NHMH NO HEALTH WITHOUT MENTAL HEALTH A 501(c)(3) non profit   San Francisco - Washington DC Director’s blog


Published Thursday 12 of February, 2015

The Mayo Clinic, in Rochester, Minnesota, is widely known as a world-class healthcare destination for patients with rare, difficult-to-treat conditions. Less well-known is the fact that Mayo has an extensive primary care system, with a diverse patient population of over 140,000, some including employees and their families, as well as those patients living in Olmsted County, Minnesota who choose Mayo for their primary care. NHMH recently asked a leading Mayo physician about efforts at Mayo to integrate the care of mental health issues into primary care.

Dr. Mark Williams is a Mayo physician with a specialty in psychiatry who was closely involved in bringing the collaborative care model to Mayo’s primary care system. After training at Mayo in Psychiatry, he spent nine years working in a variety of psychiatric settings before returning to Mayo to practice his specialty

“Mayo has always been good at forming teams,” he says explaining why he chose to return to treat primary care based patients. Shortly after coming to Mayo, Dr. Williams had the opportunity to help lead a Mayo team to attempt to integrate a collaborative care model for adult depression into one of several primary care clinics at Mayo. This project, led by the Institute for Healthcare Improvement (IHI), was attempting to see if teams could use concepts from Dr. Ed Wagner’s chronic care model to address the chronic illnesses of depression and asthma in primary care clinics around the country. The details of the model were very similar to the IMPACT (Improving Mood: Providing Access to Collaborative Treatment) collaborative care model designed by Jurgen Unutzer, M.D. and others at the University of Washington.

Despite showing improved patient outcomes from this project, the program failed to continue in the primary care clinic involved. “This was a good lesson” says Williams because it illustrates how hard it is to sustain good improvements in the complex world of clinical care. Some of the barriers included a need to reorganize the IT support, a need to have more consistent psychiatric availability, a need for a standard tool across the practice to measure outcomes for depression, and the need to develop the role of a care coordinator for nursing. It was clear true integration meant more than sharing space.

In the years following IHI’s project at Mayo, broader changes began occurring: disease management developed, Mayo merged its three primary care groups, community pediatrics, internal medicine and family medicine, into one entity. Also, the cost of high-use patients, especially those with untreated behavioral conditions and co-occurring medical conditions, became more obvious, with concerns that disease management techniques were not necessarily focused on this group. The PHQ-9 (patient questionnaire on depression symptoms) became the go-to tool for screening patients for behavioral issues in both primary and specialty medical care.

Phase Two in Mayo’s integration arc commenced in 2007 with development and implementation of the DIAMOND program (Depression Improvement Across Minnesota, Offering a New Direction) aimed at adult depression in primary care. DIAMOND was again based on a caremodel created by Wayne Katon, M.D. and tested as IMPACT in a randomized controlled trial by Dr. Unutzer. DIAMOND’s key features were use of the PHQ-9 for screening and ongoing management of depression symptoms; a registry to track patients’ progress; stepped-care approach for treatment modification if patient not improving; a relapse program; a care manager to support and coordinate care and facilitate inter-team communication; and a psychiatric consultant engaged with care manager and PCP in weekly patient caseload review. Fidelity to these components was essential.

Showing success, by 2010 Mayo had spread the DIAMOND program to all its primary care clinics. The results were even better than earlier attempts. Now sustainable good outcomes were happening and there was increased interest in integrating behavioral health on a permanent basis. Mayo formed its first Integrated Behavioral Health (IBH) group under David Katzelnick, M.D. as chair of IBH for all its clinics.

The IBH then went on to further develop the EMERALD (Evidence-Based Recognition of Adolescents Living with Depression) program for teens with depression in primary care; the CALM (Coordinated Anxiety Learning and Management) program for adults with anxiety disorders in primary care, and models for collaborative care for primary care patients with co-existing depression and cardiovascular or diabetes disease.

Mayo’s Phase Three began in 2012 when the Centers for Medicare and Medicaid Services (CMS) awarded $18 million to a national consortium led by the Institute for Clinical Systems Improvement (ICSI). The consortium, comprised of ten healthcare organizations, including the Mayo Clinic, is implementing the COMPASS (Care of Mental, Physical and Substance-Use Syndromes) collaborative care management (team-based) model to manage patients with depression and diabetes and/ or CVD in almost 200 primary care clinics in eight states. The project’s results are due in June 2015.

COMPASS is based on the TEAMcare model developed at the University of Washington, now considered the gold standard of integrated programs. Two and one-half years into the project, results are comparable to earlier TEAMcare outcomes. The COMPASS team is hopeful that the learnings from this project will help inform Medicare and Medicaid services delivery in the future, and the way those services are reimbursed, in order to support integrated care.

Dr. Williams indicates real challenges lie ahead in figuring out how to proceed in bringing quality, cost effective behavioral care into the PC setting after COMPASS. What will be the right patient population to apply this intervention? How to ensure the right resources are in place? How to measure change? So far we have seen that most health outcomes changes occur early on, while financial changes usually lag, yet timelines for decision-making come early and the pressure to save money is persistent.

NHMH asked Dr. Williams to sum up Mayo’s experience with behavioral health integration so far:

Dr. Williams’ final thoughts: “If you have doubts about the efficacy of offering collaborative care in primary care setting, just ask a PCP who has been exposed to this efficient consultative support, and ask patients who have seen both their physical and behavioral issues addressed in one place in a coordinated fashion – and see what response you get!

(Source: Mark Williams, M.D., Mayo Clinic, Wayne Katon, M.D., AIMS Center at University of Washington).

Florence C. Fee, J.D., M.A.

Executive Director