| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH |
|
|
|
|||||||
|
|||||||||
TRACK to:
|
|
Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
RESPECT Team Response to Dr. Donald Nease
RESPECT as a Template for Other Practices
Questions for the RESPECT team
Lessons Learned from the Implementation of the Three Component Model
Strategies for Sustaining Systems for Primary Care Treatment of Depression
Tipping the Scale: Sustaining Systems for Primary Care Treatment of Depression
|
|
|||
|
Allen J. Dietrich, Hanover, NH, USA Professor, Department of Community and Family Medicine, Dartmouth Medical School
Send response to journal:
|
We are grateful for the opportunity to respond to Dr. Nease's questions. In addition, interested readers will find the six-month results of the RESPECT-Depression project in the September 11, 2004, issue of the British Medical Journal. For a direct link to this article, check the Initiative website: This report shows that community practices with modest external
help and resources can increase rates of response and remission
to depression, as well as patient satisfaction. Future reports will
address long-term sustainability.
Dr. Nease asked about funding for the RESPECT-Depression
project, the methods of which were reported in August/September
2004 issue of Annals of Family Medicine. The MacArthur
Foundation Initiative on Depression and Primary Care funded
pilot tests of the Three Component Model of depression care in
two practices for each of the five participating health care
organizations. The organizations themselves providing modest
administrative support as well.
These pilot tests informed the randomized clinical trial (RCT) that
involved 60 practices. Funding for the RCT was shared between
the participating organizations and the research resources of the
Initiative. The specifics of this split varied according to the
preference of each organization. Costs for care manager time
were typically drawn from both Initiative research resources and
each participating organization. Foundation resources supported
all aspects of evaluation and study administration for the RCT.
The second question concerns whether the Three Component
Model (TCM) of depression care can be adapted as an addition to
existing disease management programs. We are pleased to report
that Three Component Model support for depression has been
incorporated into disease management programs for diabetes and
for other chronic conditions. We believe that TCM offers a model of
chronic illness patient support that applies to many conditions and
patients.
The concepts of closer collaboration between primary care and
specialist clinicians, systematic telephone support for patients, and
quantitative monitoring of patient response to inform treatment
modifications are not new nor are they unique to TCM or to
depression mangement. What TCM offers is an approach to
translating evidence-based aspects of depression management
from the research study to the examination rooms of interested
practices.
The third question from Dr. Nease concerns how TCM can be
implemented in an independent practice that isn't part of a group
and doesn't have support from a quality improvement program.
Routine use of PHQ-9 for diagnosis and follow up, formal suicide
risk assessment, and quality patient education materials can be
fairly straightforward to implement and are described and support
materials provided in the clinician training manual available on
the Initiative website Some practices that have no external care management
resources have taken the step of having a nursing staff member
take on some of the care manager function. After training and with
ongoing supervision from a primary care clinician with the practice,
these staff call selected patients to check on progress a week or so
after a new or modified prescription or referral for counseling.
These brief calls are used to provide patient education, support
self management and identify barriers to adherence to the
management plan that should be brought to the attention of the
clinician. The care manager training manual available on the
Initiative website includes materials that could be adapted to
support training of nursing staff.
Allen J. Dietrich, MD
Sheila Barry
Department of Community and Family Medicine
Dartmouth Medical School
Competing interests:
None declared |
|||
|
|
|||
|
Dean A Seehusen, Evans, GA Research Director, Eisenhower AMC
Send response to journal:
|
I would like to congratulate Dietrich et al. on a most impressive project. Family physicians and their patients will certainly benefit from frequent referral to the Depression Management Tool Kit. I also believe that the RESPECT project points the way towards the future of both research and disease management. I would like to point out, however, we will only be able to assess the most important outcome of this project far down the road. As the authors state in their discussion, this study was not conducted with typical HCO’s. The five participating HCO’s were screened for special interest in depression management, were financially supported and carefully trained. The real measurement of this project’s success will be how widespread its use becomes in the ensuing years. One of the most important questions we can ask about this study is, “is this a program that the average practice can, and does, implement”. I admire the RESPECT trial for its ambitious nature and its potential impact on depression management. I look forward to learning how well, and how many, other practices incorporate this model into their practices. Competing interests: None declared |
|||
|
|
|||
|
Donald E. Nease, USA Asst. Professor, Univ. of Michigan
Send response to journal:
|
The work of the RESPECT-Depression trial described by Dietrich, et. al. in this issue of the Annals is impressive. Implementation of a sophisticated disease management program in 60 practices is a significant achievement. However, several questions come to mind in reading this report. First, how was the program funded? Was funding primarily through the MacArthur Foundation or did the individual Health Care Organizations (HCO’s) provide the bulk of funding? Also, did funding source differ by phase? The answer to the funding question is critical, as it relates to issues of feasibility. If the participating HCO’s were able to fund the project primarily out of their existing quality improvement program budgets, the project has already proven significant feasibility. If only phase one of the project was primarily supported by the MacArthur Foundation, what financial data did HCO’s use to decide to invest in the second phase? Finally, if MacArthur Foundation largely funded both phases, how will the project’s disease management programs be sustained within each HCO’s quality improvement program’s budget? Second, are there opportunities for even more economies of scale than envisioned by RESPECT-Depression? Referring back to the previous point, if an HCO cannot afford an investment in a disease management program focused primarily on depression, can their existing programs be adapted or vice versa? The principles of the Three Component Model are not uniquely applicable to depression care, and should be able to exist at the core of coordinated disease management targeting a variety of chronic conditions. Third, how can the information from RESPECT-Depression be applied in a non-HCO practice? Nearly a quarter of family physicians work in self- owned practices(1), where the investments needed to implement a similar approach may be difficult to make. If disease management cannot be made affordable to these practices, how are they to deliver on the promise of a systematic approach to care and management of chronic diseases like depression? 1. American Academy of Family Physicians. Facts about family practice 2004. Kansas City, Mo.: American Academy of Family Physicians. Competing interests: None declared |
|||
|
|
|||
|
Neil Korsen, Portland, Maine Research Director, Maine Medical Center Family Practice Residency Program
Send response to journal:
|
I have been the principle investigator for one of the five sites of the MacArthur Foundation project called Re-Engineering Systems for Primary Care Treatment of Depression (RESPECT-Depression). Thanks to the expertise and assistance of the team from MacArthur, we have made what I believe is a permanent transformation in the way people with depression are cared for in primary care practices in our system. There is still considerable work to do to fully disseminate the model, but it is a question of when, not whether. I would like to share some thoughts about lessons learned: ·Engage leaders at all levels of the organization: We worked with senior management, physician leaders, practice leaders, and mental health leaders within the health system. We also sought support from leadership in community agencies, business, and state government. ·Engage a variety of staff in the improvement effort: Redesigning a system of care affects all segments of the office staff. Clinician involvement is necessary, but not sufficient. ·Take advantage of emergent change: That means ideas about improving work that arise from those doing the work and that are not part of planned improvement projects.(1) We found and joined with existing efforts in the system that were consistent with the goals and principles of the Three Component Model of depression care developed by the MacArthur team. We believe that this will advance the dissemination of the model. ·Help practices link measurement to their improvement efforts: We have developed a set of measures for practices that we think will help them understand their performance in care of people with depression and will guide the direction of improvement efforts. It is still a challenge to have practices integrate measurement into daily work, and we are doing what we can to automate measurement. ·Expect competing demands: We found that practices have a lot going on all the time, and making time for this improvement effort was challenging. Staff turnover is the norm. We found that being patient about the realities of practice, but persistent in our encouragement and support kept practices involved in the effort over time. ·Understand the need for reinvention: Everett Rogers, writing about diffusion of innovation, points out that reinvention is common and improves both adoption and sustainability(2). Each small practice has a unique combination of patients and staff, so that different ways of implementing the model work best for different practices. Flexibility is important. With good measurement, you will know whether a reinvention is still true to the original model. Reference List (1) Weick KE. Organizational change and development. Annual Review of Psychology. 1999;50:361-86. (2) Rogers EM. Diffusion of Innovations. Fifth ed. New York: Free Press; 2003. Competing interests: None declared |
|||
|
|
|||
|
Allen J. Dietrich, Hanover, NH Professor of Community and Family Medicine, Dartmouth Medica
Send response to journal:
|
In commenting on our RESPECT-Depression methods paper, Pincus astutely observes that strategies are needed to finance and sustain evidence-based models of care. One system change would be a CPT code that would allow psychiatrists to bill for providing telephone advice to primary care clinicians about medication management for unresponsive patients. Such informal advice was part of the intervention we describe. Another would be a mechanism to allow billing for telephone calls to patients by qualified staff to support chronic illness care. In numerous published studies such calls have been part of effective depression interventions. For references see www.depression-primarycare.org . Is any one aware of a CPT code that allows billing for depression telephone support or for other chronic illnesses? Are any health plans reimbursing for such calls? Competing interests: None declared |
|||
|
|
|||
|
Harold A. Pincus, PIttsburgh, USA Executive Vice Chairman, Department of Psychaitry, University of Pittsburgh School of Medicine
Send response to journal:
|
Tipping the Scale: Sustaining Systems for Primary Care Treatment of Depression Dietrich et al and the MacArthur Foundation have made an important contribution by: 1. Demonstrating the feasibility of implementing clear, concrete and relatively simple system changes in primary care to change practice to conform to evidence based guidelines in depression. 2. Conducting this implementation study in the context of a randomized controlled trial. 3. Making all the methods, tools, and other materials available so that we can all do this “at home.” The next steps in the evolution of quality improvement in depression care are to: 1. Develop strategies for financing and sustaining these models in the face of huge disincentives created by current financing structures that disarticulate mental health and general health care (Pincus et al, Gen Hosp Psych, 2001). 2. Integrate depression care more fully into the management of other chronic conditions (it is unlikely that there will be widespread “depression-only” care managers). 3. Balance the integration of depression and other behavioral health care with assurance that these issues will receive full and appropriate attention by purchasers, payers and providers and not get submerged into the mainstream (Pincus HA, Psychosomatics, 2003). Harold Alan Pincus, MD Professor and Executive Vice Chairman, Department of Psychiatry University of Pittsburgh School of Medicine Senior Scientist and Director, RAND -- University of Pittsburgh Health Institute Director, National Program Office Depression in Primary Care: Linking Clinical and Systems Strategies Western Psychiatric Institute and Clinic 3811 O'Hara Street, Suite 230 Pittsburgh, PA 15213 Email: pincusha@upmc.edu Telephone: (412) 246-5942 Fax: (412) 586-9049 Website: www.depressioninprimarycare.org Competing interests: None declared |
|||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH |
TRACK: