Learning from the DIAMOND Initiative

DIAMOND (Depression Improvement Across Minnesota, Offering a New Direction) offers a new way to manage the care of patients with depression in that it changes the way care is delivered and how it is paid for. The program could become the model for primary care management of managing depression going forward.

As a result, DIAMOND is of key interest nationally. The National Institute of Mental Health has provided HealthPartners Research Foundation (HPRF) with a $3 million, five-year grant to fully evaluate the DIAMOND initiative. The purpose of the study is to ensure that medical groups, payers, and purchasers receive the information they need to make decisions regarding the business case and clinical case for further expansion of the model.

The HPRF team is led by Leif Solberg, MD, Associate Medical Director for Care Improvement at HealthPartners. It includes Jürgen Unützer, MD, leader of the IMPACT trial upon which the DIAMOND model is based; other nationally recognized researchers, investigators and staff from HPRF; Nancy Jaeckels and Dr. Gary Oftedahl from the Institute for Clinical Systems Improvement (ICSI), and Dr. Ken Joslyn of Medica, an ICSI-sponsoring health plan.

The DIAMOND study will evaluate all aspects of the initiative, including changes in care delivery, patient outcomes (including productivity effects), and health care cost-effectiveness. The study involves patient surveys, analysis of patient claims data, surveys and interviews of medical group leadership, and analysis of payer, medical group and ICSI implementation costs.

One planned survey will randomly sample patients newly treated with antidepressants at their initial diagnosis and again at six months, both at ICSI-certified clinics and at clinics which have requested but not yet received ICSI certification. Not all of these patients will have been enrolled in the care management program, so their data will reflect the overall effects of DIAMOND on medicated patients with depression. Each survey will include a PHQ-9 assessment of depression symptoms.

The survey responses, plus information obtained through analysis of claims data, will answer how patients diagnosed with depression at ICSI-certified clinics differ from those at not-yet-certified clinics in regards to:

1. PHQ-9 scores at the time of diagnosis
   
2. Change in PHQ-9 scores at six months
   
3. The number and proportion of patients with a new diagnosis of depression
   
4. The demographic characteristics of patients with depression: age, gender, race, education, occupation, etc.
   
5. The number and proportion of newly diagnosed patients who are started on antidepressants
   
6. The rate of best care processes reported by patients and sustained one year post implementation
   
7. Patient satisfaction
   
8. Medication compliance
   
9. Total health care cost and utilization
   
10. Follow-up visit care
    
11. Productivity change
    
12. Change in performance rates for preventive services

Through a series of surveys and interviews with leaders at DIAMOND-participating medical groups and clinics, the study will evaluate how ICSI-certified clinics differ from not-yet-certified clinics in:

1. Organizational priority for improving depression
   
2. Change process capability
   
3. Care process content (i.e., practice systems) for depression
   
4. The proportion of depressed patients enrolled each month in the care management program

Through the collection and analysis of cost data, the study will evaluate the costs to medical groups to implement the new care model, the cost to health plans and the Minnesota Department of Human Services to implement the new payment system, and the cost to ICSI to train medical groups in the new care model.

Lastly, the study will track interest in the project both locally and nationally. It will measure the extent to which the new care model has spread to other medical groups in Minnesota, and the extent to which the new care model is spreading to other health plans, medical groups, and employers outside state.