What Does Research Tell Us?

1. What Does Research Tell Us? Care Manager Roles in Depression Care

2. Disease Management • Improve care for chronic illness (Wagner, Austin, von Korff, M., 1996). • Disease management: An intervention designed to manage and prevent a chronic condition by using a systematic approach to care and potentially employing multiple treatment modalities ( Ellrodt, et al.,1997); varies somewhat by project. -Models: Collaborative Care (primary care physicians, psychiatrists, clinical nurse specialists and P-NP’s)

3. Models (Continued) Evidence-based practice guidelines and multiple modalities (psychosocial and pharmacologic). Care management: (compilation several sources) 1)Assess symptoms of depression 2) Educate patient/ family on depression, treatment and problems solving skills. 3) Monitor for medication adherence, satisfaction 4) Behavioral activation (including motivation) 5) Relapse prevention 6) Communication with participating health personnel: specialist referral, documentation, need for PC assessment.

4. Credentials of Care Managers • Registered and advanced practice nurses* • Social workers • Psychologists • Trained interventionists without health professional licensure *majority of care managers

5. Making Sense of Research Findings • Study goals were heterogenous: patient outcomes vs. health professional outcomes • Study samples are small • Severity of depression varied • Participants at different points of the life span • Few minority group members • Included face-to-face & telephone interviews • Simple to complex interventions

6. Program Education Systematic Review • Badamgarav, et.al. 2003 24 disease management programs studied Key aspects of depression care : -detection - prescription of appropriate treatment - patients’ compliance with treatment

7. Findings • Programs had statistically significant effects on: - improvement in symptoms of depression -patients’ satisfaction with treatment -patients’ compliance with treatment -increased rates of depression detection by PCP -increased health care utilization, treatment costs, and hospitalization

8. Educational and Organizations Systematic Review • Gilbody, Whitty, Grimshaw, Thomas,(2003) 36 studies (29 RCT’s,) Effective strategies: Collaborative Care Stepped Collaborative Care Quality Improvement Pharmacy Prescribing Information and Patient Education

9. Continued • Guideline implementation Strategies • Case Management (positive results) -medication follow-up by nurses, counselors or psychologists -low intensity nurse involvement (education, counseling, telephone) - trained nurse case management

10. Findings • Elements linked to clinical effectiveness in the short term: - clinician and patient education - nurse case management - enhanced psychiatric services support - monitoring of medication adherence

11. Recommendations • Educate/train primary care physicians and care managers • Choose interventionists with aptitudes for active listening, communicating positive regard and empathy • Follow standard guidelines (AHCPR) in depression care • Further research on intervention components, cost-effective care provision • Organizational support

12. Questions Remain • Treatment results: do they depend on treatment alliance of patient and team of providers? • What are active ingredients of effective interventions? • Can we achieve clinical and cost effectiveness with nurse case management, collaborative care, care management and QI? • What interventions work over the long term care?