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Cover Story, Piedmont Triad MD News,
January 2004 Edition
THE CAROLINA BEHAVIORAL HEALTH ALLIANCE:
“PRESCRIPTION FOR RECOVERY”
This is a program for managing depression and anxiety offered to you by your health plan at no charge. The goal of this program is to offer a system of coordinated healthcare with your primary care physician through interventions and education. A clinical case manager will be available to you during the business day and after hours for emergency services. During this eight-month program you will be contacted at planned intervals to monitor your medication effects, treatment response, work/life issues, and answer any questions you have regarding symptoms and/or treatment related to your depression or anxiety.
Anxiety and depression are two common mental health illnesses that may require an uncommon amount of follow-up time for busy primary care physicians and their staffs. Through the Carolina Behavioral Health Alliance’s (CBHA) new program, Prescription for Recovery, however, expert clinical managers using tested questionnaires will soon assist with the workload required to follow and assess these patients.
“Normally, when primary care physicians receive letters from managed care organizations, they assume it just means more work for the physician’s office. This plan, however, is a service versus just reducing expenses short term,” says Peter Rosenquist, MD, a board-certified psychiatrist, who serves as the medical director for the alliance.
Prescription for Recovery deals with other physician concerns as well, adds Dr. Rosenquist. For example, some primary care physicians are reluctant to probe into depression/anxiety issues. They may ask: How much follow-up does the patient need? What if patients don’t respond to medications? What additional patient education should be conducted?
Answers to questions
The new program addresses these questions and many more. “This follow-up process will increase detection of problems, increase maintenance of therapy and improve patient education. Overall, the follow up should enhance the physician’s care plan, “ says Mark Andrews, MD, Assistant Professor of Family and Community Medicine at the Wake Forest University School of Medicine.
“There is not a lot of paperwork, extra time or energy for the primary care physician associated with the program. Our physicians are very supportive,” he adds.
The current alternative to the CBHA Prescription for Recovery program is familiar. To support the ongoing care of the patient with anxiety or depression symptoms, someone in the physician’s office must call the patient to see if he or she had the prescription filled. They must learn if the patient took the initial doses, had any side effects, or had any other concerns he or she wished to discuss with the physician. Responding to these patient concerns can mean the difference between noncompliance and adherence to treatment.
“To do the right things for the right reasons.”
“We are a provider-owned managed behavioral health care organization,” explains Judy Briggs, RN, BSN and chief executive officer for CBHA. Briggs, who has extensive experience in behavioral health as an administrator and clinician, laid the groundwork for the creation of CBHA and has brought it to its current stature.
“Our mission is to ensure that enrollees receive quality mental health and chemical dependency services care, that providers have the resources to provide this care and that enrollee benefits are used effectively and efficiently,” she explains.
“We can bring both direct and indirect value to healthcare plans. Direct benefits center around efficiencies, while indirect benefits include better productivity and less absenteeism.”
CBHA, which is headquartered in Winston-Salem, coordinates coverage for mental health and substance abuse services. Three nonprofit North Carolina medical schools own the organization: East Carolina University, UNC Chapel Hill and Wake Forest University.
CBHA provides clinical case management 24 hours a day, every day, through a network of more than 900 providers and 30 hospitals in counties throughout North and South Carolina. Providers are credentialed according to the standards of the National Committee for Quality Assurance.
A beta test in the US
“To our knowledge, this is the first program of its kind in the country to address both anxiety and depressive disorders,” says Dr. Rosenquist. “We have been creating Prescription for Recovery for two years with an overall objective of building a sound disease management program. We will begin the first week in January 2004. Our case management team will make calls from our main office.”
The program is to be funded as a benefit by employers and participants will be followed for at least an eight-month period. All patient information will be confidential, and shared with the referring physician only. No identifying information will be shared with employers however.
“We are grateful that Dr. Rosenquist offered the plan to the WFU School of Medicine’s Family and Community Medicine Clinic,” says Dr. Andrews. “We have 20 faculty and 30 residents (physicians in training). We have up to 60,000 patient visits a year and see mental health issues frequently. The program will evaluate the effectiveness of our treatment interventions and give regular feedback to providers.. It should help both patients and the business community.”
Rationale for the program
“Depression is one of the most common mental health problems we see in our practice ,” continues Dr. Andrews. “Data indicate that half of the patients who have prescription medications stop using them prematurely. Many times the patient does not tell the primary care physician about stopping the medications. Then the physician must restart the therapy program often after a substantial delay in treatment.
“Depression leads to disability and missed time from work. The follow-up process will help identify and manage patients in the long run. It will help get patients back to work and more productive.
“A number of patients don’t have any insight or acceptance of their depression or anxiety. They may be hesitant to discuss these problems with their primary care physician. Although patients may appear to process information, they may still have misconceptions about the medicines or other parts of the therapy program. The phone call from the case manager reinforces the reasons and the importance of the therapy program.”
Dr. Rosenquist adds another key benefit for primary care physicians: “We can help identify more patients with anxiety and depression. Often these people need more general medical attention. They come to their physicians with emotional problems. They need support and education about the disease of depression and anxiety. Prescription for Recovery can reduce high utilization, follow- up time for physician offices and offers a place to refer patients who might be less comfortable seeing a psychiatrist or psychologist.”
He cites several startling statistics to reinforce his point: “Studies indicate that depressed patients have more than twice the medical illnesses and go to the doctor almost twice as often as non-depressed patients.” Compared to other chronic illnesses such as heart and lung disease, arthritis, hypertension and diabetes, depressed patient are more functionally impaired both socially and physically, and proper treatment can enhance quality of life of patients and their families and lower the cost of care.
“Safety is our number one concern”
The primary clinical case manager for the program is Jack Ciancio, RN, MA. “A lot of people have misunderstanding of depression,” he says. “We need to move people past the feeling of being helpless. That is why education and support are two major components of the program.
“We will make an initial call within two weeks from the referral by the physician or direct patient referral. If the patient is doing well, we’ll call again in four weeks. We will be alert to detect a progression of improvement. Safety is our number one concern.
“If, however, after the first call we have concerns about the depression worsening, or suicidal tendencies, we will call again shortly after, discuss the situation with the physician, and possibly encourage referral to a psychiatrist. We also have the ability to monitor medication compliance. Our pharmacy benefit manager system has a database we can monitor to determine if the client has picked up prescriptions from a pharmacy.
“All through the process, we will communicate with the referring physician at least once a month. If there is a problem, our case manager can identify it sooner than the next patient visit to the physician.”
He noted that CBHA case managers will use widely accepted screening tests and scripts:
- PHQ9 Depression
- The Clinical Anxiety Scale
- SF-12 A quality of life instrument
- A questionnaire to determine compliance with medications
Measurements of success
“We’ll know the program is successful if symptoms are relieved, and if the patient’s quality of life improves. Of course, measurement will be through standardized tests,” says Judy Briggs.
“If the patient follows his or her treatment for depression, that often helps improve the physical condition, too,” adds Jack Ciancio.
Dr. Andrews agrees: “There are a lot of downstream benefits for patients, employers and the healthcare system. This can be a real service to patients and physicians. So much of managed care can be a burden. This program can be of genuine help.”
Facts about depression and anxiety
- Depression and anxiety are very common, yet highly treatable, medical illnesses
that can affect anyone
- Depression is not a character flaw, nor a sign of personal weakness
- Most people with depression or anxiety can begin to feel better in several weeks
if treated adequately
- Depressed or anxious persons’ first step toward getting better is talking to their
doctors about how they feel
- Depression occurs in one in ten Americans
- Two thirds of individuals with depression go undiagnosed and untreated
- Depression is a medical disorder just like diabetes or hypertension
Symptoms of Depression and Anxiety
- Feeling sad, blue, or down in the dumps
- Loss of interest in things you usually enjoy
- Feeling slowed down or restless
- Having trouble sleeping or sleeping too much
- Loss of energy or feeling tired all the time
- Having problems concentrating, thinking, remembering or making decisions
- Feeling worthless or guilty
- Having thoughts of death or suicide
- Panic attacks or excessive worry
The Objectives of Prescription for Recovery
- Encourage screening, early identification, and early treatment of depression and anxiety
- Empower members with depression/anxiety to manage their health and communicate effectively with their physicians
- Support the member and the physician with information, tools and resources to help manage depression and anxiety
- Monitor prescribed medications for effectiveness and adverse reactions
- Monitor the severity of symptoms and quality of life issues
- Improve outcomes and health for members with depression or anxiety
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