Depression program a success, but costly for clinics

Treating depression
Dr. Tim Hernandez says he's pleased with the progress his patient Eugene is making in the DIAMOND program. But Hernandez says his clinic is absorbing too much of the depression program's cost. He worries that the successful program will "die on the vine" if insurers and employers don't agree to pay for more DIAMOND expenses.
MPR Photo/Lorna Benson

A group of Minnesota clinics is reporting remarkable success in treating depression, but the program is costly and faces an uncertain future.

Forty-five clinics currently participate in the DIAMOND project, which is credited with helping hundreds of patients recover from their illness, often in a matter of months.

DIAMOND is an acronym that stands for "Depression Improvement Across Minnesota, Offering a New Direction." It's a wordy way of saying that the program takes a new approach to depression care.

"It's worked tremendously well," said Nancy Jaeckels. "Our patient outcomes are more than we expected."

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Jaeckels oversees the DIAMOND project at the Institute for Clinical Systems Improvement, or ICSI. The Minnesota-based, non-profit group collects research for its clinic and hospital members.

ICSI researchers created the program after reviewing all the literature they could find on depression care. The researchers discovered that patients did much better when a team of health care workers collaborated on their care.

"We actually found that there are over 30 randomized control trials showing positive results of this collaborative care model for patients with depression," Jaeckels said.

ICSI decided to test out the concept in family practice clinics because they are usually the first point of contact for depressed patients.

Dozens of Minnesota clinics agreed to participate and invested thousands of dollars in extra staffing and computer software to track the program's results. Six months later the group of clinics reported back to the institute.

Collectively they found that 58 percent of the 2,000 patients who received coordinated team care had improved significantly after six months. Forty-five percent did so well they were classified as recovered. That's a more than ten-fold improvement over usual depression care recovery rates.

"We expect it to get better," Jaeckels said.

Meredith Kurtz
Care manager Meredith Kurtz calls her DIAMOND patients every week to make sure they are working on the goals they set for themselves. Depression recovery can be full of ups and downs. Kurtz says it's important to keep tabs on patients' progress so they don't languish.
MPR Photo/Lorna Benson

For patients in the program for at least a year, she said, the response rates are closer to 70 percent with nearly half of patients classified as recovered.

It turns out that some rather simple staffing changes make a big difference in the success of depression care.

DIAMOND clinics must hire psychiatrists to review their case records periodically to make sure they were following best-care practices.

The clinics also added care managers to their team, someone who's sole job is to keep depressed patients from languishing. "What I tell my patients is (to) consider me the boot that's going to kick you in the butt, cause I'm going to push," said care manager Meredith Kurtz.

Kurtz has about 90 patients in the DIAMOND program, including Eugene. He asked that his last name not be used because he worries about the stigma associated with depression.

Eugene says Kurtz would call him on the phone every week to make sure he was working on the goals that they had set during a previous session.

Kurtz says the regular check in is important because recovering from depression is a bumpy road.

"You know if somebody's having a great week we think, 'Whoa they're going into remission.'" she said. "But the fact is it might just be a good week. So that's why we do it every week because the following week it may not be as good, and that's okay, but then we want to know why so we can catch it quickly and we can help them through it."

Dr. Tim Hernandez is Eugene's family physician. Hernandez says he's impressed with how well the DIAMOND program is working in his clinic, but he says it's an expensive program that clinics can't afford to absorb on their own.

"I think a huge concern that we have is that it may die on the vine, it may go away like other wonderful programs for lack of funding because good care does cost money," Hernandez said.

Minnesota health plans are paying for some of DIAMOND's costs, but Hernandez, who's part of a 13-clinic system, says his group is still absorbing a lot of the expense.

"Our board has said in a year that we're going to have to make a decision on whether we're going to be able to continue, whether it will be a feasible program," he said.

ICSI acknowledges that this is a critical time for all of the clinics involved in DIAMOND. The institute is trying to spread the word to health plans and employers that the program will save them money in the long run.

Depression is linked with drug and alcohol abuse, a loss of productivity and it can make other health conditions worse. Those problems can add significantly to the cost of caring for a depressed patient.

ICSI does have some cost data to back up its position. A similar program in Washington and California showed that over a 4-year-period patients working with a collaborative health care team spent $3,300 less on their care than those who were not enrolled in the program.