Depression Healthcare program A multidisciplinary approach for patients with depressive complaints

1. Depression Healthcare programA multidisciplinary approach for patients with depressive complaints Development and implementation Robert Vening MA GP/Head of Department IOZ Katinka Mijnheer MA, Programme coordinator care Welcome my fellow professionals, Mr./Mrs. chairman, Robert Vening and I are very happy that we have been given the opportunity to speak during this congress. We would like to tell you briefly something about our organisation, SGE, foundation of health care centers, and the healthcare plan of our organisation. Then we will address the actual subject of this meeting; the development and implementation of the Depression care programme. Welcome my fellow professionals, Mr./Mrs. chairman, Robert Vening and I are very happy that we have been given the opportunity to speak during this congress. We would like to tell you briefly something about our organisation, SGE, foundation of health care centers, and the healthcare plan of our organisation. Then we will address the actual subject of this meeting; the development and implementation of the Depression care programme.

2. SGE Care provider of integrated primary health care Foundation established in 1982 from the �Philips Medische Dienst� (General practitioners service) 10 Health Centres in the various neighbourhoods of Eindhoven 80,000 patients (33% population Eindhoven) Employer of 260 employees e.g: 48 general practitioners, 7 pharmacies, 29 physiotherapists, 15 psychologists, 17 practice supporters GP Turnover: +/- 25 million euros Finance sources: 90% treatments and 10% contract healthcare insurer SGE is an organisation which has grown over 26 years into an organisation which offers integrated primary health care to more than 30% of the Eindhoven population. The care provision is as much as possible tailored to the needs of the population. At this moment the care is provided to 10 health centres. Moreover there is an office for complex psychosocial care. The general and technical services operate from one, the tenth, location. You can think about support to, among others, personnel and financial matters, but also support of the development and implementation of the SGE healthcare plans are provided. The SGE healthcare plan consists of: Regularly integrated primary health care; this includes the medical aspect related to these forms of care. The care is provided in a coherent manner where collaboration takes place within the primary health care, and where indicated with, paramedical, pharmaceutical and dental care. But also non specialized mental and social health care, and prevention and information in the secondary health care. The general practitioner plays a central, often coordinating role with patients with multiple care-requirements. The SGE works with care programmes, especially for chronically ill people with COPD, Diabetes Mellitus and Depression. The care programme for people with a risk of heart and vascular diseases is in development. There is also attention within the care programmes for the tracking of risk factors, the prevention of the disorder through health-enhancing activities and the stimulation of self-management by patients. Performance agreements of the SGE concerns the continuity, the accessibility, quality, effectiveness and the customer-orientation state of the care. SGE is an organisation which has grown over 26 years into an organisation which offers integrated primary health care to more than 30% of the Eindhoven population. The care provision is as much as possible tailored to the needs of the population. At this moment the care is provided to 10 health centres. Moreover there is an office for complex psychosocial care. The general and technical services operate from one, the tenth, location. You can think about support to, among others, personnel and financial matters, but also support of the development and implementation of the SGE healthcare plans are provided. The SGE healthcare plan consists of: Regularly integrated primary health care; this includes the medical aspect related to these forms of care. The care is provided in a coherent manner where collaboration takes place within the primary health care, and where indicated with, paramedical, pharmaceutical and dental care. But also non specialized mental and social health care, and prevention and information in the secondary health care. The general practitioner plays a central, often coordinating role with patients with multiple care-requirements. The SGE works with care programmes, especially for chronically ill people with COPD, Diabetes Mellitus and Depression. The care programme for people with a risk of heart and vascular diseases is in development. There is also attention within the care programmes for the tracking of risk factors, the prevention of the disorder through health-enhancing activities and the stimulation of self-management by patients. Performance agreements of the SGE concerns the continuity, the accessibility, quality, effectiveness and the customer-orientation state of the care.

3. Depression, problems in the practice Over-treatment of non-serious depression (80% anti- depressants) Under-treatment of serious depression (waiting time, insufficient monitoring, drop-out) Under-diagnostics general practitioners practice (50% no diagnosis, diagnosis or treatment in 30% too late) No patients involvement Insufficient use of standards The Depression care programme concerns the care for adults in the primary health care who suffer, to a greater or lesser degree, from depression. Each year 737,000 adults suffer from depression in the Netherlands - of which 359,000 of those are new patients. The programme is a further elaboration of the national depression breakthrough project. The improvements which are striven for are based on recent scientific insights, among which the Dutch-standard of GP, the multi-disciplinary depression guidelines from 2005 and on expertise of good practise in the Netherlands. The most important bottlenecks in the care for Depression are indicated in this slide�..The Depression care programme concerns the care for adults in the primary health care who suffer, to a greater or lesser degree, from depression. Each year 737,000 adults suffer from depression in the Netherlands - of which 359,000 of those are new patients. The programme is a further elaboration of the national depression breakthrough project. The improvements which are striven for are based on recent scientific insights, among which the Dutch-standard of GP, the multi-disciplinary depression guidelines from 2005 and on expertise of good practise in the Netherlands. The most important bottlenecks in the care for Depression are indicated in this slide�..

4. Targets National Breakthrough project Depression To reduce the over-treatment with anti-depressives in non-serious depression To reduce the under-treatment of adults with serious depression With the use of the Stepped care method (�opt for the least intensive aid of which sufficient effect is expected�) the multidisciplinary depression guideline Here you can see the objective of the national breakthrough project. The centrally used approach is the �Stepped care� method in the diagnostics and the treatment of people with a depression. This method consists of a standardised process where patients and healthcare providers first opt for the least intensive assistance of which an effect is expected. Patients with serious or chronic complaints receive more intensive guidance. In the multi-disciplinary depression guideline the contribution of the various care providers and how cooperation can take place is described.Here you can see the objective of the national breakthrough project. The centrally used approach is the �Stepped care� method in the diagnostics and the treatment of people with a depression. This method consists of a standardised process where patients and healthcare providers first opt for the least intensive assistance of which an effect is expected. Patients with serious or chronic complaints receive more intensive guidance. In the multi-disciplinary depression guideline the contribution of the various care providers and how cooperation can take place is described.

5. Results of National Breakthrough project Depression Decline rates from 61 to 11% primary treated with antidepressants Increase of minimal interventions from 33% to 88%. Waiting times remained, but quicker diagnostics in the second line health care As you see the objectives of the previous sheets have largely been achieved. The results of the Breakthrough project are so encouraging that the SGE has chosen to implement the work method of it with the depression care programme.As you see the objectives of the previous sheets have largely been achieved. The results of the Breakthrough project are so encouraging that the SGE has chosen to implement the work method of it with the depression care programme.

6. Indicators SGEDepression care programme Within 6 months 90% a BDI score lower than 10 Two-thirds of the patients with non-serious depression receive the first 6 weeks exclusively minimal interventions In serious depression, start specific treatment within a month Cancellation within 1 month with a depression-specific treatment is lower than 15% A subdivision has been made in the care programme of the objectives on a patient level, practice level and social level. Then, and you can see this on the slide, specific indicators have been formulated. They are based on the Breakthrough method Depression. The Beck Depression Inventory (BDI, BDI-II), created by Dr. Aaron T. Beck, is a 21-question multiple-choice self-report inventory that is one of the most widely used instruments for measuring the severity of depression. In order to be able to measure indicators, collaboration takes place with the Maastricht University. Researchers have carried out an original survey (baseline measurement/research) and will analyse the SGE data files and carry out measurements. With the feedback data the SGE can implement improvements in the care.A subdivision has been made in the care programme of the objectives on a patient level, practice level and social level. Then, and you can see this on the slide, specific indicators have been formulated. They are based on the Breakthrough method Depression. The Beck Depression Inventory (BDI, BDI-II), created by Dr. Aaron T. Beck, is a 21-question multiple-choice self-report inventory that is one of the most widely used instruments for measuring the severity of depression. In order to be able to measure indicators, collaboration takes place with the Maastricht University. Researchers have carried out an original survey (baseline measurement/research) and will analyse the SGE data files and carry out measurements. With the feedback data the SGE can implement improvements in the care.

7. Original survey SGE conclusions 5 baseline characteristics not-deviating from literature Large variation prevalence between health centres High comorbidity and healthcare consumption: 80% more than 3 complaints Under registration: 49% of antidepressant users has a corresponding code The baseline research of depression, carried out by Maastricht University gives us a good picture of the depression population within SGE. The original survey is used for the evaluation and improvement of the depression care programme in order to be able to help people who suffer this disorder in a quicker and better way. The 5 baseline characteristics are: gender, age, civil status, SES, education Regarding the demographic characteristics we see that the Proportion male: female is 1:2 and that More than 50% of the population with depression is older than 40 years. We also note that people with a Lower social economic status and divorced people have a greater chance of getting a depression. There are large differences prevalence in the centres caused by Differences in the population situation and Differences in the registration by general practitioners Concerning comorbidity the survey shows that the depression population has an increased chance of chronic disorders, such as diabetes and chronic lung disorders. In the care programme extensive attention will be paid to the prescriptive behaviour, treatment policy and referral behaviour.The baseline research of depression, carried out by Maastricht University gives us a good picture of the depression population within SGE. The original survey is used for the evaluation and improvement of the depression care programme in order to be able to help people who suffer this disorder in a quicker and better way. The 5 baseline characteristics are: gender, age, civil status, SES, education Regarding the demographic characteristics we see that the Proportion male: female is 1:2 and that More than 50% of the population with depression is older than 40 years. We also note that people with a Lower social economic status and divorced people have a greater chance of getting a depression. There are large differences prevalence in the centres caused by Differences in the population situation and Differences in the registration by general practitioners Concerning comorbidity the survey shows that the depression population has an increased chance of chronic disorders, such as diabetes and chronic lung disorders. In the care programme extensive attention will be paid to the prescriptive behaviour, treatment policy and referral behaviour.

8. 8 This is the summary of the national break through project in a nutshell. In the SGE Depression care programme we like to use these findings. By means of the �stepped care method� general practitioners make a distinction between patients with serious and a mild depression ( which is 2/3 of the population with depression at the general practitioner). The general practitioners indicate the corresponding level of treatment and together with the patient an intervention is chosen. The BDI is completed by the patient him/herself on a monthly basis as of the moment of the diagnosis, with which it is possible to keep track of whether depressive complaints of a patient are increasing or diminishing. With a score of 10 or lower the patients are considered to have recovered or to be in remission. In the event of a halving compared to the starting situation we speak of a response to the treatment. Explanation of abbreviations PST= problem-solving treatment GT=Gedragstherapie (Behavioural therapy) CGT= Cognitieve gedragstherapie (Cognitive behavioural therapy) IPT= Interpersoonlijke psychotherapie (Interpersonal psychotherapy) Background information BDI The most current version of the BDI questionnaire is designed for individuals aged 13 and over and is composed of items relating to symptoms of depression such as hopelessness and irritability, cognitions such as guilt or feelings of being punished, as well as physical symptoms such as fatigue, weight loss, and lack of interest in sex.[1] There are three versions of the BDI�the original BDI, first published in 1961 and later revised in 1978 as the BDI-1A, and the BDI-II, published in 1996. The BDI is widely used as an assessment tool by healthcare professionals and researchers in a variety of settings. This is the summary of the national break through project in a nutshell. In the SGE Depression care programme we like to use these findings. By means of the �stepped care method� general practitioners make a distinction between patients with serious and a mild depression ( which is 2/3 of the population with depression at the general practitioner). The general practitioners indicate the corresponding level of treatment and together with the patient an intervention is chosen. The BDI is completed by the patient him/herself on a monthly basis as of the moment of the diagnosis, with which it is possible to keep track of whether depressive complaints of a patient are increasing or diminishing. With a score of 10 or lower the patients are considered to have recovered or to be in remission. In the event of a halving compared to the starting situation we speak of a response to the treatment. Explanation of abbreviations PST= problem-solving treatment GT=Gedragstherapie (Behavioural therapy) CGT= Cognitieve gedragstherapie (Cognitive behavioural therapy) IPT= Interpersoonlijke psychotherapie (Interpersonal psychotherapy) Background information BDI The most current version of the BDI questionnaire is designed for individuals aged 13 and over and is composed of items relating to symptoms of depression such as hopelessness and irritability, cognitions such as guilt or feelings of being punished, as well as physical symptoms such as fatigue, weight loss, and lack of interest in sex.[1] There are three versions of the BDI�the original BDI, first published in 1961 and later revised in 1978 as the BDI-1A, and the BDI-II, published in 1996. The BDI is widely used as an assessment tool by healthcare professionals and researchers in a variety of settings.

9. Modules from the Depression Care programme Module 1: Diagnostics, choice of intervention and start of monitors (BDI) Module 2: Minimal interventions (and BDI) Module 3: Referral 2nd line (serious depression) Module 4: The follow-up with serious depression (consults GP and BDI) The care programme consists of ingredients from the breakthrough project. 4 Modules have been developed within which registration and organisational agreements have been made with care providers from the primary and secondary healthcare. In Module 1 The general practitioner makes a diagnosis and distinguishes whether there is a situation of a mild or a serious depression. The GP suggests, in consultation with the patient, which minimal intervention (in the event of a mild depression) will be used Only in exceptional cases it is possible to opt for supporting medicinal therapy A starting point BDI is determined. (Beck Depression Intervention) I will address Module 2 in more detail with the next slide What concerns Module 3 In the event of a serious depression or with persistent complaints after a minimal intervention, the patient is referred to a psychiatrist, psychotherapist or psychologist in the second line health care. The patient must be seen within a month and within a waiting time of 2 weeks, independent of the complaints, at least be followed by a general practitioner or POHGGZ. The POHGGZ is a new discipline in our centres. It is a type of nurse practitioner. This professional has delegated tasks from the GP, providing psychosocial care. In module 4 the treatment has been established in the secondary healthcare and the patient has been referred back by the psychiatrist. The general practitioner monitors the patient for a period of 6 months at least 2 times. Attention points are the progress of the complaints (BDI) and the possible use of medication. The care programme consists of ingredients from the breakthrough project. 4 Modules have been developed within which registration and organisational agreements have been made with care providers from the primary and secondary healthcare. In Module 1 The general practitioner makes a diagnosis and distinguishes whether there is a situation of a mild or a serious depression. The GP suggests, in consultation with the patient, which minimal intervention (in the event of a mild depression) will be used Only in exceptional cases it is possible to opt for supporting medicinal therapy A starting point BDI is determined. (Beck Depression Intervention) I will address Module 2 in more detail with the next slide What concerns Module 3 In the event of a serious depression or with persistent complaints after a minimal intervention, the patient is referred to a psychiatrist, psychotherapist or psychologist in the second line health care. The patient must be seen within a month and within a waiting time of 2 weeks, independent of the complaints, at least be followed by a general practitioner or POHGGZ. The POHGGZ is a new discipline in our centres. It is a type of nurse practitioner. This professional has delegated tasks from the GP, providing psychosocial care. In module 4 the treatment has been established in the secondary healthcare and the patient has been referred back by the psychiatrist. The general practitioner monitors the patient for a period of 6 months at least 2 times. Attention points are the progress of the complaints (BDI) and the possible use of medication.

10. Module 2 minimal interventions Colour in your life, an internet course (9x) Interapy, an intensive internet course (1 to 3 months) Psycho-education, group meetings (3) Course �down in the dumps, out of the dumps� (12 group meetings) Problem-Solving Treatment (4-6 conversations) Mindfulness (8 group meetings) Movement (6-16 weeks, 2-3 times per week) To all minimal interventions it applies that there is attention paid, to a greater or lesser extent, on the increase of knowledge regarding depression. People learn to face the future positively and with self-confidence. Certain skills are learned, such as giving structure to the day and patients are having almost always exercises and tasks to carry out at home. The courses Interapy , Psycho-education, Course �down in the dumps, out of the dumps� and Mindfulness are guided by psychologists. Problem-solving Treatment can be given by the general practitioner, a social worker, a psychologist or by a POHGGZ for Mental healthcare. Movement The movement consultant carries out the intake and will, with the patient, come to a decision To all minimal interventions it applies that there is attention paid, to a greater or lesser extent, on the increase of knowledge regarding depression. People learn to face the future positively and with self-confidence. Certain skills are learned, such as giving structure to the day and patients are having almost always exercises and tasks to carry out at home. The courses Interapy , Psycho-education, Course �down in the dumps, out of the dumps� and Mindfulness are guided by psychologists. Problem-solving Treatment can be given by the general practitioner, a social worker, a psychologist or by a POHGGZ for Mental healthcare. Movement The movement consultant carries out the intake and will, with the patient, come to a decision

11. Attention for self management A characteristic of the minimal intervention is that the patient him/herself learns to deal with his/her problem actively. As you can see the care provider anticipates that.A characteristic of the minimal intervention is that the patient him/herself learns to deal with his/her problem actively. As you can see the care provider anticipates that.

12. Implementation Theory and paper are patient, but implementation requires some action.Theory and paper are patient, but implementation requires some action.

13. Terms and conditionsfor implementation Finances Intranet facilities, planning and online application Registration and electronic data exchange agreements between the various disciplines Patient friendly version (digital and on paper) of minimal interventions Original survey and evaluation For the financial matters there are consultations with the health insurance company and contracts are being made. A number of minimal interventions are new and are not automatically compensated. The starting point is that the patient, without being put to great expense, can participate in the depression care programme. In order to be able to cooperate successfully it is important that agreements are complied with. It is important to register well, to use the right codes and to report to each relevant professionals. Because the patient takes a substantial part of his own treatment, it is of great importance for him be provided with proper information. SGE has developed a brochure, which is also to be seen on the patients website, in which minimal interventions are described in a simple way. For the financial matters there are consultations with the health insurance company and contracts are being made. A number of minimal interventions are new and are not automatically compensated. The starting point is that the patient, without being put to great expense, can participate in the depression care programme. In order to be able to cooperate successfully it is important that agreements are complied with. It is important to register well, to use the right codes and to report to each relevant professionals. Because the patient takes a substantial part of his own treatment, it is of great importance for him be provided with proper information. SGE has developed a brochure, which is also to be seen on the patients website, in which minimal interventions are described in a simple way.

14. Implementation Project group with broad composition Involvement care providers Realistic planning Training Communication, consultation and feedback This slide shows the subjects that receive a lot of attention by SGE during the implementation. In order to guarantee the quality of the care, each care provider is expected to comply with the national guidelines of their own professional group and the multi-disciplinary guidelines relating to depression. The Deming cycle is used with the organisation of care (which is plan, do, check, act). It is expected that the described agreements and quality indicators will lead to transparency of care for people with depression. Thank you very much for your attention. This slide shows the subjects that receive a lot of attention by SGE during the implementation. In order to guarantee the quality of the care, each care provider is expected to comply with the national guidelines of their own professional group and the multi-disciplinary guidelines relating to depression. The Deming cycle is used with the organisation of care (which is plan, do, check, act). It is expected that the described agreements and quality indicators will lead to transparency of care for people with depression. Thank you very much for your attention.

15. Thank you!! Do you have any questions???Do you have any questions???