Patient-Centered Care May Aid Chronic Depression

Relatively simple interventions such as follow-up phone conversations with care managers appear to help patients control chronic depression symptoms. This care-management-based approach may provide a model for managing other chronic conditions in the primary care setting.

A September/October issue of Annals of Family Medicine, analyzes a strategy for improving and sustaining mental health results in chronically depressed patients by providing small amounts of flexible, targeted follow-up care. Patients who received interventions that included self-monitoring tools and follow-up phone calls from a care manager were more likely, a year and a half later, to have symptoms that were in remission and to have fewer reduced-function days than those receiving usual primary care treatments.

The depression interventions were introduced in five family care practices at the University of Michigan Health System. Here are the specifics:

• 728 enrollees were compared to 78 control patients receiving usual care for 18 months
• At the end of the study 49.2% of 120 enrollees who completed 18-month assessments were in remission
• At the end of the study 27.3% in the control group were in remission

The interventions were not telephone therapy, says Michael Klinkman, MD, a professor of family medicine at the University of Michigan Medical School and lead author of the study. The key was to keep patient in treatment. "Patients have a human contact, somebody who can help them become more actively involved in their own care."

With this care management approach, physicians can closely monitor if a patient's condition is worsening. In many cases, patients simply don't follow up—in this case, physicians take the initiative.

For this study, a care manager worked in collaboration with doctors' practices, rather than on the side or independently. That helped make the family practice office a home base for all of a patient's medical needs—a medical home.

That's not accidental: The intervention fits "exactly into the context of the patient-centered medical home," Kinkman says.

It's a patient-centered, rather than a disease-centered approach, he adds.

"As this program has developed over the years, we increasingly realize that its core components—patient activation, self-management instruction, goal-setting and priority-setting, and individualized follow-up—work on the person level, rather than the disease level," he explains. When we began, it was difficult to get outside support for interventions that were not disease-based. As the concept of the PCMH has taken hold, it's a natural extension of the program since the majority of the patients referred to the DPC program have more than one condition.

How to reimburse physicians for such services remains a challenge. "We've struggled with this for the past five years. The problem has been the mismatch between the cost of the program—-paid for by the practice—and the benefit, which only partly accrues to an insurance company in the short to intermediate term, and partly accrues to the employer," Kinkman says.

A variety of "mix-and match" approaches are emerging, he says, but the best solution will come from global reimbursement (vs. fee-for-service) for primary care practices "that implement the patient-centered medical home and use tools like we have developed here to support care for chronic illness.," he says. But, he adds, there is a lot of work to do to build public support for that type of change in primary care.

The approach isn't limited to depression, he says, It can also serve as a model for treating other types of chronic conditions, he says.

The paper addresses this explicitly: "All methods developed for this project were intended to be transportable to disease management programs for other chronic health conditions. By integrating care management tools and personnel across several related conditions (e.g., depression, diabetes, and heart failure), it should be possible to achieve the scalability that will make integrated disease management feasible in the patient-centered medical home." The findings "should provide valuable guidance to the development of chronic care management programs for the primary care setting."

A pilot is now underway. "We are just now extending this program into community primary care settings, and find—no surprise—that the primary care clinicians and practices are very open to extending the program to include patients with depression plus other conditions as the first trial of patient-centered chronic disease support," he said.