Moving an Innovative Depression Care Model from Research to Practice: A Conversation With IMPACT Implementation Center Director Jürgen Unützer, MD, MPH, MA
|By the Innovations Exchange Team"IMPACT is not co-location of mental health services in primary care; it requires true integration of care and collaboration of mental health and primary care providers."—Jürgen Unützer, MD, MPH, MA|
Innovations Exchange: What is the IMPACT model and how does it differ from usual care?
Unützer: The Improving Mood: Providing Access to Collaborative Treatment (IMPACT) is an evidence-based model for treating depression in primary care. A key difference from usual care is the collaboration between the patient’s primary care physician, care manager and consulting psychiatrist, which is the cornerstone of the five essential elements of the IMPACT model.
While usual care for depression involves two people: the primary care provider and the patient, IMPACT adds two more people: the care manager and the consulting psychiatrist. The care manager supports the patient and the primary care physician. S/he educates patients about depression, monitors their medication, provides supportive counseling, and creates a relapse plan when patients improve. The care manager also measures a patient’s symptoms before and after treatment with a validated depression instrument. If the patient hasn’t experienced a 50-percent symptom reduction at 10 to 12 weeks, then the treatment plan is adjusted based on clinical outcomes and an evidence-based algorithm.
The consulting psychiatrist provides clinical consultation to the care manager and the patient's primary care physician. S/he provides direct consultation for patients who don’t improve after several treatment changes or who may need specialty mental health care (e.g., bipolar, substance abuse).
What inspired you to develop this model?
A decade of research on older adults with depression showed that their symptoms were not improving. Most of them were seen in primary care settings and of those referred to mental health specialists, fewer than half of them followed through. To have a population effect on depression, we had to create a program that involved close collaboration with primary care physicians and interventions based on evidence-based treatment guidelines that primary care providers could use. We built on the work of Wayne Katon, MD, a psychiatrist, researcher, and colleague at the University of Washington, who developed a collaborative model for depression treatment that used stepped care,1 and the Chronic Care Model2 developed by Ed Wagner at the GroupHealth Center for Health Studies in Seattle.
How effective and cost-effective is the IMPACT model?
A large randomized controlled trial involving 1,800 older adult patients was conducted at 18 primary clinic sites: several Health Maintenance Organizations (HMOs), traditional fee-for-service clinics, an Independent Provider Association (IPA), an inner-city public health clinic and two Veteran's Administration clinics. The IMPACT intervention significantly improved depression symptoms, physical functioning, and pain associated with functional impairment compared with usual care for up to 2 years.3 IMPACT participants were more likely to receive evidence-based treatment such as antidepressant medication and/or psychotherapy and expressed higher satisfaction with depression care than participants in usual care.
A 4-year study examined health care costs and found that IMPACT resulted in substantial savings compared with usual care. IMPACT participants had lower mean health care costs per patient ($29,422) compared with usual care per patient ($32,785), representing a cost savings of $3,363 per patient during 4 years. In addition, IMPACT patients had lower health costs in every observed category, including outpatient mental health and medications, and inpatient medical, mental health, and substance abuse care.4
How important was cost savings in disseminating the model?
It definitely caught the attention of large payers such as Kaiser Permanente,5 an HMO, and the Veterans Administration, which pay for these costs, and with whom we worked to implement the IMPACT model. Long-term studies have also found the IMPACT model to be cost-effective in treating patients with depression and medical conditions like diabetes.6,7
When did you decide that the IMPACT model was ready to disseminate?
Although publications in peer-reviewed journals and media coverage are helpful in disseminating research findings, they are not enough to facilitate the successful adoption, implementation, or sustainability of evidence-based programs. A condition of the original grant by the John A. Hartford Foundation was that we would strive to maintain the intervention after the grant period, if it proved to be cost-effective. The IMPACT investigators, including myself, developed a 5-year plan to disseminate the model with ongoing support from the John A. Hartford Foundation.
What were the key elements of the dissemination plan and how were they implemented?
The dissemination framework has several steps, including defining the clinical problem, collecting evidence of treatment efficacy and effectiveness, and large-scale implementation. Dissemination involves marketing the IMPACT program to stakeholders, including patients, family members, consumer advocacy groups, primary care and specialized mental health providers, health care administrators, and policymakers. We created a detailed description of the intervention model and information about the startup costs associated with implementation of IMPACT in diverse health care organizations, which we made available in brochure format and on the IMPACT Web site.
The IMPACT Implementation Center Web site has proven to be a valuable dissemination tool for providing information on the model and next steps for implementation. There is information about the model, research evidence, links to media coverage, implementation tools, and training opportunities. We created a 3-step team building tool that helps people operationalize the core principles of the program for their unique clinical setting. We also included quotes and stories from patients and participating clinics about their experience with the IMPACT model.
Twin dissemination goals were to increase the demand for IMPACT and the supply of trained providers. How did you pursue those goals?
To increase the demand for our program, we pursued partnerships with key stakeholders and organizations that share our goal of improving health care, including the John A. Hartford Foundation and the American Association of Retired Persons (AARP). We also partnered with organizations that have access to large numbers of depressed adults such as disease management organizations and insurance companies including Kaiser Permanente and the Community Health Plan of Washington.
We also worked with Federal, State, and local governments, private purchasers, and employers to reduce policy and financial barriers to evidence-based programs such as IMPACT. Examples include “piggy backing” on recent Federal and State policies to fund evidence-based treatments for mental health such as those listed on the SAMHSA NREPP Web site. The IMPACT Implementation Center also helped 10 service delivery agencies implement the IMPACT model as part of a SAMHSA-funded initiative.
Efforts to increase supply included consulting with interested health care organizations and developing tools to facilitate program implementation. These tools include an implementation toolkit with intervention manuals, educational materials and the 9-item Patient Health Questionnaire. Other tools include detailed specifications of the intervention model and its core components, information on startup and operation costs, a needs assessment and implementation guide, and business models for the IMPACT model under different financing arrangements.
To help clinical staff learn how to use these tools, the IMPACT Implementation Center offers a comprehensive training program for depression care managers (DCMs) and consulting mental health professionals. This includes presentations at national and regional conferences, 1- to 2-day training conferences, and an Internet-based training program that can be accessed from the IMPACT Web site. Ongoing consultation and support is also provided to DCMs, mental health consultants, and program administrators. National experts in IMPACT also provide consultation to organizations that want to adapt the model to new health care systems or clinical populations.
The IMPACT model has been adopted and sustained by several national organizations. What are some examples?
Several health care organizations have adapted core elements of the IMPACT model as part of disease management programs for depression and other mental health problems, such as the DIAMOND program, which is statewide in Minnesota and the Mental Health Integration Project (MHIP) in Washington state. The IMPACT model or key components have been sustained successfully in several organizations that participated in the original study. In the Kaiser Permanente HMO in Southern California,5 the program was sustained, adapted, and expanded to two additional primary care clinics. The program evaluation showed the same positive results, including cost results, as found in the original study. These robust positive results convinced the HMO executives to expand the program to 12 large regional medical centers, serving approximately 3 million insured members. Clinicians from more than 500 primary care practices in the United States and Canada have been trained in the IMPACT model and several new organizations are implementing core components.
What is the role of the Advancing Integrated Mental Health Solutions (AIMS) Center in scaling up and spreading the IMPACT model?
The mission of the AIMS Center in the University of Washington Department of Psychiatry and Behavioral Sciences is to advance evidence-based mental health programs, such as IMPACT. The AIMS Center is staffed by several faculty and staff and funded by Federal and foundation grants and contracts with organizations for training, technical assistance, and implementation support.
About Jürgen Unützer
Jürgen Unützer, MD, MPH, MA, is an internationally recognized psychiatrist and health services researcher. Dr. Unützer is Professor and Vice-Chair in the Department of Psychiatry & Behavioral Sciences at the University of Washington in Seattle and Chief of Psychiatric Services at the UW Medical Center. He also directs the AIMS Center and the IMPACT Program.
Disclosure Statement: Dr. Unützer reported that he has received consulting fees from AARP Services International and the AIMS Center received payment for his lectures, development of educational presentations, and multiple grants related to his work with IMPACT and the AIMS Center.