DIAMOND - ICSI Member FAQs

DIAMOND – ICSI Member FAQs
This document describes DIAMOND, and how to integrate the model into a medical practice.

ICSI DIAMOND Initiative

What is DIAMOND and what does it stand for?
DIAMOND stands for Depression Improvement Across Minnesota, Offering a New Direction. It
is a collaborative agreement on a model and payment mechanism that supports best practices for
depression in primary care. This collaboration includes all six major Minnesota health plans, the
MN Department of Human Resources, ICSI, primary care providers, purchasers and patients.

What is the DIAMOND initiative based on?
The initiative is based on the “Collaborative Care Model” by Wayne Katon, MD, and put to practice
in the “IMPACT” study by Jurgen Unutzer, MD. More than 37 randomized controlled trials have
shown this model to improve results and to be more cost effective than usual care in improving
depression in the primary care setting. More detailed information, along with resources and tools for
implementing IMPACT evidence-based depression care, can be found at http://www.impact-uw.org.
Other data is available in the DIAMOND Training Manual: Tab 3 - Bibliography

Why is ICSI through DIAMOND focusing on depression in the primary care setting?
Major depression is a treatable cause of pain, suffering, disability and death. Yet primary care
providers detect major depression in only one-third to one-half of their patients. Additionally,
more than 80% of patients with depression have a medical co-morbidity. Usual care for
depression in the primary care setting has resulted in only about half of depressed adults getting
treated and only 20-40% of those showing substantial improvement over 12 months.
Additionally, primary care providers have limited time and provide limited follow-up. Patients
experience high rates of early treatment dropout and stay on ineffective medications too long.
There is also a lack of primary care access to evidence-based psychosocial treatments. These
factors have created a significant need and opportunity for improvement.

How is DIAMOND different from other ICSI health care initiatives?
This work brought together medical groups, six major Minnesota health plans, the Minnesota
Department of Human Services, purchasers and patients to identify a new model for structuring
and reimbursing for best practices for depression management. This action supports ICSI’s
Redesign for Results (R4R) strategic direction to build foundations for other redesign work. The
DIAMOND model could potentially expand to other chronic disease care or it could be added to
existing clinic-based care management.

How long will this initiative last?
The initial implementation phase will occur from 2008-2010 with a number of medical groups
implementing every six months starting in March 2008. Data collection will occur monthly and

will be reviewed frequently by the ICSI DIAMOND Steering Committee. A research study
funded by the National Institute of Health is concurrently evaluating the impact of this project
through 2011. With the success of DIAMOND, future possibilities include imbedding and
spreading this model as a standard of care for depression management across Minnesota and
adjacent states, and evaluating the application of this model to the management of other chronic
diseases.

The DIAMOND Model
What elements comprise the DIAMOND model of care?
There are six “care management” elements:
 1. Standard and reliable use of the nine-item Patient Health Questionnaire (PHQ-9) for
     assessment and ongoing management of depression
 2. Systematic follow-up tracking and monitoring
 3. Use of the evidence-based guideline and a stepped-care approach for treatment
     modification/intensification
 4. Relapse prevention when the patient is ready to move out of the care management program
 5. A care manager role to educate, coordinate, and troubleshoot services for the depressed
     patient
 6. A psychiatrist role to provide consultation and caseload review on a formalized basis.

What is the PHQ-9?
This is a standardized, validated health questionnaire for scoring the severity of depression and
tracking/monitoring progress improvement.

What is the care manager’s role in DIAMOND?
The care manager is a new role for primary care supported by the evidence-based IMPACT
model of shared collaborative care. In the collaborative care model, care managers typically have
backgrounds as certified medical assistants, or in nursing, social work or psychology; however,
interpersonal skills were found to be even more important than background. The care manager is
responsible for overall coordination of depression care for patients. He or she manages the
registry and follow-up contacts for patient self-management support, offers depression education,
facilitates stepped-care therapy, and provides relapse prevention. These services are performed
through consultation with the primary care provider and psychiatrist.

What is the role of the psychiatrist in DIAMOND?
A consulting psychiatrist is a new role for psychiatry. He or she provides caseload review and
consultation in the primary care setting to the care manager for two hours per week. Together,
they do a formal review (based on a registry) of patients who are in treatment and not improving.
They then generate recommendations for treatment changes (based on evidence-based
guidelines), including referral to other mental health resources if clinically indicated. Ideally, the
care manager and psychiatrist should meet in person, but if the relationship is established, this
consultation can be done virtually.

How do other mental health providers fit into this model?
Psychologists, social workers, and other mental health providers continue to play an essential
role in best practice depression care. Patients referred for therapy will need access to mental
health providers with expertise in evidence-based therapies such as cognitive-behavioral therapy

and interpersonal therapy. Ongoing communication and coordination between primary care and
specialty care is needed to continue providing quality patient care.

Who pays for DIAMOND?
This is one of the truly unique aspects of DIAMOND. To integrate DIAMOND into their
practice, medical groups need a care manager. They have to invest and make changes in their
depression care practices. Health plans and medical groups worked on a new pay model through
ICSI. Under it, the health plans give medical groups a periodic fee that covers many DIAMOND
services. Specific payment details are made between each health plan and medical group. ICSI
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.

What are the measurements of success for this initiative?
Three levels of measurement have been established: 1) care delivery process measures such as
patient enrollment and PHQ-9’s administered, and outcome measures such as response and
remission, 2) patient satisfaction and productivity via a quality of life survey, and 3) cost
effectiveness measures.

Patient Considerations

Which patients are eligible for DIAMOND services?
Eligible patients are adults age 18 and older with a diagnosis of major depression or dysthymia
(codes 296.2x, 296.3x or 300.4x) and a PHQ-9 score of 10 or above. Inactivation criteria is based
on a patient refusing or declining care, transferring care to another health care system or
permanent placement in long-term care, being in remission for three consecutive months, making
no contact for two consecutive months, or at the physician’s discretion. A medical group or
physician may choose to keep a patient in the care management program beyond 12 months;
however, insurance coverage for the care management fee is a maximum of 12 consecutive
months.

If the patient transfers to another clinic, can they still participate in DIAMOND?
If the patient’s new clinic is also a DIAMOND participating clinic, the patient can continue care
under DIAMOND. They would obviously work with a new care management team. The details
of managing this transfer of care would need to be worked out between clinics.

Is this type of collaborative care effective for various cultural groups?
IMPACT was found to be equally effective with African American, Latino and Caucasian
patients. Supporting references can be found at: http://impact-uw.org/about/research.html. At this
time, there is a lack of data on the success of this care delivery model with other cultural groups.
The ICSI Depression Guideline provides some recommendations and supporting evidence for
assessing and treating depression based on culture and beliefs. Additionally, while the PHQ-9 is
only validated in English, Spanish and Portuguese, other language versions give the patient and
care manager something to work with that is better than "usual care.” Other language versions
can be found at: http://www.phqscreeners.com/overview.aspx.

Can patients be enrolled if they are not insured by one of the health plans participating in
the DIAMOND initiative?
Yes. However, only participating health plans are providing reimbursement for DIAMOND-
covered services.

What is the process for activating a patient into the DIAMOND program?
Activation begins when the care manager first makes contact with the patient and the patient
does not opt out. The month of activation is the first month a claim can be submitted to the
patient’s health plan.

How do you file a DIAMOND claim?
A standard code—T2022—has been determined to be used by all DIAMOND medical groups
and health plans for the periodic care management claim. Submission will be based on the
individual discussion between the care health plan and care medical group.

Implementing DIAMOND
How can interested medical clinics participate in DIAMOND?
At this time, participating clinics must be ICSI member medical groups who have registered their
interest. ICSI will then conduct a readiness assessment based on implementation of the elements
of the DIAMOND care management model. A Collaborative Provisional Training Series will be
completed with new participating medical groups. Ongoing data assessment will occur as well.

Do participating medical groups need to have an EMR?
While it can make systematic tracking easier, an electronic medical record system is not
necessary to implement DIAMOND.

What is ICSI doing to support DIAMOND groups?
ICSI is facilitating the development of DIAMOND by bringing together key stakeholders to
design and oversee this initiative. ICSI is providing collaborative training sessions to all medical
groups participating in DIAMOND and will utilize national experts and others who have
implemented the Collaborative Care Model.

What does it cost for a primary care clinic to implement the model?
In the randomized trial, the cost of providing IMPACT care for 12 months averaged $580 per
patient. The costs of providing IMPACT care outside of the research study is estimated to be
$300-$500 based on the length of the program, number and type of visits (e.g. in-person vs.
telephone), and the type of care management personnel used.

Start-up costs include hiring and training of a care manager, and training of the primary care
providers, the consulting psychiatrist, and support staff in care management for depression.
Other start-up practice costs are associated with establishing and maintaining a depression
registry, tracking and reporting of PHQ-9 symptoms, and billing for care management services.
Major ongoing costs include care manager salary (80% of costs), weekly consultation with a
psychiatrist (10%), and program materials (10%).

What is the typical caseload for a care manager?
Based on the IMPACT model, the ratio was one care manager per 150-200 patients.

Do all the primary care physicians at my clinic need to participate in DIAMOND?
Yes. Building the care delivery components for DIAMOND requires a clinic-wide approach.
DIAMOND needs to be adopted as the new method for managing patients with depression.
Several physician education tools are available to help you describe the program and the benefits
it will provide to your physicians. Physician champions are in the best position to provide peer-
to-peer encouragement and support.

How many primary care providers are required to support a caseload of 150-200 patients
for care manager?
Based on experience with IMPACT, it takes 5-15 primary care providers to keep a full-time care
manager busy. This varies depending upon their patient population and their involvement in the
project. If a medical group has a more medically ill or low SES caseload with a high prevalence
of depression, and the primary care providers do a good job referring depressed patients to a care
manager, one can easily generate 50-75 referrals for a care manager from the entire caseload (~
5% of a panel of 1,500 pts). On the other hand, if a medical group has a healthier group of
patients or predominantly older men (who don’t often endorse depression even if they have it),
and/or primary care providers don’t aggressively use the program, one might generate only 15-20
referrals for a care manager (1-2% of the entire panel).

Early on, referrals tend to start slowly. This provides a good time for the “team” of the
consulting psychiatrist, the referring primary care provider and the care manager to complete
their training, figure out how to work well together, and work out the bugs in the program
(communication, documentation, handoffs, billing and clinical issues that the care managers need
to learn more about). It is strongly encouraged that the team use the early start-up time in that
way.

What has been the experience of care manager turnover?
There has been some turnover as people discover that the role isn’t what they were expecting.
For example, a licensed mental health counselor may discover that this role is not about
providing non-structured supportive counseling but about following a protocol, measuring
outcomes, supporting medication management by a primary care provider, and working in a busy
primary care environment. Or a nurse with medical setting experience may find they don’t enjoy
working full time with depressed patients. With a good fit, care manager turnover is not high
because these positions tend to be very rewarding. The care manager is supported by a
psychiatrist, feels valued in their clinic, and gets satisfaction from helping patients get well.

How often is the consulting psychiatrist contacted by the primary care provider or care
manager outside of the specific consulting time?
Experience from the IMPACT groups found that emergencies were quite rare. It is suggested that
one hour of psychiatrist consultation time per week should be designated to a formal review
(based on a registry) of patients who are in treatment and not improving in order to generate
recommendations for treatment changes (including referral to other mental health resources if
clinically indicated). The psychiatrist’s second hour could be spent with the care manager or
primary care providers to answer questions regarding specific patients in the program. Based
upon IMPACT, this second hour is an estimate of the time required on an average week. There
may be times when several patients present with challenging/emergent issues. Time required
may also depend on the level of experience and skill of the care manager (less experienced ones

need more support), the volume of cases (usually two hours of review per care manager caseload
is average), and the level of other mental health resources available to the patients and their
primary care providers.

How frequently does a patient need to see a psychiatrist under the DIAMOND model, or is
there the ability to do a "mini consult"?
The IMPACT model allowed for “mini consults.” However, the DIAMOND initiative involves
multiple health plans. While this opportunity may be desirable, it will not be a routine part of the
consulting psychiatrist’s role. If the psychiatrist is part of the network, the individual clinic may
develop some agreement with the psychiatrist. Because direct consultation between the
psychiatrist and patient is not part of the DIAMOND-covered services it would need to be billed
separately.

What is the potential malpractice risk for a DIAMOND consulting psychiatrist?
While there is no legal guarantee in the law, the risk has been found to be minimal. “Malpractice
Liability for Informal Consultations” by Olick, Robert S., JD, PhD, and Bergus, George R., MD,
MAED, published in Family Medicine, July-August 2003, Vol. 35, No.7, 476-481 addresses
malpractice risks in 'curbside consults' in which the psychiatrist is a consultant with the primary
care provider but does not have a patient-physician relationship. The psychiatrist does not treat,
personally assess, interview or bill the patient. The psychiatrist does not know the name of the
patient, nor is he or she supervising the primary care provider. The psychiatrist is taking
information in from the care manager and making recommendations to the primary care
provider, but the primary care provider makes the decision as to whether or not to even
recommend those to the patient.

How frequently should care managers call to reach a patient eligible for DIAMOND?
Care manager call frequency will vary by clinic but several care managers are trying three
attempts at three different times of day. Also, know your clinic's policy regarding leaving a
message. One clinic said they can leave a simple non-specific message such as, "This is (CM
first name) from (clinic) calling for (pt name). Please call me back at (number)."

Are there other practices that work to make the care manager-patient link?
Some care managers in the IMPACT study (upon which DIAMOND is based) look on the
schedule to see if the patient is coming back in the office for something else and then seek them
out. In addition, be proactive with getting the primary care physicians to tell all eligible patients
about DIAMOND (see DIAMOND script), tell them about the care manager - their role, their
name, their office, and introduce if at all possible. If introductions aren't possible, primary care
physicians should tell patients that the care manager will be calling them to talk more about the
program. Establish a process where someone verifies the patient's phone number and gets a back
up number as well.

Should all referrals be activated then deactivated if they opt out, even if you are still
attempting to get them in?
No referrals are activated until the care manager contacts the patient and he or she chooses to be
in the program (or not to opt out). In other words, if they opt out at the initial care manager
contact, they were never activated in the first place. Deactivation or inactivation only comes
when a patient has been activated in the program and sometime later drops out.

Does ICSI provide training for new care managers hired after the face-to-face training
session or any additional training for existing care managers?
An independent training program is now available for new care managers not hired by the last
face-to-face training. Contact Pam Pietruszewski at pam.pietruszewski@icsi.org or 952-814-
7078 for more information. For additional training, DIAMOND teams should determine what
their care managers need and who internally can provide it. Clinic-specific policies and care
manager clinical skill building are common areas needed for additional training. The ICSI
Depression Guideline can be another training resource, as can the IMPACT online training found
at: http://impact-uw.org/training/web.html

Is there a tool for tracking eligible patients that don't get referred/activated into
DIAMOND?
No, but it is a good idea to create your own tracking tool/spreadsheet/registry to include these
patients who are eligible but not referred. If they are eligible and referred to the care manager
but then choose not to activate, those should be tracked as well as an "opt out.” If you use the
online tracking tool, this can already be tracked.

Do you have suggestions for increasing patient volume for care managers?

    •   Educate providers—especially utilizing the provider champion
    •   Demonstrate value by taking on a complex patient from a physician who has not fully
        bought into the program
    •   Show provider data from groups in earlier sequences that shows the significantly
        improved patient outcomes compared to the usual care the physician alone can provide
    •   Make the case that care managers are revenue generators but only when they have a full
        roster of patients in their caseload.

Revised 03/03/2009