Care Management for Depression in Primary Care Practice: Findings From the RESPECT-Depression Trial

Paul A. Nutting; Kaia Gallagher; Kim Riley; Suzanne White; W. Perry Dickinson; Neil Korsen; Allen Dietrich

doi:10.1370/afm.742

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Table 1.

Sampling Strategy in 4 Waves of Interviews

Wave	Sampling Strategy	Themes Explored
HCO = health care organization.
Wave 1	12 Clinicians who were active users of care manager	Perceived value of care management Patterns of communication with care manager
	8 Care managers	Perceived value of care management Patterns of communication with clinicians Perception of value of mental health supervision
	6 Psychiatrists and 1 clinical psychologist	Perceived value of care management Perception of their role in supervising care managers
Wave 2	8 Clinicians who had used care manager but referred only a few patients  4 Clinicians reported by care managers to be less enthusiastic	Perceived value of care management Reservations about care management
	4 Clinicians who were active users of care management	How to integrate care management into overall pattern of care Value of suggestions received from mental health consultants
Wave 3	4 Clinicians who were active users of care management  5 Care managers and one repeat interview	Perceived barriers to care management Which patients benefited from care management
	6 Clinicians who worked with an in-practice care manager  5 Care managers who were collocated in 1 or more specific practice sites (HCO-B and HCO-D)	Pros/cons of in-practice vs central location of care manager Which patients benefited from care management Value of suggestions received from mental health consultants
Wave 4	4 Repeat interviews with care managers  4 Clinicians who worked with care managers in the dissemination phase of the project  6 Second interviews with clinicians identified by care managers as enthusiastic after working with care manager	Effect of care manager exposure on current enthusiasm

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Table 2.

Characteristics of 5 Participating Health Care Organizations (HCO)

Characteristic	HCO-A	HCO-B	HCO-C	HCO-D	HCO-E
Organizational type	Medical group	Medical group	Medical Group	Behavioral health network	Insurer
Insurance products	Fee for service	None	None	Capitated	Capitated, fee for service
Affiliated practices, No.	139	21	87	65	296
Practices owned, %	30	100	100	0	0
Total clinicians, No.	400	160	186	921	>700
Approximate patient populations, No.	>500,000 served	>100,000 served	320,000 served	>100,000 enrolled	2.3 million enrolled
Mental health carve-out, %	25	60	70	100	0
Practices from HCO participating in the study, No.	19	10	14	8	9
Among participating practices
Clinicians per practice, No. (range)	3.0 (2–6)	3.6 (2–7)	2.9 (1–6)	8.8 (2–11)	2.6 (1–4)
Clinicians participating, %	77	95	69	43	83
Practices with on-site mental health services, No. (%)	4 (21)	4 (40)	0 (0)	8 (100)	0 (0)

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Table 3.
Number of Interviews Conducted by Health Care Organization (HCO) and Role in Project
Role HCO-A HCO-B HCO-C HCO-D HCO-E Total
Care managers 1 9 1 5 2 18
Mental health specialists 1 1 1 2 2 7
Clinicians 8 11 10 7 6 42
Total 10 21 12 14 10 67

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Supplemental Appendix

Supplemental Appendix. Additional Data Supporting Major Themes Reported in the Results Section

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Supplemental data: Appendix - PDF file, 8 pages, 129 KB
The Article in Brief

Care Management for Depression in Primary Care Practice: Findings From the RESPECT-Depression Trial

Paul A. Nutting, MD, MSPH , and colleagues

Background Care management has been shown to be effective in treating depression. Care management for depression includes assessing and monitoring the patient's condition; determining the patient's preferences, barriers, and progress in treatment; providing education and developing treatment and self-management plans; coordinating care among caregivers; and encouraging patients to follow recommended treatment. Primary care doctors have been hesitant to adopt this model, and researchers set out to examine the reasons why.

What This Study Found Primary care clinicians see value in care management for their depressed patients and believe it improves the quality of care. Through interviews with 42 primary care clinicians, researchers also found that primary care practices are slow to adopt care management for depression because of lack of financial compensation and the competing time demands of primary care practice.

Implications

The major barriers to more widespread use of care management in depression are largely economic and less related to attitudes and preferences of primary care clinicians.This underscores the urgency of reimbursement policies that include coverage of depression care management.