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Depression Collaborative Care Initiative

posted Oct 7, 2013, 6:36 AM by PC/SM Chief Resident   [ updated Oct 7, 2013, 6:53 AM ]
From Magni & Joe:

We wanted to send you an email to introduce the new Depression Collaborative Care Initiative (CCI) at CHCC.  Montefiore has received state funding to change the way we manage depression at many of the primary care sites, including CHCC. The model is based on IMPACT (Improving Mood-Promoting Access to Collaborative Treatment), an evidence-based model for depression care developed out of the University of Washington at Seattle.  This email is long, but please read it!

What are the key features of the Collaborative Care Initiative?

- Collaborative Care: The PCP and depression care manager together come up with a treatment plan.  The PCP and care manager consult with a psychiatrist if the patient does not improve.  These consultations may happen during your visit with the patient, or during weekly case conferences to which the PCP is invited.
- Depression Care Manager: At CHCC the new depression care manager is Evelyn Figueroa LCSW.  She is responsible for educating patients about depression, providing psychotherapy (specifically problem-solving therapy), monitoring symptoms, and facilitating patient follow-up.
- Designated Psychiatrist:  The psychiatrist primarily serves as a consultant for these patients, joining PCPs and the care manager in their sessions with the patient if needed and giving feedback on more complex patients or patients who do not improve during weekly case conferences.  At CHCC Dr. Tony Stern is our psychiatrist.
- Outcome Measurement: changes in PHQ-9
- Stepped Care: The goal is 50% reduction in depressive symptoms within 10-12 weeks.  If the patient does not improve, the psychiatrist and care manager will suggest changes to antidepressant dosing/regimen and therapy.

For more information about the Collaborative Care Initiative, see the IMPACT website: http://impact-uw.org/about/key.html.  Also take a look at the attached JAMA article from 2002, describing some of the initial successes of IMPACT (about half had 50% or greater reduction in depressive symptoms at 12 months, versus about 20% of usual care patients).

Who should be referred?

- Patients who have moderate to severe depression (PHQ9 >= 15) and who are not already successfully enrolled in depression management at CHCC or elsewhere are eligible.  This means that patients with a new diagnosis of moderate to severe depression are eligible, as well as patients with chronic depression who have been lost to follow-up or who have not improved through standard treatment and psychotherapy at CHCC.
- The nurses screen all patients at CHCC for depression once annually using the PHQ-2.  If the PHQ-2 is positive (a score of >= 3), the nurses will do a PHQ-9.  If the patient scores >=15 on the PHQ-9, the nurse will alert the PCP.  The PCP can then discuss the diagnosis with the patient and, if the patient is interested, might start a medication and refer to the Depression Care Manager.
- For more details regarding who should be referred, please see the attached CCI work flow.

How do we refer patients?

- The goal is for this referral to happen in real time.  When we typically refer patients to mental health, many do not wait in line at the front desk to make the appointment.  Of those who do schedule an appointment, >50% do not actually attend their therapy appointment.
- If your patient seems eligible and interested, please put out your WHITE flag and ask your nurse to overhead Evelyn Figueroa.  Your patient can then either stay in the exam room or step out to the waiting room, and Ms. Figueroa will come find them and bring them downstairs to her office for a quick evaluation.  Referrals will become even easier once Ms. Figueroa gets an office upstairs in Adult Medicine.  This will happen sometime over the next few months.
- If you decide to make a referral after hours, please send Ms. Figueroa a phone note in cEMR, and she will reach out to your patient the next work day.
- No patient will get referred until after the physician and patient have a discussion and decide together that such counseling would be helpful.  EXCEPTION:  Patients who score >=2 on the 9th question of the PHQ-9 (the question about suicidal behavior) -- the LPN will call Ms Figueroa to evaluate the patient immediately.

Once I have referred a patient to the Collaborative Care Initiative, how do I participate in their care?

- The CCI team meets every Friday to discuss the initiative and to case conference specific patients.  Every other Friday (typically the 1st and 3rd), you are invited to join them from 1:30-2 (or later if you do not have a clinic session) to discuss your patient's care.  If your patient is really not improving, the care manager Ms. Figueroa will likely reach out to you ahead of time letting you know that your patient will be discussed.  However, you are always welcome to join these sessions even if your patients seem to be responding to treatment.
- When you are seeing a CCI patient in clinic, you can consult with both Ms. Figueroa and Dr. Stern, who might even be able to join you in the exam room to help assess your patient.
- While Ms. Figueroa is seeing a patient, she might reach out to you if she has a question or if she would like a medication changed.  Similarly, she might bring Dr. Stern into her therapy session.

What happens to my other patients who have less severe depression or who are already in mental health care at CHCC?

- Patients who have another mental health diagnosis or who have less severe depression but could still benefit from therapy, should be referred to the mental health team in the same way that you have always been referring them.  Although they are not eligible for care management or the CCI, they can still continue to receive their mental health care at CHCC.

What is Problem-Solving Therapy?

- Problem-Solving Therapy (PST) is an evidence-based form of psychotherapy developed in Britain for use in primary care.  PST focuses on helping patients solve "here-and-now" problems contributing to their depression and increasing their self-efficacy.  It typically consists of six to ten 30-60 minute sessions.
- PST is considered as effective as other types of psychotherapy and is considered particularly useful for primary care.  It can be successful when done by PCPs as well as by mental health professionals.
- Take a look at the attached meta-analysis about PST for more information.

Please let us know if you have additional questions about the new Depression Collaborative Care Initiative at CHCC.  We are excited to be able to provide more intensive care for our patients with depression and to hopefully help more of our patients stay in care and get better!