Improving systems of care theme of IHI's national conference

ORLANDO—Can depression be effectively managed in primary care? Are you using registries to track patients' progress? What are other physician groups doing to address overuse of specialty services? These are just a few of the quality of care issues addressed last week at the Institute for Healthcare Improvement's 22nd annual National Forum, which attracted more than 6,000 health care professionals.

Managing depression: Two workshops focused on effective models for managing depression in the primary care setting.

Henry Ford Health System is piloting a new model in seven of its 27 clinics that has increased the number of patients being screened, identified and treated for depression, said presenters Terri Robertson, PhD, and M. Justin Coffey, MD. The model calls for embedding psychiatric nurse practitioners in primary care clinics to coordinate with physicians, train medical assistants to use screening tools and provide clinical care. Medical assistants are trained to administer a two-part questionnaire to all patients as they arrive for an office visit. Patients who respond ‘yes' to one or both questions are then asked to take an expanded questionnaire based on the PHQ-9, which is embedded into the clinic's electronic health record system. Patients' answers are entered directly into the EHR and results are calculated and analyzed before the physician arrives in the exam room, freeing up the physician to focus on discussing the results with the patient. Since the pilot began at Henry Ford three years ago, 90% of patients who screened positive are being managed by their physician with a combination of cognitive behavioral therapy and pharmacotherapy and among that group, 67% of patients received pharmacotherapy and 53% had a full response to treatment, the presenters said.

The Depression Improvement Across Minnesota, Offering a New Direction (DIAMOND) model has been implemented in 83 primary care clinics in Minnesota and Wisconsin over the past two and a half years. Nine health plans support the initiative using a common payment code for evidence-based collaborative depression care management. The model relies on the PHQ-9 questionnaire as a simple tool to identify depression and track patients' response to treatment, said presenters Tim Hernandez, MD, of Family Health Services Minnesota and Nancy Jaeckels, vice president of the nonprofit Institute for Clinical Systems Improvement. Other key elements include using a computerized tracking system or registry to follow patient progress, make follow-up contacts and collect data and documentation, and taking a team approach to patient care. So far, the DIAMOND program, which began in March 2008, has improved response and remission rates among patients at participating clinics while reducing overall costs. According to data from the University of Washington's Project IMPACT (Improving Mood—Promoting Access to Collaborative Treatment), the per patient per year cost was 50% less for DIAMOND care management ($18,290) compared with usual care ($30,634).

Using specialty services effectively: If you want to lower physician use of specialty services, targeting “high utilizers” is usually a dead-end strategy, said presenter Neil Baker, MD, of IHI, which is partnering with the American College of Cardiology on an initiative to optimize use of specialty services. Instead, show physicians data on the wide variation in specialty care costs across the country and evidence that higher utilization is not associated with better outcomes. Then ask physicians to develop reasonable clinical standards that everyone in the group agrees to follow, he said. A case in point is the Palo Alto Medical Foundation, a large multispecialty group with over 900 physicians in the San Francisco Bay Area. The group gets top ratings for quality but is unaffordable for many patients, said Lawrence Shapiro, MD, of PAMF. In an effort to cut costs, PAMF launched an initiative in its ob/gyn group to reduce specialty referral costs for patients with post-menopausal bleeding (PMB). After physicians agreed to adhere to a common clinical standard for PMB patients, the group recorded savings of almost $780,000 over nine months, largely due to fewer biopsies and greater use of ultrasound for diagnosis. “The doctors have to be at the center of the process,” said Dr. Shapiro. “At first they might argue about the data but then they start talking to each other.”

—Janet Colwell