A care manager can improve outcomes at the doctor’s office.
In a common medical scenario, a teen might go to their primary care doctor with complaints of depression. The doctor — concerned, but busy — prescribes an antidepressant, and the teen receives a referral to a mental health specialist and instructions to return in 4 to 6 weeks.
That’s often the end of the story. The teen never seeks follow-up care, despite having a serious medical condition and having been told to take a medication, sometimes with significant side effects.
It’s not exactly setting up the teen or the treatment for success. “What we know is that often teens who get started on medications don’t return for follow up or discontinue them after they’re started, or they don’t make it to the mental health specialist appointment,” says Laura Richardson, MD, MPH, a professor of pediatrics at the University of Washington School of Medicine and a physician at Seattle Children’s Hospital. “Right now in primary care, our systems for tracking that and supporting patients are not as good as they could be. We leave a lot of it up the patient and the family to get the next steps in care.”
In collaborative care, a care manager checks in with a patient during the course of care. Side effects, treatment dosages, and medications can be adjusted based on the patient’s progress, preferences, and feedback. More than 80 studies have shown the model improves health outcomes and reduces costs, but Richardson’s is one of the first to examine how well it works for depression in teens.
By the age of 18, one in five teenagers experience an episode of major depression, and 14 percent of all teens have depression. Of those, fewer than half get treatment. There are long-term risks for these teens: within 5 years, more than two-thirds will experience another episode or recurrence. Early episodes also increases risk of recurring depression and other mental health disorders throughout life.
“When teens show up with depression,” Richardson notes, “it’s often their first experience. I think there’s a tremendous opportunity to work on making sure that we’re teaching skills to teens and helping them in ways that will reduce the risk for it to become a lifelong problem.”
In her study, 101 teens with major and minor depression were recruited at primary care clinics in the Seattle area. Half were provided with their depression screening results and assigned to usual care — a referral to a mental health specialist in their network. The other half worked with a depression care manager, who provided educational and brief psychotherapy sessions at the clinics’ offices. Teens and their families worked with their primary care provider and the care manager to establish a treatment plan. The care managers also followed up with the teens over a period of 12 months, calling or meeting with them every week or two to assess symptoms and their overall health and progress.
After a year, half of teens in the treatment group had achieved remission — no longer having depressive symptoms — compared to one in five in the usual-care group. Parents and teens both rated the program highly: 81 percent said they were satisfied or very satisfied with the program. Parents also said they appreciated having another caring adult in their teen’s life, while teens said it was important to them to know someone was reaching out and cared about them.
Teens rated the care managers highly, saying they were accessible and helpful, like talking to a friend. But part of the reason for such high satisfaction levels is likely also the convenience of getting help at their nearby doctor’s office. “It’s a lot easier on the family,” says Richardson. “If you think about it, with things like depression, the system is set up in such a way right now where we ask people, when they’re feeling their worst, to jump over a million hurdles to get to care. It’s at a time when they’re already having a hard time coping with what’s going on in their life, so to add a lot of hurdles is not in their best interest.”
Collaborative care avoids those difficulties. “The whole goal of collaborative care is to break down those barriers and to make sure that when we recommend a treatment, people aren’t just sitting out there thinking, ‘Well, that didn’t work, so there’s nothing that’s going to help me feel better.’ There’s someone reaching out and saying, ‘Hey, wait, you can feel better. Let’s figure this out together.’”
Collaborative care has also been found effective in treating heart disease and diabetes, both conditions that require frequent medical check-ins and medication management. Though a number of care systems have adopted it nationwide and internationally, Richardson says the biggest barrier to wider adoption is the current health care model, which bills for services performed rather than more holistic care. “How do you have a care manager in the clinic if they can’t support their time through billing?”
“This is a new role, and we really have to figure out with health care systems how to support it. There are some opportunities as the health care system moves forward in looking, not just at the number of services we provide, but the quality of outcomes that we have. I think that will create some tremendous opportunities for us to really think about how we organize care.”
December 05, 2016
Christopher Nystuen, MD, MBA