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Effectiveness of Depression Care Management in a Multiple Disease Care Management Model

Effectiveness of Depression Care Management in a Multiple Disease Care Management Model. Bruce Friedman, Ph.D. Departments of Community and Preventive Medicine, and Psychiatry University of Rochester. Acknowledgments.

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Effectiveness of Depression Care Management in a Multiple Disease Care Management Model

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  1. Effectiveness of Depression Care Managementin a Multiple Disease Care Management Model Bruce Friedman, Ph.D. Departments of Community and Preventive Medicine, and Psychiatry University of Rochester

  2. Acknowledgments • Robert Wood Johnson Foundation, “Depression in Primary Care: Testing a Consumer-Directed Care Model,” DPC #048120, Yeates Conwell, P.I. • Centers for Medicare and Medicaid Services, “A Randomized Controlled Trial of Primary and Consumer-Directed Care for People with Chronic Illnesses,” CMS # 95-C-90467, Gerald M. Eggert, P.I. • National Institute of Mental Health, “Impact of Depression and Function on Healthcare Use and Cost,” NIMH K01 MH64718, Bruce Friedman, P.I.

  3. Medicare Primary and Consumer-Directed Care Demonstration • Main Goals: • Promote empowerment and encourage greater consumer choice and control over personal health care decisions and management • Improve health status, functioning, and quality of life • Reduce Medicare and total healthcare costs • Randomized trial (N=1605) of 3 models of consumer-directed care plus a Control group (n=384) • Health Promotion Nurse (HPN) (n=382) • Voucher (n=419) • Combination (Nurse plus Voucher) (n=420)

  4. HPN Intervention Model • Monthly HPN home visits to teach and coach chronic disease self-management (empowerment) • PRECEDE health education planning model for health behavior change strategies • Depression training and focus • Differs from most disease management studies which usually concentrate on one chronic illness • The HPNs did not provide typical “hands-on” nursing care • Special Medicare payment for up to 4 physician-patient-caregiver-HPN office conferences

  5. HPN Visits • Visits per Month: Mean = 0.98 (SD=0.56) (0-5.4) Visits Total Per MonthVisits • Major depression 1.00 16.4 • No major depression 0.98 19.4 • GDS-15 score • 0-1 0.92 18.4 • 2-3 1.00 20.1 • 4-5 1.06 21.1 • 6-10 1.00 19.8 • 11-15 0.92 16.8

  6. Percent Depressed • Patient or caregiver rated screening tools completed at baseline, 12 months, or 22 months: • Major depression – 26% • Clinically significant non-major depression – 33% of cognitively intact • Identified in primary care physician records: • 33% had documentation of depression - 30% of HPN group - 35% of Control group • 43% had antidepressant prescription mentioned - 41% of HPN group - 45% of Control group • 50% had either or both - 48% of HPN group - 53% of Control group

  7. Patient-Selected Goals • 79% had at least one goal • Mean = 3.24 (SD = 3.78) (range: 0-19) • A total of 1,238 goals • Disease specific other than depression – 380 • Function – 147 Medication – 83 • Exercise – 128 Diet/nutrition – 71 • Physician related – 119 Addiction – 18 • Social support – 90 Other – 178 • Depression – 24 (1.94%) • Of patients for whom there was documentation of depression in PCP chart, 19% had a depression goal • Of patients for whom an antidepressant was mentioned in PCP chart, 11% had a depression goal

  8. Depression Treatment • Of the 138 patients with major depression at baseline, 12 months, or 22 months: • 53% had an antidepressant mentioned in the PCP’s medical records • 51% in HPN group • 55% in Control group

  9. Regression Analyses • We found no statistically significant effects of the HPN intervention on depression in logistic and OLS regression models: • Major depression at 12 months and 22 months • GDS score at 12 months and 22 months • Major depression at 12 months and 22 months for those with major depression at baseline • GDS score at 12 months and 22 months for those with major depression at baseline

  10. Conclusions • About the same number of HPN visits were received by depressed and non-depressed patients • Few depressed patients had a patient-selected depression goal • The HPN model: • No more documentation of depression in PCP records • No more documentation of the use of antidepressants in PCP records • No impact on depression at 12 and 22 months • A significant effect on ADL impairment

  11. Possible Explanations • The depression intervention may have been insufficient – not depression specialists • Competing demands • Other chronic conditions the patient, HPN, and physician are concerned with or working on • Other goals the patient has selected • Stigma or resistance of seniors to articulating depression goals • Empowerment intervention does not work as well for depressed patients

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