Untreated or undertreated depression leads to significant personal morbidity, increased medical service utilization, increased mortality, and increased burdens on employers because of absenteeism and decreased productivity. To combat these effects of depression, Companion Benefit Alternatives, Inc. (CBA) implemented Essential Solutions for depression management. CBA introduced this specialized disease management program, which recently was awarded silver honors in URAC's prestigious 2009 Best Practices in Health Care Consumer Empowerment and Protection Awards competition, in September 2006.
Columbia, South Carolina-based CBA is a managed behavioral health organization administering mental health and substance abuse benefits for more than one million people served by BlueCross and BlueShield of South Carolina and other Blue Cross and Blue Shield health plans, BlueChoice HealthPlan of South Carolina, the Federal Employee Health Benefits Program, and Planned Administrators, Inc., plans (CBA is a separate company that administers mental health benefits). In conjunction with David Oslin, MD, and the Behavioral Health Laboratory based at the Philadelphia Veterans Affairs Medical Center and the University of Pennsylvania, CBA developed Essential Solutions as a flexible service to help manage the behavioral health needs of patients seen by primary care providers (PCPs). Essential Solutions addresses all stakeholders' needs by supporting PCPs; providing education and resources for best care practices to members and physicians; supporting referrals to behavioral health specialty care, as needed; and monitoring results for cost-benefit and quality analysis.
Several principles define the program.
Crosscutting. The program provides support for depression, alcohol, and anxiety problems. For each disorder the program addresses a broad spectrum of severity, offering Watchful Waiting for subsyndromal symptoms to Referral Management for the most complex or severely affected individuals.
Targeted interventions. The program provides assessment, monitoring, early intervention, disease management, and referral management. Thus, the program can be tailored to individual needs.
Flexibility. The program allows for multiple methods of case referral/identification.
How It Works
Members and their dependents over age 18 are eligible for the program based on:
Claims for a new antidepressant prescription or depression diagnosis
Referrals from other medical health and disease management programs for conditions such as diabetes, asthma, coronary artery disease, and maternity management
Referrals from existing medical and behavioral health case management programs
Member responses to Web-based health risk assessment screenings
Direct physician referrals
Essential Solutions is an opt-out program, with all eligible members included until they request disenrollment or if contact is unsuccessful after concerted effort. Licensed master's prepared social workers (LMSWs) or RNs who have received additional training in Motivational Interviewing (MI) techniques serve as CBA disease managers and perform all program interventions by telephone.
Essential Solutions provides educational materials and one-on-one communication with members that can be individualized. The program follows members through the treatment process and into remission, with follow-up and reassessment for possible relapses after program completion. Essential Solutions is divided into the following evidence-based modules.
Core Assessment. Program enrollment begins by completing the Core Assessment, a brief, structured, 20- to 30-minute interview that provides PCPs with a comprehensive overview of patients' mental health and substance abuse symptoms. CBA's disease managers conduct the assessment by telephone and enter the results into a computer program. The assessment includes the following screening tools:
PHQ-9 for assessing depression
Screeners for generalized anxiety disorder, mania, psychosis, and PTSD
A self-harm assessment for suicidality
Work Limitations Questionnaire (gathering information on absenteeism and work performance)
CAGE-AID to assess drug and alcohol use
Blessed Cognitive scale to assess possible hearing and/or cognition difficulties
CBA also gathers information regarding medications, adherence history to medication regimens, and possible side effects.
Following the assessment's completion, the disease manager generates an individualized lab report of the interview's outcome and, with the member's consent, mails it to the prescribing physician. Patients are mailed educational materials that provide brief suggestions for dealing with specific reported mental health/substance abuse symptoms.
Watchful Waiting. WW is a telephone-based mechanism for monitoring patients with symptoms of minor or subsyndromal depression to distinguish between those in need of more formal care and those who have symptoms that resolve relatively quickly. WW involves weekly phone calls for up to eight weeks to monitor depression symptoms using the PHQ-9. During this monitoring period, CBA offers patients who either request additional treatment or exhibit persistent depressive symptoms and disability the opportunity to enroll in the Depression Disease Management module.
Depression Disease Management. This module is for patients with depressive disorders (major depressive disorders, dysthymia, depression not otherwise specified) actively enrolled in primary or medical subspecialty care. The disease manager facilitates treatment and provides assistance to the member in obtaining and continuing psychosocial therapy consistent with Agency for Healthcare Research and Quality guidelines for depression. With disease managers' assistance, members complete Health Promotion Workbooks to establish goals and reduce barriers to treatment using MI techniques.
Referral Management. This module is designed to improve low engagement rates into specialty mental health and substance abuse care among patients with severe psychiatric needs by providing clinical support and promoting problem-solving skills. MI techniques were adopted to increase motivation and reduce barriers associated with behavioral treatment.
Alcohol Misuse Disease Management. In this module, the brief alcohol intervention (BAI) is a structured psychosocial approach to treat excessive drinking that uses Health Promotion Workbooks to help patients reduce their alcohol intake to safe levels. The BAI is based on MI principles and discusses patients' problems, concerns, and ambivalence about their drinking. The program aims to help individuals recognize the risks associated with their level of alcohol use.
This comprehensive model provides dramatic results, with members reporting a significant 62.9% reduction in depressive symptoms subsequent to program participation (figure 1). Results indicate both a per-member, per-month (PMPM) and raw dollar savings in the combined medical and prescription costs, with an overall return on investment of 3.5 (figure 2).
Figure 1. This figure illustrates PHQ-9 total scores during the program's first 12 months (population = 494). PHQ-9 is a nine-item depression tool used to assess symptoms and functional impairment as well as assign a severity score as follows: 5-9, minimal symptoms or no depression; 10-14, mild depression; 15-19, moderate depression; 20+, severe depression. In the figure, “low level of symptoms” indicates members who reported initial PHQ-9 scores below 9; “depression only” indicates members who reported symptoms of a depressive disorder without other complexities; and “complex cases” indicates members with depression complicated by other medical and/or behavioral health conditions. With Essential Solutions, the overall reduction rate of depressive symptoms was 62.9%
Figure 2. This figure shows the change in per member, per month (PMPM) costs associated with Essential Solutions. Data are from the program's initial 12 months (population = 494)
Essential Solutions also provides for coordination and collaboration within the health plan and between the medical and behavioral health teams. As members are screened by medical case and disease management or respond positively to depression screenings on a health risk assessment, a warm transfer (i.e., not to voicemail) to the Essential Solutions program can take place. This ease of communication and transfer between modules serves to support clinicians who may be less comfortable dealing with behavioral health issues and unfamiliar with the treatment plan guidelines and standards of care.
For more information, call (800) 868-1032 or visit http://www.companionbenefitalternatives.com. Headshot of Loren Nix by Anita Crosby.