Karen Scott Collins, MD, MPH July 2008

Public Benefit Corporation Governing:  11 Acute Care Facilities  Four Long Term Care Facilities  Six Diagnostic & Treatment Centers  Over 80 Community Health Clinics  A Managed Care Organization (240,000 Enrollees)  A Certified Home Health Care Agency

◦ Racially, ethnically Diverse, Low Income population ◦ Large population covered by Medicaid; ◦ Uninsured population ◦ Immigrant ◦ Multi- lingual; LEP ◦ Low health literacy

 Additional tasks/measures for diabetes and heart failure teams: ◦ Start PHQ screening for depression ◦ Develop management of patients with depression within primary care

3 component model: AHRQ/MacArthur Initiative  Physician knowledge and skills on management  Collaboration with Psychiatry  Care Management CCM:  Self management support  Delivery system design  Decision support  Clinical information systems  Community resources  Health system

 Screening  Management  Communication  Self management 1. Learning sessions 2. Primary Care physician/psychiatrist teams= depression champions “Train the trainers” ◦ Regular conference calls and breakout sessions at learning sessions ◦ Support for trainers

◦ Coaching/consultation with primary care ◦ Review PHQ scores and cases with MD’s ◦ Based in ambulatory medicine/cardiology clinic a few hours/month ◦ Joint development protocols for management and referrals ◦ Jointly see patients during HF clinic

◦ Training ambulatory care nursing and social workers ◦ Early follow-up; ◦ telephone support; ◦ self management support

 PHQ incorporated into EMR  reports  Link to chronic disease registry  Brief decision support  Links to decision support  Next: ◦ creation of dedicated field for followup; ◦ Determine suicide assessment tool for EMR

Screening ◦ PCA (MA) administer PHQ-2/9 ◦ PCA gives PHQ 2/ nurse or MD gives PHQ9 Treatment ◦ Primary care MD starts Rx; determines referrals ◦ Self management support: goal setting tools Case Manager = team effort ◦ MD, psychologists, social worker, volunteers ◦ Various team members making follow-up phone calls and consulting MD to make management decisions

 Moderate- significant assistance reportedly required for patients to complete;  PCA’s being tasked to assist patient with PHQ2/ some places with PHQ9 (some resistance)  PDSA in progress: Literacy Assistance Center drafted a brief script/explanation of terms for PCA’s and pts.  PHQ screening rates (POF) 65-75% in ¾ teams  PHQ>/= 10 12%-17% among diabetes and HF teams

 492 pts. in diabetes registry  2/05-10/05 screening found 9.4% pts PHQ>10  Increasingly, primary care management  Strong psychiatry liaison

 Care Model Components ◦ BPHC/ change packages  Depression analysis tool*: ◦ Standard approach to assessing practice and planning PDSAs ◦ Review 4-5 patients for:  Did the pt have a f/u visit or call within 1-3 weeks of starting treatment?  Did the pt have a repeat PHQ within 4-8 weeks of starting treatment?  Did the pt have a self-management plan in the last six months?  Was there a clinically significant improvement (5 pt drop in PHQ) within 3 months? If not, any ideas why ? *S.Cole, MD

 Psychiatry liaison ◦ Communication/ access ◦ Availability  Clinical information system ◦ PHQ score/ recommended steps ◦ Links to resources ◦ Reminders/tools

Get started… Test…Test…Test !