The DIAMOND Initiative: Implementing Collaborative Care for Depression in 75 Primary Care Clinics

Background: The many randomized trials of the collaborative care model for improving depression in primary care have not described the implementation and maintenance of this model. This paper reports how and the degree to which collaborative care process changes were implemented and maintained for the 75 primary care clinics participating in the DIAMOND Initiative (Depression Improvement Across Minnesota–Offering a New Direction). Methods: Each clinic was trained to implement seven components of the model and participated in ongoing evaluation and facilitation activities. For this study, assessment of clinical process implementation was accomplished via completion of surveys by the physician leader and clinic manager of each clinic site at three points in time. The physician leader of each clinic completed a survey measure of the presence of various practice systems prior to and one and two years after implementation. Clinic managers also completed a survey of organizational readiness and the strategies used for implementation. Results: Survey response rates were 96% to 100%. The systems survey confirmed a very high degree of implementation (with large variation) of DIAMOND depression practice systems (mean of 24.4 ± 14.6%) present at baseline, 57.0 ± 21.0% at one year (P = \u3c0.0001), and 55.9 ± 21.3% at two years. There was a similarly large increase (and variation) in the use of various quality improvement strategies for depression (mean of 29.6 ± 28.1% at baseline, 75.1 ± 22.3% at one year (P = \u3c0.0001), and 74.6 ± 23.0% at two years. Conclusions: This study demonstrates that under the right circumstances, primary care clinics that are prepared to implement evidence-based care can do so if financial barriers are reduced, effective training and facilitation are provided, and the new design introduces the specific mental models, new care processes, and workers and expertise that are needed. Implementation was associated with a marked increase in the number of improvement strategies used, but actual care and outcomes data are needed to associate these changes with patient outcomes and patient-reported care

Prevalence of Practice System Tools for Improving Depression Care Among Primary Care Clinics: The DIAMOND Initiative

BACKGROUND: Practice system tools improve chronic disease care, but are generally lacking for the care of depression in most primary care settings. OBJECTIVE: To describe the frequency of various depression-related practice system tools among Minnesota primary care clinics interested in improving depression care. DESIGN: Cross-sectional survey. PARTICIPANTS: Physician leaders of 82 clinics in Minnesota. MAIN MEASURES: A survey including practice systems recommended for care of depression and chronic conditions, each scored on a 100-point scale, and the clinic’s priority for improving depression care on a 10-point scale. KEY RESULTS: Fewer practice systems tools were present and functioning well for depression care (score = 24.4 [SD 1.6]) than for the care of chronic conditions in general (score = 43.9 [SD 1.6]), p < 0.001. The average priority for improving depression care was 5.8 (SD 2.3). There was not a significant correlation between the presence of practice systems for depression or chronic disease care and the priority for depression care except for a modest correlation with the depression Decision Support subscale (r = 0.29, p = 0.008). Certain staffing patterns, a metropolitan-area clinic location, and the presence of a fully functional electronic medical record were associated with the presence of more practice system tools. CONCLUSIONS: Few practice system tools are in place for improving depression care in Minnesota primary care clinics, and these are less well-developed than general chronic disease practice systems. Future research should focus on demonstrating whether implementing these tools for depression care results in much-needed improvements in care for patients with depression. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1007/s11606-011-1739-0) contains supplementary material, which is available to authorized users

Effective Implementation of Collaborative Care for Depression: What Is Needed?

Objectives: To identify the care model factors that were key for successful implementation of collaborative depression care in a statewide Minnesota primary care initiative. Study Design: We used a mixed-methods design incorporating both qualitative data from clinic site visits and quantitative measures of patient activation and 6-month remission rates. Methods: Care model factors identified from the site visits were tested for association with rates of activation into the program and remission rates. Results: Nine factors were identified as important for successful implementation of collaborative care by the consultants who had trained and interviewed participating clinic teams, and rated according to a Likert Scale. Factors correlated with higher patient activation rates were: strong leadership support (0.63), well-defined and -implemented care manager roles (0.62), a strong primary care physician champion (0.60), and an on-site and accessible care manager (0.59). However, remission rates at 6 months were correlated with: an engaged psychiatrist (0.62), not seeing operating costs as a barrier to participation (0.56), and face-to-face communication (warm handoffs) between the care manager and primary care physician for new patients (0.54). Conclusions: Care model factors most important for successful program implementation differ for patient activation into the program versus remission at 6 months. Knowing which implementation factors are most important for successful activation will be useful for those interested in adopting this evidence-based approach to improving primary care for patients with depression