Bea Herbeck Belnap, Dr Biol Hum
School of Medicine
University of Pittsburgh
Learning Objectives
1. To understand the different functions and tools required to
effectively implement the Chronic Care Model for
depression management in primary care
2. To identify the core roles and qualifications of care
managers, particularly as liaisons to providers and for
patient self-management support
3. To understand the role and function of care manager
registries and their utility in fostering provider and
patient communication
Wagner Chronic Care Model
Health System
Community
Resources &
Policies
Informed,
Activated
Patient
Health Care Organization
SelfManagement
Support
Delivery
System
Design
Productive
Interactions
Decision
Support
Clinical
Information
Systems
Prepared,
Proactive
Practice Team
Functional and Clinical
Outcomes
CCM: Core Clinical Elements
Leadership
 Vision
 Resources
Practice
Design
 Care management
Clinical
Information
Systems
 Clinical information tracking
 Protocols- coordinated care
 Registry
 Feedback to clinicians
CCM: Core Clinical Elements
Decision
Support
 Guidelines
 Expert/specialist consultation
Self-management
Support
 Patient preferences
 Information on treatment
 Information on and for
Community
Resources
consumers, groups, etc.
 Access to non-provider
sources of care
Care Manager Role
Encompasses CCM core elements
General
Medical
(Chronic care,
Prevention,
Follow-up)
Care Manager
Self-management
CM/Liaison: PCP, MH
Community linkages
Crisis intervention
Registry
Behavioral
Health (crisis
referral,
complexity,
etc.)
Care Manager: Core Functions
 Patient education
 Registry tracking
 Provider communication
 Community linkages
Care Manager: Patients
 Patient education about depression, treatment
options
 Familiar with commonly used antidepressant
medications, doses
 Support medication adherence and recovery
 Brief interventions
 Theory-based approaches (MI, PST, etc.)
 Monitor treatment progress
 Know when treatment is ‘not working’
 Structured symptom assessment (PHQ-9)
 8-12 week trial
 Provider recommendations  MHS, PCP
CM: Goals of a Registry
 Identify, manage, and track patients
 Facilitate patient contacts
 Provide patient visit summaries
 Provide real-time data on tx response, etc.
 Reminders
 Performance feedback
CM: Provider Liaison
 Relay concerns/progress
 Symptom monitoring
 Refills
 Symptoms and side effects
 Urgent, emergent protocols
 Medical record documentation
 Cue providers if no improvement
 Supplement, not replace providers
CM: Community Linkage
 Cooperation with MHS
 Supervision
 Referral
 Self-help groups
 Support for comorbidities, psychosocial problems
 Financial resources
Care Management:
Patient Support
CM: Customization
 Cultural competence
 Role of families
 Role of religion/spirituality
 Competing needs
CM: Self-management
 Eliciting concerns/barriers
 Problem-solving
 Providing information
 Clarifying preferences
 Encouraging informed decision-making
 Teaching skills
 Monitoring progress
 Reinforcing self-management
 Community resources
CM: Self-management Tools
 Workbooks
 Medication lists
 Appointment reminders
 Healthy behaviors
 Pleasure activities list
 Pillboxes
 Medication information
 Websites
Care Management:
Provider Communication
CM: Provider Liaison
 Help patients and providers identify
 Potentially inadequate doses
 Ineffective treatment (e.g., persistent depression after
 Adequate duration of antidepressant trial)
 Side effects
 Facilitate patient-provider (e.g., PCP)
communication about antidepressant medications
 Consult about medication questions
Care Manager: Providers
 Tracks depressive sx and treatment response (PHQ-9)
 Screens for co-occurring MH conditions
 Alcohol use (e.g., AUDIT-C)
 PTSD (e.g., PC-PTSD)
 Consults with team psychiatrist
 Provides follow-up and recommendations to PCP who
prescribes antidepressants
 Collaborates closely with patient’s (PCP)
 Facilitates referrals to specialty, community
 Formal and informal connections
 Prepares for relapse prevention
Examples of CM-Provider Contact
 Medication toxicity, cross-reactivity
 Notifying provider of patient concerns, follow-up
 Fatigue, physical symptoms
 CM prompted provider to call pt. after missed appt
 Managing multiple medications, depression,
diabetes, and HT (medication lists, pillboxes)
 Alcohol use and grief management
Kilbourne AM, et al. Bipolar Disorders, 2008
Kilbourne AM, et al. Psychiatric Services, 2008
CM: Provider Resource
 CMs as a resource for clinic, providers
 Dissemination of specific guidelines
 Ask providers for suggestions on specific topics
 Hold CME, lunches, or disseminate information
 Examples
 Bipolar disorder in pregnancy
 Depression treatment in late life
Provider Communication Tips
 Obtain preferred mode of communication
 Emphasize as a supplemental service
 Focus on providing information on changes in
treatment response, side effects, etc. to inform
decisions
 Baseline, Current PHQ
 Length of time on medications
 Problematic symptoms/side effects
 Adequate contact, but don’t overdo it
Care Management:
Registries
Care Manager: Registry
 Registries are . . .
 Simple tools to track patient progress
 Integrated into routine clinical care
 Easily updated
 NOT EMRs
 NOT research-focused
 Best if “home-grown”
Registry Functions

Patient risk stratification

Tracking and management



Patient characteristics facilitating treatment
Acute phase
Continuation, maintenance

Performance feedback

Patient process and outcomes
Registries

Other data sources (e.g., pharmacy, EMR)
should NOT replace a registry


BUT can be used to:

Improved patient identification (top conditions)

Enhance performance measurement
Challenges to using electronic data

Cumbersome to update and merge
Time lag
 Data not available on all patients
 Privacy and security issues

Key Registry Variables
 Dates
 Patient contact information
 Best number, time to call, and leave message
 Status




No shows
Treatment stage
Current medications (dose, duration)
Self-management materials
 Depression severity score, MD assessment
 Referral status (MHS, community resources)
 Next contact, date
Registry: Sample Fields
General information (update at each contact):
 Patient contact info, including emergency contact
 Providers
 Best time to call/OK to leave message?
 Plan to keep then safe/calm
Contact (Encounter)-specific information:
 Contact or visit date
 Current Mood, Speech, Comorbidities
 Current medications/OTCs, refills needed?
 Medications not taking and reason
 Symptoms and side effects
 Health behaviors (sleeping, drug use, smoking ,exercise)
 Job/personal problems
 Education provided
 Access/barriers, provider engagement
 Next appt
Care Management:
Crisis Intervention
CM: Suicidal Ideation
If the patient articulates thoughts death/suicide:






Where are you now?
What is your phone number at the location?
Are you alone or with someone?
Do you have a plan of how you would do this?
Do you have these things available (guns, pills)?
Have you actually rehearsed or practiced how you would do
this?
 Have you attempted suicide in the past?
 Do you have voices telling you to harm or kill yourself?
CM: Crisis Intervention
 Suicidal ideation- coordinate with clinic
 Protocols
 On-call numbers
 Missed appointments
 Immediate follow-up
Care Management:
Implementation Tips
Care Manager Timeline
Initial Visit
 Rapport- providers
 Patient initial intake
 Contact preferences
 Crisis and urgent care protocols
 Assessment
 Discuss treatment options / plans
 Coordinate care with PCP
 Start initial treatment plan
 Arrange follow-up contact
 Document initial visit
Care Manager Timeline
Subsequent Visits
 Registry- ongoing tracking
 Reminders for upcoming appointments
 Regular contact with providers
Implementing Registries

Adequate staffing, who should update?

Research vs. clinical use

Integrating into routine care

How identified patients are entered

Involving PCP

IRB issues
Types of Registries
 Formats (pros and cons for each)
 Excel file
 Web-based
 Examples
 SMAHRT
 IMPACT
 REACH-NOLA
Care Manager Toolbox
1.
Manual: provider interactions



Contacts, location, communication preferences
Medication info
Protocols to ID treatment response, side effects
2. Manual: patient interactions


Brief interventions (e.g., PST, MI, others)
Crisis intervention
3. Self-management materials


Medication information
Behavioral change information (e.g., pleasure activities)
4. Registry file
Bottom Lines
 The CCM for depression includes key elements


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Self-management
Care management
Community linkages
Registries
Guidelines
 BUT the CCM is most effective if customized to local
settings . . . . .