Postgraduate Medicine
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Collaborative Care Management Effectively Promotes Self–Management: Patient Evaluation of Care Management for Depression in Primary Care Ramona S. DeJesus MD, Lisa Howell PhD, Mark Williams MD, Julie Hathaway MS & Kristin S. Vickers PhD, LP To cite this article: Ramona S. DeJesus MD, Lisa Howell PhD, Mark Williams MD, Julie Hathaway MS & Kristin S. Vickers PhD, LP (2014) Collaborative Care Management Effectively Promotes Self–Management: Patient Evaluation of Care Management for Depression in Primary Care, Postgraduate Medicine, 126:2, 141-146 To link to this article: http://dx.doi.org/10.3810/pgm.2014.03.2750
Published online: 13 Mar 2015.
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Date: 05 November 2015, At: 17:44
C L I N I C A L F E AT U R E S
Collaborative Care Management Effectively Promotes Self-Management: Patient Evaluation of Care Management for Depression in Primary Care DOI: 10.3810/pgm.2014.03.2750
Postgraduate Medicine 2014.126:141-146.
Ramona S. DeJesus, MD 1 Lisa Howell, PhD 2 Mark Williams, MD 2 Julie Hathaway, MS 3 Kristin S. Vickers, PhD, LP 2,3 Assistant Professor of Medicine, College of Medicine, Primary Care Internal Medicine, Mayo Clinic, Rochester, MN; 2Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN; 3Section of Patient Education, Mayo Clinic, Rochester, MN 1
Abstract
Background: Chronic disease management in the primary care setting increasingly involves self-management support from a nurse care manager. Prior research had shown patient acceptance and willingness to work with care managers. Methods: This survey study evaluated patientperceived satisfaction with care management and patient opinions on the effectiveness of care management in promoting self-management. Qualitative and quantitative survey responses were collected from 125 patients (79% female; average age 46; 94% Caucasian) enrolled in care management for depression. Qualitative responses were coded with methods of content analysis by 2 independent analysts. Results: Patients were satisfied with depression care management. Patients felt that care management improved their treatment above and beyond other aspects of their depression treatment (mean score, 6.7 [SD, 2]; 10 = Very much), increased their understanding of depression self-management (mean score, 7.2 [SD, 2]; 10 = Very much), and increased the frequency of self-management goal setting (mean score, 6.9 [SD, 3]; 10 = Very much). Predominant qualitative themes emphasized that patients value emotional, motivational, and relational aspects of the care manager relationship. Patients viewed care managers as caring and supportive, helpful in creating accountability for patients and knowledgeable in the area of depression care. Care managers empower patients to take on an active role in depression self-management. Some logistical challenges associated with a telephonic intervention are described. Conclusion: Care manager training should include communication and motivation strategies, specifically self-management education, as these strategies are valued by patients. Barriers to care management, such as scheduling telephone calls, should be addressed in future care management implementation and study. Keywords: behavioral activation; primary care; depression; adherence; treatment; collaborative care management
Introduction
Correspondence: Ramona S. DeJesus, MD, College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905. Tel: 507-284-5164 Fax: 507-266-0036 E-mail: [email protected]
Depression is a chronic disorder of remitting and recurring nature. It is estimated that $ one half of the population will experience $ 1 major depression episode during one’s lifetime; thus, depression is an important public health problem.1 It is ranked among the top 5 causes of disability in the world.2 In the United States, it affects up to 25% of women and 12% of men, and poses a significant burden in primary care practice.3 Collaborative care management (CCM) has been shown to be a more effective model than standard care in improving depression outcomes and achieving sustained results in primary care.4–6 Across studies, 30% of patients who were randomized to CCM experienced greater improvement compared with those under standard care.7
© Postgraduate Medicine, Volume 126, Issue 2, March 2014, ISSN – 0032-5481, e-ISSN – 1941-9260 141 ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected] Warning: No duplication rights exist for this journal. Only JTE Multimedia, LLC holds rights to this publication. Please contact the publisher directly with any queries.
Postgraduate Medicine 2014.126:141-146.
DeJesus et al
This model, which involves care managers who provide patient-centered management, has led to improved care of not only depression but also of other chronic illnesses.8 In 2012, the Community Preventive Services Task Force recommended that this model be used in the management of depression based on strong evidence of its effectiveness in achieving adherence to treatment, in patient response, and in achieving remission.9 Our institution adopted CCM in 2008 as part of a statewide depression care improvement initiative spearheaded by the Institute of Clinical System Improvement. Any patient aged $ 18 years with a Patient Health Questionnaire (PHQ-9) score of 10 or higher is eligible for the program. Key elements of the model included consistent use of a tool (ie, the PHQ-9) for screening depression and tracking outcomes; a registry; care managers providing education, self-management support, care management, and relapse prevention; and psychiatrists working collaboratively with primary care physicians (PCPs). After eligible patients were referred by a PCP, they were enrolled in CCM by care managers who were supervised by a psychiatrist providing consultative recommendations to the PCPs. Patient contact with the care manager is dictated by the clinical scenario and PHQ-9 testing; some patients are contacted weekly, and others monthly. The details of the model had been described in a prior publication.10 Self-management, an important component of chronic disease management, is incorporated in CCM; hence, care managers have been trained in motivational interviewing and goal-setting skills to provide necessary patient education and support that will facilitate self-activation in their care. The willingness of patients to work with care managers has already been documented.11,12 Although improved treatment response and remission have been associated with CCM, its effectiveness in promoting self-management and achieving patient satisfaction is less known. It had been reported that increased patient activation resulted in improved selfmanagement behaviors, but it remained unclear what specific interventions would enhance activation.13 A previously published study that reported on long-term outcomes from the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) trial, in which CCM was used for management of depression in late life, found improvement in the remission rates of depression and in patients’ physical functioning, quality of life, and satisfaction with care at 18 and 24 months when compared with standard care.14 That study, however, did not address the model’s effectiveness in promoting self-management as perceived by patients themselves. 142
Evaluating patients’ opinion of CCM is vital for c ontinuous improvement in its implementation process and in identifying priorities for care manager training. Patients with depression, in particular, may identify benefits and barriers associated with care management. In this survey study, patients’ opinions of the key aspects of care management were assessed to determine whether its intended components (eg, goal setting, behavioral activation, and depression selfmanagement) were well understood by patients and perceived as adding value to other traditional aspects of their depression management (eg, medication). The authors’ primary aim was to evaluate the effectiveness of the CCM model using care managers in enhancing and promoting self-management from the patients’ perspectives. Open-ended questions were included in the survey, as qualitative data can provide depth and context when considering patients’ personal opinions and values.15,16 It was anticipated that patients would appreciate the supportive nature of the relationship with a care manager, but it was not known if patients would identify care management as having an impact on behavior change or would perceive it as significantly contributing to the promotion of self-management and to the improvement in their depression care.
Methods Participants and Procedure
The participants were adult patients who were seen at 4 primary care sites of an academic institution in the midwestern United States, who had been enrolled in CCM for depression, and who had $ 4 contacts with a care manager as identified through a registry. A consent form and survey questionnaire packet was mailed to the first 500 eligible patients. A second mailing was sent to nonresponders 5 weeks after the initial mailing. The study was approved by the Institutional Review Board.
Measures
The survey included closed- and open-ended questions, as well as Likert-scale questions which asked the subjects to rate their responses from 0 (not at all) to 10 (very much). The survey comprised 34 questions and took approximately 15 minutes to complete. Because open-ended questions were included, qualitative data can provide additional context and meaning15,16 to enrich the data derived from the rating scales. Several questionnaire items were developed by the researchers to obtain specific information on the model’s impact on the promotion of self-management in the target population.
© Postgraduate Medicine, Volume 126, Issue 2, March 2014, ISSN – 0032-5481, e-ISSN – 1941-9260 ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected] Warning: No duplication rights exist for this journal. Only JTE Multimedia, LLC holds rights to this publication. Please contact the publisher directly with any queries.
Postgraduate Medicine 2014.126:141-146.
Depression Self-Management in Primary Care
Self-reported items addressed patient demographics, including age and years of education. Validated items addressed health literacy (eg, “How confident are you filling out medical forms by yourself?”)17 and perceived health status (eg, “Would you say your general health is …” [response choices ranged from excellent to poor]).18 Survey questions created specifically for this study addressed the patients’ depression diagnosis and treatment (eg, “How old were you when you first experienced depression for a 2-week period?” “How old were you when you were first diagnosed with depression?” “Approximately how many times have you been treated for depression [medication and/or therapy]?”). In the absence of a validated tool and in order to enhance the qualitative nature of the study, the researchers created questions that addressed patients’ attitudes about care management: “How satisfied are you with the total amount of time you have spent in communication with your care manager?” “In general, what did you focus on during your phone calls with your care manager (eg, taking your medications, stressful situations, exercise, relationships, progress with your goals)?” “Would you recommend that other patients with depression have the opportunity to work with a care manager?” Questions that were answered on an 11-point Likert scale addressed the patients’ perceptions of how often they set goals with their care manager (the scale ranged from [always] to [never]) and how much progress they made on their goals ([none at all] to [very much]). Similarly, participants were asked to rate on an 11-point Likert scale ([none at all] to [very much]) the extent to which working with a care manager improved their understanding of depression; the steps/actions they could take to manage depression; how working with a care manager increased their confidence in their ability to manage their depression symptoms; and to what extent working with their care manager had improved their motivation to manage their depression. Participants were further asked to what extent working with a care manager improved their depression treatment above and beyond other depression treatments (medication/therapy). A copy of the questionnaire is available from the authors upon request.
Statistical Analysis
Descriptive statistics (mean ± SD or frequency/percentage) were used to tabulate patient characteristics and data from the closed-ended questions, including the Likert-scale items. Qualitative responses were coded with methods of content analysis by 2 independent analysts to identify predominant themes across participants.15
Results Response Rate and Participant Characteristics
Of the 500 questionnaires that were sent initially, 89 were completed and returned. One questionnaire was returned but was not completed. Five weeks later, a second questionnaire was mailed to the 410 participants who did not respond to the initial mailing, resulting in 36 additional completed questionnaires. Thus, the study had a total of 125 participants (a 25% return rate). The respondents were predominantly Caucasian (94%) and female (79%), with an average age of 46 years (SD, 16; subject age range, 18–89 years). The average age at the first depression diagnosis was 34 years (SD, 16; subject age range, 2–76 years), although participants reported first experiencing depression symptoms at an average age of 26.9 years (SD, 16; subject age range, 5–85 years).
Participant Satisfaction and Ratings of Depression Care Management
For 34% of the subjects, this treatment protocol was their first interaction with a care manager for depression. When asked about their satisfaction with the weekly communication, 82% of subjects said that they were satisfied, whereas 7% wanted even more contact. Of note, no subject wanted less contact. Participants rated highly their satisfaction with care management and its impact in depression management (Table 1).
Qualitative Themes of Participant Attitudes on Depression Care Management
Table 2 presents predominant themes found in the qualitative analysis, with representative quotations for each theme. Four overarching themes emerged from the qualitative data. The vast majority of participants described care management as beneficial. Those who viewed care management as helpful Table 1. Participant Ratings of Depression Care Management on an 11-Point Likert Scalea Question
Mean (SD)
How satisfied are you with the services provided by your care manager? To what extent did care management increase your understanding of depression and the steps/actions you can take to manage depression? To what extent did working with your care manager improve your depression treatment above and beyond other aspects of depression treatment (meds/therapy)? How often did you set a goal with your care manager?
8.5 (2) 7.2 (2)
6.7 (2)
6.9 (3)
The scale ranged from 0 to 10, with 0 meaning “not at all” and 10 meaning “very much.”
a
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DeJesus et al
Table 2. Predominant Themes Emerging From Qualitative Data Assessing Patient Opinions of Care Managers
Table 3. Depression Self-Management Behaviors Patients Attribute to Care Management
Predominant themes
Theme
Representative quotations
Increased or improved social connection
Able to express my concerns with my husband with encouragement from my care manager Spent more time at home with my family Get out and be with people more Learning how to express my feelings How to open up more Focus on positive energy See more of my good points than bad Setting goals that helped me take steps to recover and help me do the things I need to do Increased physical activity I have been out riding my bike and walking more. I have stayed outdoors more than being inside all summer Create better sleep schedule Deep breathing while anxious helped, as did listening to the CDs Finding time to relax and de-stress by myself My care manager indicated I would likely benefit from therapy and I have seen a therapist outside of Mayo regularly. Kept my appointments with my therapist Checking on medications and trying to find medications that work. Taking my medications as prescribed Lowering or increasing doses, considering different medications, etc Reinforcement on medication regiment
Representative quotations
Postgraduate Medicine 2014.126:141-146.
Patients experience care managers as supportive
Caring ear, very sympathetic and nonjudgmental, always helpful She is very positive and nonjudgmental The people you talk to really do care about your well-being; good to know someone cares Care management provides I think it helps hold people accountable for accountability their care She keeps an eye on you to make sure that you are making progress. Keeps me on track Patients experience care Always nice to have someone to talk to who managers as knowledgeable, is educated in what you’re struggling with with expertise relevant to Helps to have someone to talk to who depression management knows how to help you and understands Care managers support Focusing on goals is extremely important self- management by to help a patient reach that goal and helping patients set goals discover that you can feel normal again and engage in depression It’s great to have someone, just to check self-care in, to make sure I don’t crash and lose motivation to do my goals. She gave me goals
reported that their relationship with and the interpersonal style of the care managers were strong assets of their treatment. Similarly, the sense of accountability provided by the care manager was valuable. They also indicated that having someone who has expert knowledge to offer suggestions for self-management of symptoms and goals was beneficial. Participants were asked to remark on the focus of their contacts with the care managers or on specific behavioral changes they made when working with their care manager. The majority of patients described . 1 area of focus for their phone calls; the most frequent areas cited were goal setting, improving sleep, and accessing resources. Patients described important depression self-management behaviors, including exercise and attending therapy. Table 3 presents patientreported self-management behaviors grouped by domains of self-management that emerged from the data. Logistical and system issues created dissatisfaction in a small minority of participants. One subject remarked about the care manager, “It was hard to get ahold of one another at times.” Another participant stated, “We communicated by phone, which was what I needed because I live out of town, but we did play phone tag sometimes.” Some participants did not like communicating by telephone, noting the “lack of the positive face-to-face conversation.” Other participants would have preferred contacting the care managers via email. Despite these problems, the vast majority of participants described satisfaction with depression care management and would recommend the model to other patients. 144
Cognitive restructuring/ positive thinking Setting goals
Exercising
Improving sleep Practicing relaxation exercises
Connecting to therapy
Managing medication
Discussion
Patients with depression who participated in CCM expressed a high level of satisfaction with their care and positively endorsed working with a care manager. Care managers were viewed as helpful in medication management, goal setting, providing motivation, and tracking treatment progress and response. A prior study had reported patient-perceived benefits of a care manager independent of health care provider accessibility; the same is seen in this study among patients with depression who worked with a care manager.11 The patients also felt that care management increased their understanding of depression and was effective in promoting self-management skills. These findings affirmed our expectation that CCM would result in significant patient satisfaction with the care manager and with the associated collaborative relationship. In addition, it appeared that care management positively impacted patient self-management behavior in areas important for improved depression outcomes. Robust data already exist on the effectiveness of the collaborative care model in
© Postgraduate Medicine, Volume 126, Issue 2, March 2014, ISSN – 0032-5481, e-ISSN – 1941-9260 ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected] Warning: No duplication rights exist for this journal. Only JTE Multimedia, LLC holds rights to this publication. Please contact the publisher directly with any queries.
Postgraduate Medicine 2014.126:141-146.
Depression Self-Management in Primary Care
achieving depression treatment response and remission. The results from this study provided a correlation between the model and improved patient activation that led to increased self-management. To our knowledge, it is the first study that addressed the patients’ perception of the benefits of the model beyond care coordination. Although the majority of patients felt they had adequate contact time with the care manager, telephone contact was the main communication method used and it posed a challenge. Conflicting schedules, conflicting commitments, and time inconvenience caused delays in interaction and frustration to both sides. Use of web-based resources, social media, and other innovative ways of enhancing patient communication and involvement should be explored and incorporated in the model. Patient preference for the modes of delivery of selfmanagement support has been shown to vary by race/ethnicity and by language proficiency.19 These factors need to be considered in refining the model. Subsequently, evaluating how an enhanced accessibility to care management impacts patients’ attitudes and perceptions would be quite revealing. Similarly, future studies should assess care managers’ and physicians’ attitudes and feedback about care management, as well as other perceived barriers to engagement in the model. It is interesting to note the time lag between the patients’ first experience of depression symptoms and the diagnosis. Studies have shown factors such as symptom underestimation by physicians, particularly when patients present primarily with somatic complaints, as contributing to depression being underdiagnosed.12 There continues to be a need to improve depression screening and prompt diagnosis so that appropriate treatment can be initiated. There were strengths and limitations to our study. Our data was collected from a convenience sample with a response rate of 25%. This response rate, although typical of studies that utilize mail surveys, is low, and the responses may not be representative of the attitudes of the larger group of participants in CCM. Subjects who did not like their experience with care management may have decided not to return the study packets. Demographic characteristics between responders and nonresponders were not compared; hence, the responses obtained may not be representative of the demographics of the entire intended sample. An additional limitation is that the amount of qualitative data collected is limited by a survey approach. In-depth individual interviews or focus groups with key participants (ie, care managers, patients, and PCPs) would provide greater understanding of the strengths and weaknesses of this model of care, and would provide the opportunity to improve it. Because the responders were
community-based, largely Caucasian patients seen at primary care clinics of an academic institution in the midwestern United States, the results may not be generalizable to other community-based practices or to minority groups. One strength of this study is that it is the first survey that provided a platform for patients to give feedback about aspects of care management that had not been previously addressed in other studies on collaborative care in depression. This study was able to confirm the vital role that self-management education contributes to the success of the model from the perspective of its major stakeholder—the patients. Furthermore, the qualitative component of the survey allowed patients to freely share their opinions on care management via a convenient and minimally burdensome method while maintaining confidentiality. It was not the aim of this study to correlate increased depression self-management among patients with outcomes such as treatment response and disease remission. Future studies looking into this relationship may provide deeper insight into specific aspects of CCM that make it an effective model for depression management.
Conclusion
This study found that most patients view care management as an effective model for improving depression treatment in the primary care setting. Participants enrolled in care management felt that it did what it was designed to do: motivate patients, engage them in depression self-management, facilitate collaborative goal setting, provide accountability and support, provide access to resources, and prevent patients from “falling through the cracks.” The relationship between the patient and the care managers appears to be a vital part of the success of care management. Consequently, care management programs and care management training should emphasize self-management education, supportive communication, and strategies to enhance patient motivation and activation.
Acknowledgments
We would like to thank Isaac Johnson and Debra Judy for their involvement with this study, including mailing the surveys, managing the data, and editing the manuscript. We also wish to thank the participants for their contribution to the study.
Conflict of Interest Statement
Ramona S. DeJesus, MD, Lisa Howell, PhD, Mark Williams, MD, Julie Hathaway, MS, and Kristin S. Vickers, PhD, LP, declare no conflicts of interest. No source of funding is associated with this study.
© Postgraduate Medicine, Volume 126, Issue 2, March 2014, ISSN – 0032-5481, e-ISSN – 1941-9260 145 ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected] Warning: No duplication rights exist for this journal. Only JTE Multimedia, LLC holds rights to this publication. Please contact the publisher directly with any queries.
DeJesus et al
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References 1. Mathers C, Lopez A, Stein C, et al. Deaths and disease burden by cause. Disease Control Priorities Project (CDPP) working paper 18. Bethesda, MD: National Institute of Health; 2004. 2. Andrews G. Reducing the burden of depression. CJM. 2008;53(7): 420–427. 3. Gelenberg AJ. The prevalence and impact of depression. J Clin Psychiatry. 2010;71(3):e06. 4. Gilbody S, Bower P, Fletcher J, et al. Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes. Arch Intern Med. 2006;166(21):2314–2321. 5. Unitzer J, Katon W, Callahan CM, et al. Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA. 2002;288(22):2836–2845. 6. Thota AB, Sipe TA, Byard GJ, et al. Collaborative care to improve the management of depressive disorders: a community guide systematic review and meta-analysis. Am J Prev Med. 2012;42(5):525–538. 7. Katon W, Guico-Pabla CJ. Improving quality of depression care using organized systems of care: a review of the literature. Primary Care Companion CNS Disord. 2011;13(1). doi:10.4088/PCC.10r01019blu. 8. Katon WJ, Lin EH, Von Korff M, et al. Collaborative care for patients with depression and chronic illnesses. N Engl J Med. 2010; 363(27):2611–2620. 9. Community Preventive Services Task Force. Recommendations from the Community Preventive Services Task Force for use of collaborative care for the management of depressive disorders. Am J Prev Med. 2012; 42(5):521–524. 10. Angstman KB, DeJesus RS, Williams MD. Initial implementation of a depression care management model: an observational study of outpatient utilization in primary care clinics. Popul Health Manag. 2009;12(5):227–230.
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11. Matthis MS, Bair MJ, Nyland KA, et al. Self-management support and communication from nurse care managers compared with primary care physicians: a focus group study of patients with chronic musculoskeletal pain. Pain Manag Nurs. 2010;11(1):26–34. 12. DeJesus RS, Vickers KS, Stroebel RJ, Cha SS. Primary care patient and provider preferences for diabetes care managers. Patient Preference and Adherence. 2010;4:181–186. 13. Hibbard JM, Mahoney ER, Stock R, Tusier M. Do increases in patient activation result in improved self-management behaviors? Health Serv Res. 2007;42(4):1443–1463. 14. Hunkeler EM, Katon W, Tang L, et al. Long term outcomes from the IMPACT randomized trial for depressed elderly patients in primary care. BMJ. 2006;332(7536):259–263. 15. Patton MQ. Qualitative Research and Evaluation Methods, 3rd ed. Thousand Oaks, CA: Sage Publications; 2002. 16. Miles MB, Huberman AM. Qualitative Data Analysis: An Expanded Sourcebook, 2nd ed. Thousand Oaks, CA: Sage Publications; 1994. 17. Wallace LS, Rogers ES, Roskos SE, et al. Brief report: screening items to identify patients with limited health literacy skills. J Gen Intern Med. 2006;21:874–877. 18. Stanford Patient Education Research Center, Self Rated Health, 2012. http//patienteducation.stanford.edu/research. 19. Sarker U, Piette JD, Gonzales R, et al. Preferences for self-management support: findings from a survey of diabetes patients in safety-net health systems. Patient Educ Couns. 2008;70(1):102–110.
© Postgraduate Medicine, Volume 126, Issue 2, March 2014, ISSN – 0032-5481, e-ISSN – 1941-9260 ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected] Warning: No duplication rights exist for this journal. Only JTE Multimedia, LLC holds rights to this publication. Please contact the publisher directly with any queries.
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Collaborative Care Management Effectively Promotes Self–Management: Patient Evaluation of Care Management for Depression in Primary Care Ramona S. DeJesus MD, Lisa Howell PhD, Mark Williams MD, Julie Hathaway MS & Kristin S. Vickers PhD, LP To cite this article: Ramona S. DeJesus MD, Lisa Howell PhD, Mark Williams MD, Julie Hathaway MS & Kristin S. Vickers PhD, LP (2014) Collaborative Care Management Effectively Promotes Self–Management: Patient Evaluation of Care Management for Depression in Primary Care, Postgraduate Medicine, 126:2, 141-146 To link to this article: http://dx.doi.org/10.3810/pgm.2014.03.2750
Published online: 13 Mar 2015.
Submit your article to this journal
Article views: 20
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [University of Sheffield]
Date: 05 November 2015, At: 17:44
C L I N I C A L F E AT U R E S
Collaborative Care Management Effectively Promotes Self-Management: Patient Evaluation of Care Management for Depression in Primary Care DOI: 10.3810/pgm.2014.03.2750
Postgraduate Medicine 2014.126:141-146.
Ramona S. DeJesus, MD 1 Lisa Howell, PhD 2 Mark Williams, MD 2 Julie Hathaway, MS 3 Kristin S. Vickers, PhD, LP 2,3 Assistant Professor of Medicine, College of Medicine, Primary Care Internal Medicine, Mayo Clinic, Rochester, MN; 2Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN; 3Section of Patient Education, Mayo Clinic, Rochester, MN 1
Abstract
Background: Chronic disease management in the primary care setting increasingly involves self-management support from a nurse care manager. Prior research had shown patient acceptance and willingness to work with care managers. Methods: This survey study evaluated patientperceived satisfaction with care management and patient opinions on the effectiveness of care management in promoting self-management. Qualitative and quantitative survey responses were collected from 125 patients (79% female; average age 46; 94% Caucasian) enrolled in care management for depression. Qualitative responses were coded with methods of content analysis by 2 independent analysts. Results: Patients were satisfied with depression care management. Patients felt that care management improved their treatment above and beyond other aspects of their depression treatment (mean score, 6.7 [SD, 2]; 10 = Very much), increased their understanding of depression self-management (mean score, 7.2 [SD, 2]; 10 = Very much), and increased the frequency of self-management goal setting (mean score, 6.9 [SD, 3]; 10 = Very much). Predominant qualitative themes emphasized that patients value emotional, motivational, and relational aspects of the care manager relationship. Patients viewed care managers as caring and supportive, helpful in creating accountability for patients and knowledgeable in the area of depression care. Care managers empower patients to take on an active role in depression self-management. Some logistical challenges associated with a telephonic intervention are described. Conclusion: Care manager training should include communication and motivation strategies, specifically self-management education, as these strategies are valued by patients. Barriers to care management, such as scheduling telephone calls, should be addressed in future care management implementation and study. Keywords: behavioral activation; primary care; depression; adherence; treatment; collaborative care management
Introduction
Correspondence: Ramona S. DeJesus, MD, College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905. Tel: 507-284-5164 Fax: 507-266-0036 E-mail: [email protected]
Depression is a chronic disorder of remitting and recurring nature. It is estimated that $ one half of the population will experience $ 1 major depression episode during one’s lifetime; thus, depression is an important public health problem.1 It is ranked among the top 5 causes of disability in the world.2 In the United States, it affects up to 25% of women and 12% of men, and poses a significant burden in primary care practice.3 Collaborative care management (CCM) has been shown to be a more effective model than standard care in improving depression outcomes and achieving sustained results in primary care.4–6 Across studies, 30% of patients who were randomized to CCM experienced greater improvement compared with those under standard care.7
© Postgraduate Medicine, Volume 126, Issue 2, March 2014, ISSN – 0032-5481, e-ISSN – 1941-9260 141 ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected] Warning: No duplication rights exist for this journal. Only JTE Multimedia, LLC holds rights to this publication. Please contact the publisher directly with any queries.
Postgraduate Medicine 2014.126:141-146.
DeJesus et al
This model, which involves care managers who provide patient-centered management, has led to improved care of not only depression but also of other chronic illnesses.8 In 2012, the Community Preventive Services Task Force recommended that this model be used in the management of depression based on strong evidence of its effectiveness in achieving adherence to treatment, in patient response, and in achieving remission.9 Our institution adopted CCM in 2008 as part of a statewide depression care improvement initiative spearheaded by the Institute of Clinical System Improvement. Any patient aged $ 18 years with a Patient Health Questionnaire (PHQ-9) score of 10 or higher is eligible for the program. Key elements of the model included consistent use of a tool (ie, the PHQ-9) for screening depression and tracking outcomes; a registry; care managers providing education, self-management support, care management, and relapse prevention; and psychiatrists working collaboratively with primary care physicians (PCPs). After eligible patients were referred by a PCP, they were enrolled in CCM by care managers who were supervised by a psychiatrist providing consultative recommendations to the PCPs. Patient contact with the care manager is dictated by the clinical scenario and PHQ-9 testing; some patients are contacted weekly, and others monthly. The details of the model had been described in a prior publication.10 Self-management, an important component of chronic disease management, is incorporated in CCM; hence, care managers have been trained in motivational interviewing and goal-setting skills to provide necessary patient education and support that will facilitate self-activation in their care. The willingness of patients to work with care managers has already been documented.11,12 Although improved treatment response and remission have been associated with CCM, its effectiveness in promoting self-management and achieving patient satisfaction is less known. It had been reported that increased patient activation resulted in improved selfmanagement behaviors, but it remained unclear what specific interventions would enhance activation.13 A previously published study that reported on long-term outcomes from the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) trial, in which CCM was used for management of depression in late life, found improvement in the remission rates of depression and in patients’ physical functioning, quality of life, and satisfaction with care at 18 and 24 months when compared with standard care.14 That study, however, did not address the model’s effectiveness in promoting self-management as perceived by patients themselves. 142
Evaluating patients’ opinion of CCM is vital for c ontinuous improvement in its implementation process and in identifying priorities for care manager training. Patients with depression, in particular, may identify benefits and barriers associated with care management. In this survey study, patients’ opinions of the key aspects of care management were assessed to determine whether its intended components (eg, goal setting, behavioral activation, and depression selfmanagement) were well understood by patients and perceived as adding value to other traditional aspects of their depression management (eg, medication). The authors’ primary aim was to evaluate the effectiveness of the CCM model using care managers in enhancing and promoting self-management from the patients’ perspectives. Open-ended questions were included in the survey, as qualitative data can provide depth and context when considering patients’ personal opinions and values.15,16 It was anticipated that patients would appreciate the supportive nature of the relationship with a care manager, but it was not known if patients would identify care management as having an impact on behavior change or would perceive it as significantly contributing to the promotion of self-management and to the improvement in their depression care.
Methods Participants and Procedure
The participants were adult patients who were seen at 4 primary care sites of an academic institution in the midwestern United States, who had been enrolled in CCM for depression, and who had $ 4 contacts with a care manager as identified through a registry. A consent form and survey questionnaire packet was mailed to the first 500 eligible patients. A second mailing was sent to nonresponders 5 weeks after the initial mailing. The study was approved by the Institutional Review Board.
Measures
The survey included closed- and open-ended questions, as well as Likert-scale questions which asked the subjects to rate their responses from 0 (not at all) to 10 (very much). The survey comprised 34 questions and took approximately 15 minutes to complete. Because open-ended questions were included, qualitative data can provide additional context and meaning15,16 to enrich the data derived from the rating scales. Several questionnaire items were developed by the researchers to obtain specific information on the model’s impact on the promotion of self-management in the target population.
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Depression Self-Management in Primary Care
Self-reported items addressed patient demographics, including age and years of education. Validated items addressed health literacy (eg, “How confident are you filling out medical forms by yourself?”)17 and perceived health status (eg, “Would you say your general health is …” [response choices ranged from excellent to poor]).18 Survey questions created specifically for this study addressed the patients’ depression diagnosis and treatment (eg, “How old were you when you first experienced depression for a 2-week period?” “How old were you when you were first diagnosed with depression?” “Approximately how many times have you been treated for depression [medication and/or therapy]?”). In the absence of a validated tool and in order to enhance the qualitative nature of the study, the researchers created questions that addressed patients’ attitudes about care management: “How satisfied are you with the total amount of time you have spent in communication with your care manager?” “In general, what did you focus on during your phone calls with your care manager (eg, taking your medications, stressful situations, exercise, relationships, progress with your goals)?” “Would you recommend that other patients with depression have the opportunity to work with a care manager?” Questions that were answered on an 11-point Likert scale addressed the patients’ perceptions of how often they set goals with their care manager (the scale ranged from [always] to [never]) and how much progress they made on their goals ([none at all] to [very much]). Similarly, participants were asked to rate on an 11-point Likert scale ([none at all] to [very much]) the extent to which working with a care manager improved their understanding of depression; the steps/actions they could take to manage depression; how working with a care manager increased their confidence in their ability to manage their depression symptoms; and to what extent working with their care manager had improved their motivation to manage their depression. Participants were further asked to what extent working with a care manager improved their depression treatment above and beyond other depression treatments (medication/therapy). A copy of the questionnaire is available from the authors upon request.
Statistical Analysis
Descriptive statistics (mean ± SD or frequency/percentage) were used to tabulate patient characteristics and data from the closed-ended questions, including the Likert-scale items. Qualitative responses were coded with methods of content analysis by 2 independent analysts to identify predominant themes across participants.15
Results Response Rate and Participant Characteristics
Of the 500 questionnaires that were sent initially, 89 were completed and returned. One questionnaire was returned but was not completed. Five weeks later, a second questionnaire was mailed to the 410 participants who did not respond to the initial mailing, resulting in 36 additional completed questionnaires. Thus, the study had a total of 125 participants (a 25% return rate). The respondents were predominantly Caucasian (94%) and female (79%), with an average age of 46 years (SD, 16; subject age range, 18–89 years). The average age at the first depression diagnosis was 34 years (SD, 16; subject age range, 2–76 years), although participants reported first experiencing depression symptoms at an average age of 26.9 years (SD, 16; subject age range, 5–85 years).
Participant Satisfaction and Ratings of Depression Care Management
For 34% of the subjects, this treatment protocol was their first interaction with a care manager for depression. When asked about their satisfaction with the weekly communication, 82% of subjects said that they were satisfied, whereas 7% wanted even more contact. Of note, no subject wanted less contact. Participants rated highly their satisfaction with care management and its impact in depression management (Table 1).
Qualitative Themes of Participant Attitudes on Depression Care Management
Table 2 presents predominant themes found in the qualitative analysis, with representative quotations for each theme. Four overarching themes emerged from the qualitative data. The vast majority of participants described care management as beneficial. Those who viewed care management as helpful Table 1. Participant Ratings of Depression Care Management on an 11-Point Likert Scalea Question
Mean (SD)
How satisfied are you with the services provided by your care manager? To what extent did care management increase your understanding of depression and the steps/actions you can take to manage depression? To what extent did working with your care manager improve your depression treatment above and beyond other aspects of depression treatment (meds/therapy)? How often did you set a goal with your care manager?
8.5 (2) 7.2 (2)
6.7 (2)
6.9 (3)
The scale ranged from 0 to 10, with 0 meaning “not at all” and 10 meaning “very much.”
a
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Table 2. Predominant Themes Emerging From Qualitative Data Assessing Patient Opinions of Care Managers
Table 3. Depression Self-Management Behaviors Patients Attribute to Care Management
Predominant themes
Theme
Representative quotations
Increased or improved social connection
Able to express my concerns with my husband with encouragement from my care manager Spent more time at home with my family Get out and be with people more Learning how to express my feelings How to open up more Focus on positive energy See more of my good points than bad Setting goals that helped me take steps to recover and help me do the things I need to do Increased physical activity I have been out riding my bike and walking more. I have stayed outdoors more than being inside all summer Create better sleep schedule Deep breathing while anxious helped, as did listening to the CDs Finding time to relax and de-stress by myself My care manager indicated I would likely benefit from therapy and I have seen a therapist outside of Mayo regularly. Kept my appointments with my therapist Checking on medications and trying to find medications that work. Taking my medications as prescribed Lowering or increasing doses, considering different medications, etc Reinforcement on medication regiment
Representative quotations
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Patients experience care managers as supportive
Caring ear, very sympathetic and nonjudgmental, always helpful She is very positive and nonjudgmental The people you talk to really do care about your well-being; good to know someone cares Care management provides I think it helps hold people accountable for accountability their care She keeps an eye on you to make sure that you are making progress. Keeps me on track Patients experience care Always nice to have someone to talk to who managers as knowledgeable, is educated in what you’re struggling with with expertise relevant to Helps to have someone to talk to who depression management knows how to help you and understands Care managers support Focusing on goals is extremely important self- management by to help a patient reach that goal and helping patients set goals discover that you can feel normal again and engage in depression It’s great to have someone, just to check self-care in, to make sure I don’t crash and lose motivation to do my goals. She gave me goals
reported that their relationship with and the interpersonal style of the care managers were strong assets of their treatment. Similarly, the sense of accountability provided by the care manager was valuable. They also indicated that having someone who has expert knowledge to offer suggestions for self-management of symptoms and goals was beneficial. Participants were asked to remark on the focus of their contacts with the care managers or on specific behavioral changes they made when working with their care manager. The majority of patients described . 1 area of focus for their phone calls; the most frequent areas cited were goal setting, improving sleep, and accessing resources. Patients described important depression self-management behaviors, including exercise and attending therapy. Table 3 presents patientreported self-management behaviors grouped by domains of self-management that emerged from the data. Logistical and system issues created dissatisfaction in a small minority of participants. One subject remarked about the care manager, “It was hard to get ahold of one another at times.” Another participant stated, “We communicated by phone, which was what I needed because I live out of town, but we did play phone tag sometimes.” Some participants did not like communicating by telephone, noting the “lack of the positive face-to-face conversation.” Other participants would have preferred contacting the care managers via email. Despite these problems, the vast majority of participants described satisfaction with depression care management and would recommend the model to other patients. 144
Cognitive restructuring/ positive thinking Setting goals
Exercising
Improving sleep Practicing relaxation exercises
Connecting to therapy
Managing medication
Discussion
Patients with depression who participated in CCM expressed a high level of satisfaction with their care and positively endorsed working with a care manager. Care managers were viewed as helpful in medication management, goal setting, providing motivation, and tracking treatment progress and response. A prior study had reported patient-perceived benefits of a care manager independent of health care provider accessibility; the same is seen in this study among patients with depression who worked with a care manager.11 The patients also felt that care management increased their understanding of depression and was effective in promoting self-management skills. These findings affirmed our expectation that CCM would result in significant patient satisfaction with the care manager and with the associated collaborative relationship. In addition, it appeared that care management positively impacted patient self-management behavior in areas important for improved depression outcomes. Robust data already exist on the effectiveness of the collaborative care model in
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Postgraduate Medicine 2014.126:141-146.
Depression Self-Management in Primary Care
achieving depression treatment response and remission. The results from this study provided a correlation between the model and improved patient activation that led to increased self-management. To our knowledge, it is the first study that addressed the patients’ perception of the benefits of the model beyond care coordination. Although the majority of patients felt they had adequate contact time with the care manager, telephone contact was the main communication method used and it posed a challenge. Conflicting schedules, conflicting commitments, and time inconvenience caused delays in interaction and frustration to both sides. Use of web-based resources, social media, and other innovative ways of enhancing patient communication and involvement should be explored and incorporated in the model. Patient preference for the modes of delivery of selfmanagement support has been shown to vary by race/ethnicity and by language proficiency.19 These factors need to be considered in refining the model. Subsequently, evaluating how an enhanced accessibility to care management impacts patients’ attitudes and perceptions would be quite revealing. Similarly, future studies should assess care managers’ and physicians’ attitudes and feedback about care management, as well as other perceived barriers to engagement in the model. It is interesting to note the time lag between the patients’ first experience of depression symptoms and the diagnosis. Studies have shown factors such as symptom underestimation by physicians, particularly when patients present primarily with somatic complaints, as contributing to depression being underdiagnosed.12 There continues to be a need to improve depression screening and prompt diagnosis so that appropriate treatment can be initiated. There were strengths and limitations to our study. Our data was collected from a convenience sample with a response rate of 25%. This response rate, although typical of studies that utilize mail surveys, is low, and the responses may not be representative of the attitudes of the larger group of participants in CCM. Subjects who did not like their experience with care management may have decided not to return the study packets. Demographic characteristics between responders and nonresponders were not compared; hence, the responses obtained may not be representative of the demographics of the entire intended sample. An additional limitation is that the amount of qualitative data collected is limited by a survey approach. In-depth individual interviews or focus groups with key participants (ie, care managers, patients, and PCPs) would provide greater understanding of the strengths and weaknesses of this model of care, and would provide the opportunity to improve it. Because the responders were
community-based, largely Caucasian patients seen at primary care clinics of an academic institution in the midwestern United States, the results may not be generalizable to other community-based practices or to minority groups. One strength of this study is that it is the first survey that provided a platform for patients to give feedback about aspects of care management that had not been previously addressed in other studies on collaborative care in depression. This study was able to confirm the vital role that self-management education contributes to the success of the model from the perspective of its major stakeholder—the patients. Furthermore, the qualitative component of the survey allowed patients to freely share their opinions on care management via a convenient and minimally burdensome method while maintaining confidentiality. It was not the aim of this study to correlate increased depression self-management among patients with outcomes such as treatment response and disease remission. Future studies looking into this relationship may provide deeper insight into specific aspects of CCM that make it an effective model for depression management.
Conclusion
This study found that most patients view care management as an effective model for improving depression treatment in the primary care setting. Participants enrolled in care management felt that it did what it was designed to do: motivate patients, engage them in depression self-management, facilitate collaborative goal setting, provide accountability and support, provide access to resources, and prevent patients from “falling through the cracks.” The relationship between the patient and the care managers appears to be a vital part of the success of care management. Consequently, care management programs and care management training should emphasize self-management education, supportive communication, and strategies to enhance patient motivation and activation.
Acknowledgments
We would like to thank Isaac Johnson and Debra Judy for their involvement with this study, including mailing the surveys, managing the data, and editing the manuscript. We also wish to thank the participants for their contribution to the study.
Conflict of Interest Statement
Ramona S. DeJesus, MD, Lisa Howell, PhD, Mark Williams, MD, Julie Hathaway, MS, and Kristin S. Vickers, PhD, LP, declare no conflicts of interest. No source of funding is associated with this study.
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