Pathways and TEAMcare Studies (Text Version)

Slide presentation from the AHRQ 2010 conference.

On September 27, 2010, Wayne Katon, made this presentation at the 2010 Annual Conference. Select to access the PowerPoint® presentation (530 KB). Free PowerPoint® Viewer (Plugin Software Help).


Slide 1

Pathways and TEAMcare Studies

Pathways and TEAMcare Studies

Wayne Katon, MD1
Mike VonKorff, ScD2
Elizabeth Lin, MD, MPH2
Paul Ciechanowski, MD, MPH1
Evette Ludman, PhD2
Carolyn Rutter, PhD2
Bessie Young, MD, MPH1
Do Peterson, MS2
David McCulloch, MD2

1University of Washington School of Medicine
2Group Health Research Institute NIMH Grants MH 41739 and MH 01643 (Dr. Katon)

Slide 2

Health Services Models

Health Services Models

TEAMcare approaches have been shown to improve quality of care and outcomes of patients with depression, diabetes, asthma and CHF.

The most complex and medical costly patients often have multiple comorbidities including at least one mental health diagnosis.

Slide 3

Medicare Patients

Medicare Patients

  • Depression, diabetes and heart disease are among the most common illnesses in aging populations but fewer than 4% of Medicare beneficiaries with any of these three illnesses have no other chronic medical conditions.
  • 80% of those with CHF, 71% with depression and 56% with diabetes have 4 or more chronic conditions.

Partnership for Solutions 2001.

Slide 4

161,697 Patients with Diabetes were Examined to Estimate Rates and Reasons for Poor Disease Control (HbA1c, SBP, LDLs)

161,697 Patients with Diabetes were Examined to Estimate Rates and Reasons for Poor Disease Control (HbA1c, SBP, LDLs)

  • 20% to 23% poor adherence.
  • Among those with adequate adherence, 30% to 47% had no evidence of treatment intensification.
  • Poor adherence and lack of treatment intensification were found in 53% to 68% of patients with poor disease control.

Schmittdiel J, et al. 2008

Slide 5

Challenge: Development of Health Services Models for "Natural" Clusters of Illness

Challenge: Development of Health Services Models for "Natural" Clusters of Illness

Definition: Illnesses with high prevalence, high comorbidity and bidirectional adverse interactions.

  • Examples:
    • Diabetes, CAD, depression
    • Depression, chronic pain, substance abuse

Slide 6

New NIMH-Funded Study: TEAMcare Inclusion Criteria

New NIMH-Funded Study: TEAMcare Inclusion Criteria

  • Evidence via automated date (ICD-9) of having diabetes and/or coronary artery disease (CAD).
  • Evidence of poor disease control (HbA1c >8.5, blood pressure >140/90, LDL >130).
  • PHQ-9 ≥10.

Slide 7

Recruitment

Recruitment

  • 14 GH clinics (e.g. Olympia, Everett, Silverdale, and BVU).
  • 150 primary care physicians signed consent.
  • 9,838 PHQ-2 screeners mailed.
  • 214 Patients randomized:
    • 106 Intervention (106)
    • 108 Control

Slide 8

TEAMcare Intervention Goals

TEAMcare Intervention Goals

  • Improve depression care: behavioral activation and antidepressants.
  • Improve medical disease control: HbA1c, HTN, LDL.
  • Improve self-care (diet, exercise, cessation of smoking, glucose checks).

Slide 9

Core Elements

Core Elements

  • Nurse Care Management:
    • Identify Goals—specific, measurable (BP, HbA1c, PHQ-9, # steps).
    • Monitor Progress of Targets—systematic, pro-active.
    • Treat-to-Target—relentless adjustment, Individualized.
    • Support Self-Care—adherence to medication adjustments.
    • Regular Clinical Review—supervised case reviews, Tx recommendations.

Slide 10

TEAMcare Interventionists

TEAMcare Interventionists

  • 3 diabetes nurse educators
  • Caseload supervision:
    • Depression: 2 psychiatrists
    • Diabetes and CAD: nephrologist, family doctor
    • E-Mail to diabetologist for complex cases

Slide 11

Nurse Training

Nurse Training

  • Motivational interviewing
  • Problem solving
  • Behavioral activation
  • Antidepressants
  • Treat-to-Target: blood glucose, HTN, LDLS

Slide 12

TEAMcare Summary Report

TEAMcare Summary Report

InitialClinicEnroll DatePHQBPHbA1c LDL 
BLNowBLNowBLNowBLNow
 NSH5/19/20081919141/69127/777.36.8168138
 NSH1/9/2008152118/80130/809.28.3138124
 EVM11/12/2007149160/98150/856.46.810867
 EVM10/30/2007132209/119126/767.37.7119103
 LYN8/23/2007143149/71111/588.17.78582

Slide 13

Improving Adherence

Improving Adherence

  • Patient self-care materials: book and video on depression, patient manual (Tools for Managing Your Chronic Disease)
  • Nurse support/education/motivational interviewing
  • Medisets
  • Simplifying medication regimen
  • $4 generics to avoid $10 co-pays

Slide 14

Self-Care Enhancements

Self-Care Enhancements

  • Glucometers: Group Health provides
  • Home blood pressure monitors
  • Pedometers to increase exercise
  • Medisets to improve adherence

Slide 15

Phases of Treatment

Phases of Treatment

  • Intervene on depression initially
    • Behavioral activation
    • Antidepressant medication

Slide 16

Medical Disease Control

Medical Disease Control

  • Is patient adhering to medication regimen?
  • If adhering and in poor control, is patient on optimal dosage?
  • If maximum dosage has been reached should a new medication be tried instead or augmentation of initial medication?
  • Team recommendations of medication changes are reviewed with primary care physician for approval.

Slide 17

TREAT-to-TARGET Guidelines

Treat-to-Target Guidelines

  • Nurses ask for physician approval for gradually increasing insulin or blood pressure medications based on these guidelines.

Slide 18

Behavioral Goals

Behavioral Goals

  • Behavioral activation/exercise
  • Dietary changes
  • Checking blood glucose/altering insulin
  • Cessation of smoking

Slide 19

Mean of SCL Score

Mean of SCL Score

Image: Line graph shows mean SCL score dropping over 12 months. The table below provides details.

MeanBaseline6 months12 months
Intervention mean (N)1.7 (105)0.8 (97)0.8 (94)
Control mean (N)1.7 (106)1.3 (96)1.1 (92)

Slide 20

Mean of HbA1c

Mean of HbA1c

Image: Line graph shows mean of HbA1c dropping over 12 months. The table below provides details.

MeanBaseline6 months12 months
Intervention mean (N)8.1 (105)7.4 (99)7.3 (101)
Control mean (N)8.0 (105)7.9 (95)7.8 (97)

Slide 21

Mean of Systolic BP

Mean of Systolic BP

Image: Line graph shows mean of systolic blood pressure (BP) changing over 12 months. The table below provides details.

MeanBaseline6 months12 months
Intervention mean (N)135.7 (105)131.9 (102)131.0 (101)
Control mean (N)131.9 (106)133.5 (101)132.3 (101)

Slide 22

Mean of LDL

Mean of LDL

Image: Line graph shows mean of LDL dropping over 12 months. The table below provides details.

MeanBaseline6 months12 months
Intervention mean (N)106.8 (105)N/A91.9 (98)
Control mean (N)109.4 (103)N/A101.4 (90)

Slide 23

Any Adjustment

Any Adjustment

Image: Bar graph compares I (Intervention) and UC (Control) for various factors. The table below provides details.

 UCI
OH26%38%
IH33%**53%**
AH49%***77%***
LL40%*56%*
AD30%***88%***

*p-value <0.05; ** p-value <0.01 ; ***p-value <0.001.

Slide 24

Satisfaction with Care of Depression

Satisfaction with Care of Depression

Image: Bar graph shows satisfaction with depression care over time. The table below provides details.

TimeInterventionControl
Baseline51%47%
6 months (p <.001)87%62%
12 months (p <.001)90%55%

Slide 25

Satisfaction with Care of Diabetes and/or CHD

Satisfaction with Care of Diabetes and/or CHD

Image: Bar graph shows satisfaction with diabetes or coronary heart disease (CHD) care over time. The table below provides details.

TimeInterventionControl
Baseline70%68%
6 months (p <.001)90%68%
12 months (p <.001)86%70%

Slide 26

Conclusions

Conclusions

  • Economies of scale: New health services interventions are needed for patients with multiple comorbidities (one of which is a psychiatric disorder).
  • The TEAMcare model is a promising approach to improving depression and medical disease control.
Current as of December 2010
Internet Citation: Pathways and TEAMcare Studies (Text Version). December 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/conference/2010/katon/index.html