Approach

The Initiative’s steering committee—including primary care physicians, psychiatrists, and psychologists—launched its work over 10 years ago by seeking a better understanding of then current practice patterns for the primary care management of depression. That research revealed two major barriers to effective treatment. One was the lack of tools to improve depression management; the other was a lack of time and support in the practice setting for managing patients with depression. Most primary care practices were not then and are not now well organized and adequately resourced to provide evidence-based depression care.

To address these needs, the Initiative set four goals:

• To develop office routines and practice patterns that could improve the management of patients with depression
• To develop educational programs and tools to help primary care physicians better recognize and care for patients with depression
• To evaluate the impact of these new practices, programs and tools
• To disseminate the new ideas and materials to primary care clinicians, medical groups, specialty societies, insurance plans and others.

To pursue these goals, the Initiative developed its Three Component Model (3CM), an approach designed to work in a wide variety of primary care settings. Under 3CM, the primary care clinician, a care manager, and a mental health professional work together to provide evidence-based care to patients with depression.

Perhaps the most innovative aspect of 3CM is its turnkey implementation approach that also allows practices to make adaptations to fit their specific settings. The research team consolidated the implementation strategies and materials into manuals to support implementation by medical groups, health plans, and others, using their own available resources. The impact of this model was tested in more than 60 practices in 5 health care organizations and shown to improve depression outcomes. Significantly more patients receiving 3CM care improved than patients receiving “usual care,” and patients who received a greater percentage of the key elements of 3CM had better outcomes.

After the study, the organization-supported changes of 3CM were extended to the usual care practices, as well as to practices that did not participate in the research trial. The responsibility for training these additional clinicians and their practices was transferred from the research team to the participating organizations supporting them and the practices to sustain 3CM over the long term. After three years of follow up, the majority of practices continued to support the model with minimal modification. Peer reviewed publications reporting this experience are available on the Initiative website.

Based on these research findings, a number of health plans have subsequently requested and received consultation and assistance with implementing 3CM. The Initiative has provided consultation to Magellan, Beacon Health, Blue Cross Blue Shield of Georgia, and Aetna. In 2006 Aetna’s Chairman’s Initiative was to improve primary care management of depression. Aetna incorporated 3CM’s training manuals and programs into a web-based education process that included care planner support for patients and Aetna consulting psychiatrist support for primary care clinicians treating covered patients with depression.

Subsequently, a variety of other organizations sought assistance from the MacArthur Initiative, as have some individual practices. The New York City Department of Health and Mental Hygiene established a Depression Initiative and chose to include 3CM as part of its effort. To complement public and physician education, consultation and training were provided by the Initiative for a pilot project to screen patients at community-based health centers and to provide 3CM care. The Department of Family Medicine of the University of Miami is working in partnership with community members of the Overtown neighborhood of Miami, historically one of the most impoverished communities. A major goal of this partnership is to improve access to mental health diagnosis and treatment in primary care. To address this goal, 3CM has been adopted and the Initiative has provided training and consultation on its implementation.

Recently, to assist the US Army with its plans to improve mental health care options for soldiers returning from service in Iraq and Afghanistan, the Initiative agreed to expand 3CM to address posttraumatic stress disorder and design a pilot project in a large primary care clinic at Ft. Bragg, North Carolina. The feasibility results from this project, “RESPECT-MIL,” have led to an expansion at additional primary care clinics at Ft. Bragg, 15 additional bases, as well as plans to expand RESPECT-MIL to another 17 army bases throughout the world.

Progress and Plans

The work of the Initiative has continued to narrow the gap between the evidence base for primary care of depression and that care provided in actual practice. The Initiative has used its website (depression-primarycare.org) to disseminate materials about the RESPECT Care Management Model. In the past 3 years, the MacArthur Depression Toolkit has been downloaded over 20,000 times by clinicians and administrators from 100 countries. Other website resources have also been frequently accessed.

We are currently surveying users of the website to determine how the downloaded materials are being used in practice and to obtain input on ways to enhance the site and its value to those who sign on. Results so far indicate that resources developed through the Initiative and made available through the website continue to meet a need.

The MacArthur Foundation Initiative on Depression and Primary Care is now in its final months. The Initiative steering committee and leadership appreciates the extraordinary support received from the Foundation over this extended period. Because the materials developed and the experience gained continue to be valued by primary care clinicians and health care organizations, the Foundation has charged Initiative leaders to develop a sustainability plan. In response to that challenge, we have created 3CM, LLC, which will continue to support the MacArthur website through 2009. 3CM, LLC is also available to provide consultation services to practices, clinicians, and to not-for-profit and for-profit organizations through a value-oriented fee schedule. To obtain such services, contact 3CMLLC@comcast.net.

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