Background
Methods
Overview
Description of healthcare systems
Phase 1: Quantitative analyses
Phase 2: Qualitative analyses
Interview guide
Qualitative data analysis
Results
Quantitative analyses
CC implementation metrics in clinics opting to enter the sustainability phase vs. opting out
Metric (median, [IQR]) | Sustaining clinics (n = 26) | Opt-out clinics (n = 6) | P value |
---|---|---|---|
Total census at clinic | 5669 [7635] | 2686 [1829] | 0.06 |
% screened per calendar year1 | 96.5% [13.0] | 87.0 [41.0] | 0.51 |
Depression care manager full-time equivalent | 1.00 [0.75] | 0.50 [0] |
0.002
|
Number of participants enrolled/FTE2 | 137.8 [89.0] | 58.0 [61.0] | 0.07 |
% of depressed patients in calendar year enrolled into collaborative care program3 | 43.0% [45.0] | 34.0% [13.0] | 0.22 |
% currently enrolled in third quarter with psychiatry consultation4 | 100% [44.0] | 90% [100] | 0.53 |
% enrolled for 6 months and still on med/therapy (%)5 | 15.0% [21.0] | 42.0% [85.0] | 0.77 |
% of patients enrolled in collaborative care ≥ 16 weeks with PHQ9 < 106 | 46.0% [53.0] | 7.5% [23.0] |
0.004
|
CC metrics 1 and 2 years into sustainability among 26 sustaining clinics
Metric (median, [IQR]) | Implementation end (2014)† | Baseline sustainability (2015)† | P value (2015 vs. 2014) | Year 1 sustainability (2016) | P value (2016 vs. 2015) | Year 2 sustainability (2017) | P value (2017 vs. 2015) |
---|---|---|---|---|---|---|---|
% screened | 96.5% [13.0] | 88.5% [19.0] |
< 0.001
| 86.0% [31.0] | 0.38 | 91.0% [18.0] |
0.01
††
|
Depression care manager full-time equivalent | 1.00 [0.75] | 1.00 [1.00]] | 0.08 | 1.00 [1.00] | 0.79 | 2.00 [1.00] | 0.09†† |
Number of participants enrolled/FTE | 56.0 [36.0] | N/A | 44.6 [18.0] | 0.23 | 36.5 [37.5] |
0.004
| |
Number of participants screening positive for depression/FTE | 297 [354] | N/A | 281 [204] | 0.17 | 337 [294] | 0.81 | |
Median Patient Health Questionnaire of current enrollees | 10.5 [5.0] | N/A | 9.75 [6.0] | 0.41 | 10.0 [3.0] | 0.23 | |
% enrolled with ≥ 3 contacts | 29.0% [33.0] | N/A | 24.0% [33.0] | 0.17 | 40.5% [24.0] |
0.03
| |
% enrolled 70 days with improvement (PHQ < 10 or 50% reduction) | 33.0% [22.0] | N/A | 49.0% [25.0] |
0.009
| 58.0% [19.0] |
0.004
| |
% not improved after 70 days with psychiatry consult | 55.0% [47.0] | N/A | 57.5% [29.0] | 1.00 | 80.5% [49.0] | 0.11 | |
% not improved after 70 days with treatment change | 48.0 [36.0] | N/A | 54.0% [39.0] | 1.00 | 73.0% [53.0] | 0.33 |
Site visit characteristics and sustainability fidelity
Clinic characteristics
CC metrics and implementation fidelity in the sustainability period
Barriers to CC implementation in the sustainability phase (themes are bolded, sub-themes are underlined and italicized)
Barriers | Total (%) | Sustaining (%) | Opt-out (%) | Quotes |
---|---|---|---|---|
Time-personnel resources | 74 | 71 | 86 | |
Inadequate personnel resources | 16 | 13 | 29 | “Did not think about logistics issues, no thought of sites, ratios, right sizing, right timing of this −3.5-4 h of .1 FTE for 6 PCPs” (opt-out site) |
Competing DCM roles | 16 | 13 | 29 | “Currently, the administrator of the program (a certified care coordinator who can do problem solving therapy and motivational interviewing) is only funded for .5FTE, so the other 50% of her time is devoted to a diabetes program in the primary care clinic.” (Opt-in PCP) |
Inadequate MD resources | 26 | 25 | 29 | “[Providers] are getting hammered with increased number of items they are supposed to manage in the visit. We have to screen every patient for risk of domestic violence…falls…travel to West Africa for Ebola, and unfortunately, this [depression screening] is one more measure” (Opt-in PCP) “Case consultation with psychiatrist did not happen. Psychiatrist available by telephone for consultation, but no set time to have him available. If you are in a crisis to call a psychiatrist this is ok, but overall not” (Opt-out PCP). |
Inadequate number of DCMs | 52 | 46 | 71 | “Only have 1 provider. It’s impossible to have her take care of all the depress[ed] people… Appointments are not always given the day of the [PCP] appointment” (opt-in PCP) |
Inadequate psychosocial resources | 19 | 21 | 14 | “At the same time, many patients want and/or need more intensive psychiatric treatment than can be offered in this setting (such as a day program or intensive outpatient treatment).” (Opt-in Psych) |
Inadequate space | 13 | 13 | 14 | |
Patient engagement | 61 | 67 | 43 | |
Lack of patient engagement | 16 | 17 | 14 | “No shows [are a problem] because rescheduling with the psychiatrist takes another 60 days” (Opt-in Psych). |
Culture- language | 16 | 13 | 29 | “[it was] hard to recruit someone who spoke language, used language lines (had to pull staff to translate)” (Opt-out Admin). |
Infeasible warm handoffs | 19 | 21 | 14 | “[we had a] part time care manager who cannot have a warm handoff [which] is much less effective” (opt-in DCM). |
Patient nonadherence | 39 | 42 | 29 | “It’s challenging to make sure that patients continue to follow up. It is difficult because it affects the entire person and you have to get them to participate in the plan. Loss to follow up.” (Opt-in PCP) |
Stigma | 13 | 13 | 14 | |
Provider/staff engagement | 48 | 50 | 43 | |
Miscommunication | 3 | 4 | 0 | “But if psychiatrist thinks that the medication needs to be increased, and then have to tell physician this message, which can sometimes be odd. The interaction between psychiatrist and physicians should be improved.” (Opt-in DCM) |
Lack of DCM engagement | 6 | 4 | 14 | |
Lack of PCP engagement | 35 | 38 | 29 | “doctors are uncomfortable either because they might get more work to do” (Opt-in PCP) |
Provider continuity | 19 | 21 | 14 | “DCM turnover with mixed experiences of quality of DCMs” (Opt-in Admin) “Residents are not always engaged because you have to teach them all over again.” (Opt-out DCM) |
Psychiatrist engagement | 13 | 13 | 14 | “Psychiatrists not motivated or interested in this model” (Opt-out Psych) |
Staff engagement | 3 | 4 | 0 | |
External factors | 39 | 38 | 43 | |
Healthcare system/guidelines | 3 | 4 | 0 | “We used to consider PHQ < 10 as remission, but now guidelines say it is under 5. PHQ < 5 is probably not realistic.” (Opt-in PCP) |
Competing primary care initiatives | 6 | 4 | 14 | “PMDs are getting hammered with increased number of items they are supposed to manage in the visit. We have to screen every patient for risk of domestic violence, risk of falls, etc. We’d love to screen patients for substance use” (Opt-in PCP) |
Other | 39 | 38 | 43 | Mental health infrastructure: “the sickest patients psychiatrically have to be referred out. That coordination is tough as it is difficult to collaborate with mental health providers outside of the clinic.” (Opt-in PCP). Restrictive CC initiative enrollment “Patients who do not have Medicaid are still screened, so they get “light touches” with the DCM to help get them referred into therapy.” (Opt-in Admin) |
Screening/referral | 32 | 33 | 29 | |
Complicated screening/referral logistics | 3 | 0 | 14 | “Screening was initially tough given cultural barriers among patients and staff as well as tester fatigue” (Opt-in Admin). “[the] MA [medical assistants] did PHQ2 but hard to make sure to alert the doctor about PHQ2 and to do the PHQ 9 if positive” (opt-out PCP). |
Triaging patients | 29 | 33 | 14 | |
Funding | 29 | 29 | 29 | |
Complex funding stream | 26 | 25 | 29 | “For patients with commercial insurance, each insurance has a different requirement/payment structure” (opt-out admin) |
Insufficient funding | 13 | 13 | 14 | “Billing is not enough, but it’s close. If CM’s have between 70–80 patients that they bill for consistently might break even. Cannot bill retainable for everyone. Does not cover psychiatry/PCP coordinator” (Opt-in PCP). |
Information technology (IT)/Registry | 26 | 29 | 14 | |
Paper referral-screening/EHR | 3 | 4 | 0 | |
Registry management | 23 | 25 | 14 | “Registry has been very challenging because there is nothing automated about the registry and the amount of work to feed into the day.” (Opt-in Admin) |
Training/knowledge | 19 | 21 | 14 | |
Inadequate DCM training | 3 | 4 | 0 | |
Inadequate physician knowledge | 16 | 17 | 14 | “Educating the PCPs, getting them more involved, have them be less afraid of prescribing and increasing the dose. They cannot see patients every month because they are so busy.” (Opt-in Psych) |
Lack of buy-in/implementation readiness | 10 | 13 | 0 | “There is too much orthodoxy, so this would be better if there were more flexibility. If the outcomes are coming out well, why do you have to replicate the studies that were done?” (Opt-in Admin) |
Facilitators to CC implementation in the sustainability phase
Facilitators | Total (%) | Sustaining (%) | Opt-out (%) | Quotes |
---|---|---|---|---|
Patient engagement | 81 | 79 | 86 | |
Appointment flexibility | 26 | 29 | 14 | |
DCM proficiency in engagement | 35 | 29 | 57 | “[She is] very accessible, great clinician…Engaging person which is necessary. She reaches out to the physicians and residents, and they know she is very available except when in session. People knock on door for emergencies.” (Sustaining Admin) |
Personalization/education/motivational messaging | 48 | 46 | 57 | “[Message] framing so that avoid stigma” (Opt-in PCP); “Staff matches patients culturally and DCMs are all bilingual in Spanish.” (Opt-in Admin); Engage: Gave gift card/ metro card, health first, talk about depression in positive way, e.g. many will not say depressed, feeling sad” (Opt-out Admin); “Newsletter to talk about positive stories” (Opt-in PCP) |
Reminder system | 13 | 17 | 0 | |
Warm handoffs | 39 | 42 | 29 | “[When you perform] warm handoffs, then many more [patients] follow up, maybe 80%” (Opt-in DCM) |
Provider/staff engagement | 77 | 71 | 100 | |
Provider/staff communication | 58 | 54 | 71 | “Mini-teams of Patient Care Administrator + Registered Nurse + PCP will help increase personal accountability for patients.” (Opt-in Admin) |
Engage staff | 19 | 13 | 43 | “Involve ALL of the staff, including support staff (nurses, MAs, clerical staff) because it is a culture transformation.” (Opt-out Admin) |
Engage PCPs | 35 | 38 | 29 | “Scripting to the PCPs that this will help your panel look better.” (Opt-in DCM) “PCPs join interdisciplinary meeting with psychiatrist and DCM. Scheduled at 1 pm during shift from morning to afternoon and food is provided.” (Opt-in Admin) |
Optimize use of psychiatry | 26 | 29 | 14 | “Psychiatrist: 50% face to face visits, 50% for chart reviews, case supervision with team, PCPs come to meeting that psychiatrist. Psychiatrists fill with 3–4 month waiting list quickly, so reserving time for not face-to face allows for more population health model. The psychiatrist sees patient only 1–3 times max.” (Opt-in Admin) |
Personnel resources | 71 | 75 | 57 | |
Add personnel resources | 52 | 50 | 57 | “We are looking for a SW but unable to find one. Salary offered is very low and the other people not qualified and thinking about increasing the level.” (Opt-in Admin); “The DCM should be co-located in the clinic.” (Opt-in Psych); “More staff: another DCM, more MAs, practice manager…More time with psychiatrist would be helpful.” (Opt-out DCM) |
Paraprofessionals | 35 | 42 | 14 | “The data manager [paraprofessional] sends referrals to the DCM and administrator, scheduled appointments, calls patients as reminders, and adds patients to the list for billing purposes.” (Opt-in Admin) “Patient educator allows SW to practice at top of license: appointment reminders, check in on treatment care goals, scheduling, in between DCM appointment contact. Makes sure patient fills new prescription, takes meds. If they have questions, helps monitor the registry” (Opt-in Admin) |
Training | 55 | 50 | 71 | |
Billing training | 6 | 8 | 0 | |
Ongoing training | 52 | 46 | 71 | “A coach teaches care managers engagement [strategies] and [staff] how to get an accurate PHQ score… [there is also] training in motivational interviewing… quarterly training, certification is intensive” (Opt-in DCM). “When you have new residents or attendings, they need to be trained.” (Opt-in Admin) |
Screening/referral | 52 | 58 | 29 | |
Screening/referral logistics | 6 | 4 | 14 | |
Flexibility/QI | 6 | 4 | 14 | |
Standardization | 45 | 50 | 29 | “Psych Nurse Practioners (NPs)/Physician Assistants (PAs) came to teach MAs how to do a PHQ-2,-9, which really helped. After the training a competency was developed, and the MAs were evaluated…This was very helping in improving screening rate and quality.” (Opt-in Admin) “Developed a protocol for medication management for depression which is VERY prescriptive. Start sertraline on certain schedule, then add bupropion, etc. 90% of the time that people do not achieve remission is because they have not followed the protocol.’ (Opt-in Admin) |
External factors | 45 | 42 | 57 | |
Healthcare system | 19 | 17 | 29 | “A lot of systems do not credential SW’s to bill. So coming up with a more streamlined approach to SW billing for hospital systems so that they have an incentive to do it.” (Opt-in PCP) |
Leadership commitment | 23 | 25 | 14 | |
Optimize long-term/community mental health | 13 | 13 | 14 | “More services would make this program better, specifically group therapy and substance abuse treatment.” (Opt-in Psych) |
Leverage national/primary care initiatives | 3 | 4 | 0 | “This model of care fits with clinic’s Patient Centered Medical Home (PCMH) activities which was helpful.” (Opt-in Admin) |
Information technology (IT) | 45 | 46 | 43 | |
Optimize EHR/registry | 16 | 8 | 43 | “If the EHR could feed into the registry, which would eliminate redundant data entry.” (Opt-in Admin) |
Dashboard/mobile technology | 10 | 8 | 14 | “We are putting PHQ-9 on iPads. Idea is to have patient fill out PHQ9. If patient screens positive, will pop up on PCP screen. If question 9 is positive [suicide question], then a hard stop will come up requiring risk assessment.” |
IT consultant | 10 | 8 | 14 | “IT person is mandatory for data collection, data analysis, and EHR updates with alerts or other changes to both be user friendly and meet the needs.” (Opt-out Admin) |
Telemedicine/psychiatry | 23 | 25 | 14 | “Psychiatric e-consults: If PCP has a question that involves psychiatric med management (NOT a diagnostic question); they use EPIC to send a message to the care manager. Each week they sit down with the psychiatrist for 10-12 min/consult to review chart and make multiple recommendations. These are primarily bipolar disorder or more complex patients, which has reduced face to face encounters by >50%.” (Opt-in Admin) |
Funding | 32 | 33 | 29 | |
Increase funding | 6 | 4 | 14 | |
Leverage current funding streams | 26 | 29 | 14 | “DOH PCMH Patient demonstration project: grant obtained in late 2012 – this helped roll out PCMH model and hire part time LCSW.” |
Accountability | 29 | 29 | 29 | “Tracking data at provider level - what site or SW has best patient engagement?” (Opt-in Admin) “Follow up with provider and a lot of support to make sure that every patient screened who is referred.” (Opt-in DCM) “Accountable to program using data and transparently showing data to the entire team” (Opt-in Admin) |