A national program sponsored by The Robert Wood Johnson Foundation
Harold Alan Pincus, MD
Director, National Program Office
Constance M. Pechura, PhD
Senior Program Officer
The Robert Wood Johnson Foundation
Frank V. deGruy, III, MD, MSFM
Chair, National Advisory Committee
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www.depressioninprimarycare.org
National Program Office
Harold Pincus, MD, Director
Jeanie Knox Houtsinger, BA, Deputy Director
Gail Wrobleski, Administrative Specialist
Susanne Salem-Schatz, ScD, Quality Improvement Consultant
John Bachman, PhD, Communications Consultant
Donna Keyser, PhD, Communications Consultant
Clinical Team
Bruce Rollman, MD, MPH
Bea Herbeck Belnap, PhD
Amy Kilbourne, PhD
H. Charles Schulberg, PhD
Economic Team
Richard Frank, PhD
Colleen Barry, MPP, PhD
Haiden Huskamp, PhD
Tom McGuire, PhD
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Evaluation Team
Daniel Ford, MD, MPH
Laura Morlock, PhD
Michael Kaminsky, MD, MBA
Lisa Cooper, MD, MPH
Gail Daumit, MD, MHS
Darryl Gaskin, PhD
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Depression in Primary Care
National Advisory Committee
Frank V. deGruy, III, MD, MSMF, Chair
Macaran A. Baird, MD, MS
Anne C. Beal, MD, MPH
Rachel Block
Christopher M. Callahan, MD
Becky J. Cherney
Kathleen Cronkite
Jeanne Miranda, PhD
Madeline Naegle, RN, CS, PhD, FAAN
Estelle Richman, MA
A. John Rush, MD
S. Alan Savitz, MD
Richard Scheffler, PhD
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Depression in Primary Care:
Linking Clinical and Systems Strategies
Final National Program Meeting
Themes: Sharing What We’ve Learned
• Alignment
• Infrastructure
• Spread
• Communication
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Questions
1.
2.
What lessons have we learned?
How can we apply them across the broader domains
of mental health, substance use and general health?
How can we establish infrastructure/leadership to:
3.
•
•
•
4.
Weave modern quality improvement strategies into the day–today practice of caring for mental health and substance use
conditions
Align policies and incentives to reinforce these practices
Spread these lessons across regions/communities
What strategies can best help us communicate our
stories?
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What We Know

Depression is a serious and prevalent
chronic disease (especially in primary care)

Longitudinal chronic illness care models
are effective but not currently implemented

Multilevel clinical and economic/system
strategies are needed to overcome barriers
among target groups (“6 Ps”)

There are special barriers in
“mainstreaming” behavioral health quality
initiatives
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Evidence-Based Chronic (Planned) Care
Approaches for Treating Depression
Are Effective
Community
Resources and
Policies
Health System
Health Care Organization
SelfManagement
Support
Informed,
Activated
Patient
Delivery
System
Design
Productive
Interactions
Decision
Support
Clinical
Information
Systems
Prepared,
Proactive
Practice Team
Functional
and Clinical Outcomes
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“6 P” Conceptual Framework
Patient/
Consumer
• Enhance self-management/participation
• Link with community resources
• Evaluate preferences and change behaviors
Providers
• Improve knowledge/skills
• Provide decision support
• Link to specialty expertise and change behaviors
Practice/
Delivery Systems
• Establish chronic care model and reorganize practice
• Link with improved information systems
• Adapt to varying organizational contexts
Plans
• Enhance monitoring capacity for quality/outliers
• Develop provider/system incentives
• Link with improved information systems
Purchasers
(Public/Private)
• Educate regarding importance/impact of depression
• Develop plan incentives/monitoring capacity
• Use quality/value measures in purchasing decisions
Populations
and Policies
• Engage community stakeholders; adapt models to
local needs
• Develop community capacities
• Increase demand for quality care enhance policy advocacy
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“10 P” Framework
• Patients / Consumers
• Professors –
Teachers, Researchers
• Providers
• Policy Makers –
Regulators, Funders
• Practices / Delivery
Systems
• Politicians
• Plans – MCO / MBHO
• Purveyors
• Purchasers – Public / Private
• Populations / Community
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What’s Unique about Behavioral Health?
•
•
•
•
Mind-body dualism
Stigma
Role of the state
Legal / regulatory distinctions (e.g., privacy,
competency)
• Multiple complex systems intrinsically involved
(e.g., social services, criminal justice, education,
consumer-directed, etc.)
• Different diagnostic systems
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What’s Unique about Behavioral Health?
(continued)
• Separate delivery systems
• More heterogeneous work force / greater solo
practice
• Few procedures
• Separate financing systems / different market
structure
• Less developed quality improvement /
performance measures
• Less linkage to IT innovations
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René Descartes
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Don’t Split Mind and Body
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“Crossing the Quality Chasm”
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What We Have Done
•
•
•
•
•
Incentives Demonstration Projects
Value Research Grants, Rounds I and II
Leadership Grants
Communication
Collaborations
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Program Components
1. Incentives Demonstration
Project Grants
Strategies/
Models
2. Value Research Grants
Ideas
3. Leadership Grants
People
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Incentives Demonstration
•
•
•
•
Partnerships of health plans (HMOs and
MBHOs) and practice groups (and
purchasers)
8 sites
Commercial, Medicaid
Implementation of:
– Clinical Model
– Economic Model
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Demonstration Project Sites
CareOregon, Project Director: David Labby, MD
•
State Medicaid
•
State Mental Health
•
Multnomah County Health Department
•
Multnomah County “Verity”
Colorado Access, Project Director: Marshall Thomas, MD
•
University of Colorado Health Sciences
•
Denver Health
•
North Colorado Family Medicine
Intermountain HealthCare, Project Director: Brenda Reiss-Brennan, MS, APRN, CS
•
Health Plans: Deseret Mutual Benefit Association (DMBA), Public Employees
Health Plan (PEHP), Intermountain Health Care (IHC), Educators Mutual
Insurance Association (EMIA), and University HealthSystem Consortium (UHC)
•
Primary Care Clinics (20 +Neighborhood Clinic, Federal Health Centers)
•
Providers (PCP + CM, MHS)
•
Employers (IHC, Auto Liv, Becton Dickinson)
MaineHealth, Project Director: Neil Korsen, MD, MS
•
Anthem Blue Cross/Blue Shield
•
Maine PHO
•
Behavioral HealthCare Program
•
Spring Harbor (inpatient/outpatient mental healthcare provider)
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Demonstration Project Sites (continued)
University of California at San Francisco, Project Director: Mitchell Feldman, MD, MPhil
•
Blue Shield of California (BSC)
•
United Behavioral Health (UBH)
University of Massachusetts, Project Director: Linda Weinreb, MD
•
Massachusetts Division of Medical Assistance
•
Boston Medical Center HealthNet Plan
•
Neighborhood Health Plan
•
Network Health
•
Primary Care Clinician Plan
•
Fallon Health Plan
•
Massachusetts Behavioral Health Partnership
University of Michigan, Project Director: Michael Klinkman, MD, MS
•
Ford Motor Company
•
Health plans (Partnership Health, M-Care)
State of Vermont Health Access, Project Director: M. Elizabeth Reardon, MPH
•
Divisions of the Vermont Agency of Human Services
•
State designated Medicaid Agency and providers:
• primary care practices associated with Rural Critical Access)
• Community Hospitals
•
Federally Qualified Health Centers
•
Community Mental Health Centers
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Clinical Model: Major Components
Leadership
• Accountability
• Vision
• Resources
Practice
Design
• Patient registry
• Protocols
• Depression Care Manager
Clinical
Information
Systems
• Red flags
• Feedback to provider on clinical
progress
• Support Depression Care
Manager
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Clinical Model: Major Components
(continued)
Decision
Support
•
•
•
•
Self-management
Support
• Patient preferences
• Information on depression,
medications
Community
Resources
• Information on and for consumer
and groups and other services
• Access to non-provider sources
of care
Guidelines
Provider training
Expert / specialist consultation
Referral pathways
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Phases of Depression Treatment
Remission
Recovery
Relapse
No Depression
Symptoms
Recurrence
Response
Syndrome
Treatment Phases
Acute
Continuation
Maintenance
Kupfer DJ. J Clin Psychiatry. 52(5s):28-34,1991.
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Economic Model
•
•
•
•
•
Reinforce clinical model
Unique issues in local context
Realign financial and non-financial
incentives
Alter contractual / organizational
arrangements
Problem solving / collaborative learning
process
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Technical Assistance Efforts:
Collaborative Learning Process
• Established two teams: Clinical model and economic
• Clinical liaison and economic liaison assigned to each
demonstration project
• Quality improvement consultant
• Monthly conference calls and reports with each demonstration
project team
• Monthly project director teleconferences
• Care manager calls
• Evaluation calls
• Topic-specific conference calls (e.g., assessing costs)
• List Serv
• Technical assistance workshops
• Site visits
• “Yellow Pages” resources (e.g., links to web sites, contact
information, etc.)
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Template for Internal Evaluation
Identified
Stakeholder
Groups
Issues of
Value to the
Stakeholder
Group
Measures to
be Used to
Collect Data
Relevant to
Stakeholder
Source(s) of
Data
Analyses
Methods for
Presenting Data
to Stakeholder
Group
(Stakeholder 1
Name)
(Stakeholder 2
Name)
(Stakeholder 3
Name)
(etc)
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Value Research Grants
•
Understand / overcome barriers at multiple
levels (“6 P”)
•
Assess value as perceived by stakeholders
•
Maximize and document value
•
192 Letters of Intent – Round I
•
306 Letters of Intent – Round II
•
26 Grants
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Value Research Grants
Performance Measurement
•
•
•
“The Quality of Depression Care: Are HEDIS Quality Indicators
Valid?”
John Williams, MD, MHSc (Duke University Medical Center)
“Rewarding Physicians for High Quality Depression Care”
Sarah Scholle, DrPH, MPH (NCQA)
“Improving Health Plans’ Depression Performance” Constance
Horgan, ScD (Brandeis University)
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Value Research Grants
Incentives
• “Financial Incentives in Depression in Primary Care”
David Smith, RPh, PhD, MHA (Kaiser Permanente Center for Health
Research)
• “Evaluation of Incentives and Collaborative QI for Depression”
Leif Solberg, MD (HealthPartners Research Foundation)
• “Evaluation of a PCP Performance-Based Incentive Program”
Lori Lackman-Zeman, PhD (Wayne State University)
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Value Research Grants
Purchaser Initiatives
•
•
•
“Marketing Improved Depression Treatment to Employer
Purchasers”
Arne Beck, PhD (Kaiser Foundation Health Plan of Colorado)
“Creating Employer Demand for Enhanced Depression Care”
Philip Wang, MD, MPH (Harvard Medical School)
“Employer-led Efforts to Improve Depression in Primary Care”
Eric Goplerud, PhD (George Washington University)
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Value Research Grants
Cost-Effectiveness
• “Cost-Effectiveness of Improved Depression Treatment”
Gregory Simon, MD, MPH (Group Health Cooperative of Puget
Sound)
• “Cost-Effectiveness of Brief CBT for Pediatric Depression”
R. Vanessa Weersing, PhD (Yale University)
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Value Research Grants
Influencing Provider Behavior
• “Supporting Watchful Waiting for Minor Depression in Primary
Care Patients with a Behavioral Assessment Laboratory”
Ira Katz, MD, PhD (Philadelphia Research & Education Foundation)
• “Watchful Waiting for Sub-threshold Depression by Primary Care
Providers”
Lisa Meredith, PhD (RAND)
• “The Effectiveness and Value of Moving to an Integrated System
for the Treatment of Depression”
Donna McAlpine, PhD (University of Minnesota)
• “Benefit Change Allows PCPs to Code Psychiatric Disorders”
Beth Goldman, MD, MPH (Blue Cross Blue Shield of Michigan)
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Value Research Grants
Disability / EAP Linkages
• “The Impact of integrated EAP-Primary Care for Depression on
Productivity Outcomes”
Brenda Reiss-Brennan, MS, APRN, CS (Intermountain Health Care)
• “The Value of Referring Medically Ill Patients to an Employee
Outreach Program Designed to Detect and Treat Depression”
Mitchell Feldman, MD, MPhil (University of California at San Francisco)
• “The Long-Term Outcomes of Treating the Depression of the
Untreated”
Daniel Polsky, PhD (University of Pennsylvania)
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Value Research Grants
Alternative Models of Integrated Care
•
•
•
•
•
“Testing a Consumer-Directed Care Model”
Yeates Conwell, MD (University of Rochester Medical Center)
“Promotoras as Mental Health Practitioners in Primary Care: Reducing
Economic, Cultural, and Linguistic Barriers to the Treatment of Depression
in Community Health Centers”
Howard Waitzkin, MD, PhD (University of New Mexico Health Sciences Ctr)
“A Randomized Clinical Trial Assessing the Cost-Effectiveness of Generalist
Care Managers for the Treatment of Depression in Medicaid Recipients in
Primary Care Settings”
Suzanne Landis, MD, MPH (Mountain Area Health Education Center)
“Depression Management through Models of Facilitated Care”
Gary J. Kennedy, MD (Montefiore Medical Center)
“Evidence-based Management of Depression in Public Sector Primary Care”
Benjamin Druss, MD (Emory University)
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Value Research Grants
Child / Adolescent / Maternal Depression
• “Project CATCH-IT”
Benjamin Van Voorhees, MD (University of Chicago)
• “Finding and Treating Depressed Students in Rural New Mexico
Through School-Based Health Centers”
Steven Adelsheim, MD (University of New Mexico Health Sciences Ctr)
• “Detection and Management of Maternal Depression in Pediatric
Settings”
Emily Feinberg, ScD, CPNP (Boston University)
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What We Have Done:
Leadership Grants
David Eisenman, MD
Barriers and Facilitators of Referrals and Follow-Up in Primary Care
University of California at Los Angeles
Faculty Mentors: Jurgen Unutzer, MD, MPH and Paul Koegel, PhD, MA
Christina Nicolaidis, MD, MPH
Addressing the Needs of Depression in Women with a History of Abuse
Oregon Health & Science University
Faculty Mentor: Martha Gerrity, MD, MPH, PhD, FACP
Laura Richardson, MD, MPH
Improving Primary Care Treatment of Depression for Adolescents
University of Washington
Faculty Mentor: Wayne Katon, MD
Sara Swenson, MD
Group Visits for Depression: A Delivery Systems Innovation for Social Support and SelfActivation
University of California at San Francisco
Faculty Mentor: Mitchell Feldman, MD, MPhil
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What We Have Done:
Communications
• Developed detailed “communications matrix” organized by target
audiences, products and work plan.
• Publications: Numerous articles in high-profile journals including
JAMA, NEJM, Health Affairs, and Milbank
• Presentations: National, state, local and purchaser / plan meetings
• Sponsored Workshops: Applicant and grantee meetings
• Communications: website (www.depressioninprimarycare.org); List
Serv; newspaper, television and radio interviews; APMH Special Issue
• Collaborations / meetings with other RWJF National Program Offices;
foundations, councils, committees, and programs; and federal
programs
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What We Have Done: Collaborations
Other RWJF National Program Offices:
• Improving Chronic Illness Care
• Partnerships for Solutions: Better Lives for People with
Chronic Conditions
• Prescription for Health: Promoting Healthy Behaviors in
Primary Care Research Networks
• Pursuing Perfection: Raising the Bar for Health Care
Performance
• Rewarding Results: Aligning Incentives with High-Quality
Health Care
• National Purchasing Institute
• Pathways to Recovery
• Center for Health Care Strategies
• Join Together
• Diabetes Initiatives
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What We Have Done: Collaborations
(continued)
Foundations, Councils, Committees, Programs:
• The John A. Hartford Foundation
• The John D. and Catherine T. MacArthur Foundation
• The Commonwealth Fund
• Institute of Medicine
• National Council for Community Behavioral Health (NCCBH)
• National Committee for Quality Assurance (NCQA)
• National Quality Forum
• LeapFrog Group
• National Business Group on Health
• California HealthCare Foundation
• Families for Depression Awareness
• Disease Management Association of America (DMAA)
• Anxiety Disorders Association of America (ADAA)
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What We Have Done: Collaborations
(continued)
Federal Programs:
• Substance Abuse and Mental Health
Services Administration (SAMHSA)
• Agency for Healthcare Research and
Quality (AHRQ)
• Health Resources and Services
Administration (HRSA)
• National Institute of Mental Health (NIMH)
• Centers for Medicare and Medicaid
Services (CMS)
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Input on Policy and Practice
• CCIP / Medicare Health Support Program
• State Medicaid Programs (e.g. Vermont Health Access)
• Linking NIMH / SAMHSA with CMS
–
–
–
–
MMA Part D
Nursing home quality
State Policy Academy
Medicare / Medicaid reimbursement
• Institute of Medicine
• Regional Initiatives – Hogg Foundation, Pittsburgh
Regional Health Initiative
• Veterans’ Administration, e.g. Behavioral Health
Laboratory
• Individual Employers, e.g. Ford, General Motors, CISCO
• National Business Group on Health – Purchaser Toolkit
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Together we have done a lot!
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The Challenges (Paradox) Ahead:
1.
2.
3.
4.
5.
Depression (and behavioral health, generally) is very
much like other chronic conditions
Care for individuals with mental and addictive disorders
will not improve on its own – it won’t be swept along
with the mainstream
We will not get maximum benefit from quality
improvement initiatives for other chronic diseases
unless we deal with behavioral health
Barriers/”disarticulations” limit implementation of IOM
aims and rules
We will not get maximum benefit on either side unless
we deal with “disarticulations” / barriers between the two
systems
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René Descartes
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Where Do We Need To Go?
• Integration?
– Clinical
– Structural
– Financial
• Intraoperability
• Synchronicity
• Alignment
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Vertical Alignment
•
•
•
•
•
Patients
Providers
Practices
Plans
Purchasers
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Horizontal Alignment (across silos)
• Mental Health
– Depression
– Anxiety
– SMI
• Substance Use
• General Health
–
–
–
–
–
Chronic Disease
Geriatric Health
Women’s Health
Child and Adolescent
Family Health
• Other Systems
– Social Services
– Criminal Justice
– Education
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Topographic Alignment
•
•
•
•
•
•
Agency
Neighborhood
Community/Regional/Market
State
Federal
Parallels in private sector
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Longitudinal Alignment
•
•
•
•
Consistent application
Follow the patient over time and place
Monitor performance over time
Communicate/coordinate (link)
–
–
–
–
Care management
Information technology
Learning
Implementation Research
• Institutionalization/Infrastructure
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Planning for the Future:
Aligning the Planets
1. Get behavioral health on the radar screen
– Create / support purchaser/regional collaboratives
– Assure inclusion of behavioral health
2. Provide leadership to infuse modern
performance improvement strategies into
behavioral health
– Quality infrastructure is seriously underdeveloped
and fragmented
– Need integrative entities to diffuse learning
(purveyors)
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Planning for the Future:
Aligning the Planets
(continued)
3.
Accelerate production of robust behavioral health
measures
–
–
4.
Standardization across silos
Measures of collaboration
Establish mechanisms to reward performance
distinction
–
–
5.
Behavioral health not part of current P4P initiatives
Accountability / alignment – incentivizing “defragmentation”
Study/fund research to:
–
–
–
Document stakeholder value
Evaluate effective implementation strategies
Translate from bench to bedside to community
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Prepare for the Future
Consumer Participation
Leadership
(PCP/MH/SUD)
Support
Standardize Practice Elements
– Clinical assessment
– Interventions
– IT infrastructure
Develop Guidelines
– Mental health
– Substance use
– General health
Measure Performance
– For each “6P” level
– Across silos
Improve Performance
– Learn
– Reward
Strengthen Evidence Base
– Document stakeholder value
– Evaluate effective strategies
– Translate from bench to bedside
to community
Clinical
(PCP/MH/SUD)
Perspectives
Integrative Processes
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Share Our Learning
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Tell Our Stories
• “I felt disoriented and disconnected from my feelings and
myself. I couldn't eat or sleep. Nothing brought me
pleasure. I couldn't stand to be around others and isolated
myself from everyone. I felt so hopeless that I wanted to
end my life.” Impact of Depression
• “I didn’t give up hope. I called my care manager because
she kept calling me even when I didn’t’ call her back for
months. I felt like their must be hope if she didn’t give up
on me.” Impact of the Clinical Model
• “I think that [the program’s annual meeting] was the best
professional meeting I have ever attended.” Impact of the
Program
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Columbia University Medical Center
New York Presbyterian Hospital
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