Self-Management & Care Management in the Treatment of Depression

1. Self-Management & Care Management in the Treatment of Depression Neil Korsen, MD MSc Amy Quatticci, RN PRISM #4 January 17, 2008

2. Improving Depression Care: Five Key Components • PHQ-9, an outcome measure for depression (for more information see eLearn Module 1: Using the PHQ-9 for Diagnosis and Management of Depression) • Use ofa registry such as the Clinical Improvement Registry • Self-management Support • Care management • Informal psychiatric consultation

3. Overview of this module I.Self-management support (SMS): What it is and how to use it Recognition and prevention of relapse and recurrence of depression II.A team approach to SMS: An effective way to implement self-management III.Care Management: An important role in SMS

4. I. Self-Management Support

5. Components include: • Education of patient and family/friends about depression • Patient self-management with goal setting and action planning • Connecting patient with useful community resources

6. Self-Management Support • What is it? • The information, education, resources, and care offered to people with chronic conditions to help them deal with their illness. The goal of self-management support is to strengthen people’s competence and confidence to manage their condition, make informed decisions about care, and adopt healthy behaviors. www.newhealthpartnerships.org • Emphasizes: • Reasonable problem solving • Realistic goal setting and action planning • Relapse prevention • Shared decision making

7. Goal Setting and Action Planning • Have the patient focus on what they want to do or what they enjoyed doing prior to depression. • Ask them to set a goal based on something they want to do or used to enjoy. • Sample goal: Increase physical activity. • Action plans involve the small steps needed to reach a goal. • Sample action plan: Walk around the block at 9 AM on Monday, Wednesday and Friday each week.

8. Action Planning: Tools All tools are available at www.mainehealth.org in “For Healthcare Professionals” and “Health Information” in “Depression.” • My Self-Care Plan can be accessed: • From the menu on the left of this eLearn module. • By clicking on the link: http://www.mainehealth.org/workfiles/mh_professional/self_management_plan_5-2-07.pdf. • Copies can be ordered online from JS McCarthy: www.jsmccarthy.com/mainehealth • Can also be written on a prescription pad or simply on a piece of paper.

9. Why action plans rather than goals? • Goals are generally too big for patients to work on all at once (e.g., lose 30 lb, quit smoking). • Goals can be overwhelming and often fail due to lack of planning the small steps towards the bigger goal. • When patients do not succeed in reaching their goal they may lose motivation. • Action planning helps patients break down goals into more doable steps.

10. Action Planning: Confidence Level • Once an action plan is set, have the patient indicate how confident they are that they can achieve it (1-10 scale). • If the confidence level is <7, discuss with the patient how they might modify the plan to reach a confidence level between 7 and 10. • Action plans should be written and a copy given to the patient.

11. Action Planning: Keys to Success • It is crucial to have success at the beginning. • Successful action plans are specific: • “I will walk for 15 minutes in the morning on Mondays, Wednesdays and Fridays”, not “I will exercise more”. • A confidence level 7 or greater on the action plan is associated with better success.

12. What can I do to help my patients succeed? • Give patients a copy of their action plan and keep one for the medical record. • Follow-up is key: • Initial follow-up should occur by phone or in person in 1 to 3 weeks. This can be arranged at the initial visit or contact can be made by a care manager or medical assistant in that time frame. • Adjustments can then be made toward a larger goal or keep tweaking the action plan until successful. • Reinforce the positive by focusing on any success, even partial completion of goals.

13. Relapse & Recurrence • Symptoms of depression can worsen (relapse) during treatment • At least half of all people who have major depression will have at least one more episode (recurrence)after some period of being symptom-free. • Part of self-management support for depression is preparing people to recognize and react to relapse or recurrence

14. Relapse Prevention • Relapse prevention involves helping people with depression identify triggers to depression and early symptoms that might serve as a warning to relapse or recurrence. • The Depression Action Planis a tool to support developing a plan with the patient about how to recognize and manage new symptoms once they’ve achieved response or remission. • You can access the depression Action Plan from the menu on the left of this eLearn Module and at: http://www.mainehealth.org/workfiles/mh_healthinformation/depressionactionplan.pdf

15. Education and Community Resources: • It is important to provide information to people with depression and their families, and to help them connect with community organizations that can provide additional information and support. • Brochures, posters and copies of the PHQ-9 in the office can start the education process. • Patient handouts are available on the MaineHealth website: • www.mainehealth.org • Follow “For Healthcare Professionals” then to link to “Depression” • MaineHealth Learning Resource Centers: • Located in Falmouth, Portland and Scarborough • Offer written materials, videos and Living Well With Chronic Conditions class

16. Consumer Organizations • National Alliance on Mental Illness (NAMI) www.nami.org • 11 local chapters in Maine; www.namimaine.org • Depression Bipolar Support Alliance (DBSA) www.dbsalliance.org • 5 local chapters in Maine; www.thewanderingmind.org Both organizations provide support and education for people with mental health problems and their families.

17. II. A Team Approach to Self-Management Support

18. Organizing your practice team for SMS • The clinician needs to support the value of SMS, but can delegate some roles to the team. • Office staff can be trained to provide self-management support to patients. • Members of the team may include the nurse, medical assistant (MA) and care manager. • The team can develop workflows to make sure that self-management support is integrated into care.

19. Some Examples of Team Approach • MA gives patient a copy of self-care action plan as part of rooming process and reviews with patient. • Clinician encourages goal setting, and MA or care manager follow up to help patient with action planning. • Care manager calls patient 1-2 weeks after office visit to follow up on action plan.

20. III. Depression Care Management

21. What is depression care management? • An evidence-based component of depression care, shown in multiple clinical trials to improve outcomes for people with depression. • Designed to improve and facilitate patient follow-up, support patient self-management, and provide the linkage of patients and community resources.

22. Key Functions of Care Management • Assess and facilitate adherence to treatment including medications, counseling and follow-up appointments with PCP. • Support self-management activities. • Provide guidance, not psychotherapy. • Assess and monitor treatment response. • Provide a key communication link between the patient and the practice.

23. Why use Care Management for depression? • CM is proven to help decrease patients’ symptoms of depression. • Evidence of increased adherence to treatment. • CM is cost-effective. • Helps PCPs overcome the barrier of lack of time: • To set goals and develop action plans • To provide patient education • A TEAM APPROACH WORKS BEST!

24. Evidence for the Value of Care Management • Simon et al, BMJ 2000 • Population – 613 people starting treatment for depression. • Results – Intervention group more than twice as likely to have improvement in symptoms. • Katzelnick et al, Arch Fam Med, 2000 • Population – 407 high utilizers of services in an HMO • Results – Intervention group had greater improvement in Hamilton Depression scores at 3, 6, and 12 months.

25. Evidence for the Value of Care Management • Hunkeler et al, Arch Fam Med 2000 • Population – 302 people in an HMO starting antidepressant medications • Results – Intervention group had greater improvement in Hamilton Depression scale at 6 weeks and 6 months • Unutzer et al, JAMA 2002 • Population – 1801 people aged 60 or older with depression. • Results – At 12 months of follow-up, intervention group was 3.5 times more likely to have improvement in symptoms • Intervention group also reported improved quality of life.

26. Evidence for the Value of Care Management • Dietrich et al, BMJ 2004 • Population – 405 adults starting or changing treatment for depression • Results – Intervention group had an increased rate of clinical improvement at 6 months • Note: MaineHealth practices were part of this study

27. Which patients with depression should be referred for Care Management? • Patients scoring 15 or higher on the PHQ-9are the group for whom there is the most evidence of the value of care management for improving outcomes. • Others who might also benefit from Care Management include: • Patients scoring lower than 15 who choose watchful waiting as their treatment (see next slide for description of watchful waiting). • Patients who lack adequate family or social support. • Patients who need help affording medications or with referrals to mental health specialists.

28. What is Watchful Waiting? • It is estimated that a third of people with mild symptoms (PHQ score less than 15) will recover without treatment. • Watchful waiting means you are seeing the patient about once a month and monitoring their PHQ-9 score, but not starting active treatment. • Self-management activities, such as exercise, socialization or relaxation, are usually a component of watchful waiting. • If the patient’s symptoms have not resolved after 2-3 months, active treatment ought to be considered.

29. Care Management Process(applies to MMC PHO members) • PCP refers patient to care manager. • Care manager initiates contact with patient via phone. • Care manager provides feedback to PCP.

30. Care Management for depression Recommended Call Schedule • Week 1 • Week 4 • Week 8 • Week 12 • Week 16 • Other calls as needed • Calls after week 16 determined by patient remission status and risk

31. Initial & Follow-up Calls • Care manager (CM) engages the patient. • CM explains role and connection to PCP. • CM answers questions and provides information. • CM may repeat the PHQ-9 by phone to assess response to treatment. • CM communicates initial and follow-up call outcomes to PCP.

32. Care Manager’s Role in SMS • Helps patient identify a self-management goal if not previously identified by PCP • Encourages small steps by helping patient develop an action plan • Assesses confidence level • Provides positive reinforcement • Monitors progress • Modifies or helps set new goals as needed • Helps patient find and access appropriate local programs, e.g., Living Well with Chronic Conditions course

33. Advantages of Care Management &Self-Management • Added resources to help patients and families understand depression and its treatment. • Maintains link between patient and practice during the acute phase of treatment, therefore fewerpatients lost to follow-up. • Improved outcomes for patients initiating antidepressant therapy.

34. Summary • Self-management support is an important component of care for people with depression. • Collaborative goal setting and action planning is more effective at promoting behavior change than traditional clinician-directed advice. • Care management is an effective tool for improving depression treatment in primary care patients.