DIAMOND FAQs for Patients
This document describes the DIAMOND model, how care is delivered in the medical clinic, patient eligibility, and ICSI’s role in developing and implementing the initiative.

What is DIAMOND and what does it stand for?
DIAMOND stands for “Depression Improvement Across Minnesota, Offering a New Direction.” It is a groundbreaking program to improve health care for people with depression because it changes the way care is given and paid for in the primary care setting. DIAMOND was launched in March 2008 and is now available through 30 primary care clinics in Minnesota. (For a list of the clinics currently offering DIAMOND, go to http://www.icsi.org/news/diamond_news/clinics_involved_with_diamond).

Why was this program started?
Major depression can cause pain, mental suffering and disability. It can even lead to death. Primary care doctors detect depression in patients only about 50% of the time. Only 20-40% of primary care-treated patients improve much over the year following detection. As a result, many patients drop out of treatment too soon or stay on ineffective medication treatment.

Many factors lead to these poor results. Primary care doctors may have too little time to visit with the patient. Or they may lack the right tools to detect major depression. For example, 80% of patients with depression also have another illness or disease. This can make depression hard to detect. Primary care doctors also may not be able to follow up with the patient. All these factors suggest the need for a new way to care for patients with depression. DIAMOND is a new model for care to overcome these problems.

What is different in how DIAMOND cares for the patient with depression in the primary care setting?
The DIAMOND approach to helping the patient with depression includes these six things:

• A checklist that helps the care team detect and monitor symptoms of depression
  
• A way for the care team to regularly keep track of the patient to see how they’re doing
  
• A proven medical guide to know how best to change or intensify treatment
  
• Tools to keep a patient who is getting better from falling back into major depression
  
• A care manager to educate and help the patient reduce their depression symptoms and improve their ability to function
  
• A psychiatrist to review patient cases with the care manager and consult with the primary care physician on any recommended changes in treatment

What is a care manager?
This is a new role created for DIAMOND. The position is based on the IMPACT model (described below), which showed that a care manager improved results for patients with depression. The care manager coordinates the patient’s care. He or she contacts patients to help them manage their depression. They educate patients on depression, and help them make changes in therapies. They also help keep the improving patient from falling back into major depression. The care manager does this work under the direction of the doctor and the psychiatrist.

What does the psychiatrist do in DIAMOND?
The psychiatrist has a new role. He or she reviews patient cases and consults with the care manager. Together they review how patients are doing. If a patient is not getting better, the psychiatrist may suggest a change in treatment. This might include recommending that the patient sees a mental health provider or have a change in medication. In all cases, the primary care doctor initiates any recommended changes in treatment.

How do other mental health providers fit into this model?
Psychologists, social workers, and other mental health providers continue to play a key role. Patients may be referred for therapy and other services as part of their treatment plan. DIAMOND provides tools for the primary care team, and those providing other services are always sharing information in order to provide quality care.

Why does this model get better results?
The DIAMOND tools give doctors a proven way to detect depression in the first place. By adding a care manager and consulting psychiatrist to the model, the primary care clinic can monitor the patient better. The care manager provides a level of contact, support and education that has proven success with depressed patients.

What is DIAMOND based upon?
DIAMOND is based on the Collaborative Care model created by Wayne Katon, MD, and put to practice in the “IMPACT” study by Jurgen Unutzer, MD. More than 37 trials have shown this method of managing depression in primary care improves patient health. A 2008 study in the American Journal of Managed Care showed a potential health care cost savings of $3,300 over a four-year period from programs like DIAMOND. More detailed information about these trials can be found at http://www.impact-uw.org.

What did the 37 trials reveal?
Patients reported 100 more depression-free days within a two-year period. They had fewer suicidal thoughts, which lowered the risk of suicide. They said they felt better physically—even those with chronic pain problems like arthritis or a bad back. Patients said they liked the care they received more, and said the program had made their life better overall.

Employers benefited because patients with depression felt better. They missed fewer days of work, and were happier and more productive while at work. Also, a recent study showed health care costs decreased by $3,300 over a four-year period compared to costs under usual primary care.

Which patients are eligible for DIAMOND services?
Eligible patients are adults age 18 and older with a diagnosis of major depression or mild chronic depression. At this time, patients can enter DIAMOND only if their primary care clinic is one of the 30 that have launched DIAMOND. A total of 90 clinics plan to offer DIAMOND by 2010. For a schedule of the DIAMOND program rollout across Minnesota and Wisconsin, please go to http://www.icsi.org/news/diamond_news/clinics_involved_with_diamond).

To be eligible, a patient’s score on the depression checklist must be 10 or above. Patients remain in the program unless they refuse or decline care, transfer care to another clinic, are permanently placed in a long-term care facility, their depression checklist score is less than five for three months in a row, they don’t contact their doctor or care manager for two months in a row, or after 12 months in the program. A doctor can also decide that a patient should not be part of the DIAMOND program if in their clinical judgment is not best for an individual. A medical group or doctor may choose to keep a patient in DIAMOND beyond a year; however, the medical clinic is not reimbursed by its health plan after 12 consecutive months.

Is this type of care effective for various cultural groups?
IMPACT was found to work equally with African American, Latino and Caucasian patients. For more information, go to http://impact-uw.org/about/research.html. At this time, there is not enough information on the success of this care delivery model with other groups. The ICSI Depression Guideline (http://www.icsi.org) provides some more information to assess and treat depression based on the patient’s culture and beliefs.

Who pays for DIAMOND?
This is one of the truly unique aspects of DIAMOND. To provide DIAMOND, medical groups need a care manager. They have to invest and make changes in their depression care practices. Through ICSI, health plans and medical groups worked on a new pay model. Under it, the health plans give medical groups a monthly fee that covers the bundle of DIAMOND services. Specific payment details are made between each health plan and medical group. The ICSI DIAMOND Steering Committee—the lead group in creating DIAMOND—recommended that there be no patient co-pays or deductibles. Each health plan will consider this course of action, and make its own decision. So there may be some patient payment responsibility with certain health plan coverage.

Which medical groups are participating in DIAMOND?
ICSI has trained a number of medical groups on how to implement the DIAMOND model. Rollout through these groups began in March 2008. Patients wanting to know if their doctor or primary care clinic offers DIAMOND services now, or plans to have it available in the near future, should go to http://www.icsi.org/news/diamond_news/clinics_involved_with_diamond.

Which health plans are participating in DIAMOND?
HealthPartners, BlueCross and BlueShield of Minnesota, Medica, PreferredOne, UCare of Minnesota, Metropolitan Health Plan, MMSI and First Plan of Minnesota are participants. The MN Department of Human Services, which represents Medicaid patients, is also participating. Thirty primary care clinics are currently offering DIAMOND, and health plans will only offer patient coverage through these clinics at this time.

Can patients enter the DIAMOND program if they are not insured by one of the participating health plans?
Yes. However, only the health plans listed above are reimbursing for DIAMOND-covered services. The patient would have to pay for DIAMOND services on their own.

Who developed DIAMOND?
DIAMOND was created by leading Minnesota medical groups, six major Minnesota health plans, the Minnesota Department of Human Services, employer groups and patients. They all worked through the Institute for Clinical Systems Improvement (ICSI) to develop it.

What is ICSI?
ICSI is an independent, non-profit organization that brings medical groups, hospitals, health plans and other groups together to improve the quality of patient care in Minnesota and surrounding states. Sponsored by six major health plans in Minnesota, ICSI has 58 medical group members representing 9,000 doctors.

How and when will we know if this new model is effective?
Results similar to those seen in the IMPACT trials are expected. Clinics offering DIAMOND will measure how many patients sign up for DIAMOND and how often the depression checklist is used. They will also track how patients improve in DIAMOND and how many no longer suffer from major depression. Clinics will also track how satisfied patients are with their ability to function.

How long will the DIAMOND program run?
The first phase will occur from 2008-2010. Data will be gathered from medical groups monthly and will be reviewed by the ICSI DIAMOND Steering Committee. At the same time, a research study funded by the National Institute of Mental Health will be tracking the impact of this project through 2011 through a grant to HealthPartners.

With the success of DIAMOND, this model could become an effective way to manage patients with depression in Minnesota and across the nation. It possibly could become the model to manage other chronic diseases such as diabetes and heart disease.

Revised 10/24/2008