaborative care by the consultants who had trained and interviewed participating clinic teams, and rated according to a Likert Scale. Factors correlated with higher patient activation rates were: strong leadership support (0.63), well-defined and -implemented care manager roles (0.62), a strong primary care physician champion (0.60), and an on-site and accessible care manager (0.59). However, remission rates at 6 months were correlated with: an engaged psychiatrist (0.62), not seeing operating costs as a barrier to participation (0.56), and face-to-face communication (warm handoffs) between the care manager and primary care physician for new patients (0.54). CONCLUSIONS: Care model factors most important for successful program implementation differ for patient activation into the program versus remission at 6 months. Knowing which implementation factors are most important for successful activation will be useful for those interested in adopting this evidence-based approach to improving primary care for patients with depression.

The DIAMOND initiative: implementing collaborative care for depression in 75 primary care clinics.

BACKGROUND: The many randomized trials of the collaborative care model for improving depression in primary care have not described the implementation and maintenance of this model. This paper reports how and the degree to which collaborative care process changes were implemented and maintained for the 75 primary care clinics participating in the DIAMOND Initiative (Depression Improvement Across Minnesota-Offering a New Direction). METHODS: Each clinic was trained to implement seven components of the model and participated in ongoing evaluation and facilitation activities. For this study, assessment of clinical process implementation was accomplished via completion of surveys by the physician leader and clinic manager of each clinic site at three points in time. The physician leader of each clinic completed a survey measure of the presence of various practice systems prior to and one and two years after implementation. Clinic managers also completed a survey of organizational readiness and the strategies used for implementation. RESULTS: Survey response rates were 96% to 100%. The systems survey confirmed a very high degree of implementation (with large variation) of DIAMOND depression practice systems (mean of 24.4 ± 14.6%) present at baseline, 57.0 ± 21.0% at one year (P = <0.0001), and 55.9 ± 21.3% at two years. There was a similarly large increase (and variation) in the use of various quality improvement strategies for depression (mean of 29.6 ± 28.1% at baseline, 75.1 ± 22.3% at one year (P = <0.0001), and 74.6 ± 23.0% at two years. CONCLUSIONS: This study demonstrates that under the right circumstances, primary care clinics that are prepared to implement evidence-based care can do so if financial barriers are reduced, effective training and facilitation are provided, and the new design introduces the specific mental models, new care processes, and workers and expertise that are needed. Implementation was associated with a marked increase in the number of improvement strategies used, but actual care and outcomes data are needed to associate these changes with patient outcomes and patient-reported care.