Depression Care ManagementLessons from Project IMPACT

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Jürgen Unützer, MD, MPHProfessor and Vice Chair of

PsychiatryUniversity of Washingtonunutzer@u.washington.edu

IMPACT Study MethodsDesign / Intervention: Randomized control trial of a collaborative care management program for depression (vs) care as usualParticipants: 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

Robust reduction in depressionacross diverse health care organizations

0

10

20

30

40

50

60

70

1 2 3 4 5 6 7 8

Usual Care Intervention

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Participating Organizations

%

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Better Physical Function

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Baseline 3 mos 6 mos 12 mos

Usual CareIntervention

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Callahan et al, in Press. JAGS.

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Baseline 3 6 12 18 * 24 *

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Mea

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Intervention Group Usual Care Group

Long-term: more Depression-Free Days

IMPACT INTERVENTION NO IMPACT

*Hunkeler, et al 2004 – unpublished data.

John A. Hartford Foundation Annual Report 2002, Photo - Courtesy of Don Battershall

IMPACT ‘Key Ingredient’: Depression care manager

Core skills for Depression Care Managers

- Educate about depression

- Clarify treatment goals, expectations, and preferences

- Convey hopefulness and encourage treatment adherence

- Support antidepressant management (side effect management)

- Teach - Problem Solving Skills- Pleasant Events Scheduling (Behavioral Activation)

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

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

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