Patients with Depression Don't Walk Through the Clinic Door

07 May 2014
Depression can be debilitating. Major depression causes pain, disability, or even death and may also lead to workplace absenteeism. According to the Institute for Clinical Systems Improvement (ICSI), primary care doctors detect depression in patients only about 30 to 50 percent of the time. Typically, of the patients who do receive a diagnosis of depression, between 20 and 40 percent show improvement within one year. Primary care physicians have lacked the know-how, time, and other resources to help patients with depression get the treatment they need.
Aligning Forces for Quality (AF4Q) clinical quality improvement work in West Michigan is led by the Michigan Center for Clinical Systems Improvement (Mi-CCSI). Mi-CCSI is successfully adapting a depression management program pioneered by ICSI and the AF4Q Alliance in Minnesota. The DIAMOND program in West Michigan unites a physician, a care manager, and a consulting psychiatrist to provide team-based care for patients with depression in primary care practices. The collaborative approach helps patients achieve remission faster and helps primary care make important cultural and workflow changes in how it cares for patients with depression. For example, patients with depression may not regularly be engaging with any care providers. “Patients with depression don’t come in to see you, so they don’t fit the traditional model of primary care. Our model doesn’t serve this kind of patient,” explained Paul Brand, president and CEO of Alliance for Health.
Six “care management” elements comprise the DIAMOND model, including assessment of the nine-item Patient Health Questionnaire for assessment, systematic follow-up, stepped care for treatment intensification, relapse prevention, the use of care managers, and a review by a psychiatrist.
Preliminary data in West Michigan are promising. On average, 72 percent of patients enrolled in DIAMOND had a follow-up questionnaire administered to track progress after three months. The remission rate for these patients was 28 percent. 
An enhanced model, under a new grant, is expanding upon the learnings of DIAMOND to treat patients with depression as well as comorbidities like diabetes and cardiovascular disease. Mi-CSSI and nine other organizations are collaborating in an $18 million challenge grant from the Center for Medicare and Medicaid Innovation to pilot Care of Mental, Physical and Substance Use Syndromes (COMPASS). Whereas DIAMOND seeks to focus quality improvement in the context of a single condition, COMPASS represents an evolution in thinking on quality improvement. “COMPASS is like an iteration—a step forward. DIAMOND teaches you some key skills in a practice. In today’s environment, you have very few patients with just depression, and that’s where COMPASS fits,” said Brand.
The power of COMPASS is meeting patients where they are. “We listened to the providers who were caring for their patients with multiple conditions, and what we heard was that depression just cast a pall over the relationship with a provider. In the old language, they were ‘non-compliant,’” said Steve Williams, executive director of Mi-CSSI. “Patients became enmeshed in their depression, so they couldn’t engage in their own health care. When you begin to screen and open the door to depression, it creates a completely different dynamic in the provider-patient relationship.”
Defining care management has allowed Mi-CCSI to bring the large primary care groups to the table to agree on a common model. “This is extremely hard work among competitors. I call it ‘heroic’ because Mi-CSSI is working against the current funding models. For physicians who have decided to aid their patients with these pilots, it’s probably costing them,” said Brand.
Transforming primary care is an enormous challenge requiring significant resources and time and thus is happening very slowly in west Michigan and throughout the country. “The barriers are incredible,” said Williams. “It is made more complex when the patients suffering depression are often not the patients walking through the clinic doors. Even with willing partners pulling together, there are enormous barriers to overcome, particularly when it is not always apparent how to sustain this work into the future.” Practice transformation is driven by a desire to provide the best care, and then comes the work of figuring out how to make the new models that serve patient needs financially sustainable for the future.