Planning to Implement the PIC Approach
Before implementing the PIC approach, an organization must plan how the quality improvement program will be implemented and make successful implementation a priority. Implementation of the PIC approach will require significant organizational commitment. QI programs not viewed as a priority by practice management are unlikely to succeed.
Successful implementation also requires a dedicated team of expert leaders, led by a primary care clinician. This team will act as champions, advocating for the program, planning it, and solving issues that arise during implementation.
The major costs for implementing the PIC quality improvement programs are start-up funds for planning and implementing the programs, and ongoing resources for patient assessment, case management, and depression treatments.
Start-up costs include support for an interdisciplinary team made up of a generalist physician expert leader, a mental health expert leader (either a psychologist or a psychiatrist), and a nurse expert leader. These individuals should receive some training in quality improvement for depression, unless they already have this expertise. You may wish to consult experts in QI, such as the Institute for Health Improvement (IHI), a not-for-profit organization dedicated to helping health care leaders improve the performance and quality of care in their organizations.
Ongoing costs for improved depression care depend upon the care model that the expert leaders design. As discussed above, the PIC experiment included two quality-improvement programs—one that emphasized psychotherapy and one that focused on antidepressant medications. Both approaches were effective in improving care and outcomes.
Selecting Expert LeadersIf a practice wishing to implement the PIC programs has access to clinicians with expertise in depression and in quality improvement, these clinicians may be able to simply use or adapt the PIC planning materials and slides, assemble the remaining necessary study personnel, train them, and implement the program. If access to such experts is not available, the practice may wish to engage a QI consultant to work with practice clinicians.
The mental-health-specialty expert leader should be an individual who can interact well with staff in the primary care setting and who has enough time dedicated to educating and supervising those staff. Many more patients can be successfully managed if a mental health specialist supports the activities of the nurse case managers and primary care clinicians--for example, by helping to supervise the nurse or by being available for emergencies. Organizations that wish to implement the Partners in Care programs should consider ways to reimburse the mental health specialist for contact time with primary care providers, as well as with patients.
Selecting Depression Nurse SpecialistsThe PIC depressions nurse specialists were not necessarily psychiatric nurses. Rather, they were acting in a typical general-nurse role in relationship to physicians, and received additional training and supervision for their role in the QI programs.
In most cases, the depression nurse specialist acted as the Nurse Expert Leader and the nurse case manager. Therefore, he or she was involved both in planning and in implementing the program, as well as in clinical care of patients.
In both programs, a nurse carried out an initial assessment of the patient, accompanied by patient education about what care should be like and activation. Activation included reviewing the patient's record with the patient to empower him or her in interactions with the primary care physician. The nurse then provided the results of the assessment to the primary care clinician.
In the medication program, the primary care practices supported the nurse to case-manage patients started on antidepressant medications for either 6 or 12 months. A half-time nurse can case-manage about 75 patients in acute-phase treatment, when patients require the most help, plus additional patients in later phases who require less-frequent monitoring.
In the psychotherapy program, the practices supported reduced co-payment for cognitive-behavioral therapy (CBT), a treatment that is as effective as medications for all but the most severely ill patients. The study trained the nurse case managers and psychotherapists.