CO-FUNDING

Making a Lasting
IMPACT on Improving
Mental Health

Project IMPACT, a groundbreaking model of depression treatment in primary care settings, gained enormous credibility when it proved twice as effective as—and less expensive than—usual treatments for depression, in what is still the largest randomized clinical trial in depression treatment.

What made this impressive randomized trial possible? Partnerships.

In 1999, the Hartford Foundation wanted to give more emphasis to the mental as well
as physical health of older adults. Through an extensive planning process that drew in researchers, advocates, and government agencies, this effort led to Project IMPACT (Improving Mood – Promoting Access to Collaborative Treatment for Late-Life Depression), a promising new team care approach pioneered by Jürgen Unützer, MD, MPH, MA, then at the University of California, Los Angeles.

Fact: 1 in 10 older adults visiting a physician suffers from depression.

“I realized early on in my career that most older adults who have depression will never see a mental health specialist, a psychologist, or psychiatrist like me. They go to their primary care doctor,” Dr. Unützer says. “We wanted to be able to build a program that meets the patient right there in the primary care doctor’s office and offer some treatment that can really help them with their depression.”

The Hartford Foundation, convinced that Dr. Unützer’s approach had the potential to be a game-changer in the field, engaged in an open planning process that helped build trust
as it reached out to potential partners to help fund the multisite trial.

One potential partner Hartford staff approached was the California HealthCare Foundation (CHCF), which had incorporated in 1996 as part of the complex negotiations that allowed Blue Cross of California to convert from a nonprofit to a for-profit organization and had just made its first grants in the area of elders and managed care.

There were two sites under review for participation in the IMPACT demonstration in California, both part of the large Kaiser Permanente network. CHCF agreed to fund one of the sites, but asked if it could add another—one outside the Kaiser Permanente network, representing large medical groups with managed care contacts that were major players in California’s health care landscape at the time.

“Hartford was incredibly flexible,” recalls Jan Eldred, MS, program officer for CHCF at the time. “They knew what we wanted and they understood why we needed to do this process.”

CHCF brought in the Desert Medical Group in Palm Desert, CA. As a result, the trial launched with seven total sites, three of which were in California. CHCF also helped fund some administrative and evaluation costs incurred on behalf of their two sites.

“There were huge numbers of pluses for us,” Ms. Eldred, now retired, says. “There was the expertise at Hartford. There was the expertise from the original research. There was a national advisory committee. Our grantees would have access to all these other grantees and experts around the country coming to the national meetings and being part of the evaluation.
This enabled them to share their ideas and learn from each other. For a new foundation, it was a no-brainer. It made perfect sense for us given our interest in improving care for frail elders in managed care plans.”

Over five years, Hartford provided $8 million for the clinical trial, and CHCF, the Hogg Foundation for Mental Health, and the Robert Wood Johnson Foundation contributed $3 million in co-funding.

(Above, clockwise from top left)
Top left: Participants in Seattle, WA discuss the implementation of IMPACT under the Social Innovation Fund.
Top right: Christopher A. Langston, PhD, Hartford Foundation Program Director.
Middle right: Dr. Masterson and (right) Ahmed V. Calvo, MD, MPH, Health Resources and Services Administration.
Bottom right: From left to right: Steven Clark, Executive Director, Valley View Health Center; Commissioner P. W. “Bill” Schulte, Board of County Commissioners, Lewis County, WA; Brian J. Masterson, MD, MPH, Office of the Surgeon General.
Bottom left: A presentation on SIF- IMPACT implementation.
Center photo: Diane Powers, Associate Director, AIMS Center.

(Below) IMPACT implementation at Partnership Health Center, Missoula, MT with team members Colleen M. Harrison, MD; Charles W. Rourke; Kesli Delgadillo; and a patient

The IMPACT model offers resources to help primary care doctors treat depression in older adults. The program trains a staff person in the office—a nurse, clinical psychologist, or social worker—to work alongside a doctor with patients suffering from depression and perform supportive tasks such as providing follow-up on medication. IMPACT also has a dedicated psychiatrist assigned to the office who meets weekly with the trained staff member to review the cases of patients who are not getting better.

The multisite trial established IMPACT as a cost-effective, evidence-based model. In 2004,
a $2.4 million Hartford grant was used to create what became the Advancing Integrated Mental Health Solutions (AIMS) center at the University of Washington in Seattle, where Dr. Unützer now is Chair of the Department of Psychiatry and Behavioral Sciences. The implementation center, which is self-sustaining, has attracted numerous other partners, from the Fan Fox and Leslie R. Samuels Foundation—which gave a grant to the Institute for Family Health to adopt the IMPACT model in its chain of health centers in New York City and the Hudson Valley—to the National Institute of Mental Health, which awarded a grant to study the rollout process across Minnesota as part of the Institute for Clinical Systems Improvement’s DIAMOND (Depression Improvement Across Minnesota, Offering a New Direction) program for depression.

And in a nice twist, Ann F. Monroe—who led the quality initiative at California HealthCare Foundation during the time those first crucial partnerships were formed around IMPACT— is now president of the Health Foundation for Western and Central New York, which just funded its first IMPACT grant in upstate New York.

“We’re not a research foundation in the sense that we look to develop brand new models,”
Ms. Monroe says. “We really look to integrate what’s been learned in our community with what has been shown to work. In order to do that, I think it’s most effective if we can have an ongoing dialogue and ongoing respect for each other’s work and really be both candid and helpful to each other in crafting various types of projects.”

“We can’t achieve our goals at this foundation unless our partners in the community are at the top of their game. We can’t have ideas and implement them if the organizations we fund aren’t up to the task. The same is true with national and local funders. They can’t achieve their goals without us—meaning smaller, local foundations—being equal partners in things, rather than just pass-through funders.” Ann F. Monroe
President, Health Foundation for
Western and Central New York

The Health Foundation for Western and Central New York grant supplements a state grant to adopt an IMPACT depression treatment model at Niagara Falls Memorial Medical Center,
which is located in a low-income area with many older adults.

It’s another example of how IMPACT continues to attract new partners who share the vision of bringing improved mental health treatment to older adults who desperately need it. And this vision has been compelling to new government partners as well. A grant from the Social Innovation Fund (SIF) ushered the Hartford Foundation into a creative new form of public-private partnership, in which the Foundation fills the role of an intermediary who helps spread the IMPACT model to the rural Northwest.

The SIF program, part of the federal Corporation for National and Community Service (CNCS), helps pool scarce financial resources and target them to support innovative practices that solve important social problems. In its role as SIF grantee, Hartford is responsible for re-granting the pooled funds to federally qualified health centers (FQHCs) that either adopt or expand the IMPACT model, along with contracting for technical assistance and evaluation services to ensure fidelity.

The result: Hartford’s $3 million investment over three to four years turns into $6 million when matched by $3 million in federal funds, and then almost $12 million with required matching funds from sub-grantees. The Foundation’s SIF grant, designed with the University of Washington’s AIMS Center, targets the five largely rural states for which the University of Washington is the only medical school: Washington, Wyoming, Alaska, Montana, and Idaho.

“Our deeply collaborative work with many institutions and clinics has a distinctly human dimension,” says Wally B. Patawaran, MPH, a program officer for the Hartford Foundation. “It’s about helping people reclaim their lives in low-income rural communities that suffer from
a lack of economic and social resources.”

In 2013, grants totaling $1.94 million for the initial two years were awarded by the Foundation to five sub-grantees—two in Washington and one each in Montana, Wyoming, and Alaska. In 2014, another two to three sub-grantees will be added. Eligible non-federal matching funds must match each sub-grant award on a dollar-for-dollar basis in cash, so the Hartford Foundation has forged partnerships for the first time with the Margaret A. Cargill Foundation (MAC) and the Rasmuson Foundation, along with smaller local funders such as Lewis County, Washington and the Kinskey Family Foundation, to come up with the matches.

Hartford Trustees and staff have worked to build a relationship with the MAC Foundation, one of three separate grantmaking charities under the Margaret A. Cargill Philanthropies, based in Minnesota, which resulted in Cargill agreeing to co-fund three of the clinic sites in Wyoming, Washington, and Montana.

The MAC Foundation added Aging Services as one of its seven program areas just two years ago, and is in the process of hiring a leader for the new program, says Terrence R. Meersman, vice president for programs. Building relationships and trust in the field of aging is very important.

“We rely a lot on expert partners who are working at scale and making a difference at the community level,” Mr. Meersman says.

The SIF grant “rang a lot of bells” for the MAC Foundation, because the Aging Services area has as its overarching goal improving the quality of life for older adults and helping keep people living independently in their homes and communities for as long as possible, he says, adding that the Foundation also has a special interest in rural areas.

And, thanks to the good offices of a Hartford Trustee, the Rasmuson Foundation joined the project as well. Rasmuson, which promotes better living for Alaskans and funds only in
the state, agreed to co-fund the Alaska site.

The SIF grant not only underscores the importance of building trust and relationships to bring new partners to the table, it also illustrates the need to weigh costs versus benefits, when considering a project for funding. In every partnership, there are costs in terms of money, time, and communication. Before deciding to pursue the grant, Foundation staff talked with prior SIF grantees and realized that the multi-layered project would include assuming responsibility to identify, select, and manage sub-grantees, as well as working with the co-funding partners and the federal government.

The infusion of public and private money to help spread the IMPACT model more than offsets additional costs to the Foundation and turns the attention of a major federal program to the issue of better mental health care for older adults in rural areas.

As IMPACT continues to bring evidence-based depression treatment to older Americans who need it, the partners who help make it possible are discovering what Eldred did 15 years ago:
“It was an absolute win-win for our foundation.”