Tiered, evidence-based, integrated care

Like many other countries, Germany is affected by the high and constantly increasing health and economic burden caused by mental illnesses. In 2015, the reference year of the RECOVER study, mental illnesses in Germany caused annual social costs of 146 billion euros, 4.8 billion euros of the gross domestic product, and the trend is rising.1 Of this, 44.4 billion euros were direct health costs including 24.9 Billions of euros in hospital costs.2 According to the Organization for Economic Cooperation (OECD), the insufficient establishment of evidence-based care models in Germany plays a role here, especially for people with serious mental illnesses.3

> Based on this health policy starting point, the RECOVER model* was developed3. From 2017 to 2021, its testing was funded by the Innovation Committee at the Federal Joint Committee (G-BA) (funding number: 01NVF16018). The three main goals of the RECOVER study were the reduction of social costs, greater effectiveness and better cost efficiency compared to standard care in Germany.3
The RECOVER care model is based on a comprehensive evidence analysis regarding the effectiveness and efficiency of managed care, care models and treatments for mental illnesses.3 Accordingly, the RECOVER model only integrates care components with (some internationally) proven evidence. In the spirit of cross-sector, tiered managed care models, the basic rules of the model included, in addition to the evidence base, coordinated and integrated collaboration between service providers and starting with the most effective and resource-saving treatment. It defines four levels of severity, which are made up of the severity of the disease and the level of psychosocial functioning. In addition, the disorder-specific lifetime risk for severe mental illnesses (e.g. schizophrenia in stage 4 with 90%igen risk) was taken into account.
The core components of the model were a (a) interdisciplinary and cross-sector managed care supply network with a care control center involving clinics and practicing doctors and psychotherapists in the care sector, (b) a clearly structured/defined access to care, (c) a multi-professional and interdisciplinary Initial examination, treatment planning and organization in the sense of a liaison outpatient clinic, (d) a multiprofessional and interdisciplinary crisis intervention team to prevent or reduce inpatient/day-care acute treatment according to the evidence-based model of the Crisis Resolution Team (CRT), (e) accompanied digital therapy by a E-Mental Platform (eRECOVER; www.erecover.de), (f) a graded individual psychotherapy and/or group therapy, (g) case management for people with general serious mental illnesses (level 3), (g) Assertive Community Treatment (ACT ) Teams for people with persistent serious mental illness (level 4), as well as (h) social work, supported employment and recovery support. In the interests of cross-sector quality assurance and transfer to other regions, 12 quality assurance manuals were created for all components and processes.
The effectiveness and efficiency of the model were
in a 12-month, two-armed random
evaluated in a controlled study in an extended care sector of the UKE. Participants aged 16 to 79 years with any mental illness were assigned to either RECOVER or Treatment-AS-Usual (TAU). A total of 891 patients were included (n = 477 in the RECOVER intervention, n = 444 in TAU).
The results showed significant and substantial reductions in the annual social costs and those borne by statutory health insurance. The reduction in hospital costs and the reduction in costs were particularly pronounced in the group with persistently severe mental illnesses (level 4). The latter result is of particular importance given the very high indirect and direct costs: Level 4 patients incurred total costs of 31,883 euros in the 6 months before inclusion, of which 10,485 euros were direct costs with over 90% hospital cost share.5 This high hospital share of direct costs Costs were also detectable with 88% for general serious mental illnesses (level 3).5 In both groups (levels 3 and 4), application psychotherapy did not play a role as a cost factor.
The overall RECOVER model proved to be mathematically extremely cost-effective compared to standard care. The results of cost reduction and cost effectiveness were also accompanied by significantly better treatment results and increased quality of care (primary endpoint calculated from clinical external and self-assessment). Subgroup analyzes also showed that before the corona pandemic, with only face-to-face study evaluation, significant differences in the primary effectiveness parameter in favor of RECOVER were also detectable. Improved quality of care was also reflected in several secondary endpoints, especially: a. regarding the participation of patients in the treatment process. As part of a strategic test of the transferability of the RECOVER model, the complete care model was transferred to another (rural) care region (Steinburg district, Itzehoe Clinic) with adaptation to local care structures and resources and successfully implemented there.
Corresponding reports were finalized at the beginning of 2023 and sent to the Innovation Committee at the Federal Joint Committee (G-BA) for assessment. Continuing the RECOVER model and its care components in future standard care is currently the subject of review within the G-BA's specialist committees.

by: Prof. Martin Lambert1, Prof. Anne Karow 1,
Prof. Holger Schulz2, Prof. Jürgen Gallinat1

1: Clinic and Polyclinic for Psychiatry and Psychotherapy, Center for Psychosocial Medicine, University Hospital Hamburg-Eppendorf (UKE), Martinistr . 52, 20246 Hamburg, Germany;
2: Institute and Polyclinic for Medical Psychology, Center for Psychosocial Medicine, University Hospital Hamburg-Eppendorf (UKE), Martinistr . 52, 20246 Hamburg, Germany

Corresponding author:

Prof. Dr. Martin Lambert

Clinic for Psychiatry and Psychotherapy

Center for Psychosocial Medicine

University Hospital Hamburg-Eppendorf

Martinistr. 52, 20246 Hamburg, Germany

Telephone: +49-40-7410-24041

Email: [email protected]