xxAACP Newsletter, Volume 16, Number 4, Fall 2002

Home

Mission

Board

Join

Newsletter

Archive

Products

Our primary care colleagues struggle to care for a diverse patient population, especially in this era of managed care, which limits the time they have with patients. They look to us for help in identifying and treating the psychiatric conditions that they encounter. A number of different approaches have been developed over the past 10-15 years to address these concerns, but the problem of too many patients who are not accurately diagnosed or effectively treated persists.

The most common psychiatric condition encountered in primary care is depression. Epidemiological, economic, and burden of disease studies underscore the enormous cost and suffering associated with untreated or undertreated depression. A new initiative has been launched to more systematically address the treatment of depression in primary care.

The Health Resources Services Administration (HRSA), the agency within the Federal Health and Human Services Department that is responsible for funding community-based primary care programs, has teamed up with the Institute for Healthcare Improvement to address the improvement of chronic conditions in primary care settings. The so-called Health Disparities Collaboratives provide organizational support to pilot community health clinic programs around the country to more systematically treat four different chronic conditions: diabetes, asthma, cardiovascular disease, and depression.

The thrust of all four collaboratives is to organize the improvement of care around the six core principles of the chronic care model, developed by Ed Wagner of Group Health of Puget Sound. These principles are:

1. Patient Self-Management. This includes the use of evidence-based self-management tools to assist patients in understanding and taking more responsibility for caring for their illness.

2. Decision Support for Providers. This involves providing ready access to evidence-based diagnostic and treatment information, as well as consultation support. For the depression collaborative, this includes the systematic use of an assessment tool, the PHQ-9.

3. Clinical Information Systems. These include the development of a patient registry with key demographic, clinical, and process variables, so that progress can be more effectively facilitated and reported.

4. Delivery System Design. The above listed elements must be organized to efficiently identify target patients, assign roles and responsibilities, to clarify practice guidelines, and to assure follow-up.

5. Organization of Healthcare. Instituting these broad changes requires buy-in from top clinical and administrative leadership, designation of consistent project leadership, and the incorporation of the initiative into an overall quality improvement program.

6. Community. The success of such initiatives depends on effective linkages with the community, both for education and support regarding the project, but also for access to necessary resources that may not be within the clinic’s area of expertise or operating budget.

I have been privileged to represent the AACP as a member of the faculty for the current depression collaborative. The faculty includes several other psychiatrists (mainly researchers), primary care experts, systems improvement specialists, and community health system administrators. Our work has involved developing training materials, the design of patient registry software, creation of practice guidelines, development of care monitor and mental health specialist positions, and setting benchmark goals for the project. We are providing three major trainings for the participants (35 community health clinic projects from all over the US), as well as monthly conference call consultations and listserv support over the 15 months of the project.

Clearly the goal of improving the outcomes of persons with depression is paramount and should be achieved. An additional benefit appears to be a general improvement in awareness and sensitivity to the needs of persons with psychiatric disorders. Hopefully, improving care for depression will facilitate improvement in care for other psychiatric conditions.

I am very enthused about my participation and high ly recommend that you look at the wealth of materials available at the websites associated with the project (www.healthdisparities.net and www.ihi.org). At both websites, you can locate the training manual (www.ihi.org/collaboratives/Depression_Apr2002.pdf or www.healthdisparities.net/Depression_Apr2002.pdf), which more thoroughly describes the project and provides an abundant list of supportive resources for others who are interested in developing similar approaches to the improvement of care.

David Pollack

Back to Fall 2002 Table Of Contents