A depression care model aiming to bridge the gap between what is known about mental health obstacles and what is being done to minimize them has led to the successful communion of science and practice across Minnesota.
The model, called Depression Improvement Across Minnesota Offering a New Direction, or DIAMOND, uses a team-based approach to facilitate the screening, diagnosis, and management of depression among patients in 83 primary care practices across the state.
The DIAMOND approach, in which the care of patients who screen positive for depression in the primary care setting is choreographed by care managers and overseen by consulting psychiatrists, is not a novel one. In fact, a well-established body of evidence indicates that team care models improve outcomes in depression and reduce health care use costs over time (J. Occup. Environ. Med. 2008;50:459-67).
The unique aspect of the DIAMOND model is that it is the first depression treatment program in the country to integrate the team-based paradigm with a reimbursement structure that supports the provision of enhanced mental health care support in primary care clinics, according to Dr. Brian Rank. Dr. Rank is medical director of HealthPartners Medical Group in Minneapolis and chair of the board of directors for the Institute for Clinical Systems Improvement (ICSI) in Bloomington, Minn. ICSI is a nonprofit group that spearheaded the development and launch of DIAMOND in 2008 in collaboration with more than 60 medical groups, hospitals, and health plans.
Specifically, each medical group participating in DIAMOND receives a monthly fee for every enrolled patient, said Dr. Mark D. Williams of the Mayo Clinic in Rochester, Minn. The fee, predetermined through collaboration with the state’s major insurers and represented by a single, specific billing code, covers the care "bundle," which includes depression screening and monitoring using the Patient Health Questionnaire (PHQ-9); weekly psychiatric consultation and case review; ongoing contact with the care manager; communication between the care manager, psychiatrist, and primary care physician; relapse prevention visits; and use of a patient registry.
"The fee addresses one of the main questions challenging health care improvement in this country: Who is going to pay for it?" Dr. Williams said in an interview. "The way health care is designed in the United States, practices are trying to manage lots of patients, because the only way they can survive is through volume. So, when you suggest trying a different model – one that requires hiring a resource care manager or pulling someone out of a different position from a busy clinic – the practices see risk. Their margins are so small already, committing to the change, even if it is evidence based, is difficult."
Because of the financial realities, the DIAMOND team had to figure out a way to implement the program in practices without the shadow of financial disincentives. "The challenge wasn’t proving it would work – there are lots of randomized controlled trials supporting the collaborative care model – the challenge was showing the practices that the costs wouldn’t be overwhelming," Dr. Williams said. "The promise of new income through the monthly fee was something that allowed the practices to go to their boards and argue that the new model would improve patient management without putting the practice at risk."
The DIAMOND protocol is built around the main elements of the Improving Mood: Promoting Access to Collaborative Treatment (IMPACT) program developed by Dr. Jürgen Unützer of the University of Washington (http://impact-uw.org/). These elements include:
• Standard and reliable use of the PHQ-9 for assessment and ongoing depression management;
• Use of an evidence-based guideline and a stepped-care approach for treatment modification or intensification;
• Development and use of a registry to monitor and track patients;
• Relapse-prevention training for patients reaching remission;
• Introduction of a trained care manager; and
• A formal relationship with a consulting psychiatrist.
The DIAMOND implementation differs from IMPACT, in that the DIAMOND care managers do not have to be nurses with psychiatric experience, according to Nancy Jaeckels, vice president of member relations and strategic initiatives for ICSI. Rather, DIAMOND has hired and trained various health care personnel to serve as care managers, including medical assistants, social workers, and licensed practical nurses, she said.
In participating practices, patients aged 18 years or older with a primary care diagnosis of major depression or dysthymia and a PHQ-9 score of at least 10 are enrolled in the DIAMOND program.
The care protocol includes an initial review of PHQ-9 results and symptoms with the primary care physician; an intake meeting with the care manager, during which patients are screened for other mental health or substance use problems; and weekly phone or in-person follow-up contact with the care manager to discuss treatment status and to complete the PHQ-9, the results of which the care manager enters into the patient registry, along with information on the patient’s medication, treatment adjustments, and behavior.