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By Robin Jay, BHC Editorial Director

A proactive group of medical groups, health plans, employers and patients have come to the table in Minnesota, through the guidance of the Institute for Clinical Systems Improvement (ICSI), for a collaboration to make a difference in treating patients with depression. How? By changing the way care is delivered, monitored and reimbursed through a unique model of care called The DIAMOND initiative: Depression Improvement Across Minnesota Offering a New Direction.

Left unaddressed, the burden of depression is tremendous. “Only 40 percent of primary care patients who have major depression are accurately diagnosed and treated, and about half of those patients once they’re identified drop out of care because there’s no one tracking them. The World Health Organization (WHO) says depression is thought to be at least the second most costly condition,” said Dr. Mark Williams, Mayo Health System Psychiatrist and DIAMOND steering committee member at ICSI. “And there’s the issue of return to work. By treating depression, the amount of absenteeism and presentism is reduced for employers, which results in increased productivity.”

Provider tools

This collaborative model results in improved patient outcomes, increased quality of life, higher productivity and long-term-care cost savings. The DIAMOND initiative involves six tools:

1. Standard assessment questionnaire that helps the primary care provider detect and monitor the patient’s symptoms of depression.
2. Tracking system to help the primary care provider monitor the patient’s status.
3. Medical guide, backed by extensive clinical research, to help the primary care provider know how to best change or intensify treatment if needed.
4. Clinical care manager to educdate the patient and coordinate their care with a consulting psychiatrist and their primary care provider.
5. Psychiatrist to consult with the care team and provide additional assistance for patients with depression that is severe or not improving.
6. Tools to help a primary care patient who is getting better from falling back into major depression.

Care managers – and payment for their services – are key

In the DIAMOND model for depression care, a care manager is a key component of ongoing program success. And although other care models have included care managers, many didn’t utilize them, at least not on a long-term basis, because the reimbursement model didn’t compensate for it. The DIAMOND model does. “The care manager in our program is not a behavioral health person. That’s an important distinction because what has happened in the past is that behavior health people want to get into counseling, and that’s not the function of the care manager in this model, they are very supportive, you could call it counseling, but they don’t spend time counseling and the behavioral health people tend to move in that direction, so they can’t handle as many patients.” said Ken Joslyn, MD, family physician and Medical Director of Quality and Population Health at Medica in Minnesota. “The other things is, if I put my payor hat on, I want to pay the lowest level person that has the capabilities of getting good results. We have many programs that are using MA’s (medial assistants), they’re just people that used to room the patient. Well, it turns out they know a lot about the patient and they can communicate well at the patients level, and if you give them the support they need, they can do well as a care manager.

Participants reaching results

Currently, 45 clinics in Minnesota offer the DIAMOND model of treatment for depression. Another 40 clinics will be doing so by March 2010. A six-month follow-up on the 2400 patients participating in the DIAMOND program showed tremendous progress. Approximately 43 percent of patients were in remission, and another 17 percent experienced a 50 percent reduction in depression severity. These results are up to 10 times better than for patients who receive care for depression through usual primary care models.

A model employers want for their employees

A vital role in the DIAMOND collaborative, in addition to the provider and payor representatives, is the employer. Timothy Crimmins, MD, is the Medical Director and Chief Medical Officer at General Mills. He says the care coordination aspect of the DIAMOND model of care is one that is very attractive as a benefit for the company’s employees. “What the employer can do is to look at the benefit set that they are providing to their employees. Traditional health plans pay for procedures, office visits, medications and surgeries. But the DIAMOND model is an opportunity for General Mills to offer a global payment fee to pay for care coordination that measures outcomes and provides assessments to make sure patients are getting better.”

For non-DIAMOND clinics who would like to implement the program standards, log on to www.icsi.org or click here for access to a resources tool kit. You'll find care manager tools, such as forms and scripts for providing collaborative care, clinical flow tools and literature supporting the key points of a collaborative model.

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