Depression Care Management and Medicare Home Health
Original Investigation Research
Invited Commentary HEALTH CARE REFORM
Now Is the Time for True Reform of Mental Health Services Constantine G. Lyketsos, MD, MHS
The rapid aging of the population is accompanied by commensurate growth in the number of individuals who have complex chronic medical conditions (diabetes mellitus, heart disease, lung disease, etc). These people are increasingly less Related article page 55 able to interact with health care services outside of their homes. At the same time, those caring for older adults are increasingly stretched in their ability to deliver care. This is especially true in providing care for mental disorders associated with chronic disease. Older patients with complex chronic conditions have high rates of mental disorders, with depression and dementia being the most common. The latter impair quality of life, worsen medical outcomes, and place substantial burden on caregivers, as well as on care delivery.1 The interaction between age and mental disorders further complicates matters because rates of depression and dementia increase substantially with age, regardless of the presence of medical comorbidities. Their co-occurrence exponentially increases illness burden and the care necessary to meet that burden. Unfortunately, mental disorders in old age go substantially undetected and undertreated, especially in mostly homebound individuals. With the above in mind, the delivery of effective mental health care to older individuals with chronic diseases often faces insurmountable barriers. Care increasingly has to be provided in ways convenient to recipients, preferably in their homes. Several models have attempted to deliver homebased mental health services to persons with depression or dementia.2 Proof of effectiveness for such home-based services has slowly been accumulating but continues to lag behind the need. For example, my coworkers and I demonstrated in early 2014 that home-based dementia care can improve the ability of patients with dementia to live at home longer, with better quality of life, while placing less burden on caregivers.3 Regarding care for depression at home, there has been less evidence of effectiveness. To address this gap, Bruce and colleagues4 in this issue of JAMA Internal Medicine report the results of a cluster randomized clinical trial for the care of patients with depression in their homes. The investigators developed the Depression CAREPATH, an approach to care delivery that is fully integrated with the day-to-day activities of home care services. In the execution of a complicated but well-designed trial, they demonstrated the effectiveness of this intervention. The researchers targeted individuals with clinical depression and compared their novel approach with enhanced usual care. While outcomes improved for all participants (regardless of the treatment arm), the Depression CAREPATH produced substantially better depression outcomes as early as 3 months after the intervention, with benefits that accrued further during the next year.
However, the benefit was evident only for individuals with moderate or more severe clinically significant depression. The benefit was independent of whether or not patients were prescribed antidepressants at baseline, suggesting that care coordination (eg, switching antidepressants and better monitoring their effects) was an important determinant of better outcomes. What is the significance of this effort if narrowly construed? The work by Bruce and collaborators provides robust proof of the principle that good mental health outcomes for depressed individuals with complex chronic medical conditions receiving care at homes are possible and can be delivered as part of routine medical care, without further burdening existing service provision. Additional elaboration and refinement of this approach are critical to improve targeting of the intervention and to evaluate benefits to quality of life, aging in place, or utilization of health care services. It is essential that funders must support the critically needed follow-up research in this area. Efforts should be targeted at those with the most severe forms of the disease, consistent with other collaborative care interventions for depression.5 In the bigger picture, this work reinforces the view that addressing underrecognized and undertreated mental disorders such as dementia and depression must be a cornerstone of health care reform. The serious adverse consequences of mental disorders in old age—especially with regard to quality of life, medical outcomes, and health care utilization—cannot be overstated.2,6 The current health care delivery structure and reimbursement are unsuitable to the provision of effective care for mental disorders and must be revised to conform to the reality of comorbidity with chronic disease. The common denominators of successful integration of mental health care into medical settings are several.7 First is careful preparation and support of frontline health care providers in detecting and managing mental disorders. This requires culture change to raise the priority to address these conditions, as well as the confidence of clinicians in delivering this care. The second involves close linkages of frontline services and mental health services through embedding of specialized mental health experts (allied professionals working closely with psychiatrists and psychologists) to provide care, support, and care coordination in primary care. Third is timely access to higher levels of mental health services if and when needed. Fourth is the application of these spearheaded programs to those at highest need. The most positive aspect of health care reform is the widespread recognition of the complexity of the primary care of patients with chronic multiple comorbid illnesses. This includes the way in which frontline clinicians prioritize care needs in the context of numerous competing risks and value judgments, as well as the management of complex care transitions and the coordination of teams deployed to reflect the
jamainternalmedicine.com
JAMA Internal Medicine January 2015 Volume 175, Number 1
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a J H Quillen College User on 05/28/2015
65
Research Original Investigation
Depression Care Management and Medicare Home Health
integration of all necessary care components. Mental health services, in this case to address dementia and depression in old age, must become a much higher priority in the health care system of the future. There is a high probability that, if done
smartly, this will lead to greater improvements in clinical outcomes and quality of life, as well as greater promise in helping older Americans age in place in their homes, which is one of their most fervent desires.8
ARTICLE INFORMATION
REFERENCES
Author Affiliations: The Johns Hopkins University, Baltimore, Maryland; Department of Psychiatry and Behavioral Sciences, Johns Hopkins Bayview Medical Center, Baltimore, Maryland.
1. Pirraglia PA, Hampton JM, Rosen AB, Witt WP. Psychological distress and trends in healthcare expenditures and outpatient healthcare. Am J Manag Care. 2011;17(5):319-328.
Corresponding Author: Constantine G. Lyketsos, MD, MHS, Department of Psychiatry and Behavioral Sciences, Johns Hopkins Bayview Medical Center, 5300 Alpha Commons Dr, Baltimore, MD 21224 ([email protected]).
2. DeMers S, Dinsio K, Carlson W. Psychiatric care of the older adult: an overview for primary care. Med Clin North Am. 2014;98(5):1145-1168.
Published Online: November 10, 2014. doi:10.1001/jamainternmed.2014.6086. Conflict of Interest Disclosures: None reported.
3. Samus QM, Johnston D, Black BS, et al. A multidimensional home-based care coordination intervention for elders with memory disorders: the Maximizing Independence at Home (MIND) pilot randomized trial. Am J Geriatr Psychiatry. 2014;22 (4):398-414. 4. Bruce ML, Raue PJ, Reilly CF, et al. Clinical effectiveness of integrating depression care management into Medicare Home Health: the
66
Depression CAREPATH Randomized Trial [published online November 10, 2014]. JAMA Intern Med. doi:10.1001/jamainternmed.2014.5835. 5. Luxama C, Dreyfus D. Collaborative care for depression and anxiety. Am Fam Physician. 2014;89 (7):524-525. 6. Lyketsos CG, Carrillo MC, Ryan JM, et al. Neuropsychiatric symptoms in Alzheimer’s disease. Alzheimers Dement. 2011;7(5):532-539. 7. Everett AS, Reese JB, Coughlin J, et al. Behavioral health interventions in the Johns Hopkins Community Health Partnership: integrated care as a component of health systems transformation. Int Rev Psychiatry. In press. 8. Reuben DB. Better care for older people with chronic diseases: an emerging vision. JAMA. 2007; 298(22):2673-2674.
JAMA Internal Medicine January 2015 Volume 175, Number 1
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a J H Quillen College User on 05/28/2015
jamainternalmedicine.com
Original Investigation Research
Invited Commentary HEALTH CARE REFORM
Now Is the Time for True Reform of Mental Health Services Constantine G. Lyketsos, MD, MHS
The rapid aging of the population is accompanied by commensurate growth in the number of individuals who have complex chronic medical conditions (diabetes mellitus, heart disease, lung disease, etc). These people are increasingly less Related article page 55 able to interact with health care services outside of their homes. At the same time, those caring for older adults are increasingly stretched in their ability to deliver care. This is especially true in providing care for mental disorders associated with chronic disease. Older patients with complex chronic conditions have high rates of mental disorders, with depression and dementia being the most common. The latter impair quality of life, worsen medical outcomes, and place substantial burden on caregivers, as well as on care delivery.1 The interaction between age and mental disorders further complicates matters because rates of depression and dementia increase substantially with age, regardless of the presence of medical comorbidities. Their co-occurrence exponentially increases illness burden and the care necessary to meet that burden. Unfortunately, mental disorders in old age go substantially undetected and undertreated, especially in mostly homebound individuals. With the above in mind, the delivery of effective mental health care to older individuals with chronic diseases often faces insurmountable barriers. Care increasingly has to be provided in ways convenient to recipients, preferably in their homes. Several models have attempted to deliver homebased mental health services to persons with depression or dementia.2 Proof of effectiveness for such home-based services has slowly been accumulating but continues to lag behind the need. For example, my coworkers and I demonstrated in early 2014 that home-based dementia care can improve the ability of patients with dementia to live at home longer, with better quality of life, while placing less burden on caregivers.3 Regarding care for depression at home, there has been less evidence of effectiveness. To address this gap, Bruce and colleagues4 in this issue of JAMA Internal Medicine report the results of a cluster randomized clinical trial for the care of patients with depression in their homes. The investigators developed the Depression CAREPATH, an approach to care delivery that is fully integrated with the day-to-day activities of home care services. In the execution of a complicated but well-designed trial, they demonstrated the effectiveness of this intervention. The researchers targeted individuals with clinical depression and compared their novel approach with enhanced usual care. While outcomes improved for all participants (regardless of the treatment arm), the Depression CAREPATH produced substantially better depression outcomes as early as 3 months after the intervention, with benefits that accrued further during the next year.
However, the benefit was evident only for individuals with moderate or more severe clinically significant depression. The benefit was independent of whether or not patients were prescribed antidepressants at baseline, suggesting that care coordination (eg, switching antidepressants and better monitoring their effects) was an important determinant of better outcomes. What is the significance of this effort if narrowly construed? The work by Bruce and collaborators provides robust proof of the principle that good mental health outcomes for depressed individuals with complex chronic medical conditions receiving care at homes are possible and can be delivered as part of routine medical care, without further burdening existing service provision. Additional elaboration and refinement of this approach are critical to improve targeting of the intervention and to evaluate benefits to quality of life, aging in place, or utilization of health care services. It is essential that funders must support the critically needed follow-up research in this area. Efforts should be targeted at those with the most severe forms of the disease, consistent with other collaborative care interventions for depression.5 In the bigger picture, this work reinforces the view that addressing underrecognized and undertreated mental disorders such as dementia and depression must be a cornerstone of health care reform. The serious adverse consequences of mental disorders in old age—especially with regard to quality of life, medical outcomes, and health care utilization—cannot be overstated.2,6 The current health care delivery structure and reimbursement are unsuitable to the provision of effective care for mental disorders and must be revised to conform to the reality of comorbidity with chronic disease. The common denominators of successful integration of mental health care into medical settings are several.7 First is careful preparation and support of frontline health care providers in detecting and managing mental disorders. This requires culture change to raise the priority to address these conditions, as well as the confidence of clinicians in delivering this care. The second involves close linkages of frontline services and mental health services through embedding of specialized mental health experts (allied professionals working closely with psychiatrists and psychologists) to provide care, support, and care coordination in primary care. Third is timely access to higher levels of mental health services if and when needed. Fourth is the application of these spearheaded programs to those at highest need. The most positive aspect of health care reform is the widespread recognition of the complexity of the primary care of patients with chronic multiple comorbid illnesses. This includes the way in which frontline clinicians prioritize care needs in the context of numerous competing risks and value judgments, as well as the management of complex care transitions and the coordination of teams deployed to reflect the
jamainternalmedicine.com
JAMA Internal Medicine January 2015 Volume 175, Number 1
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a J H Quillen College User on 05/28/2015
65
Research Original Investigation
Depression Care Management and Medicare Home Health
integration of all necessary care components. Mental health services, in this case to address dementia and depression in old age, must become a much higher priority in the health care system of the future. There is a high probability that, if done
smartly, this will lead to greater improvements in clinical outcomes and quality of life, as well as greater promise in helping older Americans age in place in their homes, which is one of their most fervent desires.8
ARTICLE INFORMATION
REFERENCES
Author Affiliations: The Johns Hopkins University, Baltimore, Maryland; Department of Psychiatry and Behavioral Sciences, Johns Hopkins Bayview Medical Center, Baltimore, Maryland.
1. Pirraglia PA, Hampton JM, Rosen AB, Witt WP. Psychological distress and trends in healthcare expenditures and outpatient healthcare. Am J Manag Care. 2011;17(5):319-328.
Corresponding Author: Constantine G. Lyketsos, MD, MHS, Department of Psychiatry and Behavioral Sciences, Johns Hopkins Bayview Medical Center, 5300 Alpha Commons Dr, Baltimore, MD 21224 ([email protected]).
2. DeMers S, Dinsio K, Carlson W. Psychiatric care of the older adult: an overview for primary care. Med Clin North Am. 2014;98(5):1145-1168.
Published Online: November 10, 2014. doi:10.1001/jamainternmed.2014.6086. Conflict of Interest Disclosures: None reported.
3. Samus QM, Johnston D, Black BS, et al. A multidimensional home-based care coordination intervention for elders with memory disorders: the Maximizing Independence at Home (MIND) pilot randomized trial. Am J Geriatr Psychiatry. 2014;22 (4):398-414. 4. Bruce ML, Raue PJ, Reilly CF, et al. Clinical effectiveness of integrating depression care management into Medicare Home Health: the
66
Depression CAREPATH Randomized Trial [published online November 10, 2014]. JAMA Intern Med. doi:10.1001/jamainternmed.2014.5835. 5. Luxama C, Dreyfus D. Collaborative care for depression and anxiety. Am Fam Physician. 2014;89 (7):524-525. 6. Lyketsos CG, Carrillo MC, Ryan JM, et al. Neuropsychiatric symptoms in Alzheimer’s disease. Alzheimers Dement. 2011;7(5):532-539. 7. Everett AS, Reese JB, Coughlin J, et al. Behavioral health interventions in the Johns Hopkins Community Health Partnership: integrated care as a component of health systems transformation. Int Rev Psychiatry. In press. 8. Reuben DB. Better care for older people with chronic diseases: an emerging vision. JAMA. 2007; 298(22):2673-2674.
JAMA Internal Medicine January 2015 Volume 175, Number 1
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a J H Quillen College User on 05/28/2015
jamainternalmedicine.com
