Going to Scale: Re-Engineering Systems for Primary Care Treatment of Depression

Allen J. Dietrich, MD; Thomas E. Oxman, MD; John W. Williams, Jr, MD, MHSC; Kurt Kroenke, MD; H. Charles Schulberg, PhD; Martha Bruce, PhD; Sheila L. Barry


Ann Fam Med. 2004;2(4) 

In This Article

Abstract and Introduction

Background: Recent trials have shown improved depression outcomes with chronic care models. We report the methods of a project that assesses the sustainability and transportability of a chronic care model for depression and change strategy.
Methods: In a randomized controlled trial (RCT), a clinical model for depression was implemented through a strategy supporting practice change. The clinical model is evidence based. The change strategy relies on established quality improvement programs and is informed by diffusion of innovations theory. Evaluation will address patient outcomes, as well as process of care and process of change.
Results: Five medical groups and health plans are participating in the trial. The RCT involves 180 clinicians in 60 practices.All practices assigned to the clinical model have implemented it. Participating organizations have the potential to disseminate this clinical model of care to 700 practices and 1,700 clinicians.
Conclusions: It is feasible to implement the clinical model and change strategy in diverse practices. Follow-up evaluation will determine the impact, sustainability, and potential for dissemination. Materials are available through http://www.depression-primarycare.org; more in-depth descriptions of the clinical model and change strategy are available in the online-only appendixes to this article.

Improving depression outcomes in primary care has been a public health priority for at least a decade[1] but remains elusive.[2] Although research has shown improved outcomes with telephone care management and closer primary care and mental health collaboration,[3,4,5,6,7,8,9,10,11] the potential for dissemination and sustainability of these strategies has not been established.

The MacArthur Foundation has charged a group of clinicians and researchers to make a difference on a national scale in the primary care management of depression.[12,13,14,15,16,17,18,19,20,21,22,23] For more on this work, see Appendix 1, which can be found online only as supplemental data at http://www.annfammed.org/cgi/content/full/2/4/301/DC1. Additional momentum comes from the US Preventive Services Task Force (USPSTF) through its endorsement of depression screening in adults[24] "in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and careful follow up." They state, "Benefits from screening are unlikely to be realized unless such systems are functioning well."

The jump from the page to the practice is long.[25] This report describes (1) a broadly applicable evidence-based clinical model of depression care, (2) a practice change strategy, and (3) the methods of a project to evaluate their impact.