The following system changes were identified by the guideline work group and represent a collaborative care model as key strategies for health care delivery systems to incorporate in support of the implementation of this guideline. The following points have not been updated during this revision.

See Annotation #6, "Comprehensive Treatment Plan with Shared Decision-Making," for definitions of the collaborative care model.

See below for health care cost analysis of a collaborative care model compared to outpatient primary care depression care as usual and review of the cost analysis for enhanced collaborative care and the impact on the workplace, e.g., absenteeism.

• Detection and diagnosis
  - Systems in place to reliably determine if a patient is depressed
  - Use of DSM-5 criteria and structured questionnaires (such as PHQ-9)
• Patient-centered care, education and self-management programs
  - Structured attention to patient preferences
  - Patient and family education materials/protocols
  - Patient self-management skills such as journal writing or self-monitoring
  - When appropriate, encourage family or loved ones to attend appointments for patient support and advocacy.
  - Involving families, as well, in care management programs
  - Care manager role to coordinate the disease management for patients with depression including such things as patient contacts, education, self-management tools and tips
• Mental health/behavioral medicine specialist involvement
  - Shared care – collaborative care between behavioral health specialists and primary care clinicians in the primary care setting. Care manager and /or primary care clinician consulting with psychiatry on a regular basis regarding the caseload of patients with depression managed in the depression care management program.
  - Appointment availability – access to behavioral health in timely manner
• Outcomes measurement
  - Build in plans for outcome measures, as well as ongoing process measures
  - Response rate to various treatments
  - Remission rates – improvement in response is stable over time
• Systems to coordinate care, ensure continuity and keep clinicians informed of status - Build automated processes for the first four core elements wherever possible
  - Reduce dependence on human behavior to ensure delivery of patient care processes
  - Use of components of the chronic care model for depression care, e.g., use of registries, community outreach
  - Structured, frequent monitoring and follow-up with patient
  - Nurse/care manager phone care and use of other modalities for patient follow-up

Cost-Effectiveness Impact of Collaborative Care Models

In a collaborative care model, the primary treatment for depression is provided by a multidisciplinary team. Most studies have concluded that creating and implementing a collaborative care model will increase effectiveness – producing significant and sustained gains in "depression-free days" (Katon, 2005; Simon, 2001a; Simon, 2001b). The six-month and one-year studies show increased cost to the outpatient care system. This is balanced by continuous accumulation of clinical and economic benefits over time. One of the factors is the decrease in the utilization of general medical services in patients with chronic medical comorbidities. The two-year studies show mixed results possibly indicating a turning point (Dickinson, 2005), and the only longer-term study conducted was the IMPACT study. This was a well-done study analyzing the costs of performing collaborative care for one year over a four-year period. The study illustrated a cost savings of $3,363 per patient over the four-year period (Unützer, 2008).

Almost all the studies done on this aspect have compared enhanced/collaborative care with care as usual. Typically, enhanced care has involved creating a list of depressed patients under treatment, having a care manager provide education, calling or meeting with patient periodically to ensure compliance with medications and/or psychotherapy, and reliably ensuring follow-up visits and measurement of outcomes. Some have involved varying participation of physicians, behavioral health professionals and/or patients.

Workplace Impact of Collaborative Care Models

These randomized controlled trials looked at cost of doing enhanced care and specifically tallied decreases of "absenteeism" and improved work performance (which means that employees are present and effectively achieving good work results, sometimes referred to as decreasing "presenteeism") (Wang, 2007; Schoenbaum, 2001). Some studies monetized the results and compared them to usual care. The significance of these studies and this analysis is that in the U.S., depression costs employers $24 billion in lost productive work time (Stewart, 2003).

In two randomized controlled trials, employers received significant return on investment (ROI) from collaborative care treatment of depression by increasing productivity/decreasing absenteeism in the workplace. Increased productivity in one study ranged from 2.6 hours to 5.6 hours per week after one year. Studies going out to two years showed continued gains in year two (Lo Sasso, 2006; Rost, 2004).

Several of the articles recommend consideration of coverage of collaborative care to ensure better patient outcomes and the ROI illustrated.