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Primary Care Based Disease Management. VISN 4 MIRECC VA Philadelphia University of Pennsylvania. Delivering Quality MH Care in Primary Care. Epidemiology Chronic Disease Model Barriers to quality care Tools / models to improve quality. Psychiatric Disorders in Primary Care. Diagnoses - PowerPoint PPT Presentation
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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
Penn
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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
10
12
14
16
18
20
22
24
26
28
30
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
0% r
edu
ctio
n
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
0
5
10
15
20
25
30
35
40
45
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