1. Effectiveness of Depression Care Management in a Multiple Disease Care Management Model Bruce Friedman, Ph.D. Departments of Community and Preventive Medicine, and Psychiatry University of Rochester

2. Acknowledgments Robert Wood Johnson Foundation, “Depression in Primary Care: Testing a Consumer-Directed Care Model,” DPC #048120, Yeates Conwell, P.I. Centers for Medicare and Medicaid Services, “A Randomized Controlled Trial of Primary and Consumer-Directed Care for People with Chronic Illnesses,” CMS # 95-C-90467, Gerald M. Eggert, P.I. National Institute of Mental Health, “Impact of Depression and Function on Healthcare Use and Cost,” NIMH K01 MH64718, Bruce Friedman, P.I.

3. Medicare Primary and Consumer- Directed Care Demonstration Main Goals: –Promote empowerment and encourage greater consumer choice and control over personal health care decisions and management –Improve health status, functioning, and quality of life –Reduce Medicare and total healthcare costs Randomized trial (N=1605) of 3 models of consumer-directed care plus a Control group (n=384) –Health Promotion Nurse (HPN) (n=382) –Voucher (n=419) –Combination (Nurse plus Voucher) (n=420)

4. HPN Intervention Model Monthly HPN home visits to teach and coach chronic disease self-management (empowerment) PRECEDE health education planning model for health behavior change strategies Depression training and focus Differs from most disease management studies which usually concentrate on one chronic illness The HPNs did not provide typical “hands-on” nursing care Special Medicare payment for up to 4 physician- patient-caregiver-HPN office conferences

5. HPN Visits Visits per Month: Mean = 0.98 (SD=0.56) (0-5.4) VisitsTotal Per MonthVisits Major depression 1.00 16.4 No major depression 0.98 19.4 GDS-15 score –0-1 0.92 18.4 –2-3 1.00 20.1 –4-5 1.06 21.1 –6-10 1.00 19.8 –11-15 0.92 16.8

6. Percent Depressed Patient or caregiver rated screening tools completed at baseline, 12 months, or 22 months: –Major depression – 26% –Clinically significant non-major depression – 33% of cognitively intact Identified in primary care physician records: –33% had documentation of depression - 30% of HPN group- 35% of Control group –43% had antidepressant prescription mentioned - 41% of HPN group- 45% of Control group –50% had either or both - 48% of HPN group- 53% of Control group

7. Patient-Selected Goals 79% had at least one goal Mean = 3.24 (SD = 3.78) (range: 0-19) A total of 1,238 goals –Disease specific other than depression – 380 –Function – 147Medication – 83 –Exercise – 128Diet/nutrition – 71 –Physician related – 119Addiction – 18 –Social support – 90Other – 178 –Depression – 24 (1.94%) Of patients for whom there was documentation of depression in PCP chart, 19% had a depression goal Of patients for whom an antidepressant was mentioned in PCP chart, 11% had a depression goal

8. Depression Treatment Of the 138 patients with major depression at baseline, 12 months, or 22 months: –53% had an antidepressant mentioned in the PCP’s medical records -51% in HPN group -55% in Control group

9. Regression Analyses We found no statistically significant effects of the HPN intervention on depression in logistic and OLS regression models: –Major depression at 12 months and 22 months –GDS score at 12 months and 22 months –Major depression at 12 months and 22 months for those with major depression at baseline –GDS score at 12 months and 22 months for those with major depression at baseline

10. Conclusions About the same number of HPN visits were received by depressed and non-depressed patients Few depressed patients had a patient-selected depression goal The HPN model: –No more documentation of depression in PCP records –No more documentation of the use of antidepressants in PCP records –No impact on depression at 12 and 22 months –A significant effect on ADL impairment

11. Possible Explanations The depression intervention may have been insufficient – not depression specialists Competing demands –Other chronic conditions the patient, HPN, and physician are concerned with or working on –Other goals the patient has selected Stigma or resistance of seniors to articulating depression goals Empowerment intervention does not work as well for depressed patients