Social Innovation Fund: Healthy Futures

IMPROVING DEPRESSION CARE IN THE RURAL WEST: SOCIAL INNOVATION FUND

Poor mental health is a major public health issue that robs millions of people of their chance to lead healthy and productive lives. Depression alone doubles overall healthcare costs, worsens other medical conditions, and results in a staggering loss of productivity at work. In underserved rural areas in the WWAMI (Washington, Wyoming, Alaska, Montana and Idaho) region, a severe shortage of mental health providers compounds these problems.

Through a public-private partnership, the AIMS Center supported eight rural community primary care clinics serving low-income patients to implement collaborative care (also called collaborative care management or CoCM) in the WWAMI region, a geographic area served by the University of Washington School of Medicine and representing 27% of the land mass of the United States. These 8 clinics planned to serve 3,250 patients but ultimately enrolled 5,392 patients. This represents 16% of the total unique patients served by these clinics and is a significant increase of the patients they were able to reach before implementing CoCM.

Read: One Clinic’s Story.

IMPACT: Improving Mood — Promoting Access to Collaborative Treatment

The legacy terms “IMPACT Care” or “IMPACT Model” is largely synonymous with Collaborative Care. The terms originate from the IMPACT study, the first large randomized controlled trial of treatment for depression. The IMPACT study demonstrated that Collaborative Care more than doubled the effectiveness of depression treatment for older adults in primary care settings.

The Collaborative Care model (CoCM) is now recognized as effective in treating a wide range of behavioral health disorders – not just depression. A team-based Collaborative Care approach can also address anxiety and trauma disorders, chronic pain, substance use disorders including alcohol and opioids, and ADHD.

In the largest treatment trial for depression to date, a team of researchers led by Dr. Jürgen Unützer followed 1,801 depressed, older adults from 18 diverse primary care clinics across the United States for two years. The 18 participating clinics were associated with eight health care organizations in Washington, California, Texas, Indiana and North Carolina. The clinics included several Health Maintenance Organizations (HMOs), traditional fee-for-service clinics, an Independent Provider Association (IPA), an inner-city public health clinic, and two Veteran’s Administration clinics.

Half of the patients were randomly assigned to receive the care normally available in their primary care clinic, including medications (70% of usual care patients) and/or referral to specialty mental health. The other half of patients were randomly assigned to receive the IMPACT model of depression care, also known as Collaborative Care. A patient registry was developed for the trial that tracked and measured patient goals and clinical outcomes and facilitated treatment adjustment if a patient was not improving as expected.

As reported in JAMA in 2002, Collaborative Care more than doubled the effectiveness of depression treatment for older adults in primary care settings. At 12 months, about half of the patients receiving Collaborative Care reported at least a 50 percent reduction in depressive symptoms, compared with only 19 percent of those in usual care. A handout of usual care versus IMPACT care presents some reasons why the results were as significant as they were. Analysis of data from the survey conducted one year after IMPACT resources were no longer available showed that the benefits of the IMPACT intervention persisted after one year. IMPACT patients experienced more than one hundred additional depression-free days over a two-year period than those treated in usual care.

Since the end of the trial, over one thousand organizations in the United States and internationally have adapted and implemented Collaborative Care with diverse patient populations and for a variety of behavioral health conditions.

OAT Telehealth

Escalating prescription opioid use and abuse have emerged as major public health problems in Washington. Rural communities in particular have been hit hard due to their limited access to specialists. This project allows mental health specialists in urban areas to support health care providers in rural areas using videoconferencing technology. Patient evaluations and recommendations, caseload supervision, and education are all done remotely via telehealth. This project aims to establish acceptance, effectiveness, and cost-efficacy of telehealth for delivery of mental health and pain medicine care in rural primary care.

LA County Mental Health Integrated Care Program

This implementation is part of California’s Mental Health Services Act and LA County’s Prevention and Early Intervention (PEI) Plan. The PEI Plan focuses on prevention and early intervention services, education, support, and outreach to help inform and identify individuals and their families who may be affected by some level of mental health issue. The Mental Health Integrated Care Program in particular targets adults with depression, anxiety, and mild to moderate PTSD. Providing mental health education, outreach and early identification (prior to diagnosis) can mitigate costly negative long-term outcomes for mental health consumers and their families.

Depression Improvement Across Minnesota, Offering a New Direction (DIAMOND)

DIAMOND was a collaborative effort of 9 health plans, 25 medical groups, and over 80 primary care clinics in Minnesota to implement and study Collaborative Care for depression. The AIMS Center provided consultation and coaching for the initiative. In addition, the National Institute of Mental Health (NIMH) awarded a $3 million grant to HealthPartners Research Foundation to study the DIAMOND initiative over five years. The study evaluated all aspects of DIAMOND, including effects of the program on patient satisfaction, productivity, and program cost-effectiveness. The project used a patient registry that tracks and measures patient goals and clinical outcomes, and facilitates treatment adjustment if a patient is not improving as expected.

Alaska Integrated Care for Depression and Substance Abuse

The Alaska Mental Health Trust Authority provided pilot funding to a Federally Qualified Health Center in Anchorage to support implementation of Collaborative Care and two Alaska Native tribal health corporations to support implementation of Collaborative Care and SBIRT (Substance Brief Intervention and Referral to Treatment). The purpose of this program was to determine if integrated mental health care can be effective given the unique challenges faced by primary care clinics in Alaska.

Texas Integrated Health Care Program

The AIMS Center provided training and coaching to five primary care organizations in Texas to implement integrated care for the two mental health conditions most commonly encountered in primary care: depression and anxiety disorders.

A study evaluating outcomes of this program found that vastly different organizations were all able to integrate mental health into primary care settings that serve disadvantaged communities. All five organizations in this program showed meaningful improvement in patient depression outcomes, regardless of varying patient characteristics. Sites that achieved the best patient outcomes engaged patients early, with multiple care manager contacts in the first 3 months of treatment, and received consultation and supervision from psychiatric providers.

Reference
Bauer, A. M., Azzone, V., Goldman, H. H., Alexander, L., Unützer, J., Coleman-Beattie, B., & Frank, R. G. (2011). Evaluating the implementation of collaborative depression management in community-based primary care clinics. Psychiatric Services. 62(9), 1047–1053. https://doi.org/10.1176/appi.ps.62.9.1047

Dulce + IMPACT: Combining depression and diabetes care management

This research project combined IMPACT depression care management with an existing diabetes care management program for low income, predominantly Spanish-speaking Latinx people in San Diego. The study shows that this combined approach is both effective and cost-effective with this population.

Building Collaborative Care in New Orleans

When hurricanes Katrina and Rita devasted New Orleans, the AIMS Center worked on a Red Cross funded initiative to rebuild the primary care system to include Collaborative Care. The project enhanced the availability of evidence-based mental health services to uninsured, disadvantaged, and minority community members offered through REACH NOLA’s Mental Health Infrastructure and Training Project. It also showed the benefits of integrated mental health care after disasters, particularly for depression and post-traumatic stress disorder (PTSD). To our knowledge, the program is the first time that a Collaborative-Care-based quality improvement approach for mental health treatment had been applied in a post-disaster recovery setting.

Alameda Health Consortium

Alameda County in California provides affordable health care to its uninsured residents, but primary care clinics struggle to meet the demand. The AIMS Center, in partnership with the Alameda Health Consortium, helped 30 primary care clinics develop an integrated mental health care initiative targeting depression, anxiety, and PTSD to increase the effectiveness of care. A key component of the project was determining how organizations can successfully use funding from Medicaid to implement Collaborative Care.