Mayo Clinic expands integrated care in primary and specialty practice

More than half of behavioral medicine consultations at Mayo Clinic in Rochester, Minnesota, now occur in team-based or integrated practice settings. James R. Rundell, M.D., cochief of the Division of Consultation, Department of Psychiatry & Psychology, says that studies suggest the team model produces considerably better outcomes and patient satisfaction than does a single-care provider approach.

In 2008, the Minnesota campus of Mayo Clinic was an initial rollout site for the Depression Improvement Across Minnesota, Offering a New Direction (DIAMOND) project. This Institute for Clinical Systems Improvement program currently involves nearly 290 primary care providers at 80 sites.

DIAMOND incorporates several processes to provide behavioral medicine consultations, including consistent patient assessment through use of the Patient Health Questionnaire (PHQ-9) and a registry that tracks patient response to treatment over time. Project participation also requires a stepped-care approach to medication and intensity of therapy, focus on relapse prevention, and 2 provider roles: primary care manager and a liaison or consultative relationship with a psychiatrist.

Mark D. Williams, M.D., a psychiatrist and principal investigator for DIAMOND project implementation at Mayo Clinic, says, "The translation of evidence-based practice into general care through consistent use of a measurement tool and an external registry allows us to fully assess patients in the context of their other health care concerns. Whatever treatment is chosen is monitored for effectiveness. We can maintain a record of their situation as it evolves. The registry also helps us monitor our entire clinic to measure depression remission rates over time."

The DIAMOND project includes a bundled model of payment for care. "Data are being gathered to assess the cost-offset of this model as it relates to returning individuals to work and reducing health care utilization costs. There is literature to predict that both indicators will improve," says Dr. Williams.

Throughout Mayo Clinic, integrated care models in specialty settings vary depending on financial, logistical, and administrative factors. Behavioral medicine care providers may see patients as part of a coordinative mental health team or as members of a multispecialty, multidisciplinary team.

Dr. Williams notes: "Before we incorporated DIAMOND procedures, a patient might be identified as depressed in primary care, but the care provider would have trouble accessing the next step in the process. Now the primary care provider has the patient complete the PHQ-9. If the patient has moderate symptoms of what the physician believes to be major depression or dysthymia, the patient meets with a care manager—literally just down the hall—who screens for other mental health conditions and compiles all information to review with a psychiatrist."

Recommendations are tailored to the individual and may involve referral to therapy, medication, or suggestions on healthy behaviors. Patients who need more attention are able to see a psychiatrist.

Depression choice study explores shared decision making

Victor M. Montori, M.D., an endocrinologist and member of the Mayo Clinic Knowledge and Encounter Research Unit, is the primary investigator for new research focused on translating knowledge of the efficacy and safety of diabetes medicines into tools to involve patients in shared decision making about their treatment.

Dr. Montori and his colleagues will use a grant awarded by the Agency for Healthcare Research and Quality to study the extent to which patients' participation in decision making can impact their depression care. "A new tool that can be used during the office visit will enable patients to participate in treatment discussions. It will let patients know the available and pertinent treatment options and how they differ on the basis of issues that patients consider important," says Dr. Montori.

Future research

Dr. Williams' team will expand the DIAMOND project study to determine the best time and place to integrate the process into primary and specialty care and the measurement tool into the health care process.

Notes Dr. Rundell: "Collaborative care models can produce more efficient financial performance, reduced documentation costs with improved compliance, and higher patient and provider satisfaction. Integration in primary and specialty practice differs because specialty care is structured differently by departments, but outcomes are the same: patient and provider satisfaction are improved, as are some indicators of clinical outcomes."