Care of Mental, Physical and Substance Use Syndromes (COMPASS)

Project Name:
Care of Mental, Physical and Substance Use Syndromes (COMPASS)
Principal Investigator:
Sanne Magnan, MD PhD; Evaluation Director: Leif Solberg, MD
Principal Investigator Contact Information:
Principal Investigator institution:
Institute for Clinical Systems Improvement; HealthPartners Institute
Centers for Medicare & Medicaid Services (CMS) / Center for Medicare & Medicaid Innovation (CMMI)
Funding Period:
07/2012 – 06/2015
Health care increasingly needs to develop ways to manage individuals with multiple coexisting chronic conditions. COMPASS is a partnership among 9 organizations and 18 care delivery systems nationally to implement the Collaborative Care model for patients in primary care suffering from depression as well as diabetes and/or cardiovascular disease that are not under control. The initiative reached approximately 4,000 patients in seven states, and improved depression in 40% and achieved control in 23% with diabetes and 58% with hypertension while improving patient satisfaction with care and physician satisfaction with the resources needed to manage such patients.
Grant Number:
Participating Sites:               
AIMS (Advancing Integrated Mental Health Solutions) Center at the University of Washington
Community Health Plan of Washington (CHPW)
HealthPartners Institute
Kaiser Permanente Colorado (KPCO)
Kaiser Permanente Southern California (KPSC)
Michigan Center for Clinical Systems Improvement (Mi-CCSI)
Mount Auburn Cambridge Independent Practice Association (MACIPA)
Pittsburgh Regional Health Initiative (PRHI)
Institute for Clinical Systems Improvement (ICSI)
Sanne Magnan, MD, PhD
Claire Neeley, MD
Leif Solberg, MD
Arne Beck, PhD
Karen Coleman, PhD
Jurgen Unutzer, MD
Rebecca Rossom, MD, MS
Lauren Crain, PhD
Michael Maciosek, PhD
Robin Whitebird, PhD, MSW, LISW
Major Goals:
The major goals are to increase the proportion of these complex uncontrolled patients who are now under control by 20% for patients with diabetes or hypertension, and to improve depression in 40%, while reducing healthcare costs
Description of study sample:
This was a demonstration project aimed at adults with active depression plus either diabetes or cardiovascular disease that were not under control. We initially targeted patients with Medicare or Medicaid, but later added other patient groups because of the unexpected difficulty of identifying and recruiting such patients.
Current Status:
The project was completed in 6/15, but most participating medical groups have continued it with a variety of modifications to fit their settings and needs
Study Registration:
Coleman KJ, Hemmila T, Valenti MD, Smith 4, Quarrell R, Ruona LK, Brandenfels E, Hann B, Hinnenkamp T, Parra MD, Monkman J, Vos S, Rossom RC. Understanding the experience of care managers and relationship with patient outcomes: the COMPASS initiative. Gen Hosp Psychiatry. 2016 Aug 18. pii: S0163-8343(16)30164-5. doi: 10.1016/j.genhosppsych.2016.03.003. [Epub ahead of print]Coleman KJ, Magnan S, Neely C, Solberg L, Beck A, Trevis J, Heim C, Williams M, Katzelnick D, Unützer J, Pollock B, Hafer E, Ferguson R, Williams S. The COMPASS initiative: description of a nationwide collaborative approach to the care of patients with depression and diabetes and/or cardiovascular disease. Gen Hosp Psychiatry. 2016 Aug 18. pii: S0163-8343(16)30166-9. doi: 10.1016/j.genhosppsych.2016.05.007. [Epub ahead of print]Rossom RC, Solberg LI, Magnan S, Crain AL, Beck A, Coleman KJ, Katzelnick D, Williams MD, Neely C, Ohnsorg K, Whitebird R, Brandenfels E, Pollock B, Ferguson R, Williams S, Unützer J. Impact of a national collaborative care initiative for patients with depression and diabetes or cardiovascular disease. Gen Hosp Psychiatry. 2016 Aug 18. pii: S0163-8343(16)30165-7. doi: 10.1016/j.genhosppsych.2016.05.006. [Epub ahead of print]Solberg LI, Ferguson R, Ohnsorg KA, Crain AL, Williams MD, Ziegenfuss JY, et al. The challenges of collecting and using patient care data from diverse care systems: lessons from COMPASS. Am J Med Qual 2017;32(5):494-499.Whitebird RR, Solberg LI, Crain AL, Rossom RC, Beck A, Neely C, Dreskin M, Coleman KJ. Clinician burnout and satisfaction with resources in caring for complex patients. Gen Hosp Psychiatry. 2017;44(1):91-95. Jul 16. pii: S0163-8343(16)30167-0. doi: 10.1016/j.genhosppsych.2016.03.004. [Epub ahead of print]Solberg LI, Ohnsorg KA, Parker ED, Ferguson R, Magnan S, Whitebird RR, Neely C, Brandenfels E, Williams MD, Dreskin M, Hinnenkamp T, Ziegenfuss JY. Preventable hospital and emergency department events: lessons from a large innovation project. The Permanente Journal 2018 (In press).
Lessons Learned:
It is possible to have multiple diverse health care organizations collaborate on a common improvement project and to use a common data system to aggregate data for reporting and analysis, although there are many challenges to doing so. Other lessons are available in the above publications. Additional publication in development describes the relation between care manager contacts and systematic case review to depression improvement.
What’s next?
Most participating organizations are continuing to use individually adapted versions of the COMPASS model for care but there will be no follow-on group project.