Depression Care Management Lessons from Project IMPACT

1. Depression Care ManagementLessons from Project IMPACT _____________________________________________________ • Jürgen Unützer, MD, MPH • Professor and Vice Chair of Psychiatry • University of Washington • unutzer@u.washington.edu

2. IMPACT Study Methods • Design / Intervention:Randomized control trial of a collaborative care management program for depression (vs) care as usual • Participants:1,801 older adults with major depression/ dysthymia from 8 diverse health care systems in 5 states. 400 primary care providers Unützer et al, Med Care 2001; 39(8):785-99

3. Robust reduction in depressionacross diverse health care organizations % all p < 0.01 > 50 % reduction in depression from baseline at 12 months Participating Organizations

4. Better Physical Function PCS-12 P<0.01 P<0.01 P<0.01 P=0.35 Callahan et al, in Press. JAGS.

5. Long-term: more Depression-Free Days IMPACT INTERVENTION NO IMPACT *Hunkeler, et al 2004 – unpublished data.

6. IMPACT ‘Key Ingredient’: Depression care manager John A. Hartford Foundation Annual Report 2002, Photo - Courtesy of Don Battershall

7. Core skills for Depression Care Managers • - Educate about depression • - Clarifytreatment goals, expectations, and preferences • - Convey hopefulness and encourage treatment adherence • - Supportantidepressant management (side effect management) • - Teach • - Problem Solving Skills • - Pleasant Events Scheduling (Behavioral Activation)

8. Depression Care Manager: Core Skills (con’t) • - Track treatment response (PHQ-9) • - Provide updates and recommendations to PCP • - Consult with team psychiatrist • - Facilitate referrals to specialty care and community resources • - Prepare for relapse prevention

9. Some Practice Considerations forCare Managers • Practice Setting • Practice size: small practices, large group practices • Practice organization: primary care, multispecialty care, • Mental health on / off site • Reimbursement • Fee-for service (e.g., Medicare), capitated (HMOs, VA, other) • Mental health coverage carved in / out • Scope of Practice • National standards / professional certification • State practice acts (licensure) • Agency requirements (internal credentialing) • Third-party payor requirements (e.g., Medicare rules and regulations; independent or incident to physician billing) • Prescriptive privileges

10. What is the vision for depression care management? • Program focus • ‘Freestanding’ depression care management program • Depression care as part of a broader disease management effort? • Depression and other common mental disorders • Depression and other chronic medical illnesses • Geriatric care management • Setting / scope • - On / off site; in person (vs) telephone • - Number of practices, providers, patients • Target Population • - Age, gender, language, special needs, comorbid medical / psychiatric / substance abuse problems, insurance benefits