Going to Scale: Re-Engineering Systems for Primary Care Treatment of Depression

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

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

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

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