Medical science has developed two comparably effective treatments for depression: antidepressant medication and behavioral counseling. Unfortunately, the majority of depressed workers fail to receive either of these treatments.
The following table presents examples of performance expectations for employers who wish to purchase this service from a health plan (health plan contract) and employers who wish to purchase this service from a managed behavioral health organization, disease management vendor, employee assistance program, or pharmacy benefits management program (vendor contract).
Depression Screening |
Health Plan Contract |
Vendor Contract |
Performance Expectation: All adult members are screened annually for depression. Adult members who have a positive screen are referred to care management for evaluation. |
Population Screening and Referral |
1. If the employer does not provide a HRA to employees that includes depression screening, the health plan will provide all adult members an annual depression screening either as part of a: i) general health risk assessment or ii) behavioral health specific screening tool.
If the employer does provide a HRA to employees that include depression screening, a separate screening is not required.
2. The health plan supports the employer’s use of employee incentives for depression screening by providing a mechanism for the employer to know which of their employees have completed depression screener/HRA
3. The health plan seamlessly notifies and refers positive screens to a care manager no later than 21 days after receipt of the employees completed depression screener/HRA.
4. The screening and referral process must be specified in the health plan’s policies and procedures. |
1. If the employer/plan does not provide a HRA to employees that include depression screening, the vendor will coordinate an annual depression screening of all covered workers with the employer’s contracted health plan(s). If the employer or plan(s) do provide a HRA to employees that include depression screening, a separate screening is not required.
2 The vendor supports the employer’s use of employee incentives for depression screening by providing a mechanism for the employer to know which of their employees have completed the screening/HRA.
3 The vendor notifies and refers positive screens to a care manager no later than 21 days after receipt of the employees completed depression screener/HRA
4. The screening and referral process must be specified in the vendor’s policies and procedures. |
Clinician Screening/Referral |
1 Health plan clinicians (physicians, physician assistants and nurse practitioners eligible for health plan reimbursement conduct depression screening/referral in targeted groups as follows:
(a) all primary care clinicians annually screen all adult members presenting for one or more visits/year.
(b) all primary care and specialty clinicians screen all adult members who fill a new episode antidepressant prescription within 7 calendar days of the dispensing of the medication. New episode antidepressant prescription refers to an antidepressant prescription for any diagnosis when any antidepressant medication has not been prescribed to the member by any health plan clinician in the previous 90 calendar days.
(c) chronic care program clinicians screen all adult members who meet the program’s criteria for outbound calls within 7 days of program entry.
2. Clinicians defined in 1(a), (b) and (c) (hereafter referred to as participating clinicians) will seamlessly refer positive screens to a care manager within 7 calendar days.
3. The screening and referral process must be specified in the health plan’s policies and procedures. |
Not Applicable |
Performance Expectation: All adult members receive depression education materials available in multiple media. |
Member Education |
1. The health plan provides members the following educational information upon clinician or member request:
(a) depression assessment (e.g., PHQ-9 & scoring instructions)
(b) course of depression with no evidence-based treatment
(c) description of evidence-based pharmacotherapy, course of depression with evidence-based pharmacotherapy, and instructions on how obtain evidence-based pharmacotherapy
(d) description of evidence-based psychotherapy, course of depression with evidence-based psychotherapy, and instructions on how to obtain evidence-based psychotherapy
(e) description of how depression care management program assists members in obtaining the preferred evidence-based treatment for depression
(f) self-management strategies for depression to complement evidence-based treatment
(g) assessment of barriers to begin and/or complete course of evidence-based treatment for depression
(h) provider guidelines for providing evidence-based treatment for depression
2 All educational material:
(a) is available on the web and in print
(b) is available in English and at least one other language
(c) except for provider guidelines, is written at the sixth grade level of literacy or lower |
1. The vendor provides members the following educational information upon clinician or member request:
(a) depression assessment (e.g., PHQ-9 and scoring instructions)
(b) course of depression with no evidence-based treatment
(c) description of evidence-based pharmacotherapy, course of depression with evidence-based pharmacotherapy, and instructions on how obtain evidence-based pharmacotherapy
(d) description of evidence-based psychotherapy, course of depression with evidence-based psychotherapy, and instructions on how to obtain evidence-based psychotherapy
(e) description of how depression care management program assists members in obtaining preferred evidence-based treatment for depression
(f) self-management strategies to complement evidence-based treatment
(g) assessment of barriers to begin and/or complete course of evidence-based treatment for depression
(h) provider guidelines for providing evidence-based treatment for depression
2 All educational material:
(a) is available on the web and in print
(b) is available in English and at least one other language
(c) except for provider guidelines, is written at the sixth grade level of literacy or lower
|
Performance Expectation: Provision of a depression care management program that: 1) identifies referred members who are eligible for the program, 2) engages eligible members in program, 3) provides short-term monitoring to engaged members, and 4) provides long-term monitoring to engaged members. |
Eligibility Identification |
1 Care managers evaluate referred members for program eligibility within 30 calendar days of referral using the following criteria to determine eligibility:
(a) age 18 or over
(b) five (5) or more positive symptoms on the PHQ-9 or score greater than or equal to twelve (12)
(c) does not meet DSM criteria for current bereavement, lifetime mania or current substance abuse
2. If the member is eligible, the care manager invites them into depression care management program and notifies the referring clinician of member status
3. If the member is ineligible because of criteria (a) or (b), the care manager provides the member with educational materials and notifies the referring clinician of member status.
4. If the member is ineligible because of criteria (c), the care manager provides the member information about appropriate treatment resources and notifies the referring clinician of member status. |
1. Care managers evaluate referred members for program eligibility within 30 calendar days of referral using the following criteria to determine eligibility:
(a) age 18 or over
(b) five (5) or more positive symptoms on the PHQ-9 or score greater than or equal to twelve (12)
(c) does not meet DSM criteria for current bereavement, lifetime mania or current substance abuse
2. If the member is eligible, the care manager invites them into depression care management program and notifies the referring clinician of member status
3. If the member is ineligible because of criteria (a) or (b), the care manager provides the member with educational materials and notifies the referring clinician of member status.
4. If the member is ineligible because of criteria (c), the care manager provides member information about appropriate treatment resources and notifies referring clinician of member status |
Engagement |
The care manager engages eligible members in program by completing the initial care management contact (outbound telephone call, outpatient visit or e-visit) within 2 weeks of eligibility determination to:
(a) monitor depression severity with PHQ-9
(b) for those employed, monitor absenteeism and productivity at work using the Workplace Limitations Questionnaire (WLQ)
(c) address (a-h) in Member Education,
(d) work with the member and the referring clinician to initiate treatment, if the member is not in treatment.
(e) offer to send member a printed copy of educational materials or refer to web-based materials. |
The care manager engages eligible members in program by completing initial management contact (outbound telephone call, outpatient visit or e-visit) within 2 weeks of eligibility determination to:
(a) monitor depression severity with PHQ-9
(b) for those employed, monitor absenteeism and productivity at work using the Workplace Limitations Questionnaire (WLQ)
(c) address (a-h) in Member Education,
(d) work with the member and the referring clinician to initiate treatment, if the member is not in treatment.
(e) offer to send member a printed copy of educational materials or refer to web-based materials.
|
Short-Term Monitoring |
1. The care manager completes four (4) or more additional contacts (outbound telephone calls, outpatient visits and/or e-visits) within 6 months of engagement to:
(a) reinforce educational content of initial care management session,
(b) monitor depression severity using PHQ-9
(c) for those employed, monitor absenteeism and productivity at work using the WLQ
(d) if treatment recommended, monitor treatment adherence
(e) encourage member to contact referring provider if member meets treatment change criteria.
(f) assess completion of evidence-based course of pharmacotherapy and/or psychotherapy by 6 months
(g) assess member satisfaction with program at 6 months
Completion of a course of evidence-based pharmacotherapy and/or psychotherapy with care management support is defined as care manager documentation that member (i) took an adequate dose of antidepressant medication 25 days out of every month for 4 or more months within 6 months of program engagement, and/or (ii) attended 8 or more psychotherapy sessions within 6 months of program engagement.
2 Care manager mails/faxes/emails a report to referring clinician following each contact following initial visit summarizing
(a) change in depression severity since initial contact
(b) for those employed, change in absenteeism/productivity at work since initial contact
(c) if treatment recommended, treatment adherence since initial contact
(d) need for treatment adjustment |
1. The care manager completes four (4) or more additional member contacts (outbound telephone calls, outpatient visits and/or e-visits) within 6 months of engagement to:
(a) reinforce educational content of initial care management session,
(b) monitor depression severity using PHQ-9
(c) for those employed, monitor absenteeism and productivity at work using the WLQ
(d) if treatment recommended, monitor treatment adherence
(e) encourage member to contact referring provider if member meets treatment change criteria.
(f) assess completion of evidence-based course of pharmacotherapy and/or psychotherapy by 6 months
(g) assess member satisfaction with program at 6 months.
Completion of a course of evidence-based pharmacotherapy and/or psychotherapy with care management support is defined as care manager documentation that member (i) took an adequate dose of antidepressant medication 25 days out of every month for 4 or more months within 6 months of program engagement, and/or (ii) attended 8 or more psychotherapy sessions within 6 months of program engagement.
2 Care manager mails/faxes report to referring clinician following each contact following initial visit summarizing
(a) change in depression severity since initial contact
(b) for those employed, change in absenteeism/productivity at work since initial contact
(c) if treatment recommended, treatment adherence since initial contact
(d) need for treatment adjustment |
Long-Term Monitoring |
1 Care manager completes one (1) contact (outbound telephone calls, outpatient visits and/or e-visits) every 3 months over 24 months beginning the ninth month after engagement with engaged members to:
(a) reinforce educational content of initial care management session
(b) monitor symptom change using PHQ-9,
(c) for those employed, monitor absenteeism and productivity at work using the WLQ
(d) if treatment recommended, monitor treatment adherence
(e) encourage member to contact referring provider if member meets treatment change criteria
(f) assess member satisfaction with program at 24 months
2 The care manager mails/faxes report to referring clinician following each contact following initial visit summarizing
(a) change in depression severity since initial contact
(b) for those employed, change in absenteeism/productivity at work since initial contact
(c) treatment adherence since initial contact if in active treatment
(d) need for treatment adjustment
3. Care management protocols must be specified in the health plan’s policies and procedures. |
1 Care manager completes one (1) contact (outbound telephone calls, outpatient visits and/or e-visits) every 3 months over 24 months beginning the ninth month after engagement with engaged members to:
(a) reinforce educational content of initial care management session
(b) monitor symptom change using PHQ-9,
(c) for those employed, monitor absenteeism and productivity at work using the WLQ
(d) if treatment recommended, monitor treatment adherence
(e) encourage member to contact referring provider if member meets treatment change criteria
(f) assess member satisfaction with program at 24 months
2 The care manager mails/faxes report to referring clinician following each contact following initial visit summarizing
(a) change in depression severity since initial contact
(b) for those employed, change in absenteeism/productivity at work since initial contact
(c) treatment adherence since initial contact if in active treatment
(d) need for treatment adjustment
3. Care management protocols must be specified in the health plan’s policies and procedures. |
Performance Expectation: The health plan/vendor will provide participating clinicians with practice-based resources to improve depression treatment |
Clinical Guidelines |
The health plan provides clinical guidelines for the treatment of depression to all participating clinicians Qualifying guidelines include nationally recognized, evidence-based guidelines or guidelines developed through a community collaborative. |
If guidelines are not distributed by health plan(s), the vendor should work with the health plan(s) to disseminate clinical guidelines to all participating clinicians Qualifying guidelines include evidence-based guidelines developed through a community collaborative effort or national task forces. |
Continuing Medical Education |
Seventy-five percent (75%) of all full-time participating clinicians (including BH providers) obtain one (1) or more units of continuing education credit in depression over four (4) contract years. |
Not Applicable |
Depression Registry |
The health plan offers all participating clinicians the technical and/or financial support to develop a practice-accessible depression registry where clinicians document their response to care managers’ summaries An electronic medical record with this functionality can be substituted for the depression registry. |
Not Applicable |
Reimbursement |
The health plan provides a financial incentive using payment codes and/or other mechanisms to all participating clinicians for:
(a)depression screening
(b)positive screen referrals
(c)review of care manager summaries
|
Together with the employer’s contracted health plan, the vendor provides a financial incentive using payment codes and/or other mechanisms to all participating clinicians for:
(a) depression screening
(b) positive screen referrals
(c) review of care manager summaries
|
Recognition |
The health plan publicly reports participating clinicians and care managers in the top decile in Clinician/Care Manager Performance Criteria listed below each year. The health plan may also recognize performance using nationally recognized clinical depression measures. |
The vendor works in coordination with the employer’s health plan(s) to publicly report participating clinicians/care managers in the top decile in Clinician/Care Manager Performance Criteria listed below each year. The health plan may also recognize performance using nationally recognized clinical depression measures. |
Performance Expectation: Formal quality improvement plan is in place for the depression care management program with specified components. |
Quality Improvement Plan |
1. The health plan has a written Quality Improvement Plan for the depression care management program.
2. The Quality Improvement Plan includes:
(a) measurable goals and objectives
(b) baseline measurement data
(c) planned activities and implementation timeline
(d) the methodology that will be used to measure the impact of the quality improvement activities
3. As part of the Quality Improvement Plan, the health plan will:
(a) assess, using care mangers’ reports, the adequacy of behavioral health provider access annually to ensure that the network includes a sufficient number of credentialed BH providers to provide evidence-based psychotherapy (8 or more one hour visits in a six month period) for depressed members in care management who prefer this treatment, and
(b) evaluate the adequacy of psychiatric support for primary care physicians seeking such support.
4. The Quality Improvement Plan is updated on an annual basis. |
1. The vendor has a written Quality Improvement Plan for the depression care management program.
2. The Quality Improvement Plan includes:
(a) measurable goals and objectives
(b) baseline measurement data
(c) planned activities and implementation timeline
(d) the methodology that will be used to measure the impact of the quality improvement activities
3 The Quality Improvement Plan is updated on an annual basis |
Performance Expectation: Measures of clinician and care manager performance in the depression care management program are reported at both the program and employer level. Performance results should be benchmarked against national best practices where available. These results are shared with participating clinicians, care managers and employers. |
Clinician Performance Criteria |
Participating clinicians receive an annual report that details individual clinician performance rates for a specified time period compared to:
(a) all clinicians in the health plan, and
(b) performance benchmarks.
Performance Benchmarks:
(a) 80% of more of targeted members in clinician caseload
complete depression screening,
(b) 95% or more of screen positive members in clinician caseload referred to depression care management
(c) among members in clinician caseload completing short-term followup, care manager
documents 40% have completed course of evidence-based pharmacotherapy and/or psychotherapy by 6 months
(d) among members in clinician caseload completing short-term followup, care manager documents that 50% or more report a 50% or greater symptom reduction or PHQ-9 LE 5 at 6 months
(e) among members in clinician caseload completing long-term followup, care manager documents that 50% or more report 50% or greater symptom reduction or PHQ-9 LE 5 at 24 months.
(f) among employed members in clinician caseload completing long-term followup, care manager documents 50% or more report a 50% or greater improvement in absenteeism/productivity at work or perfect attendance/productivity at work at 24 months.
(g) 90% or greater of all care manager summaries reviewed
(h) completion of required CME course in depression
(i) 50th percentile or greater in NCQA HEDIS measures including, but not limited to:
- Follow-up after mental illness hospitalization-7 days
- Follow-up after mental illness hospitalization-30 days
- Antidepressant medication management-acute phase Antidepressant medication management-continuation phase
- Antidepressant medication management-contacts
|
The vendor prepares an annual report summarizing average care management performance criteria compared to benchmark for:
(a) all members
(b) all members insured by a requesting employer
Reporting may be at the health plan level only if the number of employees is insufficient to generate meaningful data and/or to satisfy HIPAA requirements.
The report summarizes
(a) among members completing short-term follow-up
(i) proportion completing course of evidence-based pharmacotherapy and/or psychotherapy by 6 months,
(ii) proportion reporting 50% or greater symptom reduction or PHQ-9 LE 5 at 6 months
(iii) among employed members completing short-term follow-up, proportion reporting a 30% or greater improvement in absenteeism/productivity at work or perfect attendance/productivity at work at 6 months.
(b) among members completing long-term followup,
(i) proportion reporting 50% or greater symptom reduction or PHQ-9 LE 5 at 24 months.
(ii) among employed members completing long-term followup, proportion reporting a 50% or greater improvement in absenteeism/productivity at work or perfect attendance/productivity at work at 24 months.
(c) cost and cost per engaged participant of the care management program.
|
Care Management Performance Criteria |
Depression care managers receive
an annual report that details individual care management performance within specified window compared to:
(a) all depression care managers in the health plan, and
(b) performance benchmarks:
Performance Benchmarks:
(a) 30% or more of referred members assessed for eligibility (b) 90% or more of eligible members engaged in program
(c) 70% of engaged members complete short-term monitoring
(d) 50% of engaged members complete long-term monitoring
(e) 90% of required treatment summaries forwarded to clinician
(f) among members completing short-term followup, 80% of members report they are satisfied or very satisfied with the program at 6 months.
(g) among members completing long-term followup, 80% of members report they are satisfied or very satisfied with the program at 6 months. |
Depression care managers receive
an annual report that details individual care management performance within specified window compared to:
(a) all depression care managers in the health plan, and
(b) performance benchmarks:
Performance Benchmarks:
(a) 30% or more of referred members assessed for eligibility (b) 90% or more of eligible members engaged in program
(c) 70% of engaged members complete short-term monitoring
(d) 50% of engaged members complete long-term monitoring
(e) 90% of required treatment summaries forwarded to clinician
(f) among members completing short-term followup, 80% of members report they are satisfied or very satisfied with the program at 6 months.
(g) among members completing long-term followup, 80% of members report they are satisfied or very satisfied with the program at 6 months.
|
Employer Reporting |
1. The health plan provides employers an annual report that summarizes clinician performance rates for a specified time period compared to the performance benchmarks contained in the Clinician Performance Criteria section above.
2. The health plan provides employers with semi-annual reports that summarize the performance of care management compared to benchmarks (as specified in clinician and care manager reporting section above) for:
(a) all members
(b) all members covered by a requesting employer (not required for HEDIS data).
Reporting may be at the health plan level only if the number of employees is insufficient to generate meaningful data and/or to satisfy HIPAA requirements.
3. The health plan will annually report the following:
(a) Utilization of Behavioral Health Services for all members covered by a requesting employer:
(i) Utilization of inpatient and outpatient services, inpatient average length of stay, costs of inpatient and outpatient care by type of service, and other similar measures
(ii) Utilization of prescription drugs that are indicated for the treatment of depression, use of brand versus generic products, costs of the drug (gross and net), and other similar measures
(b) HEDIS measures for the health plan’s commercial population:
(i) Follow-up after mental illness hospitalization-7 days
(ii) Follow-up after mental illness hospitalization-30 days
(iii) Antidepressant medication management-acute phase Antidepressant medication management-continuation phase
(iv) Antidepressant medication management-contacts
(c).Cost and Return on Investment (ROI)
(i) employer-specific cost of the care management
(ii) employer-specific ROI calculated by using the Depression Calculator populated with the employer’s data. |
1. The vendor provides employers with reports that summarize the performance of care management compared to benchmarks (as specified in clinician and care manager reporting section above)
(a) all members
(b) all members insured by a requesting employer (not required for HEDIS data).
Reporting may be at the health plan level only if the number of employees is insufficient to generate meaningful data and/or to satisfy HIPAA requirements.
2. The vendor will report the following at the indicated frequency:
(a) Care Management Performance: Semi-annually
(i) percent of referred members assessed for program eligibility
(ii) percent of eligible members engaged in the program
(iii) percent of engaged members who complete short-term monitoring
(iv) percent of engaged members who complete long-term monitoring
(b) Short Term Follow-up Annually:
Among members completing
short-term followup
(i) proportion completing course of evidence-based pharmacotherapy and/or psychotherapy by 6 months,
(ii) proportion reporting 50% or greater symptom reduction or PHQ-9 LE 5 at 6 months
(iii) among employed members completing short-term followup, proportion reporting a 30% or greater improvement in absenteeism/productivity at work or perfect attendance/productivity at work at 6 months.
(c) Long Term Follow-up Annually
among members completing long-term
followup ,
(i) proportion reporting 50% or greater symptom reduction or PHQ-9 LE 5 at 24 months.
(ii) among employed members completing long-term followup, proportion reporting a 50% or greater improvement in absenteeism/productivity at work or perfect attendance/productivity at work at 24 months.
(d).Cost and Return on Investment (ROI) –Annually:
(i) employer-specific cost of care management
(ii) employer-specific ROI calculated by using the Depression Calculator populated with the employer’s data. |