BRIEF REPORTS

Effects of Staffing Choices on Collaborative Care for Depression at Primary Care Clinics in Minnesota Pamela B. Pietruszewski, M.A., Marlon P. Mundt, Ph.D., Senka Hadzic, M.P.H., Richard L. Brown, M.D., M.P.H.

Objective: This study assessed associations between staffing of a collaborative care program for depression and enrollment in the program and remission rates. Methods: Data were collected from depression care registries at 63 primary care clinics that participated in the initiative through early 2012. Project leaders at the 12 medical groups that operate the clinics were surveyed about the background of care managers and clinic characteristics. Generalized linear mixed models assessed associations of care manager background and configuration of staffing with enrollment and remission rates.

Depression causes substantial suffering, health care expenditure, additional economic loss, and death through suicide and inferior self-care of other chronic diseases (1,2). Most depression treatment is administered in primary care settings, where diagnosis, medication selection and dosing, duration of treatment, and response to treatment failure are often suboptimal (3,4). Designed to improve depression outcomes for primary care patients, collaborative care involves expanding primary care teams with the addition of two new roles. A psychiatrist conducts regular case reviews and advises on diagnosis and treatment. A care manager educates patients about depression, coordinates referrals, promotes behavior changes that decrease depression symptoms, supports adherence to treatment regimens, administers serial depression symptom questionnaires, and notifies primary care providers when responses to those questionnaires indicate inadequate improvement and a possible need to revise the treatment plan. On the basis of meta-analyses, researchers have concluded that collaborative care substantially improves depression outcomes (5,6). A randomized controlled trial involving primary care patients ages 60 years and older found that collaborative care generated substantial health care cost savings (7). From 2008 to 2012, the Institute for Clinical Systems Improvement (ICSI) assisted 87 primary care clinics in implementing collaborative care through the Depression Improvement Across Minnesota, Offering a New Direction (DIAMOND) Psychiatric Services 66:1, January 2015

Results: Enrollment was higher (p5.050) and there was a trend toward higher remission rates (p5.105) at clinics where care managers were dedicated exclusively to depression care. No differences in outcomes were obtained by registered nurses versus certified medical assistants and licensed practical nurses. Conclusions: Hiring dedicated paraprofessional care managers may maximize the cost-effectiveness of collaborative care programs and should be supported by regulations and reimbursement policies. Psychiatric Services 2015; 66:101–103; doi: 10.1176/appi.ps.201300552

initiative (8). The clinics received similar training and support but varied in how they staffed and configured care manager positions. Some care managers were registered nurses (RNs), whereas others were certified medical assistants (CMAs) and licensed practical nurses (LPNs). Some were dedicated to depression care, but others had additional responsibilities. Some served patients at one clinic, whereas others served patients at multiple clinics in the same medical group. To inform future implementation of collaborative care, we analyzed associations between two key measures of program effectiveness— patient enrollment and six-month remission rates—with care manager background and clinic characteristics. METHODS Between March 2008 and March 2010, a group of clinics began DIAMOND implementation every six months, for a total of five groups. A total of 87 clinics operated by 21 medical groups participated. This study focused on the 63 clinics, operated by 12 medical groups, that remained active through early 2012. Staff of the participating clinics aimed to enroll all patients with ICD-9 diagnoses of 296.2X, 296.3X, or 300.4 and a score of $10 on the Patient Health Questionnaire–9 (PHQ-9), suggesting probable major depression or significant dysthymia (9). Patients were discharged from DIAMOND if they met criteria for remission, defined as having PHQ-9 scores of ,5 on two consecutive occasions over a period of greater than two months. ps.psychiatryonline.org

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EFFECTS OF STAFFING CHOICES ON COLLABORATIVE CARE FOR DEPRESSION AT PRIMARY CARE CLINICS

TABLE 1. Association of enrollment in collaborative care for depression and rates of remission at 63 primary care clinics, by clinic characteristic Enrollment Variable Care manager Registered nurse (reference: CMA or LPN)a Dedicated role (reference: multiple roles) Served a single site (reference: multiple sites) Metropolitan location (reference: outstate) Group start date (reference: March 2010)b March 2008 September 2008 March 2009 September 2009

Remission

OR

95% CI

p

OR

95% CI

p

1.06

.35–3.04

ns

1.23

.56–2.69

ns

2.65

1.02–6.91

,.05

1.96

.83–4.72

ns

1.61

.41–6.84

ns

1.07

.37–3.07

ns

1.23

.44–3.62

ns

.69

.32–1.52

ns

1.57 1.17 1.20 .90

1.40–1.77 1.02–1.33 1.04–1.39 .78–1.04

,.01 ,.05 ,.05 ns

1.92 1.70 4.24 .83

1.63–2.25 1.44–2.00 3.20–5.64 .62–1.12

,.01 ,.01 ,.01 ns

enrolled patients controlled for clinic volume. We conducted the analysis with SAS, version 9.2 (11). Informed consent was not obtained from patients, nor was institutional review board approval sought, because the project was a quality improvement initiative, and no protected health information was shared with the researchers. RESULTS

Of 55,594 eligible patients, 9,179 patients enrolled in DIAMOND as of early 2012, for a 17% enEligible patients (per 1,000) .87 .83–.92 ,.01 Enrolled patients (per 100) 1.11 1.05–1.18 ,.05 rollment rate across all clinics. Enrollment rates varied from a CMA, certified medical assistant. LPN, licensed practical nurse b 1% to 55% across the particiA group of clinics began DIAMOND implementation every six months, for a total of five groups. pating clinics. The model in Table 1 indicates the associaCare managers were expected to collect PHQ-9 data from tion between enrollment and remission rates and clinic characteristics after the analyses accounted for medical group–level patients at every contact. They contacted patients weekly to effects. Clinics with a dedicated care manager had higher monthly on the basis of the severity of depression symptoms. enrollment rates than clinics in which the care manager had Monthly, clinic staff submitted deidentified data on service delivery and PHQ-9 scores for each enrolled patient. From multiple roles (odds ratio [OR]52.65, p5.050). There were no these data, the ICSI calculated total enrollment and remission significant differences in enrollment on the basis of care manrates. ager licensure (RN versus CMA or LPN), number of clinics Throughout implementation, the ICSI tracked clinic progserved, or clinic location. ress and provided technical assistance. In early 2012, the ICSI Across the clinic sites, 7,438 enrolled patients were eligible for six-month PHQ-9 follow up. Of these patients, 2,323 surveyed project leaders at each active medical group about attained remission at six months, yielding an overall remission care manager and clinic characteristics. The data indicated rate of 31%. Six-month remission rates varied from 3% to 46% whether the care manager was an RN, a CMA, or an LPN; whether the care manager was dedicated solely to depression across the clinics. As shown in Table 1, the independent varcare or had other duties; and whether the care manager proiables had no significant effects on remission rates. There was vided depression services at one or multiple clinics. Of the 63 a trend for sites with a dedicated care manager to have higher clinics, seven clinics indicated modifying their staffing models remission rates (OR51.96, p5.105). within two months of program launch, and the data reflect the Clinics that were among the first three groups to implement DIAMOND had higher enrollment and remission rates. final staffing model. Clinics located in or near the Twin Cities Enrollment rates were significantly lower at larger versus (in Hennepin or Ramsey County or adjacent counties) were smaller clinics, but remission rates were significantly higher classified as metropolitan, and the other clinics were classified as outstate. Complete data were obtained for all 63 active at larger clinics. clinics. We analyzed the relationship of care manager and clinic DISCUSSION characteristics to rate of enrollment of eligible patients and rate of remission six months (630 days) after the enrollment date. The U.S. Preventive Services Task Force (USPSTF) recommends depression screening in primary care settings only “when Generalized linear mixed models (GLMMs) were used to acstaff-assisted depression care supports are in place to assure count for multiple sources of clustering within the data (10). We accurate diagnosis, effective treatment, and follow-up” (12). conducted two separate GLMMs, one using enrollment rates and one using remission rates as the binomial outcome variable. Collaborative care clearly comprises the most effective supports. For each model, the independent variables were the three care Under the DIAMOND initiative, as the clinics implemented manager variables and clinic location. A random-effects term collaborative care, they varied in how they staffed the care accounted for medical group effect. A sequence effect term manager role. Our analysis found no differences in outcomes denoted the five different start dates. A term for number of obtained by RNs, CMAs, and LPNs, who had completed the 102

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PIETRUSZEWSKI ET AL.

same training. Our analysis also found that staffing by a dedicated care manager was associated with significantly greater enrollment and, possibly, superior treatment outcomes compared with staffing by a care manager with multiple duties, even when dedicated staff were shared across multiple clinics. A possible explanation for the superior performance of the clinics in the first three groups to implement DIAMOND may be related to selection effects. Earlier-participating clinics may have been most ready and motivated to initiate the program. The association between volume of patients served and better outcomes may indicate that managers with dedicated time are more ready and motivated to develop their skills. One limitation of the study was its focus on clinics that were still implementing collaborative care two to four years later. The data did not identify the factors that may have been associated with program discontinuation. Additional limitations were the retrospective nature of the analyses, which were possibly confounded by differences in implementation that were not measured and by the effects of idiosyncratic practices at the clinics studied. Furthermore, the study design allowed conclusions about association, not causation, given that decisions about staffing of care manager positions could have influenced service delivery or vice versa. The findings of this study support the “teamlet” model of primary care, in which medical assistants are trained to execute health coaching functions (13). A larger prospective study would provide more definitive guidance on how best to configure and staff collaborative care programs. Even if clinical data suggest how to optimize staffing, decisions about staffing must take into account the regulatory environment and financing opportunities. Regulations governing which individuals may deliver collaborative care may vary across states. In Minnesota, for example, paraprofessionals are permitted to deliver collaborative care, and major commercial payers honor a billing code for paraprofessional-administered collaborative care (14). This type of flexibility and financing is lacking in other states. Currently, Medicare reimburses for depression care only when depression care supports are in place, consistent with USPSTF recommendations. However, it does not reimburse for ongoing collaborative care. Thus most primary care settings cannot finance collaborative care through fee-for-service reimbursement. CONCLUSIONS Increasingly, health care providers are rewarded for delivering value rather than services, for example, as part of accountable care organizations. Research has documented a positive return on investment for collaborative care, which should help drive dissemination (7). As collaborative care spreads, patients and

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health care purchasers will benefit, especially if staffing decisions and relevant regulations are based on research findings rather than traditional role concepts. AUTHOR AND ARTICLE INFORMATION Ms. Pietruszewski and Ms. Hadzic are with the Institute for Clinical Systems Improvement, Bloomington, Minnesota. Dr. Mundt and Dr. Brown are with the Department of Family Medicine, University of Wisconsin School of Medicine and Public Health, Madison. Send correspondence to Dr. Brown (e-mail: [email protected]). Dr. Brown is the owner and CEO of Wellsys, LLC, which helps health care settings and workplaces implement behavioral screening and intervention. The other authors report no competing interests.

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Effects of staffing choices on collaborative care for depression at primary care clinics in Minnesota.

This study assessed associations between staffing of a collaborative care program for depression and enrollment in the program and remission rates...
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