Collaborative Care for Low-Income Patients From Racial-Ethnic Minority Groups in Primary Care: Engagement and Clinical Outcomes.

OBJECTIVE: To assess model impact and opportunities for improvement, this study examined collaborative care model (CoCM) engagement and clinical outcomes among low-income patients from racial-ethnic minority groups with depression and anxiety. METHODS: Starting in 2015, the CoCM was implemented in seven primary care practices of an urban academic medical center serving patients from racial-ethnic minority backgrounds, predominantly Medicaid beneficiaries. Eligible individuals scored positive for depressive or anxiety symptoms (or both) on the Patient Health Questionnaire-2 (PHQ-2) and PHQ-9 and the Generalized Anxiety Disorder Scale-2 (GAD-2) and GAD-7 during systematic screening in primary care settings. Screening rates and yield, patient characteristics, and CoCM engagement and outcomes were examined. Clinical improvement was measured by the difference in PHQ-9 and GAD-7 scores at baseline and at 10-to-14-week follow-up. RESULTS: High rates of screening (87%, N=88,236 of 101,091) and identification of individuals with depression or anxiety (13%, N=11,886) were observed, and 58% of 3,957 patients who engaged in minimally adequate CoCM treatment had significant clinical improvement. Nevertheless, only 56% of eligible patients engaged in the model, and 25% of those individuals did not return for at least one follow-up appointment. Being female with clinically significant comorbid anxiety and depressive symptoms and having Medicaid or commercial insurance increased the likelihood of CoCM engagement. CONCLUSIONS: CoCM can help engage vulnerable patients in behavioral health care and improve clinical symptoms. However, significant opportunity exists to advance the model's impact in treating depressive and anxiety disorders and decreasing health disparities by addressing engagement barriers.

Enhancing the scalability of the collaborative care model for depression using mobile technology.

The collaborative care model (CoCM) has substantial support for improving behavioral health care in primary care. However, large-scale CoCM adoption relies on addressing operational and financial implementation challenges across health care settings with varying resources. An academic medical center serving socioeconomically and racially diverse patients implemented the CoCM in seven practices. A smartphone application was introduced to facilitate CoCM care management during depression treatment (app-augmented CoCM). App features included secure texting, goal/appointment reminders, symptom monitoring, and health education material. A nonrandomized convenience patient sample (N = 807) was enrolled in app-augmented CoCM and compared with patients in standard CoCM (N = 3,975). Data were collected on clinical contact frequency, engagement, and clinical outcomes. App-augmented CoCM patients received more health care team contacts (7.9 vs. 4.9, p < .001) and shorter time to follow up compared with the standard CoCM sample (mean = 11 vs. 19 days, p < .001). App-augmented CoCM patients had clinical outcomes similar to the standard CoCM group (47% vs. 46% with ≥50% depression improvement or score <10), despite app-augmented patients having more prior depression treatment episodes. Further, the app-augmented group with greater app engagement demonstrated increased behavioral health appointment compliance, including more completed appointments and fewer no shows, and greater depression symptom improvement than those with less app engagement. App-augmented CoCM may improve patient engagement in treatment and provide opportunities to implement key CoCM elements without overburdening practice resources. CoCM sustainability and scalability in primary care may be enhanced by using this technology.

Comparison of Collaborative Care and Colocation Treatment for Patients With Clinically Significant Depression Symptoms in Primary Care.

OBJECTIVE: The study compared clinical outcomes of depression treatment in primary care with a colocation model versus a collaborative care model (CoCM). METHODS: Patients (N=240) with Patient Health Questionnaire-9 (PHQ-9) scores of ≥10 treated for clinically significant depression symptoms in primary care sites implementing the CoCM or a colocation model were compared. PHQ-9 scores were collected at baseline and 12 weeks. RESULTS: From baseline to follow-up, reductions in PHQ-9 scores were 33% for the CoCM sites and 14% for the colocation sites, with an unadjusted mean difference in scores of 2.81 (p=.001). CONCLUSIONS: More patients treated in sites that used the CoCM experienced a significantly greater reduction in depression symptoms, compared with patients in sites with the colocation model. As greater adoption of integration models in primary care occurs, it will be important to consider potential implications of these results for promoting adoption of CoCM elements. Further replication of these findings is warranted.

Horizon's patient-centered medical home program shows practices need much more than payment changes to transform.

Skyrocketing costs and the uneven quality of patient care challenge the US health care system. Some health insurance companies are exploring patient-centered medical homes as a way to change incentives and transform the health care delivery system by increasing primary care providers' accountability for care coordination and outcomes. Horizon Healthcare Services, Inc., New Jersey's oldest and largest health insurance company, developed medical home programs that include financial incentives with essential support tools. Our experience in implementing and evaluating various approaches indicates that medical homes require intensive and targeted patient care coordination supported by committed primary care leadership, as well as new payment structures that include a monthly care coordination fee and outcome-based payments. Our experience also indicates that considerable nonmonetary support-such as an education program for population care coordinators, a medical home guide that offers effective ways to transform a practice into a medical home, and useful data sharing-are needed to improve the quality of care and reduce costs.

An attempt to improve antipsychotic medication adherence by feedback of medication possession ratio scores to prescribers.

Poor medication adherence is well documented for patients with severe and persistent mental illness. The State of Missouri implemented an early alert system to notify caregivers when patients fail to refill essential prescriptions in a timely manner and as an educational resource for providers on best practices for improving treatment adherence. Missouri Medicaid patients who were prescribed at least 1 of 9 orally-administered antipsychotic medications and who had at least 1 medication possession ratio (MPR) score below 0.8 were included in the adherence intervention group. Their prescribing clinicians and case managers were messaged electronically 2 times per week at the point that failure to refill the targeted prescription was identified. Notification occurred when the prescription had lapsed at 7 days, 30 days, and 45 days, and occurred in real time. In addition, MPR scores were provided monthly for the most recent 6-month period. Change in MPR scores was measured for the intervention group and for a matched control group. Trends in MPR scores were analyzed for both groups pre, during, and post intervention. In both the intervention and postintervention periods, there was a significant difference in the MPR scores between the two groups. The intervention group had a significantly greater increase in MPR score between preintervention and intervention periods. After the conclusion of the intervention, the MPR score decreased somewhat but was still higher than during the preintervention period. Results suggest that clinicians and patients need specific data about adherence in order to address the issue.

Evaluation of chronic disease management on outcomes and cost of care for Medicaid beneficiaries.

OBJECTIVES: To evaluate the impacts of the chronic disease management program on the outcomes and cost of care for Virginia Medicaid beneficiaries. METHODS: A total of 35,628 patients and their physicians and pharmacists received interventions for five chronic diseases and comorbidities from 1999 to 2001. Comparisons of medical utilization and clinical outcomes between experimental groups and control group were conducted using ANOVA and ANCOVA analyses. RESULTS: Findings indicate that the disease state management (DSM) program statistically significantly improved patient's drug compliance and quality of life while reducing (ER), hospital, and physician office visits and adverse events. The average cost per hospitalization would have been $42 higher without the interventions. CONCLUSIONS: A coordinated disease management program designed for Medicaid patients experiencing significant chronic diseases can substantially improve clinical outcomes and reduce unnecessary medical utilization, while lowering costs, although these results were not observed across all disease groups. The DSM model may be potentially useful for Medicaid programs in states or other countries. If the adoption of the DSM model is to be promoted, evidence of its effectiveness should be tested in broader settings and best practice standards are expected.

Hospital provision of end-of-life services: who, what, and where?

BACKGROUND: Availability of options other than aggressive medical treatment for persons with life-limiting illnesses has provided hospitals an opportunity to adopt formalized end-of-life care services. OBJECTIVE: To describe hospital ownership types that have adopted formalized end-of-life services (who), the scope of end-of-life services offered (what), and the geographic location of service provision (where). RESEARCH DESIGN: Nationally representative cross-sectional data for 3,939 hospitals (80% of respondent hospitals) obtained from the American Hospital Association Annual Survey of Hospitals was used for the year 1998. MEASURES: A scale was developed to measure hospital provision of general end-of-life, pain management, or hospice services. A multivariate ordinary least-squares regression model was used to test the association of ownership as a predictor of end-of-life service provision, while controlling for internal (organizational) and external (market location and size) characteristics. RESULTS: Independent correlates of the number of end-of-life services provided include Catholic ownership, teaching status, number of staffed beds, and being located in a metropolitan statistical area or in New England. Forty-four percent of the sampled US hospitals provide none of the three end-of-life services included in this study. Another one third of hospitals provide only one of the three services. CONCLUSIONS: Given the attention paid by both the general public and health professionals to pain relief and providing appropriate care to dying persons, such services are slow to be institutionalized in the hospital setting. The authors' findings suggest strategies for research and policy.