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.