Focus on Depression

Improving Depression Management

The health plan featured in this Quality Profile focused on two key components of depression management: medication therapy and continuity of care following hospitalization for mental illness. Studies have shown that early recognition and treatment of depression, including long-term antidepressant medication therapy, can prevent recurrent episodes and reduce hospitalization. The lifetime prevalence of major depression is estimated to be 17%. In addition, depression can precipitate and intensify comorbid mental conditions.

The health plan found that during the activity period, 35% of all mental health admissions and 37% of outpatient encounters had a mental health-related diagnosis in the range of International Classification of Diseases, ninth revision, Clinical Modification (ICD-9-CM) codes (295-299, 300.3, 300.4, 301, 308, 309, 311-314) corresponding to HEDIS^® specifications. A significant number of hospitalizations related to depression as specified in the HEDIS^® antidepressant medication management measurement. The health plan recognized that the HEDIS^® measurement for follow-up after hospitalization does include members with other behavioral health conditions beyond depression, but they opted to use both measurements as indicators for appropriate depression treatment since all members included in the antidepressant medication measurement would also be included in the follow-up after hospitalization measurement. The managed care organization felt the differences in the measurements would not negatively impact conclusions about depression management. As a result, the health plan implemented a behavioral health care initiative for the management of depression based on significance of this condition.

The health plan began its quality improvement activity in 1998. The activity was based on the plan’s performance on HEDIS^® measures for the management of antidepressant medication during acute-phase and continuation-phase treatment, as well as patient follow-up after discharge from the hospital for mental health-related diagnoses. Baseline data was collected for the time period of January 1, 1998, through December 31, 1998. The baseline populations in the evaluation of follow-up after discharge from the hospital included 26 commercial members and 58 Medicare members aged six years or older who were hospitalized with a discharge date occurring during the first 335 days of the measurement year. The populations in the evaluation of adherence to antidepressant medication included 194 commercial members and 192 Medicare members aged 18 years and older with a depression-related diagnosis and who were treated with an antidepressant medication. Follow-up data was collected from 1999 through 2000. All eligible health plan members were included in the activity.

The first set of quantifiable measures was related to the proportion of eligible members who had a follow-up visit within 30 days after hospital discharge for a mental health diagnosis. The health plan chose benchmarks based upon data from competitors within the state. The benchmark for follow-up after hospital discharge for a mental health diagnosis was set at 88.8% for the commercial population and 96.8% for the Medicare population. The health plan also determined a performance goal for the evaluation of follow-up after hospital discharge for a mental health diagnosis of 80% in 1998 and 90% in 1999 and 2000 for commercial members. The performance goal for Medicare members was set at 52% in 1998 and 85% in 1999 and 2000.

The second set of quantifiable measures was the proportion of eligible members who received either effective acute-phase or continuous-phase treatment. The benchmarks chosen for the evaluation of effective acute-phase treatment were 63.9% in 1998 and 1999 and 70.8% in 2000 for the commercial population and 62.7% for the Medicare population. The benchmarks chosen for the evaluation of effective continuation-phase treatment were 37.9% in 1998 and 1999 and 55.9% in 2000 for the commercial population and 44.1% for the Medicare population. All commercial benchmarks were obtained from Quality Compass®, while all Medicare benchmarks were obtained from other plan locations. No separate goals were chosen for evaluation of adherence to antidepressant medication. The health plan focused on benchmark data for performance comparison.

Baseline measurements showed that 70.8% of commercial and 72.4% of Medicare members received follow-up within 30 days of discharge from the hospital for a mental health-related diagnosis; these percentages were below the benchmarks of 88.8% and 96.8%, respectively. Neither the performance goal of 80% nor the benchmark of 88.8% for the commercial population was met. While the performance goal of 52% for the Medicare population was exceeded, the benchmark rate of 96.8% was not achieved. The baseline measurement for the effectiveness of acute-phase treatment was 47.4% for commercial members and 45.3% for Medicare members. These measures of the rate of medication adherence during the acute treatment phase were below the benchmarks of 63.9% for commercial members and 62.7% for Medicare members. The baseline measurement for the effectiveness of the continuation phase of treatment was 26.8% for commercial members and 22.2% for Medicare members. These measures of the rate of adherence to medication during the continuation phase of treatment were also below the benchmarks of 37.9% for commercial and 44.1% for Medicare members (Table 1).

The subsequent analysis and identification of opportunities for improvement, and the development of interventions, were performed by the staff of the Health Services department with support from the Statistics and Study Coordinator staff in the Medical Information Support Group. Following analysis of the data, several barriers were identified that pertained to members keeping their follow-up appointments, including:

• Scheduled follow-up visits were not communicated to members at the time of discharge from the hospital


• Monitoring systems were insufficient in supporting early identification and subsequent intervention to assist newly discharged members in keeping their appointments


• Members have difficulty with transportation, childcare, and other resources that prevent them from keeping scheduled appointments


• Nonparticipating behavioral health providers do not routinely provide information on follow-up appointments for members seeking “out-of-plan” care

Additional barriers were identified based on a review of literature and expert opinion of participating practitioners working with the QI committee. Barriers that were related to adherence to antidepressant medication included:

• Member nonadherence to antidepressant medication treatment due to side effects, the stigma of the diagnosis, and the lack of perceived need for continued therapy as symptoms subside


• Clinical practice guidelines for the management of depression are not available to primary care practitioners


• The initial diagnosis was not always accurate


• Practitioners were not prescribing medications according to guidelines

Based on identified barriers to follow-up care and the prescribing of and adherence to medication, staff determined the need to increase contact with members at the time of discharge to reinforce the importance of follow-up care. The health plan monitored the success of follow-up contact, initiated physician education, provided assistance for members not receiving medication at discharge, and reinforced subsequent adherence to medication.

Based on the barriers identified following the baseline measurement period, the health plan identified several interventions that were member-, practitioner-, and system-based. These interventions were implemented during the following year. The interventions included:

• A behavioral health coordination program that addressed barriers to follow-up care


• A mental health and chemical dependency reconciliation report and process to ensure capture of discharge dates on all behavioral health discharges to ensure timely and accurate follow-up with patients needing ambulatory outreach.


• Ongoing meetings with contracted mental health providers to discuss continuity of care in behavioral health care and to share performance feedback on current rates of follow-up after discharge. Continuity of care issues addressed between the health plan and behavioral health vendors included timely information exchange between the organizations when patients are admitted to the hospital in order to ensure appropriate follow-up occurs


• A behavioral health medication management program developed to aid in identification and early intervention of nonprescribing practitioners and nonadherent patients


• A meeting with psychiatrists and non-mental health practitioners to discuss antidepressant medication management results


• The updating of clinical practice guidelines for the treatment of major depressive disorder sent to all contracted physicians via the practitioner newsletter. The guidelines were updated with input from network PCPs


• The development of a physician tool kit provided to prescribing practitioners that contained guidelines for screening and treatment of depression and a list of members with depression who were identified as potentially noncompliant based on data tracking their refilling of prescriptions


• Patient education through distribution of a newsletter discussing the signs of depression and necessity for treatment with antidepressant medication

The first remeasurement was based on data collected for the time period of January 1, 1999, through December 31, 1999. The populations included in the evaluation of follow-up after discharge consisted of 102 commercial members and 125 Medicare members aged six years or older who were hospitalized with a discharge date occurring during the first 335 days of the measurement year. The populations included in the evaluation of the management of antidepressant medications consisted of 270 commercial members and 304 Medicare members aged 18 years and older with a depression-related diagnosis who were treated with an antidepressant medication.

Behavioral Health Care Coordination To increase the rate of follow-up care following discharge from the hospital for a mental health diagnosis, the health plan developed a behavioral health care coordination program that was designed to identify patients discharged from the hospital with selected mental health principal ICD-9-CM diagnosis codes of 295-299, 300.3, 300.4, 301, 308, 309, and 311-314. The health plan obtained a log of discharges from providers for all members with the selected diagnoses within 48 hours of discharge. Case management staff then telephoned discharged members within 48 hours of receiving the discharge log to identify and address barriers that could prevent the patient from keeping the follow-up appointment. To address barriers such as transportation, finances, and childcare, the staff provided contacts to community resources and elicited support from the family. The day before the appointment, the patient received a reminder call from the case management staff. The staff then followed up with the provider the day after the visit to confirm the patient kept their appointment. If the appointment was not kept, the staff called the patient to reschedule the appointment. The health plan has continued to achieve success using this intervention to increase the rate of members keeping their follow-up appointments after hospital discharge for a mental health diagnosis.

Key findings included:

• An increase of 13.6 percentage points in commercial members who received follow-up care, although the results of 80.4% remained below the benchmark of 88.8%


• A relative increase of 10.5% in the percentage of Medicare members who received follow-up care. For these members, the result achieved of 80.1% also remained below the benchmark of 96.8%

Analysis of the data collected during the acute phase treatment showed that there was a relative increase of 17.1% in the rate of adherence to antidepressant medication among commercial members. The rate of adherence remained relatively unchanged among Medicare members, with a 0.4% relative decrease. The increase among commercial members from 47.4% to 55.6% was below the benchmark of 63.9%, and the rate of adherence to medication among Medicare members remained below the benchmark of 62.7%.

Analysis of the data from the continuation phase of treatment showed a substantial relative improvement in the rate of adherence to antidepressant medication among commercial members (+47.8%) and Medicare members (+67.6%). The relative increase among commercial members from 26.8% to 39.6% exceeded the benchmark of 37.9%. However, the relative increase in the rate of adherence to medication among Medicare members from 22.2% to 37.2% remained below the benchmark of 44.1%. The health plan considered all increases in the rates of follow-up care and adherence to medication to be meaningful (Table 2).

The health plan attributed improvements in follow-up after discharge from the hospital and adherence to medication to the interventions, which assisted members in keeping their follow-up appointments and educated practitioners regarding prescribing guidelines. The physician tool kit, which included both guidelines and data on patients not in compliance with treatment recommendations, was key in providing physicians information in a manner that was more useful, than sending the same information in separate mailings. The practitioner received comprehensive and timely information that could be acted upon immediately. The health plan felt that in order to fully realize targeted goals and benchmarks, continued efforts were needed to increase follow-up care and education of both members and providers on the prescribing on antidepressant medication and adherence.

Behavioral Health Medication Management Program The health plan developed a medication management program as an intervention for nonprescribing physicians and noncompliant patients. The program focused on members discharged from the hospital for selected mental health ICD-9-CM diagnoses of 295-299, 300.3, 300.4, 301, 308, 309, and 311-314. The health plan, in collaboration with a behavioral health services agency, shared information regarding antidepressant medication usage to assist with the monitoring of adherence to medication by members. Calls were made to practitioners, who were not prescribing medications at the time of discharge, to discuss referral and prescribing practices. The health plan considered this intervention important for increasing adherence to medication because it focused on the practitioners who were not following clinical practice guideline recommendations. Not all situations were amenable to strict guideline compliance; but even here, the discussion between the health plan and practitioner raised the level of awareness about the need for prompt initiation of therapy following discharge. In addition, educational programs were offered to patients. These educational programs included 18 separate mailings to all members identified with depression throughout the year and a video that provided information about the management of depression.

Following the first remeasurement period, most of the barriers to follow-up care and adherence to medication were noted to have persisted. Only the barrier related to monitoring systems for early identification of hospitalized members requiring ambulatory appointments was resolved with initial interventions. These persistent barriers to follow-up care required further efforts in order to fully realize the value of interventions. Barriers included:

• Scheduled follow-up appointments were not communicated to members at the time of discharge from the hospital


• Members continued to have difficulty with transportation, childcare, and other resources that prevented them from keeping scheduled appointments


• Nonparticipating behavioral health providers did not routinely provide information on follow-up appointments for members seeking “out-of-plan” care

The persistent barriers to adherence to antidepressant medication included:

• Patient nonadherence to antidepressant medication continued due to medication side effects, the stigma of diagnosis, and a lack of perceived need for continued therapy as members began to improve


• Practitioners did not prescribe medications according to guidelines


• The initial diagnosis was not always accurate

Based on the results from the first year of intervention, the health plan continued previous interventions and implemented additional actions including:

• Addition of two SSRIs (paroxetine and citalopram HBr) to formulary to expand treatment options for practitioners and improve compliance with members through increased benefits


• Transitioned all mental health services to one vendor (vs. multiple vendors) in order to improve the coordination of care and communication between the health plan and behavioral health organization

Clinical Practice Guidelines To address the need for practitioner education, the health plan updated its clinical practice guidelines for the treatment of major depressive disorder with an emphasis on treatment recommendations in the primary care setting since the majority of patients with depression were cared for by PCPs. The guidelines were sent to all contracted primary care physicians and specialists via the practitioner newsletter. The guidelines were developed in conjunction with the Corporate Technology and Guideline Committee with recommendations from the AHCPR, now known as the AHRQ, and the APA, and they were reviewed by primary care physicians within the region. The guidelines included treatment of major depressive disorder. The health plan continues to periodically update the guidelines and provide them to all practitioners.

EVALUATION TWO

The new interventions were implemented during the period of January 2000 through December 2000. Following implementation, the health plan analyzed the results for follow-up care and adherence to medication using the specified measurements. These results showed improvements in both the rates of follow-up after hospital discharge for a mental health diagnosis and adherence to antidepressant medication. For the measure of the rate of follow-up care after hospital discharge for a mental health diagnosis, the percentage of commercial patients keeping their appointments increased 14.3% and the percentage of Medicare patients keeping their appointments increased 7.0% from 1998 to 2000. The rate of adherence to medication during the acute phase of treatment increased from 12.2% for commercial members and 6.8% for Medicare members from 1998 to 2000. The rate of adherence to medication during the continuation phase of treatment increased 42.2% for commercial members and 62.6% for Medicare members from 1998 to 2000. Despite improvements, these increases did not meet the performance goals or the benchmarks (Table 3).

Continuity of Care In an effort to promote the continuity of behavioral health care within the health plan system, management of behavioral health care services was transitioned to a single behavioral health provider. This transition reduced the number of behavioral health providers for commercial members from four to one. The mental health benefit for Medicare members was also transitioned to one major provider with only one exception. The health plan felt efforts required to coordinate communication and interventions with multiple vendors were excessive, taxing staff resources and often not effective. Behavioral health vendors with a small percentage of health plan membership were not always responsive to the managed care organization’s requests. By working with a single vendor, the health plan was able to obtain a significant presence with that behavioral health organization and obtain the needed support for focusing on this initiative. The vendor selected had a significant presence statewide, so very little disruption in care for members was experienced.

The health plan further analyzed the results from the second year of intervention to identify additional barriers and opportunities for improvement. Barriers to members keeping their follow-up appointments included:

• Limited financial resources make it difficult for members to afford copays on medications and obtain transportation to follow-up visits
• Lack of member self-awareness of the disease process and social isolation perpetuating long-term illness
• Limited coordination between inpatient providers of service and long-term ambulatory follow-up services for the seriously mentally ill population

The barriers to increased adherence to antidepressant medication continued as previously identified:

• Member nonadherence to antidepressant medication continued due to medication side effects, the stigma of diagnosis, and a lack of perceived need for continued therapy as members began to improve.
• Clinical practice guidelines for the management of depression were not available to primary care practitioners
• Practitioners were not prescribing medications according to guidelines and were not aware of performance
• Initial diagnosis was not always accurate

At the completion of the activity, the health plan had not achieved performance goals or benchmark levels of performance in the first or final study periods. Nevertheless, the rate of follow-up care following discharge from the hospital for a mental health diagnosis and the rate of adherence to medication were sustained, and in some cases continued to increase over time, such that the plan felt the interventions were useful and had addressed some of the identified barriers to follow-up care and adherence to antidepressant medication.

Another Plan's Approach Case Management and Physician-Focused Interventions in the Management of Depression The coordination of medical and behavioral health care, and the early identification of patients with depression, are crucial to improving the recognition and management of depression. With this goal in mind, a health plan implemented interventions focused on case management of patients and a set of interventions focused on physicians. This network model health plan proactively identified high-risk Medicare members through administration of a member health risk questionnaire (Appendix 5). Questionnaires were mailed to all new Medicare members within 30 to 45 days of enrollment in the plan. Member who had an SF-12 mental health score below the 25th precentile were considered at risk for depression. These members then received information suggesting they discuss with their primary care physician any major changes in their lives, their energy or stress levels, and current medications. Physicians also received a personalized summary report on each of their patients who completed the health questionnaire, indicating which members were at risk for depression based on their score. The physicians were encouraged to refer members to a depression management program offered by the health plan, which educates patients on the management of depression with optional follow-up via telephone. The success of the intervention prompted the health plan to expand the proactive screening to also include all commercial members. This was accomplished by placing the screening tool on the health plan's Web site for voluntary participation by commercial members. The health plan continues to contact all commercial and Medicare members who are considered at risk of depression based upon their screening score. Another physician-focused intervention that the health plan implemented was a physician consult service line. The consult service allows physicians either to talk directly to a behavioral health provider about the diagnosis and management of mental health issues, or to e-mail their questions. The health plan promoted the service extensively among primary care physicians and other providers. The ongoing consult service provides a useful resource for physicians, especially those who lack experience recognizing mental health needs or who are unfamiliar with practice guidelines.

The health plan has continued this quality improvement activity designed to enhance the overall management of patients with depression. The health plan has sustained its behavioral health care coordination program, its behavioral health medication management program, and its efforts to educate practitioners by providing updated clinical practice guidelines to all contracted practitioners via the practitioner newsletter. The health plan has expanded its behavioral health care coordination program to include coordination of in-home behavioral health services for two visits for those members incapable of attending outpatient services. The health plan, in conjunction with the health services agency, has obtained attestation forms from the regional behavioral health authorities who provide mental health services to members entitled to government-sanctioned mental health services. This aids in promoting communication exchange and timely follow-up care between the behavioral health practitioners and PCPs. A new health management program is currently being implemented to reach patients with newly diagnosed depression referred by primary care providers. The program assists them through the first six months of therapy with case management interventions.

The plan continues to successfully implement interventions and achieve increased rates of follow-up care and medication adherence. Preliminary data from the first half of 2001 show that the rates of follow-up care have increased to 93.75% for commercial members and 90.66% for Medicare members. This is above both the benchmark and the goal for commercial members, and above the goal for Medicare members. The health plan attributes the more recent successes to the early identification of members who were not informed of their follow-up appointment or did not intend to keep their appointment due to financial or logistical barriers.