Transcript Perfect Depression Care - Henry Ford Health System

Perfect Depression Care
Justin Coffey, MD
Behavioral Health Services
Terri Robertson, PhD
Center for Clinical Care Design
Objectives
1
2
5
Recognize the value of including depression care into chronic
disease care models
Discuss the benefits of using standardized depression
screening tools, such as the PHQ-2 and PHQ-9
3
1. Understand the key components of evidenced-based
treatment for clinical depression
4
Enhance knowledge of suicide prevention strategies
Develop several strategies for integrating depression screening
and treatment into clinical practice
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Suicide Statistics
• There is a suicide every 15 minutes in the US
• 90% of people who die by suicide have a diagnosable and
treatable psychiatric disorder at the time of their death
• 70% of patients committing suicide have seen their primary
care provider within 6 weeks of the suicide
….. There is an opportunity here!!
Number of suicides per 100,000 US general population
Suicides per 100,000 HMO Patients
Suicides per 100,000
250
200
150
100
50
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Expected suicide rate for patients with an active mood disorder (21X)
Expected rate for euthymic patients with mood disorder (4-10X)
Number of suicides per 100,000 US general population
Number of suicides per 100,000 HAP-HFMG patients
Number of suicides per 100,000 US general population
Q3
YTD
Suicide Ideation Trends- HFMG
% of Primary Care Patients with a
Positive Q9 on PHQ9
25
20
15
10
5
0
2006
2007
2008
2009
2010
2011
YTD
Depression in Primary Care Model
• Registry (DocSite) to identify eligible
patients
• Standardized, evidenced-based tools
– PHQ2
– PHQ9
HFHS DST
• Automated tools
– Embedded in EHR
• Simple
– Self-scores
– Provides interpretation
– Links to treatment guidelines
• Evidenced-based treatment menu
based on patient preference
– Medication management
– Psychotherapy (CBT)
– Problem-solving therapy (PST)
• Utilize MA’s to “tee up” process
• Use Psychiatric NP’s and/or Clinical
Psychologist to spread tools/ train
clinic staff
• Cross trained Diabetes Care Center
and RN Case Managers
(collaborative care)
Depression Screening Tool
PHQ-2 branches when positive
(> 3) to full 15-item DST
Safety Visual
Management
1
2
Alerts at top of patient record:
1 D= DST score is > 10, alert is removed after DST is signed by Responsible Staff
2 S= Suicide risk question(s) answered positively, alert is removed when DST is
repeated and suicide risk questions are negative
Diabetes Care Center2011 Depression Screening Rates
PHQ-2 Rates
DST Rates
90
97%
2011 Goal=83%
80
83%
70
70%
72%
60
50
2008
2009
2 0 10
2 0 11- Q 3
% pts w/ follow-up DST
(when PHQ-2+)
% of eligible patients
screened
10 0
100
2011 Goal=85%
97%
90
80
85%
70
60
52%
50
40
30
20
10
15%
0
Before
process
change
2009*
After
process
change
2009**
2010
2011-Q3
Continuous Improvement
• Realized that clinics needed more education/ tools
specific to handling a potentially suicidal patient
• Solution:
– 1) Developed a suicide triage protocol
– 2) Partnered with the DCC staff, who selected this as
their 2011 safety goal
Diabetes Care Center
Response to Q9 for Suicide
Pre suicide safety goal (2010)
Post suicide safety goal (2011)
BHS Referral
11%
no info for
disposition
27%
52%
BHS referral
7%
No info on
disposition
PCP Referral
7%
59%
7%
Refused or
Missed
appointment
21%
N=33
7%
N=27
Outside BHS
provider
Sent to
ED/hospitalized
DCC MLP treated
Celebrate the (Not So) Small Successes!
• Recent case example from DCC
•
•
•
49 yo, AF-AM female with multiple medical conditions and known psychiatric history
Active in psychiatric treatment, medications recently changed
Seen for diabetes education, completed DST as part of standard process
–
•
•
•
•
•
Skipped suicidal ideation question, but said “YES” to plan for self harm and skipped intent question
On questioning, disclosed was feeling depressed for over a month, was having suicidal thoughts and
planned to take an overdose of pills (had access)
Admitted to purposefully lying to her mental health provider a few days prior out of fear that they would
“lock her up”
Symptoms: feeling depressed, tearful, hopeless, insomnia, loss of appetite with unintentional weight loss,
rapid and pressured speech, flight of ideas, hearing voices
Risks identified by DCC staff: history of Bipolar I Disorder, history of depression with suicidal thoughts,
very limited social support, comorbid anxiety, access to pills, possible mania/ psychosis
Outcome: relocated patient to the internal medicine clinic where clinic RN could assist with sitting with
patient; in consultation with BHS, petition was completed and patient was triaged to the ER for IPD
Psychiatric admission; police assisted (at request of EMS) without incident
THANK YOU
Questions??
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