1. Mental Health Module “Making It Real” Learning Session 1 [date]

2. Ask the Questions (Show Patient Video)

3. The Model for Improvement

4. What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement? Model for Improvement ActPlan StudyDo

5. Characteristics of the Model for Improvement Action-oriented – “What are you going to test next Tuesday?” Rapid-cycle testing of changes Evaluation and revision of all changes before implementation Testing and implementing the changes in small populations, then spreading then spreading to the larger population Impact evaluated using annotated run charts Monthly reporting of tests and outcomes

6. The Total Population of Trainer GPs and MOAs and Patients with mental health problems in BC (spread sites) Small-scale tests of change Pilot Population: Mental Health Trainers: GP and MOA population and office patients with mental health problems. Focus for the Collaborative (Aim defines) AP SD AP SD AP SD Utilize Pilot Populations to test the Program

7. The Fundamental Questions for Improvement 1.What are we trying to accomplish? 2.How will we know that a change is an improvement? 3.What changes can we make that will result in an improvement?

8. What are we trying to accomplish? Aim Statement Characteristics States that we are going to “improve” care for patients (knowledge, skills, and resource availability related to management of mental health problems in GP offices). Describes the target “population” for improvement (GP) Describes in general terms “changes” we are going to use to improve care for the population (Mental Health Change Package and Expanded Chronic Care Model) Describes the most important outcomes (measures) that we want to improve for the population that define our success (Use of screening, diagnostic, support mechanisms, etc.).

9. What are we trying to accomplish? Office Aim Statement Aim: The care for patients with mental health problems in _______ GP office will be redesigned using the mental health change package so that GPs use depression screening tools, the CBIS Assessment tools such as the Diagnostic Assessment Interview, Problem List Action Plan, Resource list and Self Assessment Questionnaire, and CBT options such as the CBIS Handouts, Antidepressant Skills Workbook and Bounceback tools/support

10. The Fundamental Questions for Improvement 1.What are we trying to accomplish? 2.How will we know that a change is an improvement? 3.What changes can we make that will result in an improvement?

11. 1)Use PHQ-9 screening tool with at least 20 patients with potential mental health problems 2)Conduct a second PHQ-9 assessment within 3-6 months for 95% of those patients in this group 3)Use the Diagnostic Assessment Interview for at least 10 patients with positive PHQ-9 Measures …/

12. Measures (cont’d) 4)Document suicide risk assessment in the patient chart if the suicide question on the PHQ-9 or Diagnostic Assessment Interview was positive 5)Develop a problem list for 10 patients with an Axis I diagnosis 6)Develop a resource list for 10 patients with an Axis I diagnosis …/

13. Measures (cont’d) 7)Develop an action plan from the problem list for 10 patients with an Axis I diagnosis. 8)Use skills from the CBIS Manual with 10 patients with mental health problems. 9)Refer 10 patients screened as having mild/moderate depression to the Bounce Back Program 10)Offer Anti-depressant Skills Workbook (ASW) and provide some coaching to 10 patients screened as having depression

14. Measurement The purpose of measurement in the collaborative is for learning not judgment

15. Fundamental Questions for Improvement 1.What are we trying to accomplish? 2.How will we know that a change is an improvement? 3.What changes can we make that will result in an improvement?

16. Mental Health Change Package Screening Tools Diagnostic Assessment Interview Problem List & Action Plan Mental Health Care Plan Resource List CBIS Skills Bounce Back program Antidepressant Skills Workbook

17. What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement? Model for Improvement ActPlan StudyDo

18. The PDSA Cycle Act What changes are to be made? Next cycle? Plan Objective Questions and predictions (why) Measure of success Plan for the cycle (who, what, where, when) Study Complete the analysis of the data Compare data to predictions Summarize what was learned Do Carry out the plan Document problems and unexpected observations Begin analysis of the data

19. Aim: To improve the care of patients with mental health problems Use of mental health screening tools will help identify patients needing support. Improved outcomes AP SD A P S D AP SD D S P A DATA D S P A Cycle 1: Test use of PHQ9 with patient A on Tuesday Cycle 2: Cycle 3: Cycle 4: Cycle 5: Test 3 ways to access skills in CBIS manual Test the use of the PHQ9 with patients B and C on Wednesday. Test Diagnostic Assessment Interview (Patient B) -Hand out Problem List Test (Patient B) + Problem List/Action Plan

22. Context / History

23. 23 Depression used as Lens Source: Descriptive Epidemiology of Major Depression in Canada. Patten, SB; Wang, JL; Williams, JVA et al. Canadian Journal of Psychiatry; Feb 2006; 51, 2; 84. Lifetime prevalence of Major Depressive Episode: 12.2% Past-year episodes: 4.8% Past-month episodes: 1.3%

24. Why Picture in BC: 2008 733,982 receiving services 638,208 by a GP 108,810 by a psychiatrist 104,441 in a community MH center 20,378 hospitalized

25. Why 2003 module developed for Health Transition Fund -75 GPs GP numbers made consultation liaison model impossible Module developed to enhance GP skills in real time Made every mistake possible DID, 18 GPs until project ended (now 30 GPs)

26. Why GPSC after GP survey, assessing our module, new fee incentive Funded this rollout

27. Why Shift from ‘acute’ to ‘planned pro-active’ MH care Focus on efficient office time management Bridge with Mental Health and Addictions 27

28. MOA Role Understand module Take CMHA course on Mental Health Feel comfortable with mental health patients Heightened awareness Know scheduling required Know the materials needed Have materials prepared/placed

29. Compensation Case examples

30. What’s Real YOU...are the experts in your practice…integrate into your practice.. Focus is adults…not directly applicable for C/Y and elderly….your judgment

31. Overview of Mental Health Module Show Overview Video

33. PHQ-9

34. 34 PHQ-2 & PHQ-9

35. 35 PHQ-2

36. 36 PHQ-9 9 questions used in scoring depression severity Functional impairment question

37. 37 PHQ-9 Scoring Step 1: Need one or both questions endorsed as “2” or “3” (“More than half the days” or “Nearly every day”)

38. 38 PHQ-9 Scoring Step 2: Major Depressive Disorder: Need 5 or more questions endorsed as “More than half the days” or “Nearly every day” (i.e. in shaded areas) Step 3: Total score: Calculate score for columns 1,2 and 3 18 89 1

39. 39 PHQ-9 Scoring Guide for Interpreting PHQ-9 Scores ScoreProvisional Diagnosis 05-09Minimal symptoms (*) 10-14Minor depression (††) Dysthymia (*) Major depression, mild 15-19Major depression, moderately severe ≥20Major depression, severe Step 4: Interpret results (*) If symptoms present ≥ two years, then probable chronic depression. (††) If symptoms present ≥ one month or severe functional impairment, consider active treatment

40. 40 PHQ-9 Scoring Step 5: Is functional impairment endorsed as “Somewhat difficult” or greater? 18 89 1

41. What is CBIS? Cognitive Behavioural Interpersonal Skills

42. Manual Layout Introduction Flow charts Assessment Education Activation Cognition Relaxation Lifestyle

43. Introduction TIPS Teaching Implementing Planning Supporting

44. Flow Charts When in doubt – go with the flow This directs you to the appropriate treatment strategies in the manual

45. Assessment Diagnostic screening interview Screening worksheet Problem list Problem list action plan Resource list Self-assessment questionnaire Self-assessment profiles

46. Education Understanding depression Frequently asked questions Signs and symptoms Medication?

47. Activation Daily activities Energize Small goals Problem solving Chunking time Improving mood Self supportive

48. Cognition Changing behaviour Changing thinking Changing feeling

49. Relaxation Benefits Stress management Breathing Grounding Relaxation Mindfulness Meditation

50. Lifestyle Sleep Nutrition Substances Exercise Wellness

51. Navigating the Skills Manual Three ways to begin: Problem list action plan Symptoms Self-assessment questionnaire

52. Problem List Action Plan No job – I’m too old to retrain ACTIVATION RELAXATION COGNITION LIFESTYLE MEDICATION REFERRAL No job – job coach Bankruptcy – debt counselling I feel tired all the time Tired all the time I don’t want to do anything Irritable – tense Drinking more coffee Having a few beers Not interested in seeing friends I overreact I feel like a failure – I’ll never get a job Stay up late watching TV Sleeping during the day Arthritis – pain Arthritis – Bounce Back

53. Flow Chart Healthy Habits For Sleeping, pg 68 It’s True: You Are What You Eat, pg 69 Physical Activity, pg 71 The Wellness Wheel, pg 72 Anti-Depression Activities, pg 31 Depression’s Energy Budget, pg 32 Small Goals, pg 34 Problem Solving, pg 36 Opposite Action Strategy, pg 37 Chunk The Day, pg 38 Improve The Moment, pg 39 Appreciation Exercise, pg 40 ACTIVATION LIFESTYLE

54. Flow Chart NEGATIVE THINKING COGNITIVE DISTORTIONS COGNITION MODULE The Circle Of Depression, pg 42 Common Thinking Errors, pg 44 Thought Change Process, pg 45 Self Talk (Mean Talk), pg 47 Thought Stopping, pg 48 Good Guilt / Bad Guilt, pg 50 Is Anger A Problem For You, pg 54 PANICKY RELAXATION MODULE Abdominal Breathing, pg 57 Grounding, pg 58 Passive Relaxation, pg 61 Mindfulness, pg 64

55. Self-assessment Questionnaire 0 = never or rarely true to me; 1 = somewhat true; 2 = quite a bit true; 3 = very true of me 1.____ It’s hard for me to say no to people even if I don’t want to agree or don’t have the time or energy 2.____ I will do almost anything to avoid hurting people’s feelings, whatever the cost to myself 3.____ I do lots of things for others, even at the expense of meeting my own needs

56. Flow Chart ACTIVATION MODULE Anti-Depression Activities, pg 31 Depression’s Energy Budget, pg 32 Small Goals, pg 34 Problem Solving, pg 36 ACTIVATION OVER-THINKER PROFILE ASSESSMENT MODULE Over-thinker Profile, pg 24 RELAXATION MODULE Abdominal Breathing, pg 57 Grounding, pg 58 Passive Relaxation, pg 61 Mindfulness, pg 64 PANICKY

57. Questions and Discussion

58. Diagnostic Assessment Interview Teaching Points

59. Diagnostic Assessment Interview Show Video

60. Diagnostic Assessment Interview Frequently Asked Question #1

61. Diagnostic Assessment Interview Frequently Asked Question #2

62. Diagnostic Assessment Interview and Handing Out the Problem List (20 min practice & 10 min debrief) GP Skills Practice Session

63. Organizing the Problem List into a Problem Action Plan Show Video

64. Problem/Resource List Action Plan Frequently Asked Questions

65. Questions and Discussion

66. Develop Problem List Action Plan (20 min & 10 min debrief) GP Skills Practice Session

67. Fee Codes Case Study #2

68. Meet Mrs. J 47 yrs. old; married, school age children SSRI for depression (laid off a year ago) 1 previous episode, also situational Mother had depression requiring treatment Osteoarthritis; diabetes and hypertension Not interested in old hobbies, no energy, crying frequently Bitter, worried; napping much of the day

69. January Headaches, not sleeping well, “blowing up” at even small irritants Not eating regularly; has lost weight Initial neurologic examination is normal You spend 20 minutes counselling her on the probable diagnosis of depression Counselling #1Fee Code 00120 Diagnostic Code 311

70. One Week Later… Labs normal; PHQ9 = 17 CBIS Diagnostic Assessment Interview confirms diagnosis of recurrent depression, and You spend 30 minutes counselling her alcohol, caffeine; problem list; SAQ Counselling #2Fee Code 00120 Diagnostic Code 311

71. Another Week Later… Problem list and the SAQ Problem List Action Plan (CBIS) BounceBack Referral You spend 30 minutes counselling Counselling #3Fee Code 00120 Diagnostic Code 311

72. Mental Health Planning Visit… Review diagnosis, Problem List Action plan, Resource List Reassess emotional and mental status Jointly develop a plan CBIS activation skills (2) 30 minutes MH Planning Visit MH Plan (30 min)Fee Code 14043 Diagnostic Code 311

73. Follow-Up… Telephone Follow-up (Day 3 and 1 week) Regular office visits (2) MH Follow-up Calls #1 and #2 Office Visit #1and #2 Phone F/U #1Fee Code 14079 Diagnostic Code 311 Phone F/U #2Fee Code 14079 Diagnostic Code 311 Office Visit #1Fee Code 00100 Diagnostic Code 311 Office Visit #2Fee Code 00100 Diagnostic Code 311

74. Unplanned Visit… Panic / overwhelmed Takes :15 min to settle her Office Visits #3 Community Patient Conference #1 Office Visit #3Fee Code 00100 Diagnostic Code 311 Comm. Pt. Conf #1Fee Code 14077 or 14016 Diagnostic Code 311 (Units x1)

75. Over next 6 months … CBIS – working on skills ASW – coaching PHQ9 down to 7 Follow up on diabetes, etc Office Visits #4 thru 9 Office Visit #4Fee Code 00100 Diagnostic Code 311 Same for Office Visits # 5, 6,7,8,9 (note: #6 = code 250)

76. Physical and CDM … Time for complete physical examination due to diabetes Review CDM Discuss mental health plan Physical Exam CDM review CPXFee Code 00101 Diagnostic Code 250 CDM DiabetesFee Code 14050 Diagnostic Code 250

77. Follow-up… Telephone follow-up MH Follow-up Call #3 Phone F/u # 3Fee Code 14079 Diagnostic Code 311

78. Next Visits (over 3 months…) Counselling visits Office visit; coaching ASW & CBIS skills 20 minutes counselling sessions (#4&5) Office Visit #10 Counselling #4Fee Code 00120 Diagnostic Code 311 Counselling #5 (GPSC)Fee Code 14044 Diagnostic Code 311 Office Visit #10Fee Code 00100 Diagnostic Code 311

79. Total Billing $ 912.04

81. Bounce Back (Overview) Funded to support Family Practice Where it fits DVD versus telephone coaching Coach is available to give overview at learning sessions Feedback loop Research stream 1-866-639-0522 81

82. Bounce Back Show Bounce Back Video

83. Tasks – Action Period 1 Conduct initial chart review – target patients with chronic conditions, thick charts, chronic pain, etc. Use PHQ-9 screening tool with at least 20 patients with potential mental health problems Conduct a 2 nd PHQ-9 assessment within 3- 6 months for 95% of those patients in this group Use the Diagnostic Assessment Interview for at least 10 patients with positive PHQ-9 Document suicide risk assessment in the patient chart if the suicide question on the PHQ-9 or Diagnostic assessment Interview was positive …/

84. Tasks – Action Period 1 Develop a problem list for 10 patients with an Axis I diagnosis Develop a resource list for 10 patients with an Axis I diagnosis Develop an action plan from the problem list for 10 patients with an Axis I diagnosis Use skills from the CBIS Manual with 10 patients with mental health problems Refer 10 patients screened as having mild/moderate depression to the Bounce Back Program Offer Anti-depressant Skills Workbook (ASW) and provide some coaching to 10 patients screened as having depression …/

85. Tasks – Action Period 1 (cont’d) Report data results with monthly narrative report Follow up with patients (MOA can follow up with patients on homework and goals agreed to in action plans) Identify changes to work processes and office re-design Records PDSA tried with plans, predictions, analysis, etc. Record overall progress towards aims Participate in team calls with support teams and peers