Absence of conflict of interest.
Citation
Highlights
- The study’s objective was to examine the implementation of the Working towards Wellness which provided telephonic care management to Medicaid recipients with children under the age of 18 who were found to have major depression.
- The study authors conducted an implementation evaluation using data from the management information system (MIS) which included a record of all contacts, attempted contacts and time between contacts, and care managers’ notes as well as information from routine telephone meetings with program staff and one in person site visit.
- The study found that care managers were able to effectively engage people with depression via telephones despite significant barriers to in-person treatment within the target population.
- The companion impact study was reviewed by CLEAR in November 2016.
Intervention Examined
Working toward Wellness (WtW)
Features of the Intervention
- Type of organization: Health Insurance Company
- Location/setting: Rhode Island
- Population served and scale: Low Income Adults; 245 participants
- Industry focus: Health Services
- Intervention activities: Phone Based Care Management
- Cost: Per participant average: $6,249
- Fidelity: Not Included
Working towards Wellness (WtW) was a telephonic care management system which looked to encourage depressed Medicaid patients in Rhode Island to seek professional treatment. Master-level clinicians administered the phone calls in which they encouraged participants to get treatment, made sure those getting treatment were complying with the terms, and provided counseling over the phone as needed. The goal of WtW was to increase mental health service receipt, decrease levels of depression and increase treatment compliance and continuation among Medicaid recipients. The authors modeled WtW off the Workplace Depression Study (2007) which was a random assignment test of the telephonic care system on working individuals. WtW’s target population was Medicaid recipients who are found to have severe depression, as well as at least one child under the age of 18. The intervention was funded by the Administration for Children and Families within the Department of Health and Human Services and had additional funding from the Department of Labor. United Behavioral Health (UBH) delivered the care management services and the Group Health Cooperative (GHC) designed the intervention and provided technical assistance and training to the UBH staff.
Features of the Study
The authors conducted both an implementation and impact study for WtW. For the implementation study, participants were recruited by telephone during which they were screened for depression using the Quick Inventory of Depressive Symptomatology-Self Report (QIDS-SR). Those who were found to have major depression and agreed were assigned to the study. The intervention was administered and staffed by UBH which already provides behavioral health services to a large proportion of Rhode Island’s Medicaid population. All three care management staff members were master’s level, licensed clinicians with previous experience in evaluating and treating depression. All staff members received onsite training from GHC which focused on the provision depression management over the telephone. The case load was divided between the 3 case managers where all clients who required or preferred care in Spanish were assigned to the bilingual case manager and all others were split between the other two case managers. At their maximum, caseloads were about 60 clients per case manager. The study authors conducted an implementation evaluation using data from the management information system (MIS) which included a record of all contacts, attempted contacts and time between contacts, and care managers’ notes as well as information from routine telephone meetings with program staff and one in person site visit.
Findings
Intervention activities/services
- Establishing contact with the clients typically included multiple attempts with an average of 30 attempts per client over the implementation period, with an average of 20 attempts in the first 6 months, further reenforcing the idea that attempts were more frequent during the first half of the program year.
Implementation challenges and solutions
- The attempt to contact ratio was about 30%. Many clients lived under circumstances of chronic stress, such as ongoing multiple, interrelated stressors, crisis situations, loss, grief, and threat of violence which often interrupted participants efforts to get professional help.
- The program initially envisioned that care managers would work collaboratively with clinicians as clients progressed in their treatment. To do this, participants agreed verbally over the telephone for care managers to contact clinicians regarding their treatment. Following the verbal agreement, the participants received a release of information (ROI) form via mail which they then signed and returned to the care manager which then sent the form to the clinician. The required documentation created an administrative burden that greatly diminished the care manager’s ability to consult with the client's clinician due to clinicians not signing off on the ROI despite repeated attempts by the care manager.
Cost/ROI
- Program enrollment cost $127 per group member and on average, care management costs were $625 per group member. The average total mental health costs per participant were $1,662 and included specialty mental health visits, general medical visits with a mental health diagnosis, antidepressant prescriptions and other mental health prescriptions. The average total non-mental health services per participants was $3,834 and included general medical visits with a non-mental health diagnosis and non-psychotherapeutic drugs. In total, the program cost on average $6,249 per participant. The net cost (difference between the cost for program and non-program group member) was $774.