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BACKGROUND & THREE COMPONENT MODEL

Background

The MacArthur Initiative on Depression and Primary Care has been charged with making a difference nationally in the primary care management of depression. Toward this end, the Initiative has launched a variety of projects to better understand current primary care management approaches and to develop strategies to enhance that management. In addition, the Initiative Steering Committee placed a priority on linkage with other researchers and organizations committed to enhancing depression care. These linkages aim to assure synergy between Initiative work and the work of others.

Re-Engineering Systems for Primary Care Treatment of Depression Project (RESPECT-Depression) was a major culmination of the charge from the Foundation. RESPECT-Depression explored the impact, dissemination and sustainability of an evidence-based approach to enhancing depression management, the Three Component Model (3CM™). The primary care clinician, a care manager, and mental health professional cooperate with the patient and with each other in providing care. The components of 3CM™ are not unique, but rather the product of a wide range of recent research. The essential components include prepared primary care clinicians and their practices, care management, and closer relationships between mental health and primary care clinicians.

What is new is the systematic approaches to implementation (the process of change) and to clinical management (the process of care). The process of change is guided by a manualized, widely applicable, easily transported set of implementation strategies and materials. The process of care is based on a structured approach to diagnostic assessment; initial steps in care, including promotion of self management; and quantitative monitoring of the response modifying treatment as needed.

Both the process of change and process of care materials from 3CM™ are ready to use or easily modified to fit the practice setting. Some practices have implemented these on their own while others have benefited from external support if available from the quality improvement support staff of their medical group or health plan or from other consultants.

RESPECT-Depression was not a typical research project with aims limited to the development of new knowledge reported through publications and presentations. It was also not a typical demonstration project limited to exploring the value and feasibility of a new approach to care. Instead, RESPECT-Depression combined elements of research, demonstration, and dissemination by exploring the impact of 3CM™, demonstrating the feasibility of sustaining its application, and disseminating 3CM™ widely.

Historically, RESPECT-Depression was developed after five years of initial project work to undersand and pilot test components. Details of this history may be found in The Initial Projects. RESPECT-Depression had three phases. In Phase One, the Project provided assistance to participating intermediaries in applying 3CM™ in a few practices to gain experience with and customize the approach. In Phase Two, the Project evaluated the impact of 3CM™ in additional practices using a randomized controlled trial assessing the process and outcomes of care. In Phase Three, RESPECT-Depression worked with intermediary health care organizations to disseminate 3CM™ widely among their affiliated practices and promote sustained use of 3CM™ for the long term.

The Three Component Model (3CM™) of Depression Care

The Three Component Model (3CM™) is a specific clinical model for depression management. The 3CM™ is a systematic approach that includes certain tools, routines, and a team approach to patient care. The three components include the prepared primary care clinician and practice, care management, and collaborating mental health specialists. Our experience to date with 3CM™ has involved the quality improvement and care management offices of health care organizations such as medical groups and insurers. However, individual clinicians can implement many of the aspects of the 3CMTM by reviewing the MacArthur tool kit and other materials included in this website.

The three components include elements shown to improve depression outcomes in recent randomized controlled trials. Telephone support for the depressed patient from a care manager is one central element as is periodic quantitative feedback about the patient's response to treatment from the care manager to the clinician. The feedback is provided through depression severity scores based on the PHQ-9. Another element is closer relationships between the primary care clinician and mental health specialists including informal psychiatric advice when needed from a psychiatrist. The psychiatrist also provides weekly supervisory support for the care manager. These elements are integrated into a systematic approach, an office system, for depression diagnosis and management as endorsed by the US Preventive Services Task Force.

The office system includes tools such as the PHQ-9 and patient education materials; defined responsibilities for the primary care clinician and staff, the care manager, and the mental health professionals involved; and routines including a schedule of care manager follow up calls.



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