Transcript Maternal Depression Screening - Texas Primary Care and Health

Collaborating Across Disciplines, Departments and Across
Houston: Screening for and Addressing Peri-Partum
Depression
Stephanie Marton, MD MPH, Jill Roth MD and Stephanie Chapman,
PhD
Objectives
• Recognize signs and symptoms of postpartum
depression that would warrant further
evaluation by the behavioral health team.
• Describe the benefits of an integrated OBpediatric-behavioral health care model when
screening for peripartum depression.
• Identify how patient centered medical homes
can effectively care for families affected by
peripartum depression.
Brief Outline
• How does the Center for Children and Women function as a
patient centered medical home?
• Who is our population?
• Why is peripartum depression a significant concern for our
patient population?
• How are women with peripartum depression identified?
• How does behavioral health assist with diagnosis,
treatment and provide community referrals?
• Example of recent quality improvement in screening for
postpartum depression
• Case study
• Future directions
TCHP The Center for Children and Women
at Greenspoint and Southwest
Southwest: Opened November 2014
Greenspoint: Opened August 2013
Patient Centered Medical Home
• Pediatrics: National Committee for Quality
Assurance (NCQA) Level 3 Patient-Centered
Medical Home
• OB: NCQA Level 3 Patient-Centered Specialty
Practice
• Multiple integral teams
5
The center departments:
Integrated Care = Easy Access
OB/GYN
Pediatrics
Behavioral
Health
Optometry
Speech
Nutrition
Pharmacy
Health
Education
Dentistry
Lab
Radiology
Care
Coordination
Pediatric Team at the Centers
• 12 pediatricians, 8 nurse practitioners, RNs and MAs
• Scheduled appointments
• Newborns, ADHD medication, Well-child checks
• Walk-in availability for sick visits
• Same day lab and Xray services
• Real time consultation with other Center departments
• Continuity of care
• Teaching facility for pediatric residents and medical
students
• Continuity clinic
• Underserved rotations
• Capstone projects
7
OB Team at the Centers
• 12 MDs, 6 midwives
– Clinic care
– Centering pregnancy
– 24-hour coverage at 2 community hospitals
• Teaching site for students
THE CENTER: Pediatric Patient Access
Hours
Pediatric Hours:
Sunday
9 AM – 7 PM
Monday
7 AM – 11PM
Tuesday
7 AM – 11PM
Wednesday 7 AM – 11PM
Thursday
7 AM – 11PM
Friday
7 AM – 11PM
Saturday
9 AM – 7 PM
The Center: Patient Demographics
0%
1%
5%
0%
0%
0.2%
GREENSPOINT
2.3%
Hispanic
3%
0.1%
0.0%
SOUTHWEST
Hispanic
3.6%
Black or African
American
3.8%
Black or African
American
White
Not Recorded
25%
White
20.2%
Not Recorded
Asian
Asian
66%
Native Hawaiian and
Other Pacific Islander
American Indian and
Alaska Native
Patient/Parent
Refused
69.8%
American Indian
and Alaska
Native
Native Hawaiian
and Other
Pacific Islander
Patient/Parent
Refused
10
Percent of Patients Engaged in
Behavioral Health Care
16
14
14
12
10
8
6
4
4
2
2
0
Percent Engaged in Behavioral Health Care
General Pediatric population
TCHP membership
Center patients
4% of TCHP membership engaged in BH as of 8/15; 14% of patients seen at Center
engage in BH care as of 4/16
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The Center for Children and Women –
A Hybrid Model
Minimal
Coordinated
– At a
Distance
Co-located
Fully
Integrated
1) Independent outpatient behavioral health services
2) Just in time behavioral health services during medical
appointments
Integrated Care
•
•
•
•
•
No offices
Team huddles
Voalte communication
Just-in-time consults
Care coordination
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Open Access Appointment Scheduling
• No referral process
• No intake paperwork
• Just in time services – medical screens and
consults
• Open scheduling –all team members can put a
patient in an appointment slot for Behavioral
Health
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Interdisciplinary Behavioral Health (BH)
Team
7 Clinicians
(psychologists,
clinical therapists)
1 Psychiatrist
4 Social
workers
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Focus on Language Access
7 clinicians
Bilingual Clinical Team
(70% speak Spanish
fluently)
All services available
in Spanish
1
Psychiatrist
4 Social
workers
All handouts available
in Spanish
Telephone
interpretation services
always available
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Flexible BH Service Delivery
• Just in time services – medical screens and
consults
• Therapy (individual and family)
• Groups (e.g., social skills and assertiveness
training groups)
• Telehealth between Centers
• Social work resourcing
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Treatment of Maternal Depression
The AAP Task Force on Mental Health and the Committee
on the Psychosocial Aspects of Child and Family Health
have promoted collaborative, colocated, and integrated
models for mental health services within primary care
medical homes. In such settings, social work staff or
mental health providers, who are colocated in the
practice as part of the care team, can provide immediate
triage for positive screening results, support and followup for mothers, and linkage and referral for more
specialized services.
-Pediatrics, 2010
Risk Factors for Maternal Depression
During Pregnancy
Postpartum Period
Maternal anxiety
Preterm birth
Limited social support
Birth trauma
Medicaid insurance – lower
income
Lower educational status
Breastfeeding problems
Single status
Limited social support
Anxiety or depression during
pregnancy
Domestic violence
History of Depression
Lancaster et al., 2010
Maternal Depression Screening - EDINBURGH
Center Screening
Points:
OB/GYN Clinic
At first visit
36 weeks
4-6 week
postpartum visit
PEDIATRIC Clinic
At 2 week wellcheck
At 2 month wellcheck
BH Diagnostic Intake
• Psychosocial interview
• Clinical observations
• Assessment measures
– Broadband measure administered (e.g., SCL-90 or
BASC-2)
– Other measures administered specific to individual
and identified concerns (e.g., Hamilton Anxiety Rating,
UCLA Trauma Rating, Mood Disorder Questionnaire)
• Feedback/ Treatment Plan
Evidence-Based Treatments For
Perinatal Depression
Interpersonal
Therapy
Cognitive
Behavioral Therapy
SSRIs
• Manualized therapy
• Addresses social / relationship
difficulties contributing to depression
• Manualized therapy
• Addresses behavioral patterns and
thinking patterns contributing to
depression
• Prozac
• Zoloft
Medication Management
1) BH Clinicians and PEDI/OBGYN physicians
partner to manage the majority of
psychotropic medication
2) Psychiatry
-patients with complex medications
- lack of progress with first line treatment
-consult role – provider to provider support to
BH, OB and PEDI teams
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2015 Top 10 OB Diagnosis Seen in
Center BH Department
Diagnostic Label
Adjustment Disorder with Depression and/or
Anxiety
MDD Recurrent
Depression Unspecified
Frequency
15.4% (168)
GAD
Anxiety Unspecified
MDD Single Episode
PTSD
8.3% (91)
6.3% (69)
6.0% (66)
5.4% (59)
Mood Disorder Unspecified
No Diagnosis
3.6% (39)
2.9% (32)
Panic Disorder
1.6% (18)
13.6% (149)
9.0% (99)
Recent Quality Improvement in
Maternal Depression Screening
OB-PediatricBehavioral
Health
Initiatives
QI Project – Paper to Pencil
Depression Screening
History:
• Peri-partum depression screens conducted via
verbal report
• Concern regarding underreporting of
symptoms
QI Initiative: implementation of paper-to-pencil
depression screening in both PEDI and OB
clinics
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% of Screens with Significant Scores
Results – Percent of Screens with
Significant Scores
Screening Target – 15% of
population expected to have
significant scores
16
14
12
10
8
6
4
2
0
Verbal screen
Paper screen
29
Unexpected Impact of QI Change
1. Spanish translation issue
• Question #8 “Me he sentido triste y
desgraciadas”
• “Desgraciadas” has negative connotations in
parts of Mexico and Central America
• MAs were uncomfortable presenting
paper/pencil questionnaire with desgraciadas
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Unexpected Impact of QI Change
1. Spanish translation issue
Results:
• Great call out for cultural improvement of
screener
• Updated screeners of the Spanish Edinburgh
are now being used at the Center, the Pavilion
and some TCPs.
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Positive Depression Screens – Provider
90
Level Utilized 26%
80
70
20%
21%
60
22%
50
40
9%
30
20
10
2%
0
Trainee
Social
Worker
Counselor
Psychologist Psychiatrist
No BH
service
Total Patients with + Screens= 294, 2015
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Reasons for No BH Contact After +
Depression Screen
Scheduling
Problems
25%
Declined BH
47%
Referral not
placed
28%
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Fishbone Analysis
•Stigma of BH
•Misunderstanding of BH services
•Appointment taking too long
•Family pressure to decline
•Patient doesn’t perceive need
Declined
BH
•No Just in time service available
•Patient left without appt; unable to reach by
phone
•BH appt different day – no show
•BH appt at next OB appt but services ran late
•No follow-up scheduled; score “drops off”
No referral
Placed
Scheduling
difficulty
•Provider forgot
•Provider unclear on cut score
•Provider read score incorrectly
•Provider determined lack of need
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QI Project – Postpartum Depression
Screening in Pediatrics Department
History:
• Concern that postpartum depression was not
being identified by the pediatrics team
• Concern that positive EPDS screens were not
being recognized
QI Initiative:
• Provider education
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QI Project – Postpartum Depression
Screening in Pediatrics Department
Provider Education: Email, Huddles, Provider Meeting
• Pediatrics
– Reminder to team that Edinburgh is to be done at 2 weeks
and 2 months
– Defined a positive screen as an Edinburgh score of 11 or
higher, or any score on suicidal question
– Reminder to providers that even if the score is missed in
“real time”, if caught later when reviewing chart, order can
still be placed to SW to follow up via phone.
• Behavioral Health
– BH to link infant and mother’s charts to document crossdepartmental care.
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Greenspoint
Q1 2014
N = 219
Q1 2015
N = 434
Q1 2016
N = 431
Q2 2016
N = 130
% of eligible patients 10 days to 90 days
screened using EPDS
84
83
77
77.7
% positive EPDS
5
4
3.6
4
% of positive screens referred to BH / BH
involvement
11
63
50
50
% of positive screens referred to BH / BH
involvement after manual chart review
56
84
58
100
Southwest
Q1 2015
N = 91
Q1 2016
N = 206
Q2 2016
N = 86
% of eligible patients 10 days to 90 days
screened using EPDS
78
84
82.5
% positive EPDS
6
2.9
5.6
% of positive screens referred to BH / BH
involvement
0
60
0
% of positive screens referred to BH / BH
involvement after manual chart review
75
100
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Potential QI Interventions
• Concern: Pediatric provider not recognizing
positive screens
– MA can directly place BH referral for positive EPDS
screen (MAs enter the score into EMR)
• Concern: OB team receiving higher percentage
of positive screens than pediatric team
– Develop MA scripting when providing the
questions to normalize mom’s feelings
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Treatment – Case Study
Case Study - Laura
24 y.o. Latina and bilingual female
seen in OB at 18 weeks gestation
Psychosocial:
lived alone with 2 children
domestic violence
underemployed
limited social support
Case Study - Laura
Diagnostic presentation:
• EDPS Screen – 23, frequent suicidal ideation
endorsed
• Sleep disturbances
• Low weight gain; reduced appetite
• Anhedonia
• Sleeps most of day; difficulty caring for kids
• Shame, guilt, belief family better off without her
• Passive suicidal ideation (hanging) – waiting for a
time when kids would be on vacation
• History of suicidal attempts – last 2 years ago
Case Study - Laura
OB
• Screened in OB
• EDPS = 23
• Just in time consult with Behavior health
BH
• BH clinician conducted Diagnostic intake
• Diagnosed Severe Depression- Recurrent
• Safety planning; care plan
• Medication initiated by OB – Sertraline titrated to 100 mg
• Weekly therapy (IPT) – total of 12 sessions ; 9 antepartum; 3
postpartum
Follow-up
• Coordinated OB/BH appointments
Results
• At 6 weeks postpartum, remission of all
depressive sxs achieved
• EDPS score = 3
• Violent relationship ended
• Increased connection with social support system
• Increased engagement in parenting
• Laura continued maintenance dose of
antidepressant
• Successfully transferred care out of clinic at end
of pregnancy medicaid term
• Baby is now cared for in pediatric clinic
Summary
• Patient centered medical homes have great
ability to identify, care for and initiate referrals
for peri-partum depression
– Expanded access
– Screening of patients
– Integrated services
– Coordinated care