Most patients with behavioral health conditions such as depression, if treated at all, are treated in primary care settings. Studies have also documented that fewer than half of patients with depression in primary care are accurately diagnosed, receive adequate dosage and duration of medication or effective counseling. Lack of time, lack of resources and gaps in training limit the effectiveness of behavioral health care provided in primary care. Many efforts to bring behavioral health treatment into primary care have not been successful because they have not used well-tested, evidence-based models of care. Several decades of research, including seminal work on the collaborative care model of depression care management at Duke, demonstrates that well-implemented models do achieve treatment targets, improve patient outcomes, enhance patient satisfaction and reduce total health care costs. However there is a substantial gap between the clearly demonstrated effectiveness of these well-tested models and what is often implemented in primary care settings. Successful integration of behavioral health treatment models in primary care, such as the collaborative care model, will be critical as Duke Medicinestrives to achieve the promise of the health care reform and the shift to value-based care.

With DIHI support, we are implementing the collaborative care model of depression care management in primary care at Duke. We are leveraging the power of Duke Medicine’s electronic health record, Maestro Care, to support effective depression care teamwork across Duke Medicine. This collaborative care approach to depression treatment has 3 key elements: 1) periodically screening for depression in primary care through systematic use of screening tools such as the Patient Health Questionnaire; 2) use of care managers to provide depression monitoring, care coordination and counseling and; 3) stepped-care recommendations to primary care providers from a team psychiatrist. The psychiatrist routinely reviews care with care managers, makes treatment recommendations following a structured treatment protocol and focuses on working with primary care providers to successfully treat depression.

Our first goal is to pilot this collaborative care depression treatment model in a single primary care practice at Duke. A key step will be to design and implement a Maestro Care-based depression care workflow to facilitate and share communication between members of the depression care team. This will include readiness assessment of the practice and training of all clinicians involved. Once these ‘kinks’are ironed out we will extend the model to several other Duke Medicine practices to gain experience and demonstrate the model can be transported across different practice settings. Key outcomes to be assessed include: the acceptability of the treatment model to patients, families and providers; effectiveness of the model in treating depression; and the cost effectiveness of this approach.