Last week I had the opportunity to attend the 2nd Annual Summit on Disease Management for Depression in Las Vegas. As Las Vegas is not my favorite place, I was reluctant to attend this meeting, but was drawn after I read the program. The meeting that was organized by the World Research Group brought together leaders from organizations that provide behavioral health managed care to share new and innovative programs being developed to identify and improve outcomes in areas of depression. One thing that struck me, which all of the presenters emphasized, was the important role that the case manager plays in working with patients at risk for depression and other behavioral health problems. It was refreshing to hear these leaders in the practice acknowledge that the expertise case managers bring to this field, in their ability to effectively educate and empower patients, leads to stronger adherence to treatment and more effective care coordination.
All of the presenters shared statistics demonstrating that, although treatment for depression is largely successful, fewer than half of those who suffer from the illness seek treatment. In addition, when patients seek treatment from their primary care physician, exhibiting traits that show they may have depression, the physician often fails to diagnose it, and it goes untreated. Also, due to some providers’ lack of knowledge regarding treatment for depression, patient education is lacking, resulting in poor adherence to treatment in those cases which have managed to advance that far.
To combat these challenges, organizations specializing in behavioral health care are ramping up efforts to provide continuing education programs for primary care physicians. They are stressing the importance of referring patients at risk for depression to a mental healthcare professional for assessment, diagnosis, treatment and continued monitoring. Effectively managing patients with depression takes a collaborative team, and a creative and proactive style of management. I was impressed with all of the presentations and the promise of the programs in various stages of development. As noted above, case management is an integral part of each program. Take a few minutes and read over the highlights of this meeting. I will definitely put this conference on my schedule for next year!
Below is a sampling of the presenters from the meeting, which spanned a day and a half.
Scott Carven, MBA, MSW, regional vice president for United Behavioral Health, opened the meeting and discussed optimizing the role of case management in disease management settings. As so many patients with chronic conditions suffer from depression, identification of patients and subsequent referral to a behavioral health specialist for treatment is essential. Scott showed that a patient who suffers from both depression and a chronic disease, such as CHF, COPD or diabetes, costs plans an average of $5,000 more than a patient with a chronic care disease without depression. He shared with the audience that the trend in many plans is now the integration of the behavioral health case manager with the medical disease manager, an important combination that can lead to the most effective and efficient care.
Rhonda Robinson Beale, MD, chief medical officer with United Behavioral Health, presented on the clinical side of depression and reinforced the need to look not only for depression but for symptoms related to anxiety, somatization and substance abuse. Many patients will not present with one condition but, in many cases, will have a combination of symptoms that must be addressed. She also explained that patients with these symptoms of pain or substance abuse may take longer to respond to medication. Patients with pain and depression need 12 weeks for most antidepressants to work, versus eight weeks for patients with depression alone. In helping to improve adherence, she pointed to the importance of learning from the patient what he considers important goals, and meshing these points into the plan of care. Helping the patient make gains toward his goal is important for the case manager. Small cases of success mean a lot for a patient with depression. Both Scott and Dr. Beale discussed which professional should take on the role of case manager. The behavioral health specialist or the nurse? Many in the audience felt that nurses were appropriate, but they need to have the psychiatric training to understand the mental, as well as the physical, issues patient present. United Behavioral Health is currently running two studies to see who is more effective — a nurse, a behavioral health specialist or a combination of the two. Their hope is to offer some insight at next year’s Summit.
Lynn Watts, RN-BC, CCM Manager, who is involved in case and disease management at Companion Benefits Alternatives, talked about the topic entitled Integrating Depression Disease Management into Existing Medical Disease Management Programs: Making the Case to Collaborate. Ms. Watts discussed the practical value of integration from the patient’s point of view, so that one professional alone works with the patient. One of the challenges is that many nurses do not feel comfortable talking about depression. Efforts are under way to ensure educational programs are in place, and to make behavioral health specialists available to answer questions and provide insight in an effort to empower the nurses.
Next, Leonard Reich, PhD, of HIP Health Plan of New York, spoke on Leveraging Tele-Health Monitoring to Meet the Need of Chronic Psychiatric Patients. Mr. Reich showed some of the tele-health tools that HIP is starting to use to improve adherence to medication and to empower patients by providing support and feedback through tele-health. This was very interesting, especially now that we have the technology to provide these tools. It seems many people are receptive to them as a way to improve their behavioral, and thus their medical, problems. Here is an example: a patient with CHF, who is depressed, can utilize the tele-health device, thus engaging in the process of identifying a problem before it becomes serious. Once weight gain, or other issues that can impact health are identified, a nurse would be alerted and would work with the patient one-on-one to help him understand what happened and how they can work together to avoid problems going forward. This project is only in the beginning stages, and it is hoped that some outcomes can be discussed at next year’s summit.
Kathy Kavolic from Managed Care Measures presented Benchmarking through Utilization of Depression Specific Data. I had heard this presentation at another meeting, but hearing it a second time enabled me to fully understand the value of this information. The goal is to provide health plans with independent, credible and reliable comparative data — norms and benchmarks — that enable appropriate planning, analysis and measurement. This information is a way for health plans to use their data and compare their plans to others to see how they are doing with respect to depression disease management metrics. The information is free and available for download. Click here to access it.
After lunch, Peg Audley, MSW, LICSW, ACSW, assistant director of the depression disease management program from CIGNA Behavioral Health, discussed: Patient or Patience? An Innovative Coaching Approach to Improve Patient Outcomes. This is a new project that CIGNA Behavioral Health has rolled out to help motivate patients, find out where they want to go, and assist them in getting there. The program has been well-received by patients and providers, and the staff are learning a great deal about how to identify issues through relationship-building. This, too, is a new program with no hard outcomes, but with high hopes for improved quality of care, patient and provider satisfaction and cost-savings.
The next program was presented by Kathryn Katz, MPH, LCSW. Kathryn is the senior quality improvement/preventive health coordinator for Connecticare Inc. Kathryn talked about her company’s DM Program on depression and how they work with their vendor, who provides services to their members. Through a close relationship with their members and their behavioral health partner, they have improved care for patients with chronic conditions.
The next two presenters were Arthur Kusserow, LCSW, and Dr. Lonnie Marshall, DO, from Highmark BCBS. They presented on the topic Shifting from Carved-Out to Cared-In Behavioral Health Services for Improved Results and Cost Savings. They provided an overview of why Highmark decided to carve back in BH and the plan to provide behavioral health services to their members in a coordinated manner. This also is a new program with no hard savings to date, but one with high expectations.
The day ended with Gary Oftedahl, MD, from the Institute for Clinical Systems Improvement, who presented The DIAMOND Initiative: Depression Improvement Across Minnesota — Offering a New Direction. This program is a best practice that many are watching to see what outcomes will come from this collaborative model. The goal of the project is to implement, through a systematic and coordinated plan, an evidence-based care management program for patients with depression in primary care medical groups in Minnesota. A key component of this project is the implementation of a care management fee, which will be paramount in supporting and sustaining the care management program, as well as the establishment of a formal consultative role for the psychiatric specialty linked to the primary care environment. Stay tuned for an update on this project at next year’s summit.
Day two started bright and early with Michael Brase, MD, vice president and medical director from Wellpoint Inc. Dr. Brase spoke on Measuring ROI for Bipolar and Depression Diagnoses: Differences and Similarities. As many know, Wellpoint is the largest payer in the managed care marketplace today, with more than 30 million covered members. They have taken a very proactive approach in managing patients with behavioral health issues. The key point that Dr. Brase put forth to all was to try to figure out a way to measure the indirect cost of depression, specifically absenteeism and presentism. These are the true drivers of cost. If plans can learn how to develop programs that improve both through early identification of illness, and work with providers to initiate treatment, success will follow. Dr. Brase reviewed some of the ways that Wellpoint is improving care for its members. They have an advantage over many plans, as they provide pharmacy management and pay claims for their members. They also have a robust continuing education program that helps their providers better understand the population they are managing.
The last speaker, William Hancur, PhD, associate director of behavioral health from Blue Cross Blue Shield of Rhode Island, presented a program that his department just rolled out on Oct 1. The title of the program was Co-Location of Primary Care and Behavioral Health Providers to Significantly Improve Behavioral Change. This program places a behavioral health specialist in the office with a primary care physician. This collaboration allows for the primary care physician and the behavioral health specialist to see patients together so that behavioral issues, as well as any medical issues, can be addressed. If you subscribe to the fact that most medical problems are the result of behavioral health issues, this model should become a best practice. If you want to learn more about this movement, you can go investigate the Collaborative Family Healthcare Association. Click here to visit their website.
Happy Halloween!
Anne Llewellyn, RN-BC, MS, BHSA, CCM, CRRN
Editor-in-Chief of Across My Desk, Case in Point magazine, and the Case Management Resource Guide
allewellyn@dorlandhealth.com
