Primary Care Based Disease Management

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Primary Care Based Disease Management

• VISN 4 MIRECC
• VA Philadelphia
• University of Pennsylvania

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Delivering Quality MH Care in Primary Care

• Epidemiology
• Chronic Disease Model
• Barriers to quality care
• Tools / models to improve quality

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Psychiatric Disorders in Primary Care

• Diagnoses
• Depressive disorders
• Anxiety Disorders (PTSD in the VA)
• Problem Drinking
• Illicit Drugs (VA)
• Cognitive Disorders (elderly)
• Clinical Features
• Common
• Often milder than cases seen in behavioral health
• Associated with significant suffering, morbidity,
  disability, excess utilization, and mortality

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Barriers to Quality MH Care

• Beliefs, experience, and expectations of patients
  and providers
• Silos of care
• Competing demands for providers and patients
• Disincentives for the implementation of chronic
  care model

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Performance Past Screening
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Tools / Models of Care

• Education of providers on best practice
• Guidelines, CMEs, seminars, etc.
• Enhancing referral mechanisms
• Provider Adjuncts
• Disease management specialist
• Technological assists

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Three Examples of Research to Enhance Treatment
Outcomes

• PRISME Study
• NIMH PROSPECT Study
• Telephone Disease Management
• Behavioral Health Laboratory

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Timeline of activity in Primary and Specialty Care
Penn Dep Ds Mgt
PROSPECT
PRISM-E
BHL
10/99
3/03
6/97
PRISM-E
ExTENd
TDM II
MIRECC
DIADS
WW
TDM I
BHL
UPBEAT Analysis
Depression Monitoring
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Study Design

• Randomized trial comparing integrated
  (collaborative) care to referral care
• Target conditions
• Depression
• Anxiety
• At-risk Drinking
• Study Phases
• Screening
• Baseline assessment
• Follow-up assessments at 3 and 6 months

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Treatment Arms

• Referral Care
• Direct referral to specialty psychiatry (most
  programs used geriatric specialty mental health
  programs for all subjects)
• Enhancements were made at many sites including
  appointments within 2 weeks, transportation,
  reduced or no patient costs
• Sites were encouraged to deliver guideline
  adherent care but no specific treatment was
  mandated
• Integrated (collaborative care)
• All sites had staff trained in Brief Alcohol
  Interventions
• Some sites used standardized depression protocols
  others were optimal clinical care

Levkoff S., et. al. (2004)
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Engagement in treatment by condition

• Engagement at least one contact with the mental
  health specialist.

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Preliminary Findings fromPROSPECTAn NIMH
supported study onPrevention of Suicide in
Primary Care Elderly Collaborative Trial
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THE TWO PREMISES OF PROSPECTS INTERVENTION

• 1. Effective treatments for depression exist
• PROSPECT has operationalized AHCPR guidelines
  for use in primary care with the elderly

• 2. Guidelines alone do not ensure both correct
  physician
• decisions and patient adherence to
  treatment.
• PROSPECT has added a depression specialist
  to
• assist the physician by providing timely and
  targeted
• patient-specific clinical strategies
• encourage patient adherence to treatment
  through
• education and support.

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PROSPECT Percent with gt 50 reduction in HDRS/24
Scores Among Patients with MDD
P.001
P0.01
P0.2
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Telephone Based Interventions

• Telephone Disease Management is algorithm driven
  care delivered by a Behavioral Health Specialist.
  
• Enhanced Usual care. The PCP can monitor, treat,
  and/or refer. The PCP is provided a diagnosis and
  references for treatment options.

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Baseline Characteristics
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Improvements with TDM
Oslin, et. al. 2003
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VA Performance Measures for 2004

• Mental Health Performance Measures for 2004
• VA Measures are modeled after HEDIS measures
• Apply to patients with
• New diagnosis of depression
• New treatment with antidepressant medication
• Measures probe the quality of acute phase (12 wk)
  tx
• with gt 3 clinical follow-up visits
• Only 1 visit can be by telephone
• At least 1 must be with the prescribing MD
• who receive adequate medication for 84 days

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Depression Care Monitoring

• Diagnosis and decision to treat
• Baseline assessment (from BHL)
• Prescription of antidepressant
• Follow-up assessment in 1-2 weeks
• With provider or designate
• Educational
• Check on adherence
• Check on side effects
• Follow-up assessments at 6 and 10 weeks by BHL
• Follow-up in-person assessments with MD at the
  conclusion of an episode of care
• If remission, discuss continuation treatment
• If no response by 6 weeks, modify treatment
• If residual symptoms at 12 weeks, modify
  treatment.

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Care Management

• Motivational based brief intervention for
  enhancing adherence and retention
• Pilot of 20 patients 70 treatment engagement

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Telephone Disease Management

• VISN 4 MIRECC
• VA Philadelphia
• University of Pennsylvania

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Purpose

• To develop a method for delivering high quality
  depression and alcoholism treatment in Primary
  Care, CBOCs, and other clinics in which there are
  significant transportation, staff resource, or
  other impediments to the delivery of face-to-face
  MH/SA care.
• To develop methods for translating effects
  demonstrated in randomized clinical trials to
  clinic populations.

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Who is Appropriate?

• Inclusion criteria
• DSM-IV Major Depression
• Age 18-85
• MMSE gt 18
• Hearing and language adequate for participation

• Exclusion criteria
• Alcohol dependence
• Other substance abuse
• Current psychosis
• Suicidal ideation
• History of primary psychosis
• History of (hypo)mania

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The Role of the Behavioral Health Specialist

• The role of Behavioral Health Specialist (BHS) is
  to influence adherence to guidelines by providing
  "on-time, on-target" information to primary care
  physicians and collaboratively make appropriate
  care decisions.

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Integration of Care with the Supervising
Psychiatrist
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Initial Assessment

• 1. Review of physician progress notes
• 2. History of psychiatric and medical conditions
• 3. List of current medications
• 4. History of use of psychotropic medications
• 5. Recent laboratory and neuroimaging reports
• 6. Record information on initial progress note

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Initial contact - Goals

• Begin to establish rapport in order to build a
  supportive and therapeutic relationship.
• Review the purpose of the phone call and the
  reasons for the referral.
• Conduct a semi-structured clinical interview in
  order to learn the patients perception of his or
  her problem and the clinicians assessment of the
  presenting problem. (PHQ-9, Beck Anxiety Scale
  (if warranted), alcohol/substance use and the UKU
  for side effects)
• Begin to develop a hypothesis of the patients
  diagnosis
• Complete a Choose a treatment algorithm based on
  the outcome of the interview
• Consult with the primary physician regarding the
  proposed treatment plan.
• Consult with the psychiatrist if needed.
• Discuss the proposed treatment plan with the
  patient, using motivational techniques
• Educate the patient regarding medications, if
  any, that are ordered.
• Set up a follow-up phone call with the patient
  and the BHS for one week later.
• Schedule a follow-up visit
• Complete a baseline progress note.

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Motivating the Patient for Treatment

• Assist the individual in recognizing their
  symptoms and developing an interest in addressing
  the symptoms.
• Motivational Interviewing helps to resolve
  ambivalence so that the patient can make a
  decision to accept and adhere to treatment
  suggestions.
• It is a supportive, respectful approach

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Roadblocks

• Religious
• Self-Change
• Denial

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Key Points

• Avoid arguments with the Patient
• Express Empathy
• Support Self-Efficacy
• Roll with Resistance
• Develop Discrepancy (help the patient identify
  where they are now and where they want to be in
  the future)

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Determining a Treatment Plan

• 1. Monitoring (but not treating) some patients.
• 2. Treatment by the physician and BHS within
  protocol guidelines.
• 3. Delay initiation of treatment algorithms
  pending further medical stabilization,
  patient/family approval, or further diagnostic
  assessment or consultation.
• 4. Referral for a consultation and/or treatment
  of patients with complicated diagnostic
  presentations, chronic benzodiazepine use, severe
  cognitive impairment, need for hospitalization,
  or primary psychotic illnesses.

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Acute Phase of Treatment for Depressive Disorders


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Maintenance Phase

• Asymptomatic or minimally symptomatic (PHQ-9
  score of 10 or less) - continuing
  pharmacotherapy of six months duration.
• During maintenance therapy, meet once a month to
  obtain clinical ratings.
• During the maintenance phase, if a patient scores
  10 or greater on the PHQ-9, s/he should be
  reassessed one week later. If the PHQ-9 score
  remains at 10 or greater, the patient may be
  relapsing therefore, the BHS should consult with
  the physician and/or supervising psychiatrist.
  The patient may need to restart the acute phase
  of the study.

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End of Treatment Procedure for Maintenance Therapy

• Siscuss with the patient her/his interest in
  continuing to take medication for relapse
  prevention.
• Patients who continue taking it are less likely
  to have a relapse than those who discontinue it.

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Adverse Event Documentation

• During each phone contact, the BHS will initially
  ask patients if they are having any problems with
  their medication in an open-ended fashion.
• The BHS will proceed with administration of the
  UKU Side Effects Rating Scale.

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Key Decision Points

• Week 6
• If PHQ-9 score is gt10,
• and NOT reduced 25 from baseline evaluation
• or if patient is actively suicidal
• Week 12
• If PHQ score is gt5,
• And NOT reduced 30 from baseline evaluation
• or if patient is actively suicidal

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Psychopharmacologic Algorithms
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General Principles

• Substitution, rather than augmentation
• Psychotherapy may be used as alternative to
  pharmacotherapy (Psychotherapy alone) or be
  combined with antidepressants (augmentation).
• Drugs that are simpler to implement in primary
  care are favored over drugs of known efficacy,
  but which require special procedures,
• Treatments that are often poorly tolerated are
  given lower priority than treatments that are
  more likely to be tolerated, even when the
  efficacy of the latter treatments may be less
  well-established, e.g., bupropion augmentation of
  SSRI's was favored over lithium augmentation of
  SSRI's,
• Venlafaxine/Bupropion will be the preferred
  treatment for patients who appear to be
  refractory.
• When following each algorithm, clinical judgment
  can override the algorithm.
• BHS clinicians are encouraged to discuss these
  cases with the supervising psychiatrist.

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30 - 50
gt 50
6 Week Response change in PHQ
Optimize (max. dose) dose
Continue
lt 30 change
Skip to 12 week response box
12 Week Response
PHQ gt 5 and lt 50 change in PHQ
PHQ gt 5 and 50 change in PHQ
PHQ lt 5
Physician Choice
Venlafaxine XR 200 mg/d
Buproprion SR 150 mg BID
Maintenance Treatment
Augment with Bupropion SR 150 mg BIDX 6 weeks
6 Week Response change in PHQ
6 Week Response
Optimize (max. dose) dose
Continue
gt 50
30 - 50
PHQ gt 5
PHQ lt 5
lt 30 change
Maintenance Treatment
D/C Bupropion and Augment with nortriptyline
plasma levels 80 -120 ng/ml X 6 weeks
Skip to 12 week response box
12 Week Response
6 Week Response
PHQ lt 5
PHQ gt 5
Maintenance Treatment
unspecified
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High Risk Management Protocol

• Be very attentive
• Remain calm and non-threatened
• Give the patient some space and time to vent
• Stress a team approach to the problem
• Be willing to say the word suicide without
  flinching