Addressing Depression Care Management in PCP Offices: Collaborative Care

Health AffairsIf you have read Beacon Health Options’ white paper, “Integration,” you learned that more than half of all adults with major depressive disorder are already managed in primary care settings. You also learned that most antidepressant medications are written by primary care physicians (PCPs). However, most concerning is that approximately 45 percent of those who complete suicide have seen their PCP within the past month.

Care management practices in American primary care offices are used less for depression than for other chronic conditions.

Authors of an article in the March issue of Health Affairs would not be surprised by this last stat. In brief, the article states that care management practices in American primary care offices are used less for depression than for other chronic conditions. Important reasons cited include time pressures, inconsistent reimbursement, stigma, psychiatrist shortages and a general divide between behavioral and physical health treatment by PCPs.

Problem-solving model

The article provides evidence to support Beacon’s position that the collaborative care model (CCM), pioneered by the AIMS Center, University of Washington, provides the strongest evidence base for integration, and by extension, treating depression in primary care settings. If all five pillars of the CCM – care that is team-based, population-based, measurement-based, evidence-based and accountable – are applied as part of a cohesive model, then we can start to address some of the system’s current shortfalls.

Let’s take a look at each problem cited above and illustrate how the CCM can address it.

  1. Psychiatrist shortages: The CCM’s collaborative team approach addresses this shortfall by redefining access and leveraging psychiatrists’ skills so that they treat only the most severely ill individuals. Instead of offering outpatient appointments weeks in advance, the CCM limits the number of pre-booked appointments to facilitate access via same-day walk-in appointments. “Warm handoffs” from PCP to psychiatrist occurring in both office-based and virtual settings replace written referrals.
  2. Time pressures: The CCM requires two new team members to the PCP setting: a care manager and consulting psychiatrist. The psychiatrist spends a few hours each week reviewing the care manager’s caseload, which enables psychiatrists to serve a far larger population than in an office-based practice. Further, the PCP is relieved of cases that he or she is not equipped to handle or, in the case of mild-to-moderate depression, is relieved of such functions as patient education and self-management support and facilitation of any required treatment change.
  3. Stigma: Even when referrals to specialists are made, individuals frequently don’t show up due to stigma. An in-person introduction resulting from warm hand-offs described in point 1 above increases patient engagement through reducing stigma.
  4. Inconsistent reimbursement: Integrated care calls for a different reimbursement model, one that is more aligned to the value of care provided. The CCM calls for a change in billing codes that ties mental health to accountability, incentivized through reimbursement. The good news is that the Medicare Physician Fee Schedule released by the Centers for Medicare and Medicaid Systems allows PCPs to receive payment for chronic care coordination and telehealth services, which means integrated care is being reimbursed for the value it provides.
  5. Persistent divide between behavioral and physical health: Because of the integrated care team approach, the CCM can pick up the slack when necessary. With the addition of the care manager and consulting psychiatrist to the PCP setting, behavioral health treatment becomes a way of life. For example, consulting psychiatrists can offer advice to PCPs on specific cases. Care managers themselves can provide counseling, such as cognitive behavioral therapy.

The collaborative care model (CCM), pioneered by the AIMS Center, University of Washington, provides the strongest evidence base for integration, and by extension, treating depression in primary care settings.

The Health Affairs article concludes that primary care offices are currently not well equipped to manage depression as a chronic condition and that policies should incentivize depression care management. Beacon takes that recommendation one step further. Real change requires a new way of doing business, a new mind set of “out with the old and in with the new.” It requires a shared accountability from all system stakeholders – not just PCPs or behavioral health professionals. The study referenced in the March Health Affairs article is just one more piece of evidence that it’s time to be serious about change.

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