Multiple Choice Question

1
Chronic disease prevention and management
for mental health problems in primary
care The Hamilton HSO Mental Health
Nutrition Program
Nick Kates and Michele Mach
2
Plan

• Why do we need to think differently about how we
  deliver care
• The chronic care model
• Evidence as to its effectiveness
• CDMP and the Hamilton HSO Mental Health and
  Nutrition Program
• Implementing CDPM programs in your practice

3
Chronic Care Model

• A new way of thinking about how we deliver care
• A way of thinking about the health of populations
  as well as individuals
• Evidence-based care
• Consumer-centred practical application of
  concepts of recovery
• Delivered by interdisciplinary teams

4
Chronic Illness Drives Medical Care Costs
People

Those w/multiple chronic conditions
33
6
31
Those w/one chronic condition
21
36
Those w/no chronic conditions
72
Costs associated with each segment
Segments within the total population
Source Kaiser Permanente Northern California
commercial membership, DxCG methodology, 2001.
5
Evidence suggests these arent being managed
as well as they could be
6
Chronic Medical Disorders Quality Chasm US
Chasm Report

• Only 60 of patients with chronic conditions
  receive recommended guideline level care
• Less than 33 of heart disease patients who would
  benefit from cardiac rehabilitation (exercise,
  education, counseling regarding behavioral
  changes) adhere to health professional
  recommendations
• Over half of patients with Type 2 diabetes have
  HbA1C levels gt 8.0

7
Primary Care Diagnosis and Treatment of Major
Depression

• Only approximately 50 diagnosed accurately
• Of those started on antidepressant treatment,
  only 40 recover by 4 to 6 months
• Of those treated, about less than 50 receive
  guideline-level pharmacotherapy and less than
  10 receive guideline-level psychotherapy

8
System Barriers in Treatment

• Interruptions in treatment are the rule rather
  than the exception
• 45 of primary care patients discontinue
  antidepressants in first 4 to 6 weeks
• Frequency of contacts falls far below minimum
  standards
• Median performance of 297 health plans on 3
  visits in 90 days after initial prescription was
  20
• Treatment intensity is rarely adjusted according
  to need

9
Common Medical Illnesses and Depression
Major Depression
30-50
Multi-condition Seniors
Stroke
23
11-15
15-20
Heart Disease
Diabetes
10
6-Month Mortality Post -MI

• Depressed post-MI patients have a three to four
  fold risk of death over the next 6 months when
  controlling for other risk factors
• Impact of depression on mortality is at least as
  significant as left ventricular dysfunction and
  history of previous MI

Frasure-Smith et al. JAMA. 19932701819.
11
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
12
Between the health care we have and the health
care we could have lies not just a gap, but a
chasmUS Institute of Medicine, 2001
13
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

14
Traditional Organisation and Culture
of Care

• Focus on acute problems
• Emphasis on triage and patient flow
• Short unprepared appointments
• Brief didactic consumer education
• Consumer initiated follow-up
• Emphasis on provider - not system - behaviour
• Wagner 1998

15
Differences between acute and chronic
conditions
(Holman et al,
2000)
16
Focus is on management of acute problems

• Treat only those people who reach us
• Cant identify problems earlier
• No prevention of episodes / recurrence
• No consistent after-care
• Disconnected system
• Not consumer-driven

17
Our focus is on individuals rather
than populations
18
Our focus is usually on the quantity
rather than the quality of care
19
Our focus is on the content of care
(interventions) rather than processes of care
(how systems support those interventions)
20
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
• Consumer education of little benefit if not
  followed-up

21
Systems are perfectly designed to get the
results they achieve
Thought for the day
22
Need to change how we deliver care

23
Need to change how we think about how we
deliver care
24
We need new approaches to managing
chronic diseases
25
The Shift

• Expensive, Effective,
• reactive, responsive
• and unplanned care and anticipatory care

26

• The Chronic Care Model

27
Essential Element of Good Chronic Illness Care
Prepared Practice Team
Informed, Activated Consumer
Productive Interactions
28
What characterizes a prepared practice team?
Prepared Practice Team
At the time of the visit, they have the
consumer information, decision support, people,
equipment, and time required to deliver
evidence-based clinical management and
self-management support
29
What characterizes a informed, empowered
consumer?
Informed, Empowered Consumer
Consumer understands the disease process, and
realizes his/her role as the daily self manager.
Family and caregivers are engaged in the
patients self-management.
30
Health System
Organization of Health Care
Community Resources Policies

• Clinical Information Systems

• Self-Management Support

• Delivery System Design

• Decision Support

Prepared Proactive Practice Team
Informed Activated Patient
Productive Interactions
Functional Clinical Outcomes
31
Self-Management

• Definition
• Self-management is the task that individuals
  must undertake to live with one or more chronic
  conditions. These tasks include having the
  confidence to deal with medical management, role
  management and emotional management of their
  conditions.
• (Institute of Medicine 2004)

32
Self-Management

• This definition incorporates three sets of tasks
  
• medical management of the chronic condition i.e.
  medications, change of diet, self-monitoring
• creation and maintenance of new meaningful life
  roles i.e. with family and friends and job and
• the emotional sequelea i.e. coping with anger,
  fear, frustration and sadness associated with the
  chronic illness(s)
• (Corbin and Strauss, 1988)

33
Self-Management Support

• Assisting patients to manage their health and
  health care through empowerment and preparation
• Emphasise the patients pivotal role in their
  health care
• Effective self-management support strategies
  (assessment, goal setting, action planning,
  problem-solving and follow-up)
• Organize resources to provide support
• More than just education

34
Stanford University, Chronic Disease
Self-Management Program (CDSMP)http//patienteduc
ation.stanford.edu

• 20 years
• 6 weeks weekly 2 hours
• lay leaders
• highly interactive, skill building, sharing
  experiences and support, disease-related problem
  solving, managing emotions, exercise, relaxation,
  distraction, self-talk, communication skills,
  using the health care system, nutrition, managing
  medications
• Rigorously evaluated (RCTs)

35
Self-Management

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

36
Completely consistent with a recovery
approach
37
Decision Support

• Provision of clinical care consistent with
  scientific evidence and patient preferences
• Evidence-based guidelines in daily practice
• Utilization of proven provider education methods
• Need to be woven into routine care incorporate
  guidelines in
• Rosters
• Flowcharts
• Assessment tools
• Treatment algorithms
• Integration of specialist expertise in primary
  care
• Share guidelines and information with patients

38
Delivery System Design

• Define roles and distribute tasks amongst team
  members
• Offer a comprehensive range of interventions
• Use planned interactions to support
  evidence-based care
• Provide clinical case management / co-ordination
  services
• Provide care / system navigation
• Ensure regular follow-up and monitoring
  (registries / telephone)
• Give care that patients understand and that fits
  their culture

39
Clinical Information System

• The Registry a system that records all
  relevant patient care information
• Support multiple problems
• Most effective when addressing multiple (related)
  problems
• Link to EMR

40
Registries The Three Rs

• Registration of a population of patients for
  whom primary care teams identify problems,
  co-ordinate care and help support their condition
• Recall of people to ensure they get the care they
  need by using prompts and reminders
• Review patients to ensure they receive the best
  evidence based care and are supported to manage
  their condition DH Department of
  Health, 2004

41
Clinical Information System

• Provide reminders for providers and patients
• Identify relevant patient subpopulations for
  proactive care
• Share information with providers and patients
• Monitor individuals over time
• Monitor performance of team and system

42
Health Care Organization

• Visibly support improvement at all levels,
  starting with senior leaders
• Promote effective improvement strategies aimed at
  comprehensive system change
• Encourage open and systematic handling of
  problems
• Develop agreements for care coordination
• Consistency in policies

43
The Community

• Mobilization of community resources to meet
  patient needs
• Encouragement of patients to participate in
  effective community programs
• Formation of partnerships / linkages with
  community organizations (collaboration to support
  and develop gaps in services)
• Advocacy for policies to enhance patient care
• Integrate community resources into mental health
  settings

44
(No Transcript)
45
Population Management More than Care Case
Management
46
CDM for Depression - What works
Evidence from Review articles
47
Badamgarav Systematic Review of the
Effectiveness of DM Programs

• 19 studies
• 24 arms (estimates)
• Pooled results
• Badamgarav et al. Am J. Psych 2003

48
Badamgarav

• Statistically significant improvements in
• Satisfaction with treatment (Effect size 0.51,
  N6)
• Adequacy of antidepressant treatment (0.44, N11)
• Adherence to treatment regimens (0.36, N7)
• Symptoms (0.33, N24)
• Health care utilisation (0.1, N8)
• Statistically non-significant changes in
• Higher health care costs (1.03, N3)
• Physical functioning (-0.05, N7)
• Social and health status (.06, N6)
• Hospitalisation rates (-0.20, N2)

49
IMPACT Depression in Seniors

• RCT
• 18 practices, 8 HMOs, 5 States
• 1801 depressed patients
• Intervention
• Depression care manager
• education
• care management
• support of medication management
• brief psychotherapy
• Supervised by a psychiatrist
• Support from primary care specialist
• Unutzer et al JAMA 2002

50
IMPACT

• At 12 months 45 improved v. 19
• More satisfied
• Less symptom severity
• Less functional impairment
• Greater quality of life
• Reduced arthritis pain
• Improved diabetes management

51
Genisichen Care Management to Improve Major
Depression in Primary Care

• 13 studies
• Systematic review and meta-analysis
• Pooled results
• Care management is equivalent to case management
  in the K.P. Triangle

52
Care Management Shown to Improve Depression
Outcomes in Primary Care
No Benefit
Large Benefit
Moderate Benefit
Randomized Trial
?
Katon 1995 Banerjee 1996
Katon 1999 Llewellyn 1999
Colmann 1999 Simon 2000
Katzelnick 2000
Hunkeler 2000 Rost 2001
Unutzer 2002
Hedrick 2003
?
?
?
?
?
?
?
?
?
?
0.2
0.4
0.6
0.8
1.0
0.0
-0.2
-0.4
Effect Size of Care Management Interventions
Meta analysis by Gensichen et al., (Psych. Med
2006)
53
Neumeyer-GromenDM Depression Programs-
systematic review and meta-analysis of RCTs

• 10 studies included in meta-analysis
• Significant effect of disease management programs
  (DMPs) on symptom severity
• Patient satisfaction and adherence to tx. regimen
  improved significantly (only in heterogeneous
  models)
• Costs per quality adjusted life compared to usual
  care 9,051-49,500
• within the range of other internationally
  accepted medical/public health interventions i.e.
  hypertension
• Neumeyer-Gromen et al, Medical Care 2004

54
Conclusions

• Conclusive evidence that CDM programs for
  depression
• Improve symptom severity
• Increase treatment adherence
• Improve quality of life / functioning
• Increase job tenure
• Increase detection rates
• Improve appropriateness of care
• Increase consumer and patient satisfaction

55
General Observations

• Very few long-term studies
• Not always in real life practices
• Difficult to sort out components of successful
  interventions
• Few addressed self-management just patient
  education
• Need to be applied flexibly

56
General Observations

• Time consuming require collaborative
  interdisciplinary teams
• Can be integrated with the care of other chronic
  diseases
• Increase costs of care offset by other savings
• Need broader system components in place for
  effective
• Provider Education
• Patient Education
• Feedback
• Utilisation of guidelines
• Screening

57
How can I re-design my system to get better
results
2nd. Thought for the day
58
Hamilton HSO Mental Health and
Nutrition Program

• 1994 MH Program started 45 physicians (all in
  HSOs)
• 1996 Expansion 41 new physicians
• 2000 Took over administration of nutrition
  program
• 2000 onwards - Physicians started to move into
  PCNs
• 2005 Became part of Hamilton Family Health Team

59
HSO Mental Health and Nutrition Program - 2006

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

60
Integrating Specialised Health Services within
Primary Care

• Ratio FTEs
  FTEs Clinicians 1996
  2005
• Counsellors 17,200 22.9
  50.5
• Psychiatrists 175,000 2.2
  4.8
• Registered 123,000 7.0
  14.2
• Dietitians
• Programs
• Central Program

61
Introducing CDM
62
Evolution to the CDPM Approach

• Program had been established for 10 years
• Successfully completed an external review by
  MoHLTC in 2003 - 04
• May 2004 - conducted an internal review to set
  priorities
• Came across the CDM literature

63
2004 Program Priorities

• Develop a Pain Component
• Develop Peer Support
• Review Services Delivered for Individuals with
  Serious Mental Illness
• Develop Standardized Models of Care
• Develop an Addictions Pilot
• Expand Child Psychiatry

64
Introduction to CDPM

• Understanding took a number of months
• Input from external consultant Mike Hindmarsh
• Literature review
• Used model to look at how we managed specific
  problems
• Used model as a tool / framework for reviewing
  overall performance of the mental health program
• New dimension to planning focus on processes as
  well as projects
• Recognition that many of the components were in
  place, in an ad hoc, non-systematic manner

65
Delivery system design What we have

• Role of counsellor as case / care co-ordinator
• Stepped model of care
• Specialist providing evidence-based advice

66
Future Directions

• Screening
• Dietitians screening for depression with diabetes
• Earlier intervention
• New
• At risk
• Follow-up of individuals seen and treated

B
67
Self-management What we have

• Not always consumer-centred
• Traditional education approaches not working
• Healthy Futures
• Not goal oriented
• Rarely shared written treatment plans

68
Future Directions

• Goal-setting
• New approaches to patient education
• Shared care plans
• Peer support

E
69
Information Systems What we have

• Program Database demographics, problems,
  processes
• Only individuals seen not those at risk
• Able to Identify Program-Wide Trends
• Cant be used for tracking / monitoring
• Rosters Left to Individual Practices
• not systematic
• usually paper based
• EMRs not yet widely used not linked
• Dont all have registry capability

70
Future Directions

• Registry capability
• At risk factors
• Ability to track after treatment
• Ability to monitor individuals at risk

F
71
Decision support What we have

• Circulation of guidelines for specific problems
• Difficulty re format / uptake
• Not in data base
• Do better with content of care rather than
  processes
• Non-standardized Models of Care
• Training workshops hadnt been successful
• Specialists in Primary Care
• Preparation of Psychiatrists

72
Decision Support Issues

• Management of depression by clinicians whose role
  expectations are very broad
• Patients present in many different ways
• How to translate evidence from trials to real
  world practices
• Need to sell the model to counsellors
• Size of program

73
Future Directions

• Introduction of standardised approaches
• Follow-up by family physician
• Follow-up by counsellor
• Post-treatment follow-up
• Greater uniformity in treatment
• Solution focused therapy

C
74
Links With Community

• Initiated by central program
• Varies from practice to practice / clinician to
  clinician
• Manage relationship with out-patient clinics
• Assisting with integration of primary and
  secondary sectors (live on both sides of the
  divide)
• Communicates changes in local policies

75
Future Directions

• Greater uniformity in utilising community
  resources
• Greater integration of community agency personnel
  in primary care

B
76
Organisational Support The Program Management
Team

• Setting Program Goals
• Setting and monitoring program standards
• Implementing Guidelines
• Evaluation
• Quality Control
• Reallocating Resources

77
The ProgramManagement Team

• Training clinical staff
• Preparing family physicians
• Needs Assessment
• Problem solving
• Provision of educational resources
• Created a bottom-up infrastructure in primary
  care

78
Gaps

• Strength
• Communication an ongoing challenge

A
79
Unique components of the program

• Central Management Team
• Integration of specialists
• Converting an existing program
• Bottom-up model
• Size of programs

80
Introduction of the Comprehensive Care Model
(CDPM)

• CDPM applied to the entire program not just a
  specific problem
• Development of specific CDM programs
• Depression
• ADD
• Addictions

81
Depression

• 2 Screening questions for family physicians
• If indicated, follow-up with PDQ-9
• Protocols for care by family physician
  follow-up
• Registries
• Follow-up after treatment by counsellors
  (?telephone)
• More standardised treatments solution focused
  therapy
• Goal setting copy to patient
• Screening diabetics for depression by RDs
• Integration with care of other chronic diseases

82
Attention Deficit Disorder

• Developed by
• Literature review
• Identification of effective practices
• Expert panel
• Priorities
• Detection Screening Instruments
• Tracking
• Evidence Based Interventions
• Family / patient education
• Stepped model Psychiatrist back-up
• Workshops not effective
• Family physician comfort

83
Alcohol Program

• Developed as per ADHD
• Change the culture of Primary Care
• Priorities
• Change attitudes - readiness for change
  (providers)
• Detection
• Tracking individuals over time
• Self-Management
• Linkages with community programs
• Grid who does what functional equivalence

84
Implementing a CDM program
85
The challenge

• Family physician needs support in managing
  depression can rarely offer both medication and
  psychotherapy
• Needs specialised staff
• Just a depression program or treating depression
  as part of mental health program (resource
  availability)

86
Issues in implementation 1) Preparation of
practices / providers

• Family Physicians may have differing expectations
  of a CDM program
• Family Physicians at different stages of
  readiness
• Need for preparation of practices
• Need for preparation of clinicians
• Need to sell the concept
• Need a leader

87
Issues in implementation 2) Need to sell the
concept

• What currently happens with management of chronic
  conditions
• Why do we need to change
• Emphasise change in system of care
• Involve family physicians who have already done
  this

88
Implementation issues 3) Introducing the model

• Clear goals for program
• Not everything at once develop a hierarchy of
  changes
• Start with pilots
• Clarification of roles
• Keep guidelines / protocols as simple as possible
• Identify key / simple messages to get across

89
Implementation issues4) Change management

• Resistance on the part of some physicians to
  making changes
• Start with those who want the program
• Resistance by counsellors to change need to
  build this in from outset / recruitment
• Patience / repetition
• Predict obstacles

90
Implementation issues5) The model

• Stepped models of care
• Each intervention is supported by another (part
  of the algorithm)
• Role of specialist in providing evidence-based
  guidelines
• Counsellors as care co-ordinators
• Importance of tracking / monitoring need EMR

91
Implementation issues6) Introducing the model

• Involve providers from the beginning
• Integrate protocols with existing practices
• Let each practice develop its own model, within
  central guidelines / common principles
• Need to try to change the culture
• CDM
• Specific problems
• Specialists
• Think about health of populations

92
Implementation issues7) Preparation of staff

• Difficulties in changing from just a
  collaborative model - training general clinicians
  to follow treatment guidelines
• Training workshops not sufficient
• Collaboratives need to be considered

93
Nick Kates Contact information

• Email nkates_at_mcmaster.ca
• Phone [phone]

94
Chronic Care Model

• Literature review
• Improving Chronic Illness Care
• National Program of the Robert Wood Johnson
  Foundation
• www.improvingchroniccare.org
• Depression Training Manual
• Institute for Healthcare Improvement, 2002
• www.IHI.org
• Depression Management Toolkit, 2004
• The Macarthur Initiative on depression Primary
  Car at Dartmouth Duke
• www.depression-primarycare.org
• Environmental Scan