Implementation Stories

If you are considering IMPACT for your practice, you might find it helpful to read about the experiences of organizations that have already implemented the program. Hear about how they adapted IMPACT to fit their organization's needs and culture and their experiences with patients and providers once the project was up and running.

Kaiser Permanente of Southern California: Kaiser is a large HMO that serving over 3 million people in southern California. Two of their San Diego clinics participated in the original IMPACT research study. At the end of the study, they conducted a pilot study of an adapted version of IMPACT. Based on the pilot study results, Kaiser rolled out the program region-wide.

Sutter Health: Sutter Health is a family of not-for-profit hospitals and physician organizations that share resources and expertise to advance health care quality. Serving more than 100 communities in Northern California, Sutter Health doctors and hospitals are regional leaders in pediatric, obstetrical, heart and cancer care.

Institute for Urban Family Health: IUFH is a federally qualified health center (FQHC) that serves a low-income, largely uninsured population in New York City. They were the first organization to implement IMPACT after the end of the research study.

Kaiser Permanente Southern California improves depression

(Note: Kaiser's IMPACT program is profiled in a streaming video produced by the American Journal of Nursing and Trinity Healthforce Learning for clinicians who are treating older adults with depression. Read more...)

Unlike wrinkles, depression is not a given as we age. However, for a 75-year-old woman with unrelenting arthritis pain or a 60-year-old man kept homebound by congestive heart failure, depression can become a way of life

For more resources and information about Kaiser's implementation, explore the links below. Abstract describing outcome of program evaluation at Kaiser Permanente Graphs displaying outcomes from Kaiser Permanente program evaluation Excerpt from The Robert Wood Johnson Foundation's report "Integrating Publicly Funded Physical and Behavioral Health Services: A Description of Selected Initiatives" describing the Kaiser Permanente implementation. Link to entire report.

The IMPACT model, with its team approach to identifying and treating depression, produces rewarding clinical successes. Intervening in a personally tailored way, IMPACT helps thousands of people lighten the load of their depression.

Kaiser’s early involvement

Kaiser Permanente Southern California, like other quality healthcare organizations, constantly searches for ways to improve the care and health of their patients. They were in on the ground floor of exploring the effectiveness of IMPACT and their patients have been enjoying its valuable results ever since.

As one of the eight health care organizations involved in the IMPACT study, Kaiser Permanente San Diego studied whether this innovative care model could help their older patients with depression. Kaiser leaders encouraged primary care physicians to use a simple nine-item questionnaire, called the PHQ-9, to identify older patients with depression and refer them to the study.

The PHQ-9 is a widely used, brief questionnaire that includes nine questions, each one about a particular symptom of depression and how often the patient experiences it. Questions such as, “Do you have very little interest or pleasure in doing things?” “Do you feel bad about yourself or have thoughts of death or self-harm?” The questionnaire helps patients and their doctors identify and focus on thoughts and feelings associated with depression and helps practitioners determine if a person is suffering from clinical depression.

Mr. Lopez volunteers

During a routine office visit with his primary care physician, a 62-year-old man—we’ll call him Mr. Lopez—complained of sleeping poorly, having little energy and losing weight. His doctor knew that these symptoms can be signs of depression . To help assess whether or not Mr. Lopez was depressed, the doctor asked him to complete a PHQ-9 questionnaire.

Mr. Lopez said he wasn’t too sure what this “depression” was all about, but he “had all the symptoms on this list.” Clearly, though he did not know much about depression, Mr. Lopez had come in looking for help. His physician evaluated him, diagnosed depression, and prescribed an antidepressant medication. He also referred Mr. Lopez to the IMPACT program, which provided him with a Depression Care Manager.

Depression Care Managers—central to the team approach

Patients were not simply given a prescription and then sent off on their own. In contrast to common primary-care practice, care managers worked closely with each patient’s primary care provider to coordinate care. They supported patients in following the treatment program prescribed by their primary care physician. They monitored how well patients’ medications were working and helped them manage side effects if they occurred. The care managers educated patients about depression, and at each visit, encouraged patients to plan and follow through with pleasant activities. Care managers also offered patients an optional 6-8 week psychotherapy treatment called Problem Solving Treatment in Primary Care (PST-PC).

Most importantly, the care managers closely monitored how each patient responded to the treatment plan. If the patient’s depression and symptoms were not getting better, the care manager would consult with the primary care provider about changing the treatment plan. If the patient still wasn’t improving, the care manager would talk with the consulting psychiatrist to get ideas for further treatment adjustments.

The program and its patients earn an “A”

Patients who participated in the IMPACT study were twice as likely as patients treated in the usual manner to have a significant improvement in their depression. They also showed considerable improvements in their physical functioning, chronic pain, and quality of life. Primary care providers who participated in the project were uniformly enthusiastic about the value of the IMPACT program.

Kaiser’s Primary Care Administrator, Walter Borschel, LSCW, CHE, was very encouraged by the results. “Some of our successes were with patients who had been seen in our psychiatry department for long periods of time and hadn’t gotten better. They had chronic, disabling depression. They not only got better but also maintained their gains. That was extremely impressive and surprised me,” said Borschel.

These very positive study results demonstrated the value of a more personalized, comprehensive approach to helping older adults with depression. Based on these dramatic results, Kaiser decided to investigate how they might adapt IMPACT to fit their particular health care culture so that they could continue to offer IMPACT care and make the program available to adults of all ages, after the research study ended.

Inspired commitment

These heartening results changed the way Kaiser looks at caring for depressed patients. Borschel says, “It’s made me more committed to Kaiser’s doing a better job of treating depression within primary care. For three reasons: First, it increased my knowledge and understanding of how many depressed patients we see within primary care. Second, we can do something to make it better. And third, it looks like some of these things we could do by using our existing resources differently. Those are all things I feel very good about.”

Adapting the program to the reality of a large health care system

To insure long-term sustainability, Kaiser staff worked closely with the IMPACT Coordinating Center to make several adaptations to the treatment model to fit it into the Kaiser delivery system. These adaptations included:

• Expanding the program to all adult patients, not only those 60 and over
• Adding an optional group education class about depression offered by the Member Health Education Department
• Tailoring the number and frequency of visits according to each patient’s need (instead of providing every patient with a pre-determined number of visits, as was done in the research study).
• Adding a medical assistant to perform some of a care manager’s tasks, such as routine follow-up phone calls to patients to measure their symptoms of depression.

Sustainable change and return on investment

Does the adapted version of IMPACT work as well as the research study version? To answer that question, Kaiser staff conducted a program evaluation with the first 284 patients enrolled in the Kaiser version of IMPACT.

Their findings were very encouraging. Patients seen with the adapted version of IMPACT averaged half the number of clinic visits and one-third the number of phone contacts as the patients enrolled in the formal research study. Despite this, these patients showed the same dramatic benefits after six months of treatment that were seen in the original research study. Participants in the pilot also had lower health care costs per year when compared to patients receiving usual care or patients who had received IMPACT care in the original study.

Expanding practice innovation

A big ship doesn’t make sudden turns on the high seas. Its captain calculates the best and safest course and maneuvers the vessel slowly and deliberately. So it is with implementing healthcare innovation in a delivery system as large as Kaiser Permanente Southern California. Thoughtfully and deliberately, Kaiser made a big decision. They considered the results of the original IMPACT study, the post-study program evaluation, and several other efforts to improve care for depressed members. Based on their findings, they made IMPACT care available in all 12 of their Southern California regional medical centers.

Over the past year, Kaiser has trained an additional 75 staff from all 12 medical centers to provide IMPACT-style care to depressed members. This region, which serves over three million people, is also educating their primary practice physicians in using the PHQ-9 as a tool to diagnose and treat their depressed patients.

Impressive study results fueled staff confidence about using the IMPACT model. Their experience helped them envision healthier, happier patients. Kaiser, like other organizations using the IMPACT model, enjoyed the added advantages of consultation and expertise from the IMPACT Coordinating Center, the materials in the IMPACT toolkit, and help with developing a Web-based patient registry to help keep track of patients with depression.

Communication is key

IMPACT demonstrates success in organizations and practices by creating more effective communication and collaboration between providers and patients. Everybody involved feels the charge—a current moving them toward improved patient care.

Andrew Golden, MD, former Chief of the Department of Family Practice and a long-time Kaiser physician sums it up well.” The exciting part is the cooperation, integration, and acceptance between psychiatry, primary care, and patients. We felt it could happen, we just hadn’t found a way to do it.” Giving IMPACT an enthusiastic thumbs up, he adds, “This is one model that’s really done well.”

“This could revolutionize the way depression is treated in medical settings,” says Dr. Richard Della Penna, head of Kaiser Permanente’s Aging Network (KPAN) and an investigator with the original IMPACT trial. “The strong results of this important study and our experiences with the IMPACT program have clearly shown the value of the team care model for depression.”

* based on content originally published in the 2002 John A. Hartford Foundation annual report. Used with permission.

IMPACT brightens lives at Sutter Health Care, Northern and Central California

Meet Betty, * a 79-year-old retired teacher. Betty had been suffering from so much chronic pain and depression that she rarely left her house. She had been living with debilitating arthritis ever since her last year of teaching, 12 years ago. Grieving for elderly friends as they died, missing social activity, and living with constant pain was taking its toll. Betty was depressed. But a year ago, she started fighting back. She took an antidepressant, another medication for her anxiety, and various narcotic medications for her arthritis pain. But nothing seemed to ease the darkness Betty dwelled in day after day.

Depression and chronic illness: a difficult mix

Depression frequently leaves people feeling helpless about their lives and hopeless about ever feeling better. Their sleep, eating, and concentration patterns are often impaired; just walking down the block can feel like running a marathon. Depressed patients, in part because of these difficulties, are less able than other patients to

fully participate in programs to manage their chronic medical illnesses. Practitioners at Sutter Health were concerned because so many of their patients weren’t improving their ability to self-manage their chronic disease(s). Like Betty, depressed patients are at increased risk for continual and new medical problems.

Priming the pump

Sutter Health wanted to have a greater impact on their depressed patients’ lives. They were open to an infusion of innovation to their healthcare delivery system to meet this goal. Jan van der Mei, Continuum Case Management Director at Sutter Health in Sacramento learned about IMPACT from Sutter’s Medical Director, Dr. Cheryl Phillips. This collaborative-care model that helps patients manage their depression seemed like a good option. In early 2005, Jan decided to bring IMPACT to primary care patients at Sutter Health. Care managers were already working with patients suffering from chronic diseases like diabetes and congestive heart failure. Their current protocol included preventive care models and education programs aimed at keeping these patients healthy and out of the hospital. But clearly, they needed something more, and Jan saw IMPACT as a promising model.

Getting started

The IMPACT Coordinating Center helps healthcare organizations implement the model in their own health care systems; Coordinating Center staff helped Sutter Health develop an IMPACT training program for their care managers. The first part of the training also included the primary care physicians and a psychiatrist who would be involved in the project. As important stakeholders in this new, groundbreaking program, they too needed to become familiar with how they, the care managers, and the patients themselves could achieve success with IMPACT.

With their training complete, staff members were now ready to identify patients like Betty who needed a new approach for treating their depression. “It’s usually pretty easy to identify the depressed patients with chronic medical illnesses because they are the ones who say, ’I can’t’ or ‘I won’t’ when you try to work with them,” says Jürgen Unützer, Director of the IMPACT Coordinating Center.

The next hurdle: creating time

Doctors became excellent referral sources; file reviews were also good sources for potential IMPACT patients. However, even though patients and providers were interested, time was a problem. Donna Christensen, R.N. had been a care manager at Sutter Health for three and one-half years. Once she transitioned to the IMPACT model and identified the depressed patients needing intervention, she found that her biggest challenge was time. Office visits didn’t allow enough time for her to sit with the patients, assess them, and introduce them to the problem-solving component of IMPACT.

Donna did some problem solving herself and came up with an innovative solution: she began conducting her initial visit in each patient’s home. This valuable face-to-face contact gave her enough time to fully involve the depressed patient in the program. For many, this individualized, focused encounter was the beginning of the end of their sense of helplessness and hopelessness.

Betty begins

When Donna first met with Betty, she administered the PHQ-9, a widely used, brief index that includes nine questions, each one about a particular symptom of depression and how often the patient experiences it. Questions such as, “Do you have very little interest or pleasure in doing things?” “Do you feel bad about yourself or have thoughts of death or self-harm?” The questionnaire helps patients and their doctors identify and focus on thoughts and feelings associated with depression and helps practitioners determine if a person is suffering from clinical depression.

Betty’s PHQ-9 score was 17, which meant that her depression was moderately severe. “I knew right away that Betty would be a good candidate for IMPACT,” says Donna. And she was. At their first meeting, Betty agreed to switch to a new antidepressant, which was much move effective for her. Her body began feeling better and she could move around more freely. As Betty became more mobile, she felt good enough to reenter her social life, minimize her isolation, and enjoy herself.

Betty’s activities have come full circle: because she is more active, she is in less pain, once again feels connected to others, and is less depressed. Betty routinely swims for exercise and is an active board member for the gated community where she lives. At last check, her PHQ-9 score showed no residual depression at all. Clearly, IMPACT works well for Betty.

Kindness matters

The caring connection that the IMPACT model fosters makes a difference in the lives of depressed patients and contributes to job satisfaction for the practitioners using it. “Patients tell me that their quality of life has improved,” says Donna. “They are simply happy to have someone who they believe cares about them to offer help and support.”

Caring and encouragement meant the world to Abby—another of Donna’s patients—who was depressed and stuck in an emotional rut. She lived on an inadequate, fixed income. She had not had deep pockets in the past and had no savings today. In order to obtain her antidepressant medication at no cost, Abby had to complete complex forms that she considered a real pain in the neck. Depression had zapped much of her energy, hope, and enthusiasm so Abby just went around the system: she stopped taking her antidepressant altogether!

Thanks to Donna’s initial home assessment, Abby began feeling that just maybe her rut was reversible. She and Donna talked about her symptoms of depression and possible treatments to move her toward feeling better. Donna explained that there were other antidepressants available that didn’t require Abby to fill out any forms.

The next day, Donna contacted Abby’s primary care doctor who didn’t realize that Abby had stopped taking her antidepressant medication. She hadn’t seen Abby for four months, since the day she initially prescribed it for her. After conferring with Donna, Abby’s doctor agreed to prescribe one of the antidepressants that would be easy for Abby to obtain.

Since then, Abby has been taking her medication and feels the energy and joy in life that was lacking during her depression. “I’m feeling a lot better,” she says. “The time that Donna took to come to my house and help me has made a big difference for me. She took the time to help me understand more about depression and to help me find a way to get the medication that I need. I am so thankful for her. ” +

* Patients’ names, professions and financial circumstances have been changed to protect their confidentiality.

+ Story based in part on content originally published in the 2002 John A. Hartford Foundation annual report. Used with permission.

Big Changes in the Big Apple: The Institute for Urban Family Health Adopts IMPACT

“It is good to see that mental health is once again becoming a part of the medical interview, as so much of our patients’ health depends on their mental well being.” - Dr. Eric Gayle

For millions of Americans, access to health care is a “privilege” they can’t afford. In 1994, in response to the country’s widening health care gap, the Institute for Urban Family Health began a groundbreaking service-delivery program. Founded by Neil Calman, MD, President and CEO, the Institute maintains an open mind to innovative programs and open arms to patients from a broad spectrum of economic, social and ethnic backgrounds. The Institute serves individuals and families without health care coverage, immigrants, those with limited income and homeless patients in New York City.

Using the family medicine model, this unique, non-profit health care organization runs 13 clinics and sees patients at nine sites that include soup kitchens and homeless shelters. In addition to its medical mission, the Institute conducts health services research, develops health policies, manages the Urban Family Health Residency at Beth Israel Hospital and works to spread this innovative approach around the country.

If you are interested in adapting IMPACT for your practice, please contact the Implementation Center.

Urban elders and depression

People can become depressed due to one or more factors such as genetics, brain chemistry imbalances, illness, loss and trauma – just to name a few. Poverty piles on its own risk for depression. It often feeds a chronic sense of hopelessness by robbing individuals of their personal power, limiting their options and their ability to advocate for their own, or their family’s health care needs. The Institute for Urban Family Health provides an important safety net for many individuals and families who fall through the cracks in the health care system. However, the Institute’s altruistic approach has its share of challenges and roadblocks. Many of their immigrant patients are accustomed to prevention and treatment methods unlike those offered in the United States. Language barriers challenge provider and patient communication. Economic and social stress makes it difficult for many, particularly seniors, to seek care and follow up with appointments. Some are not ambulatory or lack money for transportation while others are kept busy at home caring for grandchildren, putting their own health needs on hold.

A very smart move

Effectively treating depression in an underserved, urban population is fraught with obstacles such as those listed above. Overcoming these obstacles is the mission of Virna Little, Vice President for Psychosocial Services and Community Affairs, who has been with the Institute for over ten years.

A few years ago, the Institute received a Fan Fox and Leslie R. Samuels Foundation grant to help identify and treat depressed seniors in primary care. Little’s contact at the Foundation suggested that she look into a program called IMPACT, a model of depression care that more than doubles the effectiveness of depression treatment for older adults in primary care settings. The strong research evidence supporting the IMPACT model quickly convinced Little of its value. She saw it as an opportunity to improve care for the Institute’s patients. She returned from an IMPACT training conference in San Francisco inspired and ready to roll.

The Institute first implemented IMPACT at five of its sites. Inspired by the results, the institute now uses the model in all of its clinics. Physicians and staff have found that the IMPACT program provides them with tools that help successfully identify and treat depressed patients who might otherwise have slipped through the cracks. They are so committed to the model that they have built program components into their electronic medical record system and built their own database to track the effectiveness of treatment for depressed patients. For example, when a patient fills out the PHQ-9, a quick tool that measures depression symptoms, their results automatically show up in their medical chart. “Staff consider PHQ-9 results a lab value and any score of 10 or above is flagged as an abnormal lab,” says Little. This signals the provider to initiate treatment and monitor their patient’s depression and progress.

“Project IMPACT has allowed me to incorporate a new tool (PHQ-9) into my primary practice, which has improved the accuracy of my diagnosis while increasing my efficiency and productivity as well,” says Joseph Lurio, MD, a provider at the Institute’s 68th Street clinic in Manhattan. “It helped me identify patients I initially overlooked.”

Pain and courage – Art’s story

"I was a mess after my wife died,” says Art, an 80-year-old patient from the Bronx. He walked into the Institute’s 86th Street clinic one day feeling overwhelmed with grief and sadness. “I was very, very depressed, lonely, and just lost without her and didn't know how to keep going," he remembers.

The insight and bravery it took for Art to seek help was matched by the support and treatment he found at the clinic. His clinician, Kat, met with him and administered the PHQ-9 as part of her assessment. Art’s score of 22 on the PHQ-9 indicated that he was suffering from serious depression. Kat felt sure that Art would greatly benefit from the IMPACT model. He agreed to attend ongoing therapy and a depression education group, both of which helped him cope with his loss. In time, he added an antidepressant to his treatment plan.

Art is indeed the poster patient for Project IMPACT. He set self-care management goals to overcome his depression and worked toward achieving these goals with the support of his care manager. At his three-month follow-up appointment, Art’s PHQ-9 score had dropped to eight – a huge improvement over his initial score of 22. His hard work and the care he received at the Institute turned his life around. Art feels more energetic, less depressed and more like socializing with other people. He is finding balance between meeting his own needs and those of others. He sees Kat for a dose of "maintenance therapy" twice a month. Clearly, Art has found a satisfying way to go on living, even though he still misses his beloved wife.

IMPACT breaks the age barrier

The Institute recognized the IMPACT model’s value and versatility. The success they had using IMPACT with seniors inspired them to use it with all of their adult patients. The organization set a goal: screen all Institute patients 18 years and older. So far, they have achieved an impressive 89 percent screening rate! First, they screen patients using the PHQ-2, which asks two questions to determine if a patient is most likely depressed and in need of further assessment. One-third of patients screen positive for depression with this tool and one-third of those subsequently test positive for depression on the longer PHQ-9.

Listen, respect, adapt – the road to patient participation

“Depression in [the] primary care setting is too often overlooked. Thus, depression screening is a welcomed tool for addressing an important and hidden psychosocial need, especially within inner-city communities,” says Dr. Elizabeth Reynolds. Depending on each patient’s needs and wishes, treatment may include medication and/or individual therapy, depression education classes or support groups. Patients are assigned a care manager who works closely with them and their primary care provider to coordinate their treatment and measure whether or not it is working. If the patient does not respond well, the care manager, patient and primary care provider make a new treatment plan.

Even the very best treatment cannot help if patients don’t feel comfortable participating in treatment. A focus group held in the Bronx with people of color helped educate staff about cultural roadblocks to good care and alternate routes to achieve the same goal – reducing the suffering of patients with depression. Their message could not have been clearer. Within this community, resistance grounded in cultural norms challenge each step. “There is a stigma about going to therapy,” explains Little. “Many times, a patient’s first response is ‘I’m not crazy.’” The prevailing sentiment in the focus group was that people didn’t want to participate in one-to-one therapy sessions. They preferred groups, but not ones called “depression groups” or “depression classes.” The Institute uses staff trained in social work to coordinate care for their depressed patients. But in the Bronx, an impoverished community, the title “social worker” has a bad association, reminding people of negative experiences with public assistance and child protective service agencies.

In response to focus group feedback, the Institute’s staff made simple, but important, adjustments to the IMPACT program to help these patients feel more comfortable about depression care. Patients see ‘health consultants,’ rather than ‘social workers. ‘Story groups’ are more social and solution focused than ‘depression groups.’ “People bring in photographs, primarily of their families, and tell stories about the photographs,” says Little. “We get to their issues that way.”

System-wide changes bring system-wide results

Every clinic has its “frequent flyer”patients whose somatic complaints bring them into the office time and again—often with symptoms that point to stress and depression. Since the Institute implemented IMPACT, Little has seen a big decrease in visits from these patients, lower Emergency Department utilization and an increase in specialty appointments, like cardiology and endocrinology. Translation: people are taking better care of themselves.

Dr. Nicole Kichta says of one senior patient, “ … during her physical, she [the patient] told me that the PHQ-9 ‘saved her life.’ She told me that her depression was just something that she dealt with and, until we asked, she had never told anyone. She is now doing extremely well.”

Other patients, health care providers and independent researchers tell the same story. The Institute partnered with researchers from Fordham University to conduct an independent evaluation of their IMPACT implementation. Preliminary results show that the Institute’s program is equally as effective as the original IMPACT research study. That is, it doubles the effectiveness of depression care.

The Institute’s vision

“We continue to see improvements in the quality of life in many of our patients who have participated in Project IMPACT,” says Calman. “The project has given us the tools to continue to identify and treat patients with depression in our ambulatory care centers.” For example, because more than half of the depressed seniors have one or more chronic illnesses, all patients who have suffered a myocardial infarction or have Hepatitis C are automatically flagged for a PHQ-9 depression assessment. Calman’s staff now has a successful treatment option for their depressed patients who can and will get better with personal determination and the support of a caring staff.

Art, the elderly widower profiled above, best sums up the effects of implementing IMPACT at the Institute of Urban Family Health: "Project IMPACT saved my life."