The Issue

One-third of Medicare patients have diabetes and another 30% have coronary artery disease. When depression is present (15% of the time), health care costs are 65% higher. In addition, the majority of patients with depression have other chronic conditions1-3.

There is a bidirectional relationship between depression and many chronic medical disorders, with each side contributing to disease and care costs for the other4-6. Patients with depression and diabetes or cardiovascular disease have poorer self-care, greater functional impairment, and an increased risk of developing complications and mortality7.

The Solution

There is substantial scientific evidence that collaborative care management for patients with chronic physical and mental health conditions can greatly improve their quality of care, outcomes, and satisfaction; and can generate healthcare cost-savings over time.

The primary care practice is where most people go for routine care, yet depression is often overlooked. By addressing mental and physical chronic diseases with the COMPASS model, the physician can more readily identify patients with depression and risky substance use. By treating these behavioral diseases, patients can better deal with managing their physical diseases.

Through a three-year cooperative agreement with the Centers for Medicare and Medicaid Innovation, a consortium of eight implementation partners, led by the Institute of Clinical Systems Improvement and including the Pittsburgh Regional Health Initiative, is implementing and evaluating a collaborative care management model (CCMM) to improve the care of patients with both physical and mental health conditions. As an implementation partner, PRHI is responsible for project management, practice recruitment, training and coaching, implementation, community involvement, and sustainability in Pennsylvania.

COMPASS (Care of Mental, Physical and Substance Use Syndromes) is a CCMM created by integrating several existing, evidence-based CCMMs (IMPACT, TEAMcare, and SBIRT) and the best practices discovered in their implementation (e.g., ICSI’s DIAMOND and PRHI’s Partners in Integrated Care implementation initiatives). It was designed to create a system within the primary care setting to treat adult patients who have depression along with poorly controlled diabetes and/or cardiovascular disease.

Components of COMPASS include

  • Care team comprised of a primary care team, systematic case review team, care manager, and the patient
  • Thorough initial evaluation, including screening for relevant comorbidities, measuring condition severity, and supporting patient self-management to control key disease parameters, including PHQ- 9, HbA1C, SBP and LDL
  • A computerized registry for care monitoring of both individual patients and overall panel management
  • Treatment to target and treatment intensification when there is a lack of clinical improvement
  • Prevention of avoidable hospital and emergency department admissions and readmissions
  • A care manager to monitor condition status, provide self-management support, refer to community resources, coordinate care, facilitate communication between the physician consultant(s) and the primary care physician, and provide proactive follow-up
  • Expert physician consultant(s) with clearly defined roles to provide a weekly review of inadequately responding cases with the care manager and suggest treatment changes to improve depression and glycemic, lipid and blood pressure control, or further evaluation to the primary care physician
  • Aggregate data evaluation and quality improvement

Measure of Success

The consortium-wide goals are to effect a decrease in PHQ-9 by ≥ 5 or PHQ-9 < 10 for 40%; improve diabetes and hypertension control rates by 20%, improve patient and clinician satisfaction with care by 20%; and reduce healthcare costs by $25 million for enrolled patients.

Results to Date

More than 270 patients engaged in the care model from over 25 primary care offices.

Robert Ferguson
Program Manager
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1Adler GS. Diabetes in the Medicare aged population, 2004. Health Care Finance Rev. Winter 2007;29(2):91-101.
2Unutzer J, Schoenbaum M, Katon WJ, et. Al. Health care costs associated with depression in medically ill fee-for-service Medicare participants. J Am Geriatr Soc. Mar 2009;57(3):506-510.
3Bambauer KZ, Safran DG, Ross-Degnan D, et al. Depression and cost-related medication non-adherence in Medicare beneficiaries. Arch Gen Psychiatry. May 2007;64(5):602-608.
4Rush WA, Whitebird RR, Rush MR, et al. Depression in patients with diabetes: does it impact clinical goals? J Am Board Fam Med. Sep-Oct 2008;21(5):392-397.
5Dirmaier J, Watzke B, Koch U, et al. Diabetes in primary care: prospective associations between depression, non-adherence and glycemic control. Psychother Psychosom. 2010;79(3):172-178.
6Katon WJ. Epidemiology and treatment of depression in patients with chronic illness. Dialogues Clin Neurosci. 2011;13(1):7-23.
7National Alliance on Mental Disease. Depression and chronic illness fact sheet. October 2009.