Bea Herbeck Belnap, Dr Biol Hum

School of MedicineUniversity of Pittsburgh

Learning Objectives

1. To understand the different functions and tools required to effectively implement the Chronic Care Model for depression management in primary care

2. To identify the core roles and qualifications of care managers, particularly as liaisons to providers and for patient self-management support

3. To understand the role and function of care manager registries and their utility in fostering provider and patient communication

Wagner Chronic Care ModelWagner Chronic Care Model

Informed,ActivatedPatient

ProductiveInteractions

Prepared,ProactivePractice Team

Functional and Clinical Outcomes

DeliverySystemDesign

Decision Support

ClinicalInformation

Systems

Self-Management

Support

Health SystemCommunity Health Care Organization

Resources & Policies

CCM: Core Clinical ElementsLeadership

Practice Design

Clinical Information Systems

Vision Resources

Care managementProtocols- coordinated

care

Clinical information tracking

RegistryFeedback to clinicians

CCM: Core Clinical ElementsDecision Support

Self-managementSupport

Community Resources

GuidelinesExpert/specialist

consultation

Patient preferencesInformation on treatment

Information on and for consumers, groups, etc.

Access to non-provider sources of care

General Medical

(Chronic care, Prevention, Follow-up)

Care Manager Self-management

CM/Liaison: PCP, MHCommunity linkagesCrisis intervention

Registry

Behavioral Health (crisis

referral, complexity,

etc.)

Care Manager: Core FunctionsPatient educationRegistry trackingProvider communicationCommunity linkages

Care Manager: PatientsPatient education about depression, treatment

optionsFamiliar with commonly used antidepressant

medications, dosesSupport medication adherence and recovery

Brief interventionsTheory-based approaches (MI, PST, etc.)

Monitor treatment progressKnow when treatment is ‘not working’

Structured symptom assessment (PHQ-9)8-12 week trialProvider recommendations MHS, PCP

CM: Goals of a RegistryIdentify, manage, and track patientsFacilitate patient contacts Provide patient visit summariesProvide real-time data on tx response, etc.RemindersPerformance feedback

CM: Provider LiaisonRelay concerns/progress

Symptom monitoringRefillsSymptoms and side effectsUrgent, emergent protocolsMedical record documentation

Cue providers if no improvementSupplement, not replace providers

CM: Community LinkageCooperation with MHS

SupervisionReferral

Self-help groupsSupport for comorbidities, psychosocial

problemsFinancial resources

Care Management:Patient Support

CM: CustomizationCultural competenceRole of familiesRole of religion/spiritualityCompeting needs

CM: Self-managementEliciting concerns/barriersProblem-solvingProviding informationClarifying preferencesEncouraging informed decision-makingTeaching skillsMonitoring progressReinforcing self-managementCommunity resources

CM: Self-management ToolsWorkbooks

Medication listsAppointment remindersHealthy behaviorsPleasure activities list

PillboxesMedication informationWebsites

Care Management:Provider Communication

CM: Provider LiaisonHelp patients and providers identify

Potentially inadequate dosesIneffective treatment (e.g., persistent depression

afterAdequate duration of antidepressant trial)Side effects

Facilitate patient-provider (e.g., PCP) communication about antidepressant medications

Consult about medication questions

Care Manager: ProvidersTracks depressive sx and treatment response

(PHQ-9)Screens for co-occurring MH conditions

Alcohol use (e.g., AUDIT-C)PTSD (e.g., PC-PTSD)

Consults with team psychiatristProvides follow-up and recommendations to PCP

who prescribes antidepressantsCollaborates closely with patient’s (PCP)Facilitates referrals to specialty, community

Formal and informal connectionsPrepares for relapse prevention

Examples of CM-Provider ContactMedication toxicity, cross-reactivity

Notifying provider of patient concerns, follow-up

Fatigue, physical symptomsCM prompted provider to call pt. after

missed appt

Managing multiple medications, depression, diabetes, and HT (medication lists, pillboxes)

Alcohol use and grief managementKilbourne AM, et al. Bipolar Disorders, 2008

Kilbourne AM, et al. Psychiatric Services, 2008

CM: Provider ResourceCMs as a resource for clinic, providersDissemination of specific guidelines

Ask providers for suggestions on specific topicsHold CME, lunches, or disseminate information

ExamplesBipolar disorder in pregnancyDepression treatment in late life

Provider Communication TipsObtain preferred mode of

communicationEmphasize as a supplemental serviceFocus on providing information on

changes in treatment response, side effects, etc. to inform decisionsBaseline, Current PHQLength of time on medicationsProblematic symptoms/side effects

Adequate contact, but don’t overdo it

Care Management:Registries

Care Manager: RegistryRegistries are . . .

Simple tools to track patient progress Integrated into routine clinical careEasily updatedNOT EMRsNOT research-focusedBest if “home-grown”

Patient risk stratificationTracking and management

Patient characteristics facilitating treatmentAcute phase Continuation, maintenance

Performance feedbackPatient process and outcomes

Registry FunctionsRegistry Functions

Other data sources (e.g., pharmacy, EMR)

should NOT replace a registry BUT can be used to:

Improved patient identification (top conditions) Enhance performance measurement

Challenges to using electronic data Cumbersome to update and merge Time lag Data not available on all patients Privacy and security issues

RegistriesRegistries

Key Registry VariablesDatesPatient contact information

Best number, time to call, and leave messageStatus

No showsTreatment stage Current medications (dose, duration)Self-management materials

Depression severity score, MD assessmentReferral status (MHS, community resources)Next contact, date

Registry: Sample FieldsGeneral information (update at each contact):

Patient contact info, including emergency contactProvidersBest time to call/OK to leave message?Plan to keep then safe/calm

Contact (Encounter)-specific information:Contact or visit dateCurrent Mood, Speech, ComorbiditiesCurrent medications/OTCs, refills needed?Medications not taking and reasonSymptoms and side effectsHealth behaviors (sleeping, drug use, smoking ,exercise)Job/personal problemsEducation providedAccess/barriers, provider engagementNext appt

Care Management:Crisis Intervention

CM: Suicidal IdeationIf the patient articulates thoughts

death/suicide:Where are you now?What is your phone number at the location?Are you alone or with someone?Do you have a plan of how you would do this?Do you have these things available (guns, pills)?Have you actually rehearsed or practiced how you

would do this?Have you attempted suicide in the past?Do you have voices telling you to harm or kill

yourself?

CM: Crisis InterventionSuicidal ideation- coordinate with clinic

ProtocolsOn-call numbers

Missed appointmentsImmediate follow-up

Care Management:Implementation Tips

Care Manager TimelineInitial VisitRapport- providersPatient initial intake

Contact preferences Crisis and urgent care protocols

AssessmentDiscuss treatment options / plansCoordinate care with PCPStart initial treatment planArrange follow-up contactDocument initial visit

Care Manager TimelineSubsequent Visits

Registry- ongoing trackingReminders for upcoming appointmentsRegular contact with providers

Adequate staffing, who should update? Research vs. clinical use Integrating into routine care How identified patients are entered Involving PCP IRB issues

Implementing RegistriesImplementing Registries

Types of RegistriesFormats (pros and cons for each)

Excel fileWeb-based

ExamplesSMAHRTIMPACTREACH-NOLA

Care Manager Toolbox1. Manual: provider interactions

Contacts, location, communication preferences Medication info Protocols to ID treatment response, side effects

2. Manual: patient interactions Brief interventions (e.g., PST, MI, others) Crisis intervention

3. Self-management materials Medication information Behavioral change information (e.g., pleasure

activities)4. Registry file

Bottom LinesThe CCM for depression includes key elements

Self-management Care management Community linkages Registries Guidelines

BUT the CCM is most effective if customized to local settings . . . . .