Transcript Walking Patients Through Depression Pathway - PCMH e

WALKING PATIENTS THROUGH THE
DEPRESSION PATHWAY: AF WILLIAMS
QUALITY IMPROVEMENT PROJECT TO IMPROVE
DEPRESSION CARE
Desire Taylor M.A., Allison Wainer M.A., Shandra Brown Levey Ph.D., & Corey Lyon, DO
AF WILLIAMS FAMILY MEDICINE CENTER
Urban primary care residency training clinic
with fully integrated behavioral health and
medical services
 Associated with University of Colorado Health
 Serves individuals across the lifespan
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QUALITY IMPROVEMENT AT AF WILLIAMS
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Continuous QI based on:
 Clinic
and patient needs
 Resident 3rd year projects
 PCMH and other initiatives

Commitment to improving care for patients
DEPRESSION
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Depression is a wellrecognized threat to both
individual and public health
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In 2012, 16 million adults
experienced a major
depressive episode within the
previous year (NIMH, 2014)
Major depression carries the
heaviest burden of disability
among mental and behavioral
disorders (WHO, 2010)
Enhancing primary care
providers’ ability to recognize
and treat depression is key
to addressing the
population-level burden of
this disease
OPPORTUNITY FOR INTEGRATED CARE
Majority of health care services are delivered in the
primary care setting
2. Patients with mental health and substance use
conditions often first present and are solely seen in
primary care
3. Depression and anxiety disorders are the most
common mental health conditions identified by
PCPs, often complicating other medical conditions
and increasing the cost of care
1.
OPPORTUNITY FOR INTEGRATED CARE (CONT)
4. Attempts
to refer externally to specialty behavioral
health have generally led to low rates of patient
response, low treatment initiation and completion
rates, limited communication and care coordination
5. When the core elements of the PCMH (e.g. patientcentered care, coordinated care, systematic screening
and diagnosis) are included as part of the integrated
model, we can achieve better mental health outcomes
6. Evidence that medication along with psychotherapy is
optimal for treating depression
OUR RATIONALE
Medical use decreased 15.7% for
those receiving behavioral health
treatment, while medical health use
increased 12.3% for controls who did
not get behavioral health
Decrease
cost
Improve
outcomes
Enhance
patient
experience
Depression treatment in primary
care had $3,300 lower total
healthcare cost over 48 months.
Depression treatment in primary
care for those with diabetes had
$896 lower total healthcare cost over
24 months.
Of the top five conditions driving
overall health cost (work related
productivity + medical + pharmacy
cost), depression is number one
TAKING ADVANTAGE OF INTEGRATED CARE
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DEPRESSION PATHWAY
The goal of the depression pathway is to
provide optimal care for patients with
depression
 In order to do this, AF William has designed,
implemented and assessed the effectiveness of
a team-based treatment algorithm and
workflow for management of newly diagnosed
depression
 The algorithm and workflow were designed by
adapting evidence-based depression care
programs to leverage the available clinic
resources
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DEPRESSION CARE WORKFLOW
Six in-person visits with a behavioral health
and/or medical provider
 Five phone calls by a behavioral health provider
between office visits
 PHQ-9 scores and clinical presentation
assessed at each office visit and are used to
guide treatment decisions based on a stepwise
algorithm
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DEPRESSION PATHWAY TIMELINE
WINTER
2012SPRING
2013:
Project
Planning
SUMMER
2013:
Initiation of
Depression
Pathway
Check-In
Check-In
Check-In
SUMMER
2014:
Initial data
analyses and
dissemination of
findings
TEAM ROLES
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MA:
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Provider (physician, nurse practitioner, physician assistant):
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Reviewing the completed wellbeing survey including the PHQ9 scores with patient
Assess depression
Medication management
Contact behavioral health
Behavioral Health Providers:
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Administer PHQ2 as part of the vital signs at all clinic visits
Distribute wellbeing survey (including PHQ 9) to all patients with a PHQ2 score greater than 3
or for patients who present for a depression-focused visit regardless of PHQ2 score
Warm hand off, co-consult, brief counseling
Managing the depression registry including keeping track of visits, no shows, PHQ9 scores,
treatment strategies
Contact patients via telephone as defined by depression pathway
Handing off to RN for telephone contact when patient is appropriate
RNs:
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Calling patients to monitor medical adherence and side effects, barriers to care, progress with
self-management support goals at time specified by depression care program
CLINIC EDUCATION
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Team AF Williams
 Bi
monthly meetings with entire clinic staff
 Presentations and technical assistance
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Reminders in various clinic meetings and in
“MD minute” from medical director
DEPRESSION PATHWAY
A.F. Williams – Depression 36 Week Care Plan
Notes
Suggested Visit Type By Week
ß
Week 0
Pt. New
Depression Dx
Clinical
Interview +
Wellbeing
Screener
PHQ-9 >10
Discuss options
for treatment
and send
inbasket message
to BH for f/u
Acute Phase
Week 1
Contact
(call or visit)
Week 2-4
Co-consult
Visit
Wellbeing
Screener
Week 5
Contact
(call or visit)
←|→
Week 6-8
Provider/
Co-consult
Visit
Wellbeing
Screener
Clinical
Interview +
Action Plan
Clinical
Interview +
Adjust tx as
needed
Make f/u
appt and
print AVS
Make f/u
appt and
print AVS
- Referral made to BH In basket
- Group visit during continuation phase
- Phone calls: RN, BH, CM
- Document on SharePoint
- CTA for appointment reminders
- Visit template
- Action Plan – Present and discuss with patient during first month of
depression care
- Additional BH support available PRN
- Schedule for 40 minute appointments
Week 9
Contact
(call or visit)
Week 10-12
Provider/
Co-consult
Visit
Wellbeing
Screener
Clinical
Interview +
Adjust tx as
needed
Make f/u
appt and
print AVS
Continuation Phase
Week 18
Contact
(call or visit)
Week 24
Provider/
Co-consult
Visit
Wellbeing
Screener
Clinical
Interview +
Adjust tx as
needed
Make f/u
appt and
print AVS
Week 32
Contact
(call or visit)
→
Week 36
Provider/Coconsult Visit
Follow up
as needed
every 3-6
months
INITIAL SCREEN
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MA will provide PHQ-2 depression screening
on all patients and document results in
Document Flowsheets
 If
PHQ-2<3, no further action is needed
 If PHQ-2 >3, MA administers the Wellbeing
Survey
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Medical provider will review the Wellbeing
Survey with the patient and complete
additional assessment for mental health
diagnoses as clinically indicated
INITIAL SCREEN (CONT)
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Provider may involved Behavioral Health for
assistance with diagnosis and safety planning.
If provider diagnoses a different mental or physical
illness, s/he treats appropriately (This workflow no
longer applies)
 If provider confirms diagnoses of depression, patient is
added to the depression pathway
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Provider or MA will document PHQ-9 results in the
Document Flowsheets section of the EMR
WELL BEING SCREEN
STARTING THE DEPRESSION PATHWAY
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Provider will orient patient to our Depression
Pathway and create a depression action plan
for the patient using shared decision making
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When possible Behavioral Health meets with patient
to assist with initial education and self-management
support
Provider will route the patient’s progress note to
the Behavioral Health inbox to enroll them in
the Depression Care Management Program and
add them to the manual Depression Registry
FOLLOW UP DEPRESSION CARE
Behavioral Health
• 4 to 6 1:1 sessions
implementing evidence-based
depression action plan
• Phone calls between visits
Co-Consults
• Continued assessment of
adherence, medication, and
&
safety
Communication
•Document visits in EMR
and forward to medical
provider
•Track depression
pathway registry
Medical Provider
• Work with patient to
establish therapeutic dose of
depression medication
• Continued care for medical
concerns
• Medical counseling and
treatment planning
EVIDENCE-BASED DEPRESSION ACTION PLAN
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Action Plans include:
 Brief
Psychoeducation
 Insight Development
 Coping Skills
 Goal Setting for Self Management Support
PSYCHOEDUCATION
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Nearly 17% of adults in the U.S. experience
depression at some point in their life. It can affect
feelings, thoughts, behaviors, relationships and
physical health.
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“Depression symptoms” include a sense of
sadness or unhappiness, a lack of interest in
things you used to enjoy, changes in appetite,
difficulty concentrating, trouble sleeping, loss of
energy, feelings of worthlessness, and may include
thoughts of suicide
PSYCHOEDUCATION (CONT)
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BEAST-Biology, Emotions, Action, Situation, Thoughts
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Evidence-Based practices for treating depression
 Best evidence for psychotherapy in combination
with medication
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Reiteration of medication side effects
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Discussion of expected barriers to treatment
DEVELOPING INSIGHT & BUILDING COPING SKILLS
•
•
•
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Take a breath break. When you notice
depression symptoms, try a relaxation breath.
STOP, breathe and then decide on your next
step.
When feeling blue, get ACTIVE! It is great for your
body and mind. When we are active the brain
releases feel good chemicals that can help
decrease depression. Activities such as walking,
swimming, running, gardening, biking, or house
cleaning can help you get the just 10 minutes of
light physical activity needed each day to help
reduce your depression.
Connect. When feeling depressed, it can be
helpful to talk with a friend or family member.
Staying connected to people who are positive
and supportive is always a good coping strategy.
Pleasant activities/hobbies. Increasing the
number of fun, enjoyable, and meaningful
activities or hobbies in your life can also help you
feel less depressed.
Depression Thermometer
Color in the thermometer to the
number (10=high, 0=none) that
best describes how depressed
you have been in the past
week:
1-2-3
1 = STOP
2 = BREATHE
3 = ACT
Remember relaxation can
occur in seconds – telling
yourself to “STOP” and
“BREATHE” can be a quick
and effective way to reduce
depression.
______________________________
How to question
depressed or unhelpful
thinking
1. When you have a negative
thought, try to ask yourself how
you might see it another way.
2. Is my negative thought
always true? How can I stick to
the facts?
How do you feel in you’re your
body, your thoughts and your
mood when you’re at a…
0 =______________________
______________________
5 = ______________________
______________________
10 = _____________________
_____________________
3. Are there strengths or
positives in the situation that I
am ignoring?
4. If my best friend or someone
I loved had this thought, what
would I tell them?
5. What are more helpful or
realistic statements to replace
the upsetting ones?
GOAL SETTING FOR SELF MANAGEMENT
MY ACTION PLAN
Activity Breeds Activity!!
During the next seven days, I will:
____________________________________________________________________________________
Frequency: ___________ times a__________________
Importance:_____ Confidence:_____
I will:
____________________________________________________________________________________
Frequency: ___________ times a__________________
Importance:_____ Confidence:_____
I will:
____________________________________________________________________________________
Frequency: ___________ times a__________________
Importance:_____ Confidence:_____
This is your ACTION PLAN, so set reasonable goals that you feel you can accomplish!
How confident are you that you can follow through with your overall ACTION PLAN before your next visit?
1
2
3
4
Not at All Confident
5
6
7
8
9
10
Very Confident
If you have questions, contact Behavioral Health Consultant: ________________ Phone:
_________________
Next appointment:___________________________________
DEPRESSION PATHWAY REGISTRY AND TRACKING
Behavioral health has created and is
maintaining a registry and tracking form
 Information included:

 Primary
Care Provider
 Behavioral Health Provider
 Visit dates
 Contact dates and types (in person or call)
 PHQ-9 scores
 Antidepressant Medications
DEPRESSION PATHWAY REGISTRY AND
TRACKING (CONT)

Importance of the registry
 Indicates
when follow up is needed
 Helps determine patient response to outreach
attempts
 Informs residents of which patients are on the
pathway and how they are doing
 Identifies which patients are (or are not) responding
to treatment
DEPRESSION PATHWAY OUTCOMES
Mean
PHQ-9
Score
Visit 1
Mean
PHQ-9
Score
Visit 2
Mean
PHQ-9
Score
Visit 3
Mean
PHQ-9
Score
Visit 4
Mean
PHQ-9
Score
Visit 5
Mean
PHQ-9
Score
Visit 6
16.29
10.25
8.79
5.48
7.11
4.73
Preliminary analyses suggest a clinically
significant decrease in mean PHQ-9 scores
from baseline to final (36 week) follow-up
 These results indicate that the depression
pathway is a useful and effective strategy for
treating depression symptoms in a primary
care setting
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OVERCOMING CHALLENGES
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Providers remembering and using the depression
pathway
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Reminders at various meetings, via e-mail, with
providers 1:1 and during precepting
Difficulties associated with the use of a manual
database
Epic cannot pull patient reports in a useful way
 Working with Epic teams to improve this
 BH Team is responsible for tracking in the mean time
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MOVING FORWARD
Work with Epic to develop a system for registry
management and updating
 Transition from paper assessments to tablets
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 Less
work for MAs
 More honest patient responses
 Available in multiple languages both written and
spoken
QUESTIONS?
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