From The Field N O V E M B E R 1 9 , 2 0 1 2 Coming Soon? The Ongoing Effort to Promote Better Depression Services in Primary Care CHRISTOPHER A. LANGSTON, PH.D. Program Director, The John A. Hartford Foundation L ike many members of Grantmakers In Health, Depression is one of the most common disabling and debilitating health we have worked for many conditions in the United States and internationally...only about 20 years to improve the quality and percent of patients treated for depression in primary care are significantly lower the costs of health care— improved a year later. in our case, focused on older Americans in particular. We have funded demonstrations of innovative models of care for issue that calls for a prepared and proactive primary care geriatric conditions, and we have learned that changing how practice and an engaged patient. care is actually delivered is a lot like the movie business. You Unfortunately, most primary care practices are ill-equipped have to have a concept, a script, talent, partners, and money to for this kind of chronic care and, as a result, only about 20 make a movie, but making the movie is only the start. Having percent of patients treated for depression in primary care are made a movie, there are still gigantic, if less obvious, challenges significantly improved a year later. Recognizing this paradox, to bringing it to theaters across the country— there are the U.S. Preventative Services Task Force (USPSTF), does significant investments required to market a movie and make NOT recommend screening for depression in primary care it into a blockbuster. UNLESS the practice has an evidence-based systematic One of our top “concepts” is better depression care for older approach to follow-up and treatment. (Imagine if the USPSTF patients. Depression is one of the most common disabling and made a similarly hedged recommendation about screening for debilitating health conditions in the United States and inter- hypertension…) nationally. In older adults depression often co-occurs with To change this situation, our “script” has been the chronic medical diseases, complicating clinical care. While Improving Mood – Promoting Access to Collaborative Treatment (IMPACT) model for treating depression in IMPACT uses a team approach in which the patient and primary care primary care. IMPACT uses a provider receive support for evidence-based care from a disease management team approach in which the clinical specialist (such as a specially trained nurse, social worker, or patient and primary care psychologist) and a system of planned care. provider receive support for evidence-based care from a disease management clinical antidepressant drugs are some of the most commonly pre- specialist (such as a specially trained nurse, social worker, or scribed (and advertised) in the United States, most people’s psychologist) and a system of planned care. An on-line care still does not follow best practice guidelines and therefore tracking and reminder system supports close follow-up of does not produce the full benefits of treatment. Non-pharma- depressive symptoms and ensures that patients receive revi- ceutical therapies are also effective but can be hard to find and sions of the treatment plan as needed. IMPACT engages afford. More than 15 years ago we realized that this was not a patients in their own care, systematically measures improve- “mental health” specialty issue, as the majority of depressed ments in their mood, and builds in regularly scheduled people and especially older adults are (and wish to be) diag- provider-to-provider consultation with a psychiatrist. nosed and treated in primary care settings by their generalist Research shows that this collaborative, team-based approach providers. Nor is the overburdened specialty mental health sys- results in twice as many patients achieving significant tem capable of providing this care. This is a chronic disease improvement in their symptoms as in usual care. To date, IMPACT has been adopted by more than 600 practices, health Through implementing models, such as IMPACT, these practices can enhance plans, and other provider the quality of care, improve the health of the population, and lower per-capita organizations. health care spending. Our “talent” has included many stars, but top billing goes to our long-time grantee – now known as the Advancing technical assistance and evaluation services to ensure fidelity. Integrated Mental Health Solutions (AIMS) Center at Our plan, designed with AIMS, will target the five, largely the University of Washington, directed by Jürgen Unützer. rural states for which the University of Washington is the only Dr. Unützer not only directed the $10 million multisite, medical school: Washington, Wyoming, Alaska, Montana, and randomized clinical trial to demonstrate the benefits of the Idaho. Across this region (constituting almost 30 percent of IMPACT model on clinical and cost outcomes, but also the U.S. landmass), we will make awards to five to eight com- has worked tirelessly on the less glamorous but even more munity health centers to adopt the model. Over time, we important work of taking the results from the pages of expect that our local bastions of innovation will both sustain The Journal of the American Medical Association or British the work they have started and spread the model farther across Medical Journal and making them available around the the region. country. Under our award, our money and federal funds match Our partners have included the California HealthCare one-to-one and then are subject to a second one-to-one match Foundation, Hogg Foundation for Mental Health, at the sub-grantee level. Thus, our contribution of $3 million and the Robert Wood Johnson Foundation for our over three to four years will be matched by $3 million from the original randomized controlled trial of the collaborative federal government (contingent upon a planned renewal, the care treatment model, and The Fan Fox and Leslie R. availability of funds, and satisfactory performance). Our Samuels Foundation, National Institute of Mental awards to sub-grantees totaling some $4.5 million (less the core Health, and Centers for Medicare and Medicaid Services costs of technical assistance and program evaluation) will for the dissemination and implementation phases of this require a matching $4.5 million from other sources, such as initiative. additional local or national funders, resulting in a project Despite having an excellent product like IMPACT, large- totaling $10.7 million. scale, real world change is still very hard. Change in health care is slow at best, even for “easy” changes like the introduc- COMING ATTRACTIONS tion of new medications. Change at the practice redesign level In the long run, we hope that many more places adopt requires time, thoughtful marketing, multiple communica- IMPACT and make it the standard approach to the delivery of tions opportunities, and serious external support (just as the mental health services in primary care for older patients. We philanthropic community is learning with regards to the also hope to influence how primary care practices use teams to “medical home” model). Compared to film distribution, implement evidence-based care for chronic conditions more which can saturate advertizing channels, put marketing tie-ins generally. Through implementing models, such as IMPACT, in every McDonald’s, and get a print to thousands of screens these practices can enhance the quality of care, improve the for opening night, we just do not have the infrastructure, the health of the population, and lower per capita health care experience, or the money. spending. This kind of transformation and these kinds of We learned from Dr. Unutzer the saying, “It costs more to outcomes will no doubt take time, but we look forward to market the movie than to make the movie.” We have still not continuing to market this “movie” and others like it until they lived up to this standard in our support of post-production are in “theaters” everywhere. “marketing,” but through our newest (distribution) partner- ship we finally will. NEW DISTRIBUTION PARTNERS: LEVERAGING GOVERNMENT SUPPORT We are proud to have been awarded one of four grants in 2012 from the Social Innovation Fund (SIF), part of the federal Corporation for National and Community Service. In this public-private partnership program, an intermediary organization (such as ourselves) applies for matching fund- ing from the SIF to spread innovative practices that solve important social problems, such as IMPACT. We then are responsible for re-granting the pooled funds to local sites Views from the Field is offered by GIH as a forum that will be adopting the model, along with contracting for for health grantmakers to share insights and experiences. If you are interested in participating, please contact Faith Mitchell at 202.452.8331 or fmitchell@gih.org.