DIAMOND Is Gem for Depression Care

A depression care model aiming to bridge the gap between what is known about mental health obstacles and what is being done to minimize them has led to the successful communion of science and practice across Minnesota.

The model, called Depression Improvement Across Minnesota Offering a New Direction, or DIAMOND, uses a team-based approach to facilitate the screening, diagnosis, and management of depression among patients in 83 primary care practices across the state.

The DIAMOND approach, in which the care of patients who screen positive for depression in the primary care setting is choreographed by care managers and overseen by consulting psychiatrists, is not a novel one. In fact, a well-established body of evidence indicates that team care models improve outcomes in depression and reduce health care use costs over time (J. Occup. Environ. Med. 2008;50:459-67).

The unique aspect of the DIAMOND model is that it is the first depression treatment program in the country to integrate the team-based paradigm with a reimbursement structure that supports the provision of enhanced mental health care support in primary care clinics, according to Dr. Brian Rank. Dr. Rank is medical director of HealthPartners Medical Group in Minneapolis and chair of the board of directors for the Institute for Clinical Systems Improvement (ICSI) in Bloomington, Minn. ICSI is a nonprofit group that spearheaded the development and launch of DIAMOND in 2008 in collaboration with more than 60 medical groups, hospitals, and health plans.

Specifically, each medical group participating in DIAMOND receives a monthly fee for every enrolled patient, said Dr. Mark D. Williams of the Mayo Clinic in Rochester, Minn. The fee, predetermined through collaboration with the state’s major insurers and represented by a single, specific billing code, covers the care "bundle," which includes depression screening and monitoring using the Patient Health Questionnaire (PHQ-9); weekly psychiatric consultation and case review; ongoing contact with the care manager; communication between the care manager, psychiatrist, and primary care physician; relapse prevention visits; and use of a patient registry.

"The fee addresses one of the main questions challenging health care improvement in this country: Who is going to pay for it?" Dr. Williams said in an interview. "The way health care is designed in the United States, practices are trying to manage lots of patients, because the only way they can survive is through volume. So, when you suggest trying a different model – one that requires hiring a resource care manager or pulling someone out of a different position from a busy clinic – the practices see risk. Their margins are so small already, committing to the change, even if it is evidence based, is difficult."

Because of the financial realities, the DIAMOND team had to figure out a way to implement the program in practices without the shadow of financial disincentives. "The challenge wasn’t proving it would work – there are lots of randomized controlled trials supporting the collaborative care model – the challenge was showing the practices that the costs wouldn’t be overwhelming," Dr. Williams said. "The promise of new income through the monthly fee was something that allowed the practices to go to their boards and argue that the new model would improve patient management without putting the practice at risk."

The DIAMOND protocol is built around the main elements of the Improving Mood: Promoting Access to Collaborative Treatment (IMPACT) program developed by Dr. Jürgen Unützer of the University of Washington (http://impact-uw.org/). These elements include:

• Standard and reliable use of the PHQ-9 for assessment and ongoing depression management;

• Use of an evidence-based guideline and a stepped-care approach for treatment modification or intensification;

• Development and use of a registry to monitor and track patients;

• Relapse-prevention training for patients reaching remission;

• Introduction of a trained care manager; and

• A formal relationship with a consulting psychiatrist.

The DIAMOND implementation differs from IMPACT, in that the DIAMOND care managers do not have to be nurses with psychiatric experience, according to Nancy Jaeckels, vice president of member relations and strategic initiatives for ICSI. Rather, DIAMOND has hired and trained various health care personnel to serve as care managers, including medical assistants, social workers, and licensed practical nurses, she said.

In participating practices, patients aged 18 years or older with a primary care diagnosis of major depression or dysthymia and a PHQ-9 score of at least 10 are enrolled in the DIAMOND program.

The care protocol includes an initial review of PHQ-9 results and symptoms with the primary care physician; an intake meeting with the care manager, during which patients are screened for other mental health or substance use problems; and weekly phone or in-person follow-up contact with the care manager to discuss treatment status and to complete the PHQ-9, the results of which the care manager enters into the patient registry, along with information on the patient’s medication, treatment adjustments, and behavior.

The DIAMOND protocol also includes a weekly meeting between the consulting psychiatrist and the care manager to review care and discuss patient-related issues or concerns; and periodic direct contact between the psychiatrist and the primary care provider, who is the medication prescriber, to assess treatment response and make adjustments as necessary.

"In some instances, there are patients who need more than DIAMOND can offer, so we spend a fair amount of energy linking with local mental health resources, advocating for the patients as much as possible," Dr. Williams said.

Patients enrolled in DIAMOND are covered for a maximum of 12 consecutive months, Ms. Jaeckels said. Before moving out of care management, they complete a relapse prevention plan with their care manager that includes an action plan if symptoms recur, she said.

The DIAMOND model addresses important deficiencies in the current management of depression in primary care, Dr. Williams said. "Even though we have outcome measures to tell when someone [with depression] is in trouble or improving, a lot of times primary care physicians don’t use these and instead ask questions like, ‘How is it going?’ or ‘How is the depression?’ That’s kind of like asking a patient with hypertension how he or she is doing without measuring blood pressure. It doesn’t make sense."

Another obstacle in traditional settings is that patients with depression "typically are not activated," Dr. Williams said. "They have trouble getting going and doing things, and they commonly feel overwhelmed by the fragmentation of the health care system, the difficulty getting appointments, problems with their prescriptions, to the point where they just stop doing what they should be doing and things get really bad," he explained. "This is where the care managers are so important, because they reach out to the patients, maintain the connection, and help them navigate."

The effort appears to be worth it, according to a review of primary outcome data from March 2008 through March 2010 reported on the public Minnesota Health Scores Web site. The site reported 6-month depression remission rates between 7% and 51%, compared with rates between 0% and 10% in clinics not using DIAMOND. An additional 16% of the DIAMOND patients experienced at least a 50% reduction in depression symptom severity – a rate nearly 10 times higher than that observed in the usual-care patients (www.mnhealthscores.org).

In addition to addressing symptoms of depression, the program leads to improvements in other areas, Dr. Williams said. "When patients are depressed, they tend not to deal with their other issues, such as asthma, diabetes, and alcohol abuse. As their symptoms improve and through the care collaboration, we start to identify some of those issues." This is one reason that, on paper, the health care costs during the first year of the program occasionally increase, he said.

"After some of these issues are addressed, the health care utilization costs actually drop substantially per patient, but that can take 3-4 years, and insurance companies are interested in the fiscal year."

Financial considerations, although addressed on the front end through the bundled fee, might ultimately present the biggest challenge to DIAMOND’s survival, Dr. Williams stated.

"Medicare and Medicaid have not yet agreed that this is worth paying for, despite having evidence that it works better than usual care and that the initial costs are likely to be offset quickly." This is because "there is a lot of pressure on them with universal health care to talk about the health care home," he said. "There’s a lot of uncertainty about whether the health care home is going to be a reality, so there is a hesitation to commit to other collaborative models."

In reality, the DIAMOND program, with its sustainable payment model, could be an important building block for the health care home, Dr. Williams stressed. In a recent case study evaluating the DIAMOND effort, he and his colleagues concluded that the model "offers a new direction" for achieving the goal of creating value in depression management, particularly at the mental health and primary care interface (Qual. Prim. Care 2010;18:327-33).

Dr. Williams and Dr. Rank have no relevant financial disclosures.

A depression care model aiming to bridge the gap between what is known about mental health obstacles and what is being done to minimize them has led to the successful communion of science and practice across Minnesota.

The model, called Depression Improvement Across Minnesota Offering a New Direction, or DIAMOND, uses a team-based approach to facilitate the screening, diagnosis, and management of depression among patients in 83 primary care practices across the state.

The DIAMOND approach, in which the care of patients who screen positive for depression in the primary care setting is choreographed by care managers and overseen by consulting psychiatrists, is not a novel one. In fact, a well-established body of evidence indicates that team care models improve outcomes in depression and reduce health care use costs over time (J. Occup. Environ. Med. 2008;50:459-67).

The unique aspect of the DIAMOND model is that it is the first depression treatment program in the country to integrate the team-based paradigm with a reimbursement structure that supports the provision of enhanced mental health care support in primary care clinics, according to Dr. Brian Rank. Dr. Rank is medical director of HealthPartners Medical Group in Minneapolis and chair of the board of directors for the Institute for Clinical Systems Improvement (ICSI) in Bloomington, Minn. ICSI is a nonprofit group that spearheaded the development and launch of DIAMOND in 2008 in collaboration with more than 60 medical groups, hospitals, and health plans.

Specifically, each medical group participating in DIAMOND receives a monthly fee for every enrolled patient, said Dr. Mark D. Williams of the Mayo Clinic in Rochester, Minn. The fee, predetermined through collaboration with the state’s major insurers and represented by a single, specific billing code, covers the care "bundle," which includes depression screening and monitoring using the Patient Health Questionnaire (PHQ-9); weekly psychiatric consultation and case review; ongoing contact with the care manager; communication between the care manager, psychiatrist, and primary care physician; relapse prevention visits; and use of a patient registry.

"The fee addresses one of the main questions challenging health care improvement in this country: Who is going to pay for it?" Dr. Williams said in an interview. "The way health care is designed in the United States, practices are trying to manage lots of patients, because the only way they can survive is through volume. So, when you suggest trying a different model – one that requires hiring a resource care manager or pulling someone out of a different position from a busy clinic – the practices see risk. Their margins are so small already, committing to the change, even if it is evidence based, is difficult."

Because of the financial realities, the DIAMOND team had to figure out a way to implement the program in practices without the shadow of financial disincentives. "The challenge wasn’t proving it would work – there are lots of randomized controlled trials supporting the collaborative care model – the challenge was showing the practices that the costs wouldn’t be overwhelming," Dr. Williams said. "The promise of new income through the monthly fee was something that allowed the practices to go to their boards and argue that the new model would improve patient management without putting the practice at risk."

The DIAMOND protocol is built around the main elements of the Improving Mood: Promoting Access to Collaborative Treatment (IMPACT) program developed by Dr. Jürgen Unützer of the University of Washington (http://impact-uw.org/). These elements include:

• Standard and reliable use of the PHQ-9 for assessment and ongoing depression management;

• Use of an evidence-based guideline and a stepped-care approach for treatment modification or intensification;

• Development and use of a registry to monitor and track patients;

• Relapse-prevention training for patients reaching remission;

• Introduction of a trained care manager; and

• A formal relationship with a consulting psychiatrist.

The DIAMOND implementation differs from IMPACT, in that the DIAMOND care managers do not have to be nurses with psychiatric experience, according to Nancy Jaeckels, vice president of member relations and strategic initiatives for ICSI. Rather, DIAMOND has hired and trained various health care personnel to serve as care managers, including medical assistants, social workers, and licensed practical nurses, she said.

In participating practices, patients aged 18 years or older with a primary care diagnosis of major depression or dysthymia and a PHQ-9 score of at least 10 are enrolled in the DIAMOND program.

The care protocol includes an initial review of PHQ-9 results and symptoms with the primary care physician; an intake meeting with the care manager, during which patients are screened for other mental health or substance use problems; and weekly phone or in-person follow-up contact with the care manager to discuss treatment status and to complete the PHQ-9, the results of which the care manager enters into the patient registry, along with information on the patient’s medication, treatment adjustments, and behavior.

The DIAMOND protocol also includes a weekly meeting between the consulting psychiatrist and the care manager to review care and discuss patient-related issues or concerns; and periodic direct contact between the psychiatrist and the primary care provider, who is the medication prescriber, to assess treatment response and make adjustments as necessary.

"In some instances, there are patients who need more than DIAMOND can offer, so we spend a fair amount of energy linking with local mental health resources, advocating for the patients as much as possible," Dr. Williams said.

Patients enrolled in DIAMOND are covered for a maximum of 12 consecutive months, Ms. Jaeckels said. Before moving out of care management, they complete a relapse prevention plan with their care manager that includes an action plan if symptoms recur, she said.

The DIAMOND model addresses important deficiencies in the current management of depression in primary care, Dr. Williams said. "Even though we have outcome measures to tell when someone [with depression] is in trouble or improving, a lot of times primary care physicians don’t use these and instead ask questions like, ‘How is it going?’ or ‘How is the depression?’ That’s kind of like asking a patient with hypertension how he or she is doing without measuring blood pressure. It doesn’t make sense."

Another obstacle in traditional settings is that patients with depression "typically are not activated," Dr. Williams said. "They have trouble getting going and doing things, and they commonly feel overwhelmed by the fragmentation of the health care system, the difficulty getting appointments, problems with their prescriptions, to the point where they just stop doing what they should be doing and things get really bad," he explained. "This is where the care managers are so important, because they reach out to the patients, maintain the connection, and help them navigate."

The effort appears to be worth it, according to a review of primary outcome data from March 2008 through March 2010 reported on the public Minnesota Health Scores Web site. The site reported 6-month depression remission rates between 7% and 51%, compared with rates between 0% and 10% in clinics not using DIAMOND. An additional 16% of the DIAMOND patients experienced at least a 50% reduction in depression symptom severity – a rate nearly 10 times higher than that observed in the usual-care patients (www.mnhealthscores.org).

In addition to addressing symptoms of depression, the program leads to improvements in other areas, Dr. Williams said. "When patients are depressed, they tend not to deal with their other issues, such as asthma, diabetes, and alcohol abuse. As their symptoms improve and through the care collaboration, we start to identify some of those issues." This is one reason that, on paper, the health care costs during the first year of the program occasionally increase, he said.

"After some of these issues are addressed, the health care utilization costs actually drop substantially per patient, but that can take 3-4 years, and insurance companies are interested in the fiscal year."

Financial considerations, although addressed on the front end through the bundled fee, might ultimately present the biggest challenge to DIAMOND’s survival, Dr. Williams stated.

"Medicare and Medicaid have not yet agreed that this is worth paying for, despite having evidence that it works better than usual care and that the initial costs are likely to be offset quickly." This is because "there is a lot of pressure on them with universal health care to talk about the health care home," he said. "There’s a lot of uncertainty about whether the health care home is going to be a reality, so there is a hesitation to commit to other collaborative models."

In reality, the DIAMOND program, with its sustainable payment model, could be an important building block for the health care home, Dr. Williams stressed. In a recent case study evaluating the DIAMOND effort, he and his colleagues concluded that the model "offers a new direction" for achieving the goal of creating value in depression management, particularly at the mental health and primary care interface (Qual. Prim. Care 2010;18:327-33).

Dr. Williams and Dr. Rank have no relevant financial disclosures.

A depression care model aiming to bridge the gap between what is known about mental health obstacles and what is being done to minimize them has led to the successful communion of science and practice across Minnesota.

The model, called Depression Improvement Across Minnesota Offering a New Direction, or DIAMOND, uses a team-based approach to facilitate the screening, diagnosis, and management of depression among patients in 83 primary care practices across the state.

The DIAMOND approach, in which the care of patients who screen positive for depression in the primary care setting is choreographed by care managers and overseen by consulting psychiatrists, is not a novel one. In fact, a well-established body of evidence indicates that team care models improve outcomes in depression and reduce health care use costs over time (J. Occup. Environ. Med. 2008;50:459-67).

The unique aspect of the DIAMOND model is that it is the first depression treatment program in the country to integrate the team-based paradigm with a reimbursement structure that supports the provision of enhanced mental health care support in primary care clinics, according to Dr. Brian Rank. Dr. Rank is medical director of HealthPartners Medical Group in Minneapolis and chair of the board of directors for the Institute for Clinical Systems Improvement (ICSI) in Bloomington, Minn. ICSI is a nonprofit group that spearheaded the development and launch of DIAMOND in 2008 in collaboration with more than 60 medical groups, hospitals, and health plans.

Specifically, each medical group participating in DIAMOND receives a monthly fee for every enrolled patient, said Dr. Mark D. Williams of the Mayo Clinic in Rochester, Minn. The fee, predetermined through collaboration with the state’s major insurers and represented by a single, specific billing code, covers the care "bundle," which includes depression screening and monitoring using the Patient Health Questionnaire (PHQ-9); weekly psychiatric consultation and case review; ongoing contact with the care manager; communication between the care manager, psychiatrist, and primary care physician; relapse prevention visits; and use of a patient registry.

"The fee addresses one of the main questions challenging health care improvement in this country: Who is going to pay for it?" Dr. Williams said in an interview. "The way health care is designed in the United States, practices are trying to manage lots of patients, because the only way they can survive is through volume. So, when you suggest trying a different model – one that requires hiring a resource care manager or pulling someone out of a different position from a busy clinic – the practices see risk. Their margins are so small already, committing to the change, even if it is evidence based, is difficult."

Because of the financial realities, the DIAMOND team had to figure out a way to implement the program in practices without the shadow of financial disincentives. "The challenge wasn’t proving it would work – there are lots of randomized controlled trials supporting the collaborative care model – the challenge was showing the practices that the costs wouldn’t be overwhelming," Dr. Williams said. "The promise of new income through the monthly fee was something that allowed the practices to go to their boards and argue that the new model would improve patient management without putting the practice at risk."

The DIAMOND protocol is built around the main elements of the Improving Mood: Promoting Access to Collaborative Treatment (IMPACT) program developed by Dr. Jürgen Unützer of the University of Washington (http://impact-uw.org/). These elements include:

• Standard and reliable use of the PHQ-9 for assessment and ongoing depression management;

• Use of an evidence-based guideline and a stepped-care approach for treatment modification or intensification;

• Development and use of a registry to monitor and track patients;

• Relapse-prevention training for patients reaching remission;

• Introduction of a trained care manager; and

• A formal relationship with a consulting psychiatrist.

The DIAMOND implementation differs from IMPACT, in that the DIAMOND care managers do not have to be nurses with psychiatric experience, according to Nancy Jaeckels, vice president of member relations and strategic initiatives for ICSI. Rather, DIAMOND has hired and trained various health care personnel to serve as care managers, including medical assistants, social workers, and licensed practical nurses, she said.

In participating practices, patients aged 18 years or older with a primary care diagnosis of major depression or dysthymia and a PHQ-9 score of at least 10 are enrolled in the DIAMOND program.

The care protocol includes an initial review of PHQ-9 results and symptoms with the primary care physician; an intake meeting with the care manager, during which patients are screened for other mental health or substance use problems; and weekly phone or in-person follow-up contact with the care manager to discuss treatment status and to complete the PHQ-9, the results of which the care manager enters into the patient registry, along with information on the patient’s medication, treatment adjustments, and behavior.

The DIAMOND protocol also includes a weekly meeting between the consulting psychiatrist and the care manager to review care and discuss patient-related issues or concerns; and periodic direct contact between the psychiatrist and the primary care provider, who is the medication prescriber, to assess treatment response and make adjustments as necessary.

"In some instances, there are patients who need more than DIAMOND can offer, so we spend a fair amount of energy linking with local mental health resources, advocating for the patients as much as possible," Dr. Williams said.

Patients enrolled in DIAMOND are covered for a maximum of 12 consecutive months, Ms. Jaeckels said. Before moving out of care management, they complete a relapse prevention plan with their care manager that includes an action plan if symptoms recur, she said.

The DIAMOND model addresses important deficiencies in the current management of depression in primary care, Dr. Williams said. "Even though we have outcome measures to tell when someone [with depression] is in trouble or improving, a lot of times primary care physicians don’t use these and instead ask questions like, ‘How is it going?’ or ‘How is the depression?’ That’s kind of like asking a patient with hypertension how he or she is doing without measuring blood pressure. It doesn’t make sense."

Another obstacle in traditional settings is that patients with depression "typically are not activated," Dr. Williams said. "They have trouble getting going and doing things, and they commonly feel overwhelmed by the fragmentation of the health care system, the difficulty getting appointments, problems with their prescriptions, to the point where they just stop doing what they should be doing and things get really bad," he explained. "This is where the care managers are so important, because they reach out to the patients, maintain the connection, and help them navigate."

The effort appears to be worth it, according to a review of primary outcome data from March 2008 through March 2010 reported on the public Minnesota Health Scores Web site. The site reported 6-month depression remission rates between 7% and 51%, compared with rates between 0% and 10% in clinics not using DIAMOND. An additional 16% of the DIAMOND patients experienced at least a 50% reduction in depression symptom severity – a rate nearly 10 times higher than that observed in the usual-care patients (www.mnhealthscores.org).

In addition to addressing symptoms of depression, the program leads to improvements in other areas, Dr. Williams said. "When patients are depressed, they tend not to deal with their other issues, such as asthma, diabetes, and alcohol abuse. As their symptoms improve and through the care collaboration, we start to identify some of those issues." This is one reason that, on paper, the health care costs during the first year of the program occasionally increase, he said.

"After some of these issues are addressed, the health care utilization costs actually drop substantially per patient, but that can take 3-4 years, and insurance companies are interested in the fiscal year."

Financial considerations, although addressed on the front end through the bundled fee, might ultimately present the biggest challenge to DIAMOND’s survival, Dr. Williams stated.

"Medicare and Medicaid have not yet agreed that this is worth paying for, despite having evidence that it works better than usual care and that the initial costs are likely to be offset quickly." This is because "there is a lot of pressure on them with universal health care to talk about the health care home," he said. "There’s a lot of uncertainty about whether the health care home is going to be a reality, so there is a hesitation to commit to other collaborative models."

In reality, the DIAMOND program, with its sustainable payment model, could be an important building block for the health care home, Dr. Williams stressed. In a recent case study evaluating the DIAMOND effort, he and his colleagues concluded that the model "offers a new direction" for achieving the goal of creating value in depression management, particularly at the mental health and primary care interface (Qual. Prim. Care 2010;18:327-33).

Dr. Williams and Dr. Rank have no relevant financial disclosures.