Sustainability of Depression Care Improvements: Success of a Practice Change Improvement Collaborative

The Journal of the American Board of Family Medicine

Paul A. Nutting¹  Deborah G. Graham²  W. Perry Dickinson¹  Michelle Jeffcott-Pera²  Donald E. Nease Jr.⁴  Kaia M. Gallagher³ 

[1] Department of Family Medicine, University of Colorado Health Sciences Center, Denver (PAN, WPD);National Research Network, American Academy of Family Physicians, Leawood, KS (DGG, MJ-P);Center for Research Strategies, Denver, CO (PAN, KMG);Department of Family Medicine, University of Michigan, Ann Arbor (DEN)

关键词: Depression;    Depression Screening;    Practice Improvement;   

DOI  :  10.3122/jabfm.2010.05.090212

学科分类：过敏症与临床免疫学

来源: The American Board of Family Medicine

【 摘 要 】

Background:Long-term sustainment of improvements in care continues to challenge primary care practices. During the 2 years after of our Improving Depression Care collaborative, we examined how well practices were sustaining their depression care improvements.

Methods:Our study design used a qualitative interview follow-up of a modified learning collaborative intervention. We conducted telephone interviews with practice champions from 15 of the original 16 practices. Interviews were conducted during a 3-month period in 2008, and were recorded and professionally transcribed. Data on each of the depression care improvements and the change management strategy emphasized during the learning collaborative were summarized after review of the primary data and a consensus process to resolve differing interpretations.

Results:During the period from 15 months to 3 years since our project began, depression screening or case finding was sustained in 14 of 15 practices. Thirteen practices sustained use of the 9-item Patient Health Questionnaire for depression monitoring, and one additional practice initiated it. Seven practices initiated self-management support and 2 of 3 practices sustained it. In contrast, tracking and case management proved difficult to sustain, with only 4 of 8 practices continuing this activity. Diffusion of use of the 9-item Patient Health Questionnaire to other clinicians in the practice was maintained in all but 3 practices and expanded in one practice. Six of the practices continued to use the change management strategy, including all 4 of the practices that sustained tracking.

Conclusions:Practices demonstrated long-term sustained improvement in depression care with the exception of tracking and care management, which may be a more challenging innovation to sustain. We hypothesize that sustaining complex depression care innovations may require active management by the practice.

• Depression
• Depression Screening
• Practice Improvement

“Give a man a fish and you feed him for a day. Teach a man to fish and you feed him for a lifetime.” —Chinese proverb

This well-known proverb succinctly captures the hypothesis underlying the Improving Depression Care study started in 2005 by the American Academy of Family Physicians’ National Research Network and the American College of Physicians Research Network. Further stated, our goal was to teach practices a change management method for implementing and sustaining quality improvement, in the context of a study about improving depression care processes. We believed that if practices could learn and implement the change management process, ie, “learn to fish,” they would be more successful in implementing and sustaining the depression care improvements. This article builds on findings from our previous report on short-term outcomes,¹ and specifically addresses the long-term sustainability of depression care improvements in our participating practices 2 years after the completion of our intervention.

The larger context of our work highlights the difficulty and importance of implementing and sustaining change in primary care. With respect to depression, Wells and colleagues^2,3 have published 2 reports based on 9-year follow-up data from the intensive Partners in Care study, which show modest effects at best. Beyond the focus of a single chronic disease, the national push to pursue the patient-centered medical home has captured the imagination of insurers, employers, Medicare, and state governments.^4–10 The recent TransforMED National Demonstration Project experience illustrates the challenges of instituting broad change, implicit in patient-centered medical home models, in busy primary care practices.¹¹

We sought a model for intervention in practices that did not require on-site work and that could therefore be scaled; we chose a quality improvement collaborative model for our project. Collaboratives have gained momentum for enhancing clinicians’ ability to plan and test local improvement in health care.1,^12–18 Collaboratives typically bring together groups of clinicians, administrators, and top-level leaders from different health care organizations to a series of “learning sessions,” during which participants are exposed to best practice guidelines and the evidence supporting them, as well as change strategies for implementing and sustaining local improvements. During subsequent learning sessions, participants share experiences of making changes in their own settings. Research has not yet established conclusively whether collaboratives consistently lead to sustained improvement changes,^19–22 although reports from some collaboratives have been encouraging.^12,16,23,24

The goal of this article is to report on both the change management processes and the depression care improvements that practices were using 2 years after the conclusion of our Improving Depression Care intervention. This extends the findings presented in our original article that reported on improvements at 15 months.¹ Directly related to our belief that “learning to fish” and “eating for a lifetime” are related, we also seek to illuminate possible relationships between practices’ use of the change management process and their continued depression care improvements.

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