Implementing a CDPM program for depression in primary care : The Hamilton FHT Depression Program

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Implementing a CDPM program for depression in
primary care The Hamilton FHT Depression Program
Nick Kates Program Director, Hamilton Family
Health Team
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Chronic Disease - the Issue

• 66 of Canadians over the age of 45 have a
  chronic condition (CC)
• 55 suffer from two or more chronic condition
• 80 of primary care visits are for a CC
• 67 of all hospital admissions are for a CC

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The Canadian health system doesnt do CDM very
well

• lt30 of hypertensives have their blood pressure
  properly controlled
• 60 of diabetics have gone gt1yr without an eye
  examination or a check for proteinuria
• 60 of asthmatics are not properly controlled
• 20 of heart failure patients are readmitted lt60
  days
• 20 of patients with depression get guideline
  based care

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U.S. Institute of Medicine
Between the health care we have and the health
care we could (should) have lies not just a gap,
but a chasmUS Institute of Medicine, 2001
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U.S. Institute of Medicine
- Chasm Report

• These quality problems occur typically not
  because of failure of good will, knowledge,
  effort or resources directed to health care, but
  because of fundamental shortcomings in the way
  care is organized

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Systems are perfectly designed to get the
results they achieve
Thought for the day
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Chronic Disease Management

• Better management and outcomes of individuals
  with chronic diseases requires changes in the
  ways systems of care are organised

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Depression is a Chronic and Recurrent Disorder -
Recurrence
0 .5 1 2 3 4 5
Years
Keller et al, 1992
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Primary Care Diagnosis and Treatment of Major
Depression

• Only approximately 50 diagnosed
• Of those treated, about less than 50 receive
  guideline-level pharmacotherapy and less than
  10 receive guideline-level psychotherapy
• 45 of individuals stop anti-depresants
  within 6 weeks (33 dont tell their family
  physician)
• Only 20 of patients seen 3 times within
  90 days of starting an antidepressant

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Common Medical Illnesses and Depression
Major Depression
30-50
Multi-condition Seniors
Stroke
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11-15
15-20
Heart Disease
Diabetes
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Psychiatric Illness and Symptoms of Poor Glucose
Control

• 71 of diabetic patients had lifetime histories
  of one or more psychiatric illnesses
• Recent psychiatric illness significantly
  associated with symptoms of poor glucose control
• 5-10 receive optimal care of their depression
• Leads to increased morbidity and mortality rates

Katon et al Medical Care Dec., 2004
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Traditional Organisation and Culture
of Care

• Focus on acute problems
• Emphasis on triage and patient flow
• Short unprepared appointments
• Follow-up is usually consumer initiated
• Treat only those people who reach us
• Cant identify problems earlier
• No prevention of episodes / recurrence
• Brief didactic consumer education
• Emphasis on provider - not system behaviour
• Wagner 1998

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Chronic Disease Management How to view it

• Another planet
• Relative test
• Visionary

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Essential Element of Good Chronic Illness
Care
Prepared Practice Team
Informed, Activated Consumer
Productive Interactions
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Chronic Care Model
Health System
Community
Health Care Organization
Decision Support
ClinicalInformationSystems
Resources and Policies
DeliverySystem Design
Self-Management Support
Prepared, Proactive Practice Team
Informed, Activated Consumer
Productive Interactions
Improved Outcomes
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The Kaiser Triangle
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Population Management More than Care Case
Management
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Self-Management Support

• New partnership between providers and consumers
• Next revolution in health care
• Only beginning to understand what it means for a
  consumer to be a partner in care
• Most consumer education to date is ineffective

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Are our instructions always clear
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Self-Management

• Behaviour change does not necessarily
  result in changes in health status
• Feelings of being more in control of
  the illness
• Self Efficacy

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Self-Management - options

• Patient goals
• Consumer plans
• Relapse prevention plans
• Healthy lifestyle
• Copies of records
• Education
• Health passport
• Groups

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Completely consistent with a recovery
approach
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Evidence from the literature
re CDPM for depression
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BreakThrough Series reviews What works
successful depression projects

• Depression has best outcomes of all CDM programs
• Patient registry
• Care co-ordination
• Proactive follow-up
• Psychiatric consultation / Diagnostic assessment

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BreakThrough Series reviews What doesnt work

• Education not effective on its own
• Guidelines not effective on their own
• Screening not effective unless linked to
  follow-up
• Feedback no benefit on its own

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Hamilton FHT (HSO) Mental Health (and
Nutrition) Program

• 1994 MH Program started 45 physicians
• 1996 Expansion 41 new physicians
• 2000 Took over administration of nutrition
  program
• 2005 Became part of Hamilton Family Health Team

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HSO Mental Health and Nutrition Program - 2006

• 80 practices
• 105 sites
• 145 family physicians
• 340,000 patients (68)

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Integrating Mental Health Services within
Primary Care

• Ratio
  FTEs FTEs
  Clinicians 1996 2006
• Counsellors 17,200 22.9
  50.5
• Psychiatrists 175,000 2.2
  4.8
• Programs
• Central Program

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Original goals of the program
1. To increase accessibility to mental health
care for primary care patients 2. To expand the
range of mental health services
delivered in primary care 3. To strengthen
linkages between primary care and mental
health/community programs. 4. To increase family
physicians skills and comfort in handling mental
health problems.
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Outcome measures CES-D

• Mean change 21.2
• Improved gt 1 SD 68
• Score reduced
• gt 50 79
• All changes significant plt.05

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Outcome measures SF-8

• Mean change 17.8
• Improved gt 1 SD 62
• Score reduced
• gt 50 68
• All changes significant plt.05

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Co-location is not enough
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CHANGING THE PARADIGM

• Focus on populations
• Focus on longitudinal care / closing the loop (a
  system of care)
• Requires teams
• Identified care co-ordinator
• Patients as partners
• IT support

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Chronic Disease Management

• Better management and outcomes of individuals
  with chronic diseases requires changes in the
  ways systems of care are organised

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Introducing CDPM
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CHANGING THE PARADIGM

• Not a model
• A way of conceptualising care
• A framework for re-organising care
• Applicable to any system

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How can I re-design my system to get better
results
2nd. Thought for the day
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What we already had

• Role of counsellor as case / care co-ordinator
• Stepped model of care
• Specialist providing evidence-based advice
• Teams in many primary care practices
• Limited self-management support

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What we already had

• No registries / ability to monitor
• No population focus
• Not standardised treatments
• Use of specialists for decision support
• Links with community resources (program not
  practice)
• Program management team
• Created a bottom-up model

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CDPM / PROGRAM PLANNING GRID FOR THE HAMILTON FHT CDPM / PROGRAM PLANNING GRID FOR THE HAMILTON FHT CDPM / PROGRAM PLANNING GRID FOR THE HAMILTON FHT CDPM / PROGRAM PLANNING GRID FOR THE HAMILTON FHT CDPM / PROGRAM PLANNING GRID FOR THE HAMILTON FHT CDPM / PROGRAM PLANNING GRID FOR THE HAMILTON FHT CDPM / PROGRAM PLANNING GRID FOR THE HAMILTON FHT CDPM / PROGRAM PLANNING GRID FOR THE HAMILTON FHT
Screening / Detection Provider preparation Screening Instruments Assessment Tools Patient Information Practice review    
Treatment Algorithm Case Management System navigation Specialist Consultation Prepared Appointment    
Follow up / Monitoring Telephone Registry Routine recall Reminders      
Self Management Goals Plan / relapse prevention Access to Records Education Provision of resources / aids Health Passport Groups
Information Systems Flow sheets Templates Website        
Decision Support Provider education Specialist Access Targets      
Organizational Change Goals Team creation Evaluation EMR Provider Training Change Management Co-ordinating Care
Community Links Key Partners Agencies in primary care Links with agencies        
Community Action Building healthy policy Supportive environments          
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PDSA cycles Plan Do Study Act
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PDSA cycles Plan Do Study Act
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Not everything will work out exactly as
anticipated
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Detection

• 2 Screening questions for family physicians
• If indicated, follow-up with PHQ-9
• Include all patients with a chronic illness

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www.depression-primarycare.org/clinicians/toolkits
/
www.nice.org.uk/CG023
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Treatment by Family Physician

• Initiation of an antidepressant
• See monthly for 3 months
• Follow existing treatment protocols re dose /
  duration
• Discuss with psychiatrist if any questions /
  issues arise
• Use PHQ-9 to monitor
• Supportive psychotherapy
• Self-management support / lifestyle counselling

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Referral

• To counsellor
• ? Criteria
• ? Reason for referral
• To psychiatrist
• For discussion or consultation
• Non response to 2 antidepressants
• Diagnostic question
• Other related issues (ie insurance claim)
• 1-2 visits
• Discuss
• (To exercise specialist / registered dietitian /
  peer)

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Treatment by Counsellor

• Assessment
• ? CBT or IPT
• ? Time-limited
• ? When to involve psychiatrist
• Involve significant others
• Care manager / co-ordinator
• Pursue patients who dont show
• Follow-up phone call at 3, 6, 12 and 18 months -
  scripted

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Incorporate self-management support

• Help each patient develop their own goals
• Develop a plan
• Give patient a copy of the plan
• List of medications and written instructions if
  necessary
• Give patient a copy of reports / relevant notes
• Educational materials printed / web sites
  INTERACTIVE

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Co-ordination of care In a Practice

• Development of a registry
• Initially prospectively
• Paper or Excel
• Build in medication
• Build in follow-up calls
• Build in other care components
• Identify who will oversee registry development /
  follow-up
• Identify who will call re follow-up
• Prepared visit morning huddle

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Preparation of practices / providers

• Involve practices in planning from the outset
• Frequent meetings / visits
• Facilitator
• Lunchtime meetings - ? Offsite
• Preparatory session for counsellors /
  psychiatrists
• Follow-up sessions at 6 months

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Introducing the model

• Not everything at once develop a hierarchy of
  changes
• Start with pilots
• PDSA
• Keep guidelines / protocols as simple as possible
• Each practice will adapt to its own situation

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Challenges

• Providers adjusting to a new model
• Family physicians
• Mental health counsellors
• Functioning v. symptom severity
• Addressing co-mprbid problems
• Counsellors see more than just depression
• Criteria for referral
• Logistics