SummaryIn collaboration with six nonprofit health plans, multiple medical groups, the Minnesota Department of Human Services, employers, and patients, the Institute for Clinical Systems Improvement redesigned the way primary care practices identify, treat, and get reimbursed for patients with depression. Under this program (known as Depression Improvement Across Minnesota Offering a New Direction or DIAMOND), participating health plans pay DIAMOND–certified practices a flat monthly rate for providing a bundled set of services to each patient who meets certain eligibility criteria. These practices implement the DIAMOND care model and receive monthly performance reports based on data they submit each month on process and outcome measures for depression care. The initiative has generated high rates of remission and treatment response among participating patients, along with high levels of provider satisfaction.Suggestive: The evidence consists of post-implementation data on key outcomes measures, including patients achieving remission and response to treatment, and anecdotal reports from providers about their satisfaction with the program.
Developing OrganizationsInstitute for Clinical Systems Improvement
Date First Implemented2008
Insurance Status > Commercial; Vulnerable Populations > Mentally ill
Problem AddressedMental health conditions are common and often lead to significant negative consequences. Although many patients with such conditions seek care in the primary care setting, most primary care providers (PCPs) lack the time, resources, and reimbursement support to identify and treat them on their own. Integrating mental health assessment and treatment into primary care can yield clinical and cost benefits,1 but most primary care clinics do not offer integrated care, and those that do may not be reimbursed for the services they provide.
- A common, costly disorder: At any given time, approximately 9 percent of Americans have a depressive disorder2; the direct and indirect costs of such disorders total as much as $43 billion annually.3
- Significant negative consequences: Conditions such as depression and anxiety can cause functional impairment and have a major negative effect on quality of life. For example, adults with depression use more medical services, experience more physical symptoms, adhere less well to medication regimens, and engage in poorer self-management behaviors than do adults without depression. Depressed adults also face an increased risk of death from suicide and medical illnesses.4,5
- Challenges in primary care to diagnose and treat mental health conditions: PCPs often fail to diagnose and treat depression. Overall, PCPs diagnose major depression in only 35 percent to 50 percent of adult patients who have it.6 One study of 500 primary care patients found that 29 percent had mental health conditions, but providers identified only one-third of these conditions over a 5-year period.7 Patients diagnosed in the primary care setting also do not often receive effective treatment. In fact, only approximately one-half of these patients receive any treatment in the primary care setting, and, among those who do, only 20 percent to 40 percent show meaningful improvement in the year after diagnosis.5
- Few integrated programs, partially due to lack of reimbursement: Despite links between physical and mental health, most primary care clinics do not have integrated programs to assess or treat mental health conditions.5,8 The reason for this lack of programs is that payers often do not reimburse for mental health services delivered in the primary care setting.
Description of the Innovative ActivityIn collaboration with six nonprofit health plans, multiple medical groups, the Minnesota Department of Human Services, employers, and patients, the Institute for Clinical Systems Improvement (ICSI) redesigned the way that primary care practices identify, treat, and get reimbursed for patients with depression. Under this program, known as DIAMOND, participating health plans pay certified practices a flat monthly rate for providing a bundled set of services to each patient who meets certain eligibility criteria. These practices implement the DIAMOND care model and receive monthly performance reports based on data they submit each month on process and outcome measures for depression care. Key program elements include the following:
- Training and certifying clinics: To ensure that participating practices can successfully implement the care model, ICSI staff conduct a readiness assessment of any practice that expresses interest in the program. Level of readiness is evaluated based on several factors, including past experience with team-based care, the involvement of a physician champion, leadership support, a history of appropriate depression coding, and use of DSM-IV-TR diagnostic criteria. Those practices deemed ready participate in a learning collaborative series of inperson meetings, conference calls, and a 1.5-day care manager training (see below for more details on this position), along with customized assistance in adjusting operational workflows and adopting best practices in depression care. After completing the training, practices become "certified" to offer the DIAMOND program. As of February 2013, there are 68 certified primary care clinics; more than 9,700 adult patients have been activated into the DIAMOND program to date.
- Standardized eligibility criteria and service bundle: Based on the work of a steering committee (see Planning and Development section for details), participating practices use the DIAMOND care delivery model, which features standardized eligibility criteria and a core bundle of services, as outlined below:
- Standardized eligibility criteria: Patients 18 years and older who have a diagnosis of major depression or dysthymia and a Patient Health Questionnaire-9 (PHQ-9) score of 10 or higher are eligible to participate in the program for up to 12 consecutive months. The PHQ-9 is a validated, 9-item questionnaire that assesses the severity of depression on a scale of 0 through 27.
- Standardized bundle of services: The typical patient receives a standardized bundle of services, as described below:
- Patient assessment using validated instrument: If a provider suspects that a patient may have depression (e.g., positive brief depression screen, clinical interview, a history of depression, reported symptoms), the provider administers the PHQ-9. If the score is 10 or higher, the provider confirms the diagnosis of depression and explains the DIAMOND program.
- Dedicated care manager: Patients interested in participating are introduced to a care manager, who has regularly scheduled inperson or telephone meetings with the patient, during which he or she provides education, supports goal setting and self-management, and monitors treatment adherence.
- Evidence-based, stepped treatment: Physicians follow ICSI’s evidence-based guideline for depression care (see the Tools section for more information). This guideline incorporates a stepped approach for treatment modification, which involves intensifying, changing, or adding treatment options such as medication or counseling based on depression severity, patient preferences, side effects, and progress (as measured by a change in the PHQ-9 score).
- Patient registry to track progress: At each meeting, the care manager readministers the PHQ-9 and enters the score into a patient registry, along with any relevant information related to medication and treatment adjustments. Care managers use the registry to track a patient’s progress over time and to identify those cases to be discussed with the consulting psychiatrist (see below).
- Psychiatric consultation and caseload review: Every week, the care manager and a consulting psychiatrist meet by telephone or in person to review the care manager’s cases, mainly focusing on new patients, those who are not improving based on their PHQ-9 scores, or those with additional complexities. The goal of these case reviews is to develop next steps for patients with severe depression who are not making adequate progress. Recommendations might include medication adjustments or referrals to other mental health providers or community resources. Approximately 15 psychiatrists have contracts with the participating medical groups to provide these consulting services.
- PCP approval to implement psychiatrist recommendations: The care manager notifies the PCP about any changes recommended by the psychiatrist and then initiates all PCP-approved changes. The psychiatrist and PCP have the option to consult directly as needed.
- Relapse prevention plan: For any patient who goes into remission (defined as a PHQ-9 score below 5 for 2 consecutive months), the care manager and patient jointly develop a relapse prevention plan. The plan lists the patient’s depression triggers, outlines a maintenance plan (e.g., continued adherence to medication and counseling regimens, regular physical activity), lists symptoms that might indicate a relapse, and details an action plan if symptoms reappear.
- Referral to more intensive services: On average, DIAMOND patients reach remission within 4 to 9 months. If progress is not being made as patients are nearing the 1-year mark, the care team discusses options for more intensive treatment and helps the patient coordinate a transition.
- Fixed monthly reimbursement: Certified DIAMOND clinics use a single billing code and get paid a flat monthly fee for each patient in the program. The code covers the bundled services of the initial and followup care manager contacts, weekly consultations, and psychiatrist case reviews for a maximum of 12 months. Each participating health plan negotiates a fee with each participating clinic to avoid violating antitrust laws.
- Monthly reporting to promote improvement: Participating clinics submit performance data on various process and outcome measures to ICSI each month. These data include the number of patients enrolled, percent of PHQ-9s administered at initial contact, percent of patients responding to treatment (defined as at least a 50-percent reduction in the baseline PHQ-9 score) at the 6- and 12-month points after program entry, and patients in remission (also 6 and 12 months after entry). These measures align with Minnesota Community Measurement, the state’s public reporting agency. Data are also shared among participating groups to support improvement, spread learning, and share best practices with the others.
References/Related ArticlesInstitute for Clinical Systems Improvement. The DIAMOND program: success in primary care depression treatment and extension to other health care challenges. 2013.
Institute for Clinical Systems Improvement. DIAMOND: co-creating a unique care delivery and payment model for treatment of depression in primary care. Unpublished manuscript.
Solberg LI. DIAMOND: A Large Scale Implementation Initiative. PowerPoint presentation.
Contact the InnovatorPam Pietruszewski, MA
Health Care Consultant, ICSI
8009 34th Avenue South, Suite 1200
Bloomington, MN 55425
Innovator DisclosuresMs. Pietruszewski reported that her institution received grant funding, consulting fees, and honoraria payments for presentations and training related to the DIAMOND program.
ResultsThe DIAMOND program has generated high rates of remission and clinical response among patients with depression, and high levels of satisfaction among providers.
Suggestive: The evidence consists of post-implementation data on key outcomes measures, including patients achieving remission and response to treatment, and anecdotal reports from providers about their satisfaction with the program.
- Many patients achieving remission: Participating practices reported that 49 percent of participating patients achieved remission at the 6-month followup. At 12 months, 53 percent of patients had achieved remission.
- Many patients responding to treatment: Roughly two-thirds of patients achieved a clinical response to treatment at the 6-month followup, and 53 percent did so at the 12-month point. (Note: Some patients who responded to treatment also achieved clinical remission.)
- High levels of provider satisfaction: Many PCPs report high levels of satisfaction with DIAMOND, believing it has enhanced their clinic’s culture, improved care continuity and coordination, and facilitated closer linkages with external psychiatrists.
Context of the InnovationICSI is a nonprofit organization dedicated to improving the quality and value of the care delivered by its member organizations. Sponsored by five nonprofit health plans and made up of more than 50 member medical groups and hospitals (primarily in Minnesota), ICSI brings diverse stakeholders together to tackle complex health care system issues. ICSI also creates evidence-based guidelines for the prevention, diagnosis, and treatment of more than 50 health conditions and helps its members implement these guidelines and associated best practices.
ICSI has published an evidence-based depression care guideline since 1994, but member groups identified multiple barriers to providing high-quality depression care in primary care practices, including medical coding issues, PCP discomfort with discussing and treating mental health issues, lack of compensation for mental health services delivered in the primary care setting, and inconsistent followup care. These findings prompted ICSI member groups and sponsoring health plans to design an improved model for depression care in primary care practices.
Planning and Development ProcessSelected steps included the following:
- Forming steering committee: ICSI formed a DIAMOND steering committee that included representatives from physician groups, health plans, purchasers, the Minnesota Department of Human Services, and the patient community. The committee approved the standardized eligibility criteria.
- Reviewing literature: The steering committee conducted a literature review of existing care models and found ample evidence that a collaborative care approach could improve patient outcomes.
- Adapting existing care model: The steering committee started with a collaborative care model developed by Wayne Katon, MD4 that had been tested and found effective in a randomized controlled trial.5 This model served as the foundation for the DIAMOND program. The committee adopted its core elements and discussed and resolved issues related to coverage of specific services, patient eligibility, program duration, and medical group reimbursement.
- Recruiting health plans: ICSI representatives described the program to leaders of Minnesota’s six largest nonprofit health plans and the Minnesota Department of Human Services. They all agreed to participate, because of the gap in care, the health and cost impact of untreated depression, and the need to redesign care and payment models that support the "Triple Aim" of improving health, the experience and quality of care, and the affordability of care.
- Designing reimbursement model: A subgroup that included ICSI representatives and steering committee members designed criteria for the reimbursement model, taking into account anticipated medical group costs, health plan liability, and the individual health plan products that would participate in the program. They used this information to determine the appropriate level and structure of reimbursement.
- Phasing implementation: ICSI rolled out the program in five waves over a 2.5-year period, with a new set of clinics implementing it every 6 months.
- Expanding program: Based on the program's success, ICSI is expanding the use of DIAMOND as a model to care for patients with other chronic and behavioral health conditions. For example, ICSI and three other regional collaboratives are participating in an Agency for Healthcare Research and Quality grant that combines DIAMOND for depression and the Screening, Brief Intervention, and Referral to Treatment (SBIRT) program to address risky substance use. In 2012, ICSI and nine other medical groups received a Center for Medicare & Medicaid Innovation award to spread a DIAMOND-like collaborative care model in primary care clinics across eight states to improve the care of patients with diabetes or heart disease, plus depression and possibly risky substance use.
Resources Used and Skills Needed
- Staffing: The program requires a dedicated onsite care manager in each participating practice. A full-time care manager can handle between 80 and 120 patients with depression, the approximate case load in a 12- to 15-physician practice. Care managers typically have backgrounds as nurses, medical assistants, social workers, or psychologists. Some participating practices have hired new staff to serve as care managers, whereas others have integrated care manager–related duties into the responsibilities of existing staff.
- Costs: Data on program costs are being collected by HealthPartners Institute for Education and Research as part of a National Institute of Mental Health grant. Upfront costs include training the care team, establishing an electronic care management tracking system, and contracting with a psychiatrist. The primary ongoing costs for participating medical groups consist of salary and benefits for the care managers and the costs of ongoing contracting with a psychiatrist.
Funding SourcesInstitute for Clinical Systems Improvement
Health plan reimbursement covers a portion of a medical group’s cost of participating in the program. These groups generally pay for additional program-related expenses out of their own budgets or through grant funding.
Tools and Other ResourcesThe ICSI evidence-based depression guideline is available at: https://www.icsi.org/guidelines__more/catalog_guidelines_and_more/catalog_guidelines/catalog_behavioral_health_guidelines/depression/.
Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Evaluation of Mental Disorders. Patient Health Questionnaire. JAMA. 1999;282(18):1737-44. [PubMed]
Getting Started with This Innovation
- Create sense of urgency: Share data on “usual care” for depression, the consequences of untreated or poorly managed depression, and the high rates of comorbidity with other health conditions. These messages typically resonate with PCPs and payers and pique their interest in participating in this type of program.
- Incorporate care manager into primary care team: The care manager must be treated by physicians, nurses, and other primary care staff as a critical member of the care team whose role will be respected. Reaching this point often requires the presence of a physician champion who can help change the culture.
- Seek a neutral convener: ICSI facilitated multistakeholder meetings as a trusted, neutral source that could bring diverse perspectives together to work on care and payment redesign.
- Be persistent on the “tough” issues: The support and participation of a critical mass was the expectation set from the start. Having significant backing elevated the value and momentum to make DIAMOND a statewide effort.
Sustaining This Innovation
- Rely on reimbursement, not grant funding: Program-related services should be paid for by a sustainable model such as payer reimbursement rather than outside grant funding.
- Use phased implementation: A phased approach allows program developers to evaluate and refine the process on an ongoing basis, improve training, and share best practices among participating clinics.
- Share data: Regularly sharing performance data with participating medical practices and health plans helps to highlight the program's value and keep stakeholders engaged over time.
- Emphasize broader applicability of model: The program will have a larger impact and receive more sustained support from medical group and health plan leaders if it is seen as an important component in larger programs and care models, such as patient-centered medical homes and accountable care organizations. As noted, program leaders are now using a similar approach for the care of patients with other health conditions, making the model even more relevant in today’s health care environment.
Additional Considerations and LessonsIn 2010, DIAMOND received the American Psychiatric Association Gold Award for Community-Based Programs.
Use By Other OrganizationsICSI maintains a consulting services department known as Professional Partnerships that helps spread the model to organizations in other states, including the Michigan Center for Clinical System Improvement/Western Michigan Physicians for Transformation; the Hawaii Primary Care Association and Hawaii Medical Service Association; and the National Council for Community Behavioral Healthcare, which is facilitating a five-state collaborative to improve depression care in mental health organizations.
Strine TW, Mokdad AH, Balluz LS, et al. Depression and anxiety in the United States: findings from the 2006 Behavioral Risk Factor Surveillance System. Psychiatr Serv. 2008;59(12):1383-90. [PubMed]
Pignone MP, Gaynes BN, Rushton JL, et al. Screening for depression in adults: summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2002;136(10):765-76. [PubMed]
Katon W, Schoenbaum M, Fan MF, et al. Cost-effectiveness of improving primary care treatment of late-life depression. Arch Gen Psychiatry. 2005;62(12):1313-20. [PubMed]
Unutzer J, Katon W, Callahan CM. et al. Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA. 2002;288(22):2836-45. [PubMed]
Kessler RC, Chiu WT, Demler O, et al. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005;62(6):617-27. [PubMed]
Jackson J, Passamonti M, Kroenke K. Outcome and impact of mental disorders in primary care at 5 years. Psychosom Med. 2007;69(3):270-6. [PubMed]
8 Watt T. A Process and outcome evaluation of two integrated behavioral health care models: People’s Community Clinic and Lone Star Circle of Care. Year three final report. San Marcos (TX): Texas State University. 2009.
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Original publication: June 19, 2013.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: July 03, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.