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| IMPLEMENTATION STORIES
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RESPECT-Depression in Maine
MaineHealth was fortunate to have participated in the MacArthur Foundation funded study Re-Engineering Systems in Primary Care Treatment of Depression (RESPECT-Depression). As a result of this opportunity, and with additional support from the Robert Wood Johnson Foundation, we have successfully disseminated much of the Three Component Model throughout the MaineHealth system. This effort involved adaptation of the model to facilitate wide-scale distribution and substantial support from MaineHealth. It also required considerable patience as improving depression care competed with other important priorities in primary care practices.
Adaptation of the TCM involved linking it to Wagner’s Chronic Care Model. Using that framework, we described five key changes for primary care practices to improve depression care. They are listed in the table.
| KEY CHANGES |
CHRONIC CARE MODEL |
| Use of PHQ-9 for diagnosis and outcomes measurement |
Delivery system design
Decision support
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| Depression registry |
Clinical information system |
| Self-management |
Self-management support |
| Care management |
Delivery system design |
| Informal psychiatric consults |
Delivery system design
Decision support
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We used the Institute for Healthcare Improvement’s Learning Collaborative approach to pilot test the model with 20 primary care practices over a three-year period. In doing this, we were able to learn some lessons about how primary care practices would implement and refine the model.
During this time, MaineHealth provided two important components of the model to support our work. The first was the development of a module for depression care within the Clinical Improvement Registry (CIR). The CIR had initially been developed to track key clinical data about patients with diabetes and asthma, and the depression module was added as a result of our work with RESPECT-Depression. The second was the creation of a Chronic Illness Care Management program that would place nurse care managers in primary care practices around the system. These care managers had all been trained in depression care management using the approach that is part of the Three Component Model. At this point, there are over 16,000 patients with depression in the registry, including over 6,000 with a PHQ-9 measured in the past 12 months. There are 25 care managers supporting 199 primary care clinicians in 69 practices. Over 1,000 patients with depression have had care management services in the past 12 months.
At the conclusion of our work with practices using the Learning Collaborative, we were invited to disseminate the depression treatment model to all primary care clinicians who were members of the Maine Medical Center Physician Hospital Organization (MMC-PHO), the largest physician group within the MaineHealth system. We accomplished this using a variety of approaches for training, reinforcement, and incentives. We used a flexible approach to training, offering group sessions, such as grand rounds and staff meetings, outreach visits to practices, and online learning. We have spread the model in a stepwise fashion, focusing on the use of the PHQ-9 in one year and the treatment of depression with medications the next, followed by the role of the care manager and self-management support in treating depression. The online learning modules remain available to reinforce training.
We have also used newsletter articles to focus on new information in the literature and other aspects of depression care. Performance reports in the CIR help primary care providers (PCP’s) monitor their use of the depression model components and identify individual patients that lack important aspects of care. Financial incentives have been used to reward PCP’s for completing training and to further reinforce aspects of depression care, such as screening high-risk populations with the PHQ-9 and performing follow up PHQ-9’s on patients who are diagnosed with depression. In the past 4 years, over $250,000 in financial incentives have been paid to MMC-PHO primary care clinicians and practices as rewards for quality depression care. More than 80% of primary care physicians completed training in the use of the PHQ-9, 66% completed training in treating depression with medications, and 54% completed training in care management and self-management in the treatment of depression.
We have not yet been able to add the component of informal psychiatric consultation to our depression program. This is a result of the lack of reimbursement for this service. We are currently exploring ways to pilot this important aspect of the TCM.
The system-wide dissemination of the depression model has taken place during a time when multiple demands are placed on our primary care practices. These include quality improvement programs related to other conditions, implementation of a system-wide ambulatory electronic health record, and increasing financial pressures on primary care practices. It has been important to develop processes and offer training in ways that have minimal impact on busy physicians and practices.
We have broadened our focus in the last several years and are in the midst of pilot testing a mental health integration program based on the model developed at Intermountain Healthcare. This program involves locating one or more mental health professionals in primary care practices and using a set of standardized mental health assessments, including the PHQ-9, to screen for common mental health conditions seen in primary care patients. It also requires creating a team approach to care involving the primary care clinicians and staff, care manager, and mental health professionals. Our partnership with Intermountain in this effort is a direct result of our participation in the MacArthur Initiative.
We appreciate the support of the MacArthur Foundation that helped us launch our depression program. Thousands of patients and hundreds of clinicians have benefited from the lessons we have learned.
Neil Korsen, MD, MSc
Medical Director
Primary Care Mental Health Program
MaineHealth
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