Debbie Oswalt, Executive Director, Virginia Health Care Foundation
Cat Hulburt, Chief Program & Engagement Officer, Virginia Health Care Foundation
Inadequate access to mental health services, diabetes, and obesity are the top-ranked critical service gaps in virtually all community health needs assessments conducted by local health departments and nonprofit hospitals throughout Virginia. Diabetes and depression are also among the top three conditions treated in Virginia’s health safety net (HSN) organizations. Recognizing this and the contributory relationship between depression and diabetes, the Virginia Health Care Foundation (VHCF) and several other health funders throughout the state collaborated on Defeating the Deadly Double: Depression and Diabetes (DDD).
Approximately 40 percent of individuals with diabetes have depression – double the prevalence of depression in the general population. Successful diabetes management requires active patient involvement in lifestyle changes (e.g., healthy eating, exercise). Depression, however, often impedes a diabetic’s capacity to meaningfully engage in needed changes.
Depression and diabetes can be treated simultaneously. Managing one condition impacts the other. National studies suggest that 59 percent to 80 percent of patients with depression recover completely with adequate treatment. Without intervention, only 30 percent to 50 percent of diabetics with depression are typically identified and treated. This leaves many patients who have these co-occurring chronic diseases in a downward spiral with higher A1c levels, greater symptom burden, and more day-to-day difficulties.
A Possible Solution
DDD was designed to reduce the severity of depression in participating diabetic patients, so they could more actively manage their diabetes, via an elevated level of behavioral health integration within participating HSN practices. This required increasing staff awareness and collaboration and changing protocols and workflows for diabetic patients with depression. The thesis was that focusing on a discrete group of patients would be manageable. It was also thought that successes resulting from elevated behavioral health integration with the targeted group of patients would stimulate a desire to replicate the success by making the same types of changes for other patients.
To help achieve successful patient outcomes, DDD required ongoing collaboration with grantees. VHCF and the experts it hired provided comprehensive technical assistance during the project period and, along with grantees, adjusted programmatic and evaluative approaches throughout the initiative. This included examining and fine-tuning protocols, workflows, and procedures to better identify, treat, and track diabetics with depression.
The success of this two-year $1.3 million initiative was measured by a reduction in: severity of depression on a PHQ-9 test; blood sugar via hemoglobin A1c test; and weight and BMI.
- Of the targeted patients enrolled in DDD for at least 12 months, 61 percent reduced their levels of depression and 60 percent improved their hemoglobin A1c scores. Additionally, 52 percent lost weight and decreased BMI; all DDD patients combined lost more than 4 tons of weight.
- The participating organizations reported higher levels of collaboration and significant advances integrating the delivery of behavioral health and medical services.
- Workflows changed to ensure that all diabetic patients were screened for depression and treated, as appropriate.
Grantmaking Techniques Utilized
- Competitive RFP, intensive pre-proposal workshop, and extensive review process.
- Written personal commitment of clinic and administrative leaders to actively participate in internal interdisciplinary teams and DDD collaboration at health center/clinic practice and at quarterly meetings of all DDD grantees.
- A $10,000 per year stipend to support collaboration time and effort.
- Grantee assessments of their practice protocols and workflows, as well as determination, implementation, and tweaking of new ones that ensured a depression screening for each diabetic patient and provision of needed depression treatment at no cost.
- Quarterly convenings of all grantee teams to debrief, evaluate data, learn from other grantees, and hear from experts about mutual challenges.
- Uniformity of patient data collection to measure results and analyze factors key to patient outcomes.
- Content and leadership of quarterly meetings and evaluation of DDD initiative by knowledgeable independent consultant.
As a grantmaker, continued involvement at the granular level, such as helping to create, build, implement, and evaluate the systems for capturing and analyzing data, provided an important look into the technical assistance needs of the grantee cohort. As the use of data to guide programmatic decision-making continues to grow in importance, the role of the grantmaker in setting up sustainable systems for such evaluations will grow, as well.
VHCF has used the levels of behavioral health integration developed by the Substance Abuse and Mental Health Services Administration (SAMHSA) as a tool to guide the evolution of this important approach to treating the whole patient.
VHCF plans to fund DDD 2.0 incorporating lessons learned from the perspectives and feedback of grantee teams, VHCF staff, and the project consultants.
DDD was supported by the Anthem Foundation, Kaiser Permanente, the Collis-Warner Foundation, the Dominion Foundation, Richmond Memorial Health Foundation, the Gwathmey Trust, and the Virginia Association of Health Plans.