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Karim R, Lipman PD, Weeks K, Hsu YJ, Brown D, Carletto E, Dietz K, Cooper LA, Marsteller J. Health Care Leaders' Experience with a Multi-Level Intervention to Reduce Hypertension Disparities: A Qualitative Analysis. HEALTH EDUCATION & BEHAVIOR 2024:10901981241268156. [PMID: 39143736 DOI: 10.1177/10901981241268156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/16/2024]
Abstract
With health equity growing as a priority within health care, health systems must transform that calling into action within their social, economic, and political environments. The current literature has not compared how different organizations manage the same health disparities intervention. This qualitative study aims to illustrate how different organizations navigated the implementation and sustainability of a hypertension disparities intervention by comparing experiences across Federally Qualified Health Centers (FQHCs), a private health system, and other non-clinical partnering organizations. As a study within a randomized controlled trial designed to reduce disparities in hypertension care, we conducted interviews with health care leaders before and after participation in the trial's multi-level intervention. Before participation, we interviewed five health care leaders representing five health systems. Following the intervention, we interviewed 14 leaders representing the five health systems and two partnering organizations. Discussions focused on intervention implementation and plans for sustainability. The primary considerations in implementation were appropriate staffing and multi-level organizational buy-in. When discussing long-term planning, health systems prioritized the structure of a stepped-care protocol incorporating community health workers (CHWs) and case managers. The sustainability of the CHW intervention at FQHCs was dependent on funding, whereas a private, non-FQHC physician practice network focused on expanding current resources for more patients. These findings serve as anticipatory guidance for organizations aiming to reduce hypertension disparities and provide support for policies that financially assist these interventions. Further investigation is warranted on the organizational factors that may influence the degree of success in eliminating health care disparities.
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Affiliation(s)
- Razeen Karim
- Johns Hopkins School of Medicine, Baltimore, MD, USA
- Johns Hopkins University, Baltimore, MD, USA
| | | | - Kristina Weeks
- Johns Hopkins School of Medicine, Baltimore, MD, USA
- Johns Hopkins University, Baltimore, MD, USA
| | - Yea-Jen Hsu
- Johns Hopkins School of Medicine, Baltimore, MD, USA
- Johns Hopkins University, Baltimore, MD, USA
| | - Deven Brown
- Johns Hopkins School of Medicine, Baltimore, MD, USA
- Johns Hopkins University, Baltimore, MD, USA
| | - Emily Carletto
- Johns Hopkins School of Medicine, Baltimore, MD, USA
- Johns Hopkins University, Baltimore, MD, USA
| | - Katie Dietz
- Johns Hopkins School of Medicine, Baltimore, MD, USA
- Johns Hopkins University, Baltimore, MD, USA
| | - Lisa A Cooper
- Johns Hopkins School of Medicine, Baltimore, MD, USA
- Johns Hopkins University, Baltimore, MD, USA
| | - Jill Marsteller
- Johns Hopkins School of Medicine, Baltimore, MD, USA
- Johns Hopkins University, Baltimore, MD, USA
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McConnell KJ, Edelstein S, Hall J, Levy A, Danna M, Cohen DJ, Lindner S, Unützer J, Zhu JM. The effects of behavioral health integration in Medicaid managed care on access to mental health and primary care services-Evidence from early adopters. Health Serv Res 2023; 58:622-633. [PMID: 36635871 PMCID: PMC10154169 DOI: 10.1111/1475-6773.14132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE To evaluate the impacts of a transition to an "integrated managed care" model, wherein Medicaid managed care organizations moved from a "carve-out" model to a "carve-in" model integrating the financing of behavioral and physical health care. DATA SOURCES/STUDY SETTING Medicaid claims data from Washington State, 2014-2019, supplemented with structured interviews with key stakeholders. STUDY DESIGN This mixed-methods study used difference-in-differences models to compare changes in two counties that transitioned to financial integration in 2016 to 10 comparison counties maintaining carve-out models, combined with qualitative analyses of 15 key informant interviews. Quantitative outcomes included binary measures of access to outpatient mental health care, primary care, the emergency department (ED), and inpatient care for mental health conditions. DATA COLLECTION Medicaid claims were collected administratively, and interviews were recorded, transcribed, and analyzed using a thematic analysis approach. PRINCIPAL FINDINGS The transition to financially integrated care was initially disruptive for behavioral health providers and was associated with a temporary decline in access to outpatient mental health services among enrollees with serious mental illness (SMI), but there were no statistically significant or sustained differences after the first year. Enrollees with SMI also experienced a slight increase in access to primary care (1.8%, 95% CI 1.0%-2.6%), but no sustained statistically significant changes in the use of ED or inpatient services for mental health care. The transition to financially integrated care had relatively little impact on primary care providers, with few changes for enrollees with mild, moderate, or no mental illness. CONCLUSIONS Financial integration of behavioral and physical health in Medicaid managed care did not appear to drive clinical transformation and was disruptive to behavioral health providers. States moving towards "carve-in" models may need to incorporate support for practice transformation or financial incentives to achieve the benefits of coordinated mental and physical health care.
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Affiliation(s)
- K. John McConnell
- Center for Health Systems EffectivenessOregon Health & Science UniversityPortlandOregonUnited States
| | - Sara Edelstein
- Center for Health Systems EffectivenessOregon Health & Science UniversityPortlandOregonUnited States
| | - Jennifer Hall
- Department of Family MedicineOregon Health & Science UniversityPortlandOregonUnited States
| | - Anna Levy
- Center for Health Systems EffectivenessOregon Health & Science UniversityPortlandOregonUnited States
| | - Maria Danna
- Department of Family MedicineOregon Health & Science UniversityPortlandOregonUnited States
| | - Deborah J. Cohen
- Department of Family MedicineOregon Health & Science UniversityPortlandOregonUnited States
| | - Stephan Lindner
- Center for Health Systems EffectivenessOregon Health & Science UniversityPortlandOregonUnited States
| | - Jürgen Unützer
- Department of Psychiatry & Behavioral SciencesUniversity of WashingtonSeattleWAUnited States
| | - Jane M. Zhu
- Division of General Internal MedicineOregon Health & Science UniversityPortlandOregonUnited States
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Gosling R, Parry S, Stamou V. Community support groups for men living with depression: barriers and facilitators in access and engagement with services. Home Health Care Serv Q 2021; 41:20-39. [PMID: 34617500 DOI: 10.1080/01621424.2021.1984361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Approximately 10% of the general population will experience depression in adulthood. Concerningly, men with depression are more likely to take their own lives and less likely to seek professional support. Given men's preference for community-based support, this study employed interviews with service providers to explore the barriers and facilitators involved in community support groups for men living with depression. Nine interviews were conducted with service providers across Greater Manchester, UK. Data were analyzed via thematic analysis and revealed four themes: 'Mental Health as a Weakness,' 'Empowering Practice,' 'Trust and Security' and 'Group Support as a Gateway to Treatment.' Men living with depression experience identity conflict, which reduces help-seeking. Community support groups facilitate access and engagement with treatment by providing safe spaces to resolve internal conflicts. Gender-specific group support may facilitate access to support and address long waiting lists of statutory services. Implications for practice, policy and future research are discussed.
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Affiliation(s)
- Rebecca Gosling
- Department of Psychology, Faculty of Health, Psychology & Social Care, Manchester Metropolitan University, Brooks Building, Birley Fields Campus, Manchester, UK
| | - Sarah Parry
- Department of Psychology, Faculty of Health, Psychology & Social Care, Manchester Metropolitan University, Brooks Building, Birley Fields Campus, Manchester, UK
| | - Vasileios Stamou
- Department of Psychology, Faculty of Health, Psychology & Social Care, Manchester Metropolitan University, Brooks Building, Birley Fields Campus, Manchester, UK
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Charlesworth CJ, Zhu JM, Horvitz-Lennon M, McConnell KJ. Use of behavioral health care in Medicaid managed care carve-out versus carve-in arrangements. Health Serv Res 2021; 56:805-816. [PMID: 34312839 DOI: 10.1111/1475-6773.13703] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 04/01/2021] [Accepted: 04/14/2021] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To evaluate differences in access to behavioral health services for Medicaid enrollees covered by a Medicaid entity that integrated the financing of behavioral and physical health care ("carve-in group") versus a Medicaid entity that separated this financing ("carve-out group"). DATA SOURCES/STUDY SETTING Medicaid claims data from two Medicaid entities in the Portland, Oregon tri-county area in 2016. STUDY DESIGN In this cross-sectional study, we compared differences across enrollees in the carve-in versus carve-out group, using a machine learning approach to incorporate a large set of covariates and minimize potential selection bias. Our primary outcomes included behavioral health visits for a variety of different provider types. Secondary outcomes included inpatient, emergency department, and primary care visits. DATA COLLECTION We used Medicaid claims, including adults with at least 9 months of enrollment. PRINCIPAL FINDINGS The study population included 45,786 adults with mental health conditions. Relative to the carve-out group, individuals in the carve-in group were more likely to access outpatient behavioral health (2.39 percentage points, p < 0.0001, with a baseline rate of approximately 73%). The carve-in group was also more likely to access primary care physicians, psychologists, and social workers and less likely to access psychiatrists and behavioral health specialists. Access to outpatient behavioral health visits was more likely in the carve-in arrangement among individuals with mild or moderate mental health conditions (compared to individuals with severe mental illness) and among black enrollees (compared to white enrollees). CONCLUSIONS Financial integration of physical and behavioral health in Medicaid managed care was associated with greater access to behavioral health services, particularly for individuals with mild or moderate mental health conditions and for black enrollees. Recent changes to incentivize financial integration should be monitored to assess differential impacts by illness severity, race and ethnicity, provider types, and other factors.
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Affiliation(s)
- Christina J Charlesworth
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, Oregon, USA
| | - Jane M Zhu
- Division of General Internal Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Marcela Horvitz-Lennon
- RAND Corporation, Cambridge Heath Alliance and Harvard Medical School, Boston, Massachusetts, USA
| | - K John McConnell
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, Oregon, USA
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Boustani M, Unützer J, Leykum LK. Design, implement, and diffuse scalable and sustainable solutions for dementia care. J Am Geriatr Soc 2021; 69:1755-1762. [PMID: 34245584 DOI: 10.1111/jgs.17342] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/14/2021] [Accepted: 05/16/2021] [Indexed: 12/20/2022]
Abstract
Most innovations developed to reduce the burden of Alzheimer disease and other related dementias (ADRD) are difficult to implement, diffuse, and scale. The consequences of such challenges in design, implementation, and diffusion are suboptimal care and resulting harm for people living with ADRD and their caregivers. National experts identified four factors that contribute to our limited ability to implement and diffuse of evidence-based services and interventions for people living with ADRD: (1) limited market demand for the implementation and diffusion of effective ADRD interventions; (2) insufficient engagement of persons living with ADRD and those caring for them in the development of potential ADRD services and interventions; (3) limited evidence and experience regarding scalability and sustainability of evidence-based ADRD care services; and (4) difficulties in taking innovations that work in one context and successfully implementing them in other contexts. New investments in the science of human-centered design, implementation, and diffusion are crucial for meeting the goals of the National Plan to Address Alzheimer's Disease under the auspices of the National Alzheimer's Project Act.
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Affiliation(s)
- Malaz Boustani
- Department of Medicine, Indiana University, Center for Health Innovation and Implementation Science, Indianapolis, Indiana, USA.,Sandra Eskenazi Center for Brain Care Innovation, Eskenazi Health, Indianapolis, Indiana, USA.,Regenstrief Institute, Inc, Indianapolis, Indiana, USA
| | - Jürgen Unützer
- Department of Psychiatry, University of Washington, Seattle, Washington, USA
| | - Luci K Leykum
- Department of Internal Medicine, South Texas Veterans Healthcare System, Austin, Texas, USA.,Dell Medical School, The University of Texas at Austin, Austin, Texas, USA
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Byatt N, Moore Simas TA, Biebel K, Sankaran P, Pbert L, Weinreb L, Ziedonis D, Allison J. PRogram In Support of Moms (PRISM): a pilot group randomized controlled trial of two approaches to improving depression among perinatal women. J Psychosom Obstet Gynaecol 2018; 39:297-306. [PMID: 28994626 PMCID: PMC5893445 DOI: 10.1080/0167482x.2017.1383380] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
PURPOSE This pilot study was designed to inform a larger effectiveness trial by: (1) assessing the feasibility of the PRogram In Support of Moms (PRISM) and our study procedures; and, (2) determining the extent to which PRISM as compared to an active comparison group, the Massachusetts Child Access Psychiatry Program (MCPAP) for Moms alone, improves depression among perinatal women. METHODS Four practices were randomized to either PRISM or MCPAP for Moms alone, a state-wide telephonic perinatal psychiatry program. PRISM includes MCPAP for Moms plus implementation assistance with local champions, training, and implementation of office prompts and procedures to enhance depression screening, assessment and treatment. Patients with Edinburgh Postnatal Depression Scales (EPDS) ≥ 10 were recruited during pregnancy, and completed the EPDS and a structured interview at baseline and 3-12 weeks' postpartum. RESULTS Among MCPAP for Moms alone practices, patients' (n = 9) EPDS scores improved from 15.22 to 10.11 (p = 0.010), whereas in PRISM practices patients' (n = 21) EPDS scores improved from 13.57 to 6.19 (p = 0.001); the between groups difference-of-differences was 2.27 (p = 0.341). CONCLUSIONS PRISM was beneficial for patients, clinicians, and support staff. Both PRISM and MCPAP for Moms alone improve depression symptom severity and the percentage of women with an EPDS >10. The improvement difference between groups was not statistically significant due to limited power associated with small sample size.
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Affiliation(s)
- Nancy Byatt
- University of Massachusetts Medical School and UMass Memorial Health Care, Worcester, MA, USA
| | - Tiffany A. Moore Simas
- University of Massachusetts Medical School and UMass Memorial Health Care, Worcester, MA, USA
| | - Kathleen Biebel
- University of Massachusetts Medical School and UMass Memorial Health Care, Worcester, MA, USA
| | - Padma Sankaran
- University of Massachusetts Medical School and UMass Memorial Health Care, Worcester, MA, USA
| | - Lori Pbert
- University of Massachusetts Medical School and UMass Memorial Health Care, Worcester, MA, USA
| | - Linda Weinreb
- University of Massachusetts Medical School and UMass Memorial Health Care, Worcester, MA, USA
| | - Douglas Ziedonis
- Department of Psychiatry, University of California, San Diego, CA, USA
| | - Jeroan Allison
- University of Massachusetts Medical School and UMass Memorial Health Care, Worcester, MA, USA
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Moore Simas TA, Flynn MP, Kroll-Desrosiers AR, Carvalho SM, Levin LL, Biebel K, Byatt N. A Systematic Review of Integrated Care Interventions Addressing Perinatal Depression Care in Ambulatory Obstetric Care Settings. Clin Obstet Gynecol 2018; 61:573-590. [PMID: 29553986 PMCID: PMC6059986 DOI: 10.1097/grf.0000000000000360] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
This systematic review searched 4 databases (PubMed/MEDLINE, Scopus, CINAHL, and PsychINFO) and identified 21 articles eligible to evaluate the extent to which interventions that integrate depression care into outpatient obstetric practice are feasible, effective, acceptable, and sustainable. Despite limitations among the available studies including marked heterogeneity, there is evidence supporting feasibility, effectiveness, and acceptability. In general, this is an emerging field with promise that requires additional research. Critical to its real-world success will be consideration for practice workflow and logistics, and sustainability through novel reimbursement mechanisms.
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Affiliation(s)
- Tiffany A. Moore Simas
- University of Massachusetts Medical School, Worcester, MA
- UMass Memorial Health Care, Worcester, MA
- Department of Obstetrics and Gynecology
- Department of Psychiatry
- Department of Pediatrics
| | - Michael P. Flynn
- University of Massachusetts Medical School, Worcester, MA
- Department of Obstetrics and Gynecology
| | | | | | - Leonard L. Levin
- University of Massachusetts Medical School, Worcester, MA
- Francis A. Countway Library of Medicine, Harvard Medical School, Boston, MA
- Department of Family and Community Medicine
| | - Kathleen Biebel
- University of Massachusetts Medical School, Worcester, MA
- Department of Psychiatry
| | - Nancy Byatt
- University of Massachusetts Medical School, Worcester, MA
- UMass Memorial Health Care, Worcester, MA
- Department of Obstetrics and Gynecology
- Department of Psychiatry
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Carlo AD, Unützer J, Ratzliff ADH, Cerimele JM. Financing for Collaborative Care - A Narrative Review. CURRENT TREATMENT OPTIONS IN PSYCHIATRY 2018; 5:334-344. [PMID: 30083495 PMCID: PMC6075691 DOI: 10.1007/s40501-018-0150-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
PURPOSE OF REVIEW Collaborative care (CoCM) is an evidence-based model for the treatment of common mental health conditions in the primary care setting. Its workflow encourages systematic communication among clinicians outside of face-to-face patient encounters, which has posed financial challenges in traditional fee-for-service reimbursement environments. RECENT FINDINGS Organizations have employed various financing strategies to promote CoCM sustainability, including external grants, alternate payment model contracts with specific payers and the use of billing codes for individual components of CoCM. In recent years, Medicare approved fee-for-service, time-based billing codes for CoCM that allow for the reimbursement of patient care performed outside of face-to-face encounters. A growing number of Medicaid and commercial payers have followed suit, either recognizing the fee-for-service codes or contracting to reimburse in alternate payment models. SUMMARY Although significant challenges remain, novel methods for payment and cooperative efforts among insurers have helped move CoCM closer to financial sustainability.
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Affiliation(s)
- Andrew D Carlo
- University of Washington School of Medicine, Department of Psychiatry and Behavioral Sciences - 1959 NE Pacific Street, Box 356560, Room BB1644, Seattle, WA 98195-6560
| | - Jürgen Unützer
- University of Washington School of Medicine, Department of Psychiatry and Behavioral Sciences - 1959 NE Pacific Street, Box 356560, Room BB1644, Seattle, WA 98195-6560
| | - Anna D H Ratzliff
- University of Washington School of Medicine, Department of Psychiatry and Behavioral Sciences - 1959 NE Pacific Street, Box 356560, Room BB1644, Seattle, WA 98195-6560
| | - Joseph M Cerimele
- University of Washington School of Medicine, Department of Psychiatry and Behavioral Sciences - 1959 NE Pacific Street, Box 356560, Room BB1644, Seattle, WA 98195-6560
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Bishop TF, Ramsay PP, Casalino LP, Bao Y, Pincus HA, Shortell SM. Care Management Processes Used Less Often For Depression Than For Other Chronic Conditions In US Primary Care Practices. Health Aff (Millwood) 2017; 35:394-400. [PMID: 26953291 DOI: 10.1377/hlthaff.2015.1068] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Primary care physicians play an important role in the diagnosis and management of depression. Yet little is known about their use of care management processes for depression. Using national survey data for the period 2006-13, we assessed the use of five care management processes for depression and other chronic illnesses among primary care practices in the United States. We found significantly less use for depression than for asthma, congestive heart failure, or diabetes in 2012-13. On average, practices used fewer than one care management process for depression, and this level of use has not changed since 2006-07, regardless of practice size. In contrast, use of diabetes care management processes has increased significantly among larger practices. These findings may indicate that US primary care practices are not well equipped to manage depression as a chronic illness, despite the high proportion of depression care they provide. Policies that incentivize depression care management, including additional quality metrics, should be considered.
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Affiliation(s)
- Tara F Bishop
- Tara F. Bishop is an associate professor in the Department of Healthcare Policy and Research at Weill Cornell Medical College, in New York City
| | - Patricia P Ramsay
- Patricia P. Ramsay is a research specialist and administrative director of the Center for Healthcare Organizational and Innovation Research (CHOIR) in the School of Public Health, University of California, Berkeley
| | - Lawrence P Casalino
- Lawrence P. Casalino is the Livingston Farrand Professor of Public Health and chief of the Division of Health Policy and Economics in the Department of Healthcare Policy and Research, at Weill Cornell Medical College
| | - Yuhua Bao
- Yuhua Bao is an associate professor of healthcare policy and research at Weill Cornell Medical College
| | - Harold A Pincus
- Harold A. Pincus is a professor and vice chair of Columbia Psychiatry, Columbia University; director of quality and outcomes research at New York-Presbyterian Hospital, and codirector of the Irving Institute for Clinical and Translational Research at Columbia University, all in New York City. He also is a senior scientist at the RAND Corporation
| | - Stephen M Shortell
- Stephen M. Shortell is the Blue Cross of California Distinguished Professor, a professor of organization behavior, director of CHOIR, and dean emeritus, all at the School of Public Health, University of California, Berkeley
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Byatt N, Pbert L, Hosein S, Swartz HA, Weinreb L, Allison J, Ziedonis D. PRogram In Support of Moms (PRISM): Development and Beta Testing. Psychiatr Serv 2016; 67:824-6. [PMID: 27079994 PMCID: PMC5515590 DOI: 10.1176/appi.ps.201600049] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Most women with perinatal depression do not receive depression treatment. The authors describe the development and beta testing of a new program, PRogram In Support of Moms (PRISM), to improve treatment of perinatal depression in obstetric practices. A multidisciplinary work group of seven perinatal and behavioral health professionals was convened to design, refine, and beta-test PRISM in an obstetric practice. Iterative feedback and problem solving facilitated development of PRISM components, which include provider training and a toolkit, screening procedures, implementation assistance, and access to immediate psychiatric consultation. Beta testing with 50 patients over two months demonstrated feasibility and suggested that PRISM may improve provider screening rates and self-efficacy to address depression. On the basis of lessons learned, PRISM will be enhanced to integrate proactive patient engagement and monitoring into obstetric practices. PRISM may help overcome patient-, provider-, and system-level barriers to managing perinatal depression in obstetric settings.
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Affiliation(s)
- Nancy Byatt
- Dr. Byatt and Dr. Ziedonis are with the Department of Psychiatry, Dr. Pbert is with the Department of Medicine, Ms. Hosein is a medical student, Dr. Weinreb is with the Department of Medicine and Community Health, and Dr. Allison is with the Department of Quantitative Heath Sciences, all at the University of Massachusetts Medical School, Worcester (e-mail: ). Dr. Byatt is also with the Department of Obstetrics and Gynecology, University of Massachusetts Medical School, Worcester. Dr. Swartz is with the Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. Marcela Horvitz-Lennon, M.D., M.P.H., is editor of this column
| | - Lori Pbert
- Dr. Byatt and Dr. Ziedonis are with the Department of Psychiatry, Dr. Pbert is with the Department of Medicine, Ms. Hosein is a medical student, Dr. Weinreb is with the Department of Medicine and Community Health, and Dr. Allison is with the Department of Quantitative Heath Sciences, all at the University of Massachusetts Medical School, Worcester (e-mail: ). Dr. Byatt is also with the Department of Obstetrics and Gynecology, University of Massachusetts Medical School, Worcester. Dr. Swartz is with the Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. Marcela Horvitz-Lennon, M.D., M.P.H., is editor of this column
| | - Safiyah Hosein
- Dr. Byatt and Dr. Ziedonis are with the Department of Psychiatry, Dr. Pbert is with the Department of Medicine, Ms. Hosein is a medical student, Dr. Weinreb is with the Department of Medicine and Community Health, and Dr. Allison is with the Department of Quantitative Heath Sciences, all at the University of Massachusetts Medical School, Worcester (e-mail: ). Dr. Byatt is also with the Department of Obstetrics and Gynecology, University of Massachusetts Medical School, Worcester. Dr. Swartz is with the Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. Marcela Horvitz-Lennon, M.D., M.P.H., is editor of this column
| | - Holly A Swartz
- Dr. Byatt and Dr. Ziedonis are with the Department of Psychiatry, Dr. Pbert is with the Department of Medicine, Ms. Hosein is a medical student, Dr. Weinreb is with the Department of Medicine and Community Health, and Dr. Allison is with the Department of Quantitative Heath Sciences, all at the University of Massachusetts Medical School, Worcester (e-mail: ). Dr. Byatt is also with the Department of Obstetrics and Gynecology, University of Massachusetts Medical School, Worcester. Dr. Swartz is with the Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. Marcela Horvitz-Lennon, M.D., M.P.H., is editor of this column
| | - Linda Weinreb
- Dr. Byatt and Dr. Ziedonis are with the Department of Psychiatry, Dr. Pbert is with the Department of Medicine, Ms. Hosein is a medical student, Dr. Weinreb is with the Department of Medicine and Community Health, and Dr. Allison is with the Department of Quantitative Heath Sciences, all at the University of Massachusetts Medical School, Worcester (e-mail: ). Dr. Byatt is also with the Department of Obstetrics and Gynecology, University of Massachusetts Medical School, Worcester. Dr. Swartz is with the Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. Marcela Horvitz-Lennon, M.D., M.P.H., is editor of this column
| | - Jeroan Allison
- Dr. Byatt and Dr. Ziedonis are with the Department of Psychiatry, Dr. Pbert is with the Department of Medicine, Ms. Hosein is a medical student, Dr. Weinreb is with the Department of Medicine and Community Health, and Dr. Allison is with the Department of Quantitative Heath Sciences, all at the University of Massachusetts Medical School, Worcester (e-mail: ). Dr. Byatt is also with the Department of Obstetrics and Gynecology, University of Massachusetts Medical School, Worcester. Dr. Swartz is with the Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. Marcela Horvitz-Lennon, M.D., M.P.H., is editor of this column
| | - Douglas Ziedonis
- Dr. Byatt and Dr. Ziedonis are with the Department of Psychiatry, Dr. Pbert is with the Department of Medicine, Ms. Hosein is a medical student, Dr. Weinreb is with the Department of Medicine and Community Health, and Dr. Allison is with the Department of Quantitative Heath Sciences, all at the University of Massachusetts Medical School, Worcester (e-mail: ). Dr. Byatt is also with the Department of Obstetrics and Gynecology, University of Massachusetts Medical School, Worcester. Dr. Swartz is with the Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. Marcela Horvitz-Lennon, M.D., M.P.H., is editor of this column
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Abstract
Despite strong efforts, the diagnosis and treatment of depression bring many challenges in the primary care setting. Screening for depression has been shown to be effective only if reliable systems of care are in place to ensure appropriate treatment by clinicians and adherence by patients. New evidence-based models of care for depression exist, but spread has been slow because of inadequate funding structures and conflicts within current clinical culture. The Affordable Care Act introduces potential opportunities to reorganize funding structures, conceivably leading to increased adoption of these collaborative care models. Suicide screening remains controversial.
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Affiliation(s)
- D Edward Deneke
- Department of Psychiatry, University of Michigan Health System, University of Michigan, 4250 Plymouth Road, Ann Arbor, MI 48109-2700, USA.
| | - Heather E Schultz
- Inpatient Psychiatry, University of Michigan Hospital and Health Systems, University of Michigan University Hospital, 9C 9150, 1500 East Medical Center Drive, SPC 5120, Ann Arbor MI 48109, USA
| | - Thomas E Fluent
- Department of Psychiatry, University of Michigan Health System, University of Michigan, 4250 Plymouth Road, Ann Arbor, MI 48109-2700, USA
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12
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Abstract
Despite strong efforts, the diagnosis and treatment of depression bring many challenges in the primary care setting. Screening for depression has been shown to be effective only if reliable systems of care are in place to ensure appropriate treatment by clinicians and adherence by patients. New evidence-based models of care for depression exist, but spread has been slow because of inadequate funding structures and conflicts within current clinical culture. The Affordable Care Act introduces potential opportunities to reorganize funding structures, conceivably leading to increased adoption of these collaborative care models. Suicide screening remains controversial.
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Affiliation(s)
- D Edward Deneke
- Department of Psychiatry, University of Michigan Health System, University of Michigan, 4250 Plymouth Road, Ann Arbor, MI 48109-2700, USA.
| | - Heather Schultz
- Department of Psychiatry, University of Michigan Health System, University of Michigan, 4250 Plymouth Road, Ann Arbor, MI 48109-2700, USA
| | - Thomas E Fluent
- Department of Psychiatry, University of Michigan Health System, University of Michigan, 4250 Plymouth Road, Ann Arbor, MI 48109-2700, USA
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Abstract
During the past two decades, research in the field of depression and cardiovascular disorders has exploded. Multiple studies have demonstrated that depression is more prevalent in populations with cardiovascular disease, is a robust risk factor for the development of cardiovascular disease in healthy populations, and is predictive of adverse outcomes (such as myocardial infarction and death) among populations with preexisting cardiovascular disease. Mechanistic studies have shown that poor health behaviors, such as physical inactivity, medication nonadherence, and smoking, strongly contribute to this association. Small randomized trials have found that antidepressant therapies may improve cardiac outcomes. Based on this accumulating evidence, the American Heart Association has recommended routine screening for depression in all patients with coronary heart disease. This review examines the key epidemiological literature on depression and cardiovascular disorders and discusses our current understanding of the mechanisms responsible for this association. We also examine current recommendations for screening, diagnosis, and management of depression. We conclude by highlighting new research areas and discussing therapeutic management of depression in patients with cardiovascular disorders.
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Affiliation(s)
- Mary A Whooley
- Department of Medicine, University of California, San Francisco, California 94143, USA.
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Levey SMB, Miller BF, deGruy FV. Behavioral health integration: an essential element of population-based healthcare redesign. Transl Behav Med 2012; 2:364-71. [PMID: 24073136 PMCID: PMC3717906 DOI: 10.1007/s13142-012-0152-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The fundamental aim of healthcare reform is twofold: to provide health insurance coverage for most of the citizens currently uninsured, thereby granting them access to healthcare; and to redesign the overall healthcare system to provide better care and achieve the triple aim (better health for the population, better healthcare for individuals, and at less cost). The foundation for this improved system will rest on a redesigned (i.e., sufficiently comprehensive and integrated) system of primary care, with which all other providers, services, and sites of care are associated. The Patient-Centered Medical Home (PCMH) and its congeners are the best current examples of the kind of primary care that can achieve the triple aim, if they can become sufficiently comprehensive and can adequately integrate services. This means fully integrating behavioral healthcare into the PCMH, a difficult task under the most favorable circumstances. Creating functioning accountable care organizations is an even more daunting task: this requires new principles of collaborating and financing and the current prototypes have generally failed to incorporate behavioral healthcare sufficient to meet even the basic needs of the target population. This paper will discuss (1) the case for and the difficulties associated with integrating behavioral healthcare into primary care at three levels: the practice, the state, and the nation; and (2) how this looks clinically, operationally, and financially.
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Affiliation(s)
- Shandra M Brown Levey
- Department of Family Medicine, University of Colorado Denver School of Medicine, Mail Stop F496, Academic Office 1, 12631 East 17th Avenue, Aurora, CO 80045 USA
| | - Benjamin F Miller
- Department of Family Medicine, University of Colorado Denver School of Medicine, Mail Stop F496, Academic Office 1, 12631 East 17th Avenue, Aurora, CO 80045 USA
| | - Frank Verloin deGruy
- Department of Family Medicine, University of Colorado Denver School of Medicine, Mail Stop F496, Academic Office 1, 12631 East 17th Avenue, Aurora, CO 80045 USA
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Curran GM, Sullivan G, Mendel P, Craske MG, Sherbourne CD, Stein MB, McDaniel A, Roy-Byrne P. Implementation of the CALM intervention for anxiety disorders: a qualitative study. Implement Sci 2012; 7:1-11. [PMID: 22404963 PMCID: PMC3319426 DOI: 10.1186/1748-5908-7-14] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2011] [Accepted: 03/09/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Investigators recently tested the effectiveness of a collaborative-care intervention for anxiety disorders: Coordinated Anxiety Learning and Management(CALM) []) in 17 primary care clinics around the United States. Investigators also conducted a qualitative process evaluation. Key research questions were as follows: (1) What were the facilitators/barriers to implementing CALM? (2) What were the facilitators/barriers to sustaining CALM after the study was completed? METHODS Key informant interviews were conducted with 47 clinic staff members (18 primary care providers, 13 nurses, 8 clinic administrators, and 8 clinic staff) and 14 study-trained anxiety clinical specialists (ACSs) who coordinated the collaborative care and provided cognitive behavioral therapy. The interviews were semistructured and conducted by phone. Data were content analyzed with line-by-line analyses leading to the development and refinement of themes. RESULTS Similar themes emerged across stakeholders. Important facilitators to implementation included the perception of "low burden" to implement, provider satisfaction with the intervention, and frequent provider interaction with ACSs. Barriers to implementation included variable provider interest in mental health, high rates of part-time providers in clinics, and high social stressors of lower socioeconomic-status patients interfering with adherence. Key sustainability facilitators were if a clinic had already incorporated collaborative care for another disorder and presence of onsite mental health staff. The main barrier to sustainability was funding for the ACS. CONCLUSIONS The CALM intervention was relatively easy to incorporate during the effectiveness trial, and satisfaction was generally high. Numerous implementation and sustainability barriers could limit the reach and impact of widespread adoption. Findings should be interpreted with the knowledge that the ACSs in this study were provided and trained by the study. Future research should explore uptake of CALM and similar interventions without the aid of an effectiveness trial.
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Affiliation(s)
- Geoffrey M Curran
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
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Perry DF, Nicholson W, Christensen AL, Riley AW. A Public Health Approach to Addressing Perinatal Depression. INTERNATIONAL JOURNAL OF MENTAL HEALTH PROMOTION 2011. [DOI: 10.1080/14623730.2011.9715657] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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17
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Chronic disease management for depression in US medical practices: results from the Health Tracking Physician Survey. Med Care 2011; 49:634-40. [PMID: 21430575 DOI: 10.1097/mlr.0b013e31821041c7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Chronic care model (CCM) envisages a multicomponent systematic remodeling of ambulatory care to improve chronic diseases management. Application of CCM in primary care management of depression has traditionally lagged behind the application of this model in management of other common chronic illnesses. In past research, the use of CCM has been operationalized by measuring the use of evidence-based organized care management processes (CMPs). OBJECTIVES To compare the use of CMPs in treatment of depression with the use of these processes in treatment of diabetes and asthma and to examine practice-level correlates of this use. STUDY DESIGN Using data from the 2008 Health Tracking Physician Survey, a nationally representative sample of physicians in the United States, we compared the use of 5 different CMPs: written guidelines in English and other languages for self-management, availability of staff to educate patients about self-management, availability of nurse care managers for care coordination, and group meetings of patients with staff. We further examined the association of practice-level characteristics with the use of the 5 CMPs for management of depression. RESULTS CMPs were more commonly used for management of diabetes and asthma than for depression. The use of CMPs for depression was more common in health maintenance organizations [adjusted odds ratios (AOR) ranging from 2.45 to 5.98 for different CMPs], in practices that provided physicians with feedback regarding quality of care to patients (AOR range, 1.42 to 1.69), and in practices with greater use of clinical information technology (AOR range, 1.06 to 1.11). CONCLUSION The application of CMPs in management of depression continues to lag behind other common chronic conditions. Feedbacks on quality of care and expanded use of information technology may improve application of CMPs for depression care in general medical settings.
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Bao Y, Casalino LP, Ettner SL, Bruce ML, Solberg LI, Unützer J. Designing payment for Collaborative Care for Depression in primary care. Health Serv Res 2011; 46:1436-51. [PMID: 21609327 DOI: 10.1111/j.1475-6773.2011.01272.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To design a bundled case rate for Collaborative Care for Depression (CCD) that aligns incentives with evidence-based depression care in primary care. DATA SOURCES A clinical information system used by all care managers in a randomized controlled trial of CCD for older primary care patients. STUDY DESIGN We conducted an empirical investigation of factors accounting for variation in CCD resource use over time and across patients. CCD resource use at the patient-episode and patient-month levels was measured by number of care manager contacts and direct patient contact time and analyzed with count data (Poisson or negative binomial) models. PRINCIPAL FINDINGS Episode-level resource use varies substantially with patient's time in the program. Monthly use declines sharply in the first 6 months regardless of treatment response or remission status, but it remains stable afterwards. An adjusted episode or monthly case rate design better matches payment with variation in resource use compared with a fixed design. CONCLUSIONS Our findings lend support to an episode payment adjusted by number of months receiving CCD and a monthly payment adjusted by the ordinal month. Nonpayment tools including program certification and performance evaluation and reward systems are needed to fully align incentives.
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Affiliation(s)
- Yuhua Bao
- Department of Public Health, Weill Cornell Medical College, 402 E 67th St., New York, NY 10065, USA.
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19
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Initiation of Primary Care-Mental Health Integration programs in the VA Health System: associations with psychiatric diagnoses in primary care. Med Care 2010; 48:843-51. [PMID: 20706160 DOI: 10.1097/mlr.0b013e3181e5792b] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Providing collaborative mental health treatment within primary care settings improves depression outcomes and may improve detection of mental disorders. Few studies have assessed the effect of collaborative mental health treatment programs on diagnosis of mental disorders in primary care populations. In 2008, many Department of Veterans Affairs (VA) facilities implemented collaborative care programs, as part of the VA's Primary Care-Mental Health Integration (PC-MHI) program. OBJECTIVES To assess the prevalence of diagnosed mental health conditions among primary care patient populations in association with PC-MHI programs, overall and for patient subpopulations that may be less likely to receive mental health treatment. RESEARCH DESIGN Using a difference-in-differences analysis, we evaluated whether the rates of psychiatric diagnoses among primary care patient populations at 294 VA facilities changed from fiscal year (FY)07 to FY08, and whether trends differed at facilities with PC-MHI encounters in FY08. Subgroup analyses examined whether trends differed by patient age and race/ethnicity. SUBJECTS, MEASURES, AND RESULTS: From FY07 to FY08, the prevalence of diagnosed depression, anxiety, post-traumatic stress disorder, and alcohol abuse increased more in the 137 facilities with PC-MHI program encounters than in the 157 facilities without these encounters. Increases were more likely among patients who were younger (18-64) and white. CONCLUSIONS Initiation of PC-MHI programs was associated with elevated diagnosis patterns, which may enhance recognition of mental health needs among primary care patients. Increases in diagnosis prevalence were not uniform across patient subgroups. Further research is needed on treatment processes and outcomes for individuals receiving services in PC-MHI programs.
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Stakeholder Benefit from Depression Disease Management: Differences by Rurality? J Behav Health Serv Res 2010; 38:114-21. [DOI: 10.1007/s11414-009-9204-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2009] [Accepted: 12/01/2009] [Indexed: 12/01/2022]
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Katon W, Unützer J, Wells K, Jones L. Collaborative depression care: history, evolution and ways to enhance dissemination and sustainability. Gen Hosp Psychiatry 2010; 32:456-64. [PMID: 20851265 PMCID: PMC3810032 DOI: 10.1016/j.genhosppsych.2010.04.001] [Citation(s) in RCA: 154] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2010] [Revised: 04/05/2010] [Accepted: 04/06/2010] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To describe the history and evolution of the collaborative depression care model and new research aimed at enhancing dissemination. METHOD Four keynote speakers from the 2009 NIMH Annual Mental Health Services Meeting collaborated in this article in order to describe the history and evolution of collaborative depression care, adaptation of collaborative care to new populations and medical settings, and optimal ways to enhance dissemination of this model. RESULTS Extensive evidence across 37 randomized trials has shown the effectiveness of collaborative care vs. usual primary care in enhancing quality of depression care and in improving depressive outcomes for up to 2 to 5 years. Collaborative care is currently being disseminated in large health care organizations such as the Veterans Administration and Kaiser Permanente, as well as in fee-for-services systems and federally funded clinic systems of care in multiple states. New adaptations of collaborative care are being tested in pediatric and ob-gyn populations as well as in populations of patients with multiple comorbid medical illnesses. New NIMH-funded research is also testing community-based participatory research approaches to collaborative care to attempt to decrease disparities of care in underserved minority populations. CONCLUSION Collaborative depression care has extensive research supporting the effectiveness of this model. New research and demonstration projects have focused on adapting this model to new populations and medical settings and on studying ways to optimally disseminate this approach to care, including developing financial models to incentivize dissemination and partnerships with community populations to enhance sustainability and to decrease disparities in quality of mental health care.
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Affiliation(s)
- Wayne Katon
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA 98195, USA.
| | - Jürgen Unützer
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA 98195, USA
| | - Kenneth Wells
- Department of Psychiatry and Biobehavioral Sciences, UCLA Medical School, Los Angeles, CA 90095, USA
| | - Loretta Jones
- Charles R. Drew University of Medicine and Science, Los Angeles, CA 98059, USA
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Maurer J, Rebbapragada V, Borson S, Goldstein R, Kunik ME, Yohannes AM, Hanania NA. Anxiety and depression in COPD: current understanding, unanswered questions, and research needs. Chest 2008; 134:43S-56S. [PMID: 18842932 DOI: 10.1378/chest.08-0342] [Citation(s) in RCA: 457] [Impact Index Per Article: 28.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Approximately 60 million people in the United States live with one of four chronic conditions: heart disease, diabetes, chronic respiratory disease, and major depression. Anxiety and depression are very common comorbidities in COPD and have significant impact on patients, their families, society, and the course of the disease. METHODS We report the proceedings of a multidisciplinary workshop on anxiety and depression in COPD that aimed to shed light on the current understanding of these comorbidities, and outline unanswered questions and areas of future research needs. RESULTS Estimates of prevalence of anxiety and depression in COPD vary widely but are generally higher than those reported in some other advanced chronic diseases. Untreated and undetected anxiety and depressive symptoms may increase physical disability, morbidity, and health-care utilization. Several patient, physician, and system barriers contribute to the underdiagnosis of these disorders in patients with COPD. While few published studies demonstrate that these disorders associated with COPD respond well to appropriate pharmacologic and nonpharmacologic therapy, only a small proportion of COPD patients with these disorders receive effective treatment. CONCLUSION Future research is needed to address the impact, early detection, and management of anxiety and depression in COPD.
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Nutting PA, Gallagher K, Riley K, White S, Dickinson WP, Korsen N, Dietrich A. Care management for depression in primary care practice: findings from the RESPECT-Depression trial. Ann Fam Med 2008; 6:30-7. [PMID: 18195312 PMCID: PMC2203406 DOI: 10.1370/afm.742] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE This qualitative study examined the barriers to adopting depression care management among 42 primary care clinicians in 30 practices. METHODS The RESPECT-Depression trial worked collaboratively with 5 large health care organizations (and 60 primary care practices) to implement and disseminate an evidence-based intervention. This study used semistructured interviews with 42 primary care clinicians from 30 practice sites, 18 care managers, and 7 mental health professionals to explore experience and perceptions with depression care management for patients. Subject selection in 4 waves of interviews was driven by themes emerging from ongoing data analysis. RESULTS Primary care clinicians reported broad appreciation of the benefits of depression care management for their patients. Lack of reimbursement and the competing demands of primary care were often cited as barriers. These clinicians at many levels of initial enthusiasm for care management increased their enthusiasm after experiencing care management through the project. Psychiatric oversight of the care manager with suggestions for the clinicians was widely seen as important and appropriate by clinicians, care managers, and psychiatrists. Clinicians and care managers emphasized the importance of establishing effective communication among themselves, as well as maintaining a consistent and continuous relationship with the patients. The clinicians were selective in which patients they referred for care management, and there was wide variation in opinion about which patients were optimal candidates. Care managers were able to operate both from within a practice and more centrally when specific attention was given to negotiating communication strategies with a clinician. CONCLUSIONS Care management for depression is an attractive option for most primary care clinicians. Lack of reimbursement remains the single greatest obstacle to more widespread adoption.
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Affiliation(s)
- Paul A Nutting
- The Center for Research Strategies, Denver, Colorado 80203, USA.
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Steinman LE, Frederick JT, Prohaska T, Satariano WA, Dornberg-Lee S, Fisher R, Graub PB, Leith K, Presby K, Sharkey J, Snyder S, Turner D, Wilson N, Yagoda L, Unutzer J, Snowden M. Recommendations for treating depression in community-based older adults. Am J Prev Med 2007; 33:175-81. [PMID: 17826575 DOI: 10.1016/j.amepre.2007.04.034] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2007] [Revised: 04/04/2007] [Accepted: 04/28/2007] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To present recommendations for community-based treatment of late-life depression to public health and aging networks. METHODS An expert panel of mental health and public health researchers and community-based practitioners in aging was convened in April 2006 to form consensus-based recommendations. When making recommendations, panelists considered feasibility and appropriateness for community-based delivery, as well as strength of evidence on program effectiveness from a systematic literature review of articles published through 2005. RESULTS The expert panel strongly recommended depression care management-modeled interventions delivered at home or at primary care clinics. The panel recommended individual cognitive behavioral therapy. Interventions not recommended as primary treatments for late-life depression included education and skills training, comprehensive geriatric health evaluation programs, exercise, and physical rehabilitation/occupational therapy. There was insufficient evidence for making recommendations for several intervention categories, including group psychotherapy and psychotherapies other than cognitive behavioral therapy. CONCLUSIONS This interdisciplinary expert panel determined that recommended interventions should be disseminated throughout the public health and aging networks, while acknowledging the challenges and obstacles involved. Interventions that were not recommended or had insufficient evidence often did not treat depression primarily and/or did not include a clinically depressed sample while attempting to establish efficacy. These interventions may provide other benefits, but should not be presumed to effectively treat depression by themselves. Panelists also identified primary prevention of depression as a much under-studied area. These findings should aid individual clinicians as well as public health decision makers in the delivery of population-based mental health services in diverse community settings.
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Affiliation(s)
- Lesley E Steinman
- Department of Health Services, University of Washington School of Public Health and Community Medicine, Seattle, Washington, USA
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Williams JW, Gerrity M, Holsinger T, Dobscha S, Gaynes B, Dietrich A. Systematic review of multifaceted interventions to improve depression care. Gen Hosp Psychiatry 2007; 29:91-116. [PMID: 17336659 DOI: 10.1016/j.genhosppsych.2006.12.003] [Citation(s) in RCA: 179] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2006] [Revised: 12/04/2006] [Accepted: 12/05/2006] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Depression is a prevalent high-impact illness with poor outcomes in primary care settings. We performed a systematic review to determine to what extent multifaceted interventions improve depression outcomes in primary care and to define key elements, patients who are likely to benefit and resources required for these interventions. METHOD We searched Medline, HealthSTAR, CINAHL, PsycINFO and a specialized registry of depression trials from 1966 to February 2006; reviewed bibliographies of pertinent articles; and consulted experts. Searches were limited to the English language. We included 28 randomized controlled trials that: (a) involved primary care patients receiving acute-phase treatment; (b) tested a multicomponent intervention involving a patient-directed component; and (c) reported effects on depression severity. Pairs of investigators independently abstracted information regarding (a) setting and subjects, (b) components of the intervention and (c) outcomes. RESULTS Twenty of 28 interventions improved depression outcomes over 3-12 months (an 18.4% median absolute increase in patients with 50% improvement in symptoms; range, 8.3-46%). Sustained improvements at 24-57 months were demonstrated in three studies addressing acute-phase and continuation-phase treatments. All interventions involved care management and required additional resources or staff reassignment to implement; interventions were delivered exclusively or predominantly by telephone in 16 studies. The most commonly used intervention features were: patient education and self-management, monitoring of depressive symptoms and treatment adherence, decision support for medication management, a patient registry and mental health supervision of care managers. Other intervention features were highly variable. CONCLUSION There is strong evidence supporting the short-term benefits of care management for depression; critical elements for successful programs are emerging.
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Affiliation(s)
- John W Williams
- Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, NC, USA.
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Moore DE, Cervero RM, Fox R. A conceptual model of CME to address disparities in depression care. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2007; 27 Suppl 1:S40-S54. [PMID: 18085583 DOI: 10.1002/chp.134] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
The gap between best practices and actual practice in depression care--the difference between "what should be" and "what is"--is wider for ethnic and racial minorities than for the general population. Education alone is not reducing the gap or improving outcomes. Interventions such as the chronic care model have demonstrated improvements in physician performance and patient health status, both in the general population and among ethnic and racial minorities. Recent reviews of continuing medical education (CME) have shown that it is effective when the planned activities include (1) needs assessment and a focus on higher-level outcomes, (2) multiple ongoing activities that are sequenced for learning, (3) planning that considers the context in which the learned principles will be applied, (4) interactivity, and (5) active learning. The authors describe an approach to planning CME reflecting these five factors and suggest that CME planned in this way be combined with the chronic care model to enhance outcomes further.
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Affiliation(s)
- Donald E Moore
- Division of Continuing Medical Education, Vanderbilt University School of Medicine, 320 Light Hall, 2215 Garland Avenue, Nashville, TN 37232, USA.
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Moore DE, Overstreet KM, Like RC, Kristofco RE. Improving depression care for ethnic and racial minorities: a concept for an intervention that integrates CME planning with improvement strategies. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2007; 27 Suppl 1:S65-S74. [PMID: 18085584 DOI: 10.1002/chp.136] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Depression is one of the most common reasons that individuals seek treatment in the primary care setting. Research in the past 15 years has shown that dramatic improvement in the management of patients with depression is possible. Advances in pharmacotherapy and delivery of depression care have been reported, but few currently benefit members of ethnic and racial minorities. Educating physicians and other health professionals has been suggested as one approach to address the issues related to disparities in depression care. There is little evidence, however, that education alone is effective. The authors of this article believe that incorporating physician learning activities that are planned using approaches that have been shown to be effective in interventions currently demonstrating some success in improving depression care provided to ethnic and racial minorities will enhance the impact and sustainability of these interventions. This article--the conclusion of this supplement--will describe an intervention concept that integrates a quality improvement model (the Institute for Health Improvement's Breakthrough Series Collaborative model) with an evidence-based approach to planning CME and supports the integration by using action inquiry technologies and community-based participatory research methods. Relevant approaches from implementation research are discussed, and suggestions for testing the intervention concept are provided.
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Affiliation(s)
- Donald E Moore
- Division of Continuing Medical Education, Vanderbilt University School of Medicine, 320 Light Hall, 2215 Garland Avenue, Nashville, TN 37232, USA.
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