Coordinated care goes beyond simply making sure patients have a follow-up appointment after hospital discharge.
Coordinating patients' diabetes and cardiovascular treatment with mental health care can both reduce depression and improve patients' glucose and blood pressure numbers, according to a nationwide program.
Eighteen care systems and 172 clinics enrolled 3,609 patients with depression and comorbid diabetes or cardiovascular disease across the United States in a nationwide initiative called COMPASS (Care of Mental, Physical and Substance-use Syndromes).
Patients who were enrolled in the initiative talked at least once a month with a care manager, who worked with their primary care physician, about their depression and their medication for diabetes, hypertension or both.
Forty percent of patients with uncontrolled disease at enrollment achieved depression remission or response; 23% achieved glucose control; and 58% achieved blood pressure control during a mean follow-up of 11 months, according study results published in the journal General Hospital Psychiatry. Surveys also showed that patients and clinicians were satisfied with COMPASS care.
Care managers at each clinic conducted patient outreach and regularly reviewed patient cases with a psychiatrist and primary care physician. If patients were new or not improving, the outreach to patients and the reviews were done weekly.
Care managers had either behavioral health or medical training, but also had expressed an interest in treating the patient as a whole person, rather than treating one condition at a time.
The Center for Medicare and Medication Innovation funded the $18-million, three-year initiative.
Continuity of Care Innovation is Closer Than You Think
"This was a successful wide-scale implementation of a collaborative care model that demonstrated it can be used in a variety of health care settings with positive effects for providers and patients," Karen J. Coleman, PhD, MS, Kaiser Permanente Southern California Department of Research & Evaluation, said in a statement.
Coleman also said the work indicates that patients with mild and moderate depression can be cared for in the primary care setting.
"Depression is a chronic disease like diabetes," Coleman said. "Healthy behavioral changes like sleep, exercise, and better eating can improve diabetes and depression.
"If medications are given for depression, they can be managed in a collaborative care model, just like medications for diabetes."