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Re-engineering systems in the treatment of depression in primary care:
The Colorado Access Experience
In 2001, Colorado Access, a non-profit public sector health maintenance organization (HMO), began looking for evidence–based models to improve the treatment of depression, anxiety, and substance abuse in its primary care population. This process led to Colorado Access’ participation in the MacArthur Foundation’s Re-Engineering Systems in Primary Care Treatment of Depression (RESPECT-Depression) Initiative.
This project consisted of a pilot phase and a randomized controlled trial that assessed the ability of health plans to implement and disseminate a depression care management model, the Three Component Model, in primary care practices. The RESPECT-Depression trial was initially implemented in the Colorado Access’ behavioral health business plan using mental health clinicians who were trained as care managers. Primary care clinics affiliated with the Colorado Access physical health plan used the PHQ-9 to screen patients for depression before referring them for depression care management provided by the health plan clinician, supervising psychiatrist, and the clinic primary care physician (PCP).
Colorado Access’ ability to develop its own sustainable depression care management program was greatly enhanced by its experience in implementing the RESPECT-Depression trial. The RESPECT-Depression Project built and delivered to the health plan a depression care management model that incorporated ready-made patient and provider ‘‘tool kits’’ and well-defined operational processes for clinical assessment and follow up. Through its experience with the RESPECT-Depression program, Colorado Access learned practical lessons about implementing depression care management in its Medicaid population.
Participation in the program by Colorado Access affiliated clinics revealed that there was a great deal of unmet need for depression treatment. Furthermore, primary care providers were most interested in obtaining treatment help for patients with multiple psychiatric, medical, and psychosocial needs. Also, many PCPs felt that the depression screening and referral process, though relatively efficient, was too time consuming for a busy practice. During the clinical trial, the adoption of these procedures was extremely variable across providers and practices. If Colorado Access wanted to efficiently screen a large number of depressed patients within specific target populations across many practices, the health plan would need to take the lead in screening and enrolling potential care management candidates.
In order to sustain the depression care management program after the RESPECT-Depression trial, Colorado Access embedded depression intervention into the existing intensive care management services delivery system. This allowed follow-up depression assessment and care management to be conducted centrally at the health plan, thus reducing the clinical burden on primary care providers. It also allowed Colorado Access to identify a cohort of depressed patients with medical illnesses who would likely benefit from integrated depression and medical care management. In this centralized depression program, specific components of the Three Component Model continued to be incorporated into training, patient assessment and follow up, self-management strategies, and supervision in an effort to maintain fidelity to the RESPECT-Depression protocol.
Through its experience with the RESPECT-Depression trial, Colorado Access has been able to sustain depression care management and demonstrate favorable clinical, cost, and utilization outcomes. The RESPECT-Depression protocol, tool kits, and patient materials allowed easy, efficient, and effective adoption of the program at the health plan level. This successful endeavor with the RESPECT-Depression Project has led Colorado Access to adopt depression care management as one of its core competencies and a valuable service for providers and health plan members. Colorado Access continues to work toward effective depression treatment and management for both patients and health care providers. All the resources and support provided by The MacArthur Foundation are greatly appreciated.
For more details on CME manager training, supervision, patient self-management, click here.
Visit Colorado Access website.
Marshall R. Thomas, MD
President and CEO, Colorado Access
Executive Director, University of Colorado Denver
Department of Psychiatry Depression Center
Jeanette A. Waxmonsky, PhD
Assistant Professor
University of Colorado Denver
Department of Psychiatry Depression Center
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