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CARE MANAGER MANUAL Download Manual
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Cover  |  Preface  |  Knowledge Objectives  |  Table of Contents  |  Overview


OVERVIEW OF THE DEPRESSION CARE PROCESS


The process of care for detecting and managing depressive disorders in primary care can be divided into steps. These steps are listed below and described in more detail in the following pages.
Steps involving the care manager are in BOLD and marked with a

1.   Recognition and Diagnosis
   •   “Flags” for depression
   •   Two question screen
   •   PHQ-9 for depression diagnosis/severity
   •   Suicide risk
   •   Other pertinent diagnostic assessments
   •   Formulate and explain diagnosis

2.   Treatment Selection
   •   Additional history including previous treatment, co-morbidity
   •   Explain treatment options
   •   Elicit patient treatment preferences

3.   Initial Acute Phase Treatment
   •   Patient engagement
   •   Provide key educational messages
   •   Set self-management goals
   •   Explain and recommend care management
   •   Set time for first care management call

4.   Care Management Process
   Initial call(s) to monitor treatment initiation / adherence
   Mail written educational materials (Unless PCC has provided)
   Follow-up calls using PHQ-9 to assess treatment response
   Care management supervision with psychiatrist
   Communication with clinician

5.   Acute Phase Follow-Up
   Care management contacts coordinated with PCC office visits
   Evaluate patient response to treatment with a goal of remission
   •   Modifying treatment when sub-optimal response
   •   Strive for remission

6.   Continuation & Maintenance Phase Care
   Continue treatment response monitoring after remission
   Administer maintenance dysthymia questionnaire
   Discuss risk factors / need for long-term prophylactic treatment during care management supervision
   •   Continue counseling and/or antidepressant treatment for 4-9 months to prevent relapse
   •   Continue long-term prophylactic treatment and monitoring for at risk patients


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