Development, Implementation and

Evaluation of a Psychiatric Home Care

Evidence Based Practice

Rose Madden-Baer DNP MHSA BC-PHCNS

CPHQ, CHCE, COS-C

.

Why develop a depression care model?

Prevalence of depression in the homebound elderly ranges from 13.5% to 46%. Homebound elderly patients are twice as likely to have depression compared to those in primary care. (Bruce, 2002)

Estimates of the direct and indirect medical costs of patients with depression were approximately 83.1 billion in the year 2000. (USPSTF, 2009)

Lack of screening for patients with depression and under treatment of their diagnosis and symptoms. Bruce et.al. (2002) (78% of the depressed patients not receiving treatment and 40% receiving inadequate therapy)

Valente (2005) -25% incidence rate of depression in the homebound elderly. Depression is a prevalent co-morbidity with heart disease, cancer and diabetes Assoc with hastened mortality in these conditions. (Kang-Yi and Gellis, 2010)

Carson and Vanderhorst (2010) 36% to 38% mortality rate in two year period with depression and Diabetes.

Depression associated with medical and functional disabilities and increased risk for falls even when controlling for anti-depressant use. (Byers et al., 2008; Sheeran, Byers, & Bruce, 2010)

Raue and colleagues--continued persistence of depression even after one month receipt of standard home care services. (Raue et al., 2003)

Consensus on Home Care

Challenges

Navigating complex regulatory and reimbursement requirements (Zeltzer & Kohn, 2006)

Programs and populations are under-reimbursed, expensive in terms of resource utilization and not financially sustainable (Cunningham, 2007; Zeltzer & Kohn, 2006)

Processes needed for recruitment and training of qualified, competent staff to deliver psychiatric home care nursing are impractical (Cunningham, 2007; Friedman, Delavan, Sheeran, & Bruce, 2009)

Patient level barriers such as a lack of awareness and reluctance, and complexities with the various risk screening tools and assessments (Brown, Raue, Schulberg, & Bruce, 2006; Brown, Raue, Roos, Sheeran, & Bruce, 2010;Brown, McAvay, Raue, Moses, & Bruce, 2003; Bruce et al., 2007; Bruce et al., 2002; Ell, Unutzer, Aranda, Sanchez, & Lee, 2005; Holroyd, 2000; Sheeran et al., 2010)

Multidisciplinary approach is required for effective depression treatment: Coordinated care delivery and communication models with primary care physicians, psychiatric specialists and home health nurses can be significant logistical challenges (Sheeran, Byers, et al., 2010; Zeltzer & Kohn, 2006)

Establishment of eligibility is achieved through an

assessment of risk or exhibited signs/symptoms

through evidence based valid and reliable tools

Interventions are based upon evidence based

practice for both diagnosis/symptoms and provision

of skilled counseling including behavior therapy

techniques

Metrics are utilized to evaluate clinical quality,

outcomes and financial sustainability

VNSNY Program Objectives

Overall Program Structure

Team composition: Psychiatrists, Psychiatric Nurse Practitioners, Psychiatric CNS and Psychiatric Home Care Nurses

Care planning components are driven by the comprehensive assessment including OASIS C items and specific behavior assessment items

Predictive model algorithm for screening under care and EBP tools for evaluation internal/external dependent upon behavior

PHQ 2, PHQ9, Hamilton Anxiety, SAD Persons (suicide risk) GDS and Mini Cog and FAST for dementia; MANIA scale for Bi-Polar disorders and BPRS for Schizophrenia.

Evidence Based Clinical Protocols & Visit Guidelines are utilized in best practice in psychiatric care management guidelines for homebound individuals :

Use of combination therapy including treatment and psychopharmacology consults and CBT counseling

Risk and Evaluation

Under care internal referrals are received via an initial identification of potential risk as determined by a predictive model algorithm which incorporates various data elements.

Positive predictive algorithm has a .78 AUC (area under the curve) for sensitivity and specificity when evaluated in 2011

Secondary assessment utilized to establish the patient’s program needs and medical necessity eligibility

Practice Design

Care plan problems and interventions are then developed according to behavioral health specific assessments:

Psychiatric evaluations,

Cognitive Behavioral Therapy,

Psychopharmacology consultations,

Medication management,

Primary care physician coordination

Patient outcomes measured over time pre-treatment and post-treatment comparison GDS scores or other EBP tools at SOC, recertification and at discharge to evaluate effectiveness.

Program Evaluation

Design: Used RE-AIM Framework to evaluate DCM EBP

Evaluation period: Sept. 2010 through Sept. 2011

Data collection & analysis period: Year end 2011

REACH METRICS:

Demographic patterns

Clinical attributes e.g. Diagnoses

Referral volume

EFFECTIVENESS METRIC:

Change in GDS score

ADOPTION METRICS:

Referral to admission (yield) metric

Team transfer metric

Program Evaluation

IMPLEMENTATION FIDELITY METRICS:

Completion of a pretreatment and post treatment GDS

Activated CBT care plans

Number of nursing visits per episode

MAINTENANCE METRICS:

Program/episode margin

Success with meeting revenue and budget targets

Number of payer denials

DATA ANALYSIS & RESULTS of DCM

Model

REACH METRICS

597 patients were referred for DCM services from Sept.

2010 through Sept. 2011 reporting period.

Diagnoses: Heart diseases, Diabetes, Neoplasms,

Orthopedic disorders Average age 75 80% Female

40% Living alone

2011 referral target 50 per month or 600 as 12 month total

The 600 referral target represented an estimated 15%

prevalence rate of patients determined “at risk” who

were “under care” based on a 2009 VNSNY analysis

Referral to Admission (yield rate)

546 of 597 patients referred to DCM were admitted:

This number represents that 91% of patients referred were

accepted and admitted onto the DCM program

Reasons for not accepted (9%):

1. 6% of patients refused services;

2. 2 % patients were already receiving “in home” community

mental health services;

3. <1% “other” reasons such as moving out of service area

ADOPTION METRICS

Physician adoption:

1% PCP viewed service as not needed

COC Adoption:

Target transfer rate for COC adoption was 30%

Actual adoption rate was 29.2% which varied by

region with pilot regions at 35-40% and roll out

to subsequent regions at approximately 20%.

Implementation Fidelity

Implementation

Measure Yes No

Pre-treatment

GDS score

100%

0%

Post-treatment

GDS score

87% **13%

Improvement area

Activated CBT

care plan

90%

10%**

(Note 21 cases CBT noted

in free text) for 99%

compliance in total

Implementation Fidelity

Measure

Average nursing visits per episode were 8.3.

DCM target was 8-10 per episode based on

guideline.

** Fidelity measures reached target post pilot

when clinical tools migrated from paper to EMR

OTHER STUDY MEASURES

Change in Depression Score- effectiveness

measure: mean reduction 3 points P<.0001

Patient satisfaction: 91% overall satisfaction

Employee satisfaction overall engagement 96%

Maintenance Metrics

1. 0 Payer denials

2. 17% Contribution margin

3. Positive margin per episode.

4. Exceeded budget targets on revenues

and contribution margin

Where is Program Now?

Top 5 diagnoses in order of frequency

Depression

Anxiety

Dementia (early onset)

Bipolar Disorders

Schizophrenia

2012 admissions approx 1900 ADC 285-90

2013 Average daily census is 372 w year

end budget target of 400

Program Data

Average visits per episode for 2012 was 7.4-8.2 for all psych diagnoses

Average CMI for BH episodes 1.36

Positive contribution margin and revenues over expenses

Testing new frontiers in voice recognition

2012 Results The mean level of depressive symptoms at start of care was 7.88 (s =

3.21) points on the 15 point GDS scale and at post treatment the

mean was 6.28 (s = 3.35), which was a statistically significant

improvement

Box-Plot of Pre-and Post-Treatment Scores on the

Geriatric Depression Scale

Results (continued)

Pre-

Treatment

Post-

Treatment

Paired

Samples Test

Outcomes Mean (SD) Mean (SD) p-value

Geriatric Depression Scale * 7.88 (3.21) 6.28 (3.35) <.001

Number of Activities of Daily Living

Requiring Assistance 3.38 (2.19) 2.10 (2.18) <.001

Frequency of Anxiety 1.24 (0.96) 1.18 (0.70) .280

Number of Cognitive, Behavioral, and

Psychiatric Symptoms 0.46 (0.81) 0.41 (0.80) .266

Frequency of Disruptive Behavioral

Symptoms 0.51 (1.34) 0.71 (1.52) .017

Results (continued)

Valid

Cases

Observed

Percent

National

2012

Outcomes N % (n) %

Hospitalization (Within 60-Days of First GDS

Assessment)

405 5.4 (22) 22.0

Emergency Room Visit (Within 60-Days of First

GDS Assessment)

405 5.4 (22) 14.7

Improvement in Score on the Geriatric

Depression Scale (GDS)

405 74.3 (301) NA

Improvement in Number of Activities of Daily

Living Requiring Assistance

382 84.6 (323) NA

Improvement in Frequency of Anxiety 382 71.7 (274) 58.3

Improvement in Frequency of Disruptive

Behavioral Symptoms

382 84.8 (324) 70.8

Improvement in Number of Cognitive, Behavioral,

and Psychiatric Symptoms

382 85.6 (327) NA

Awards and Media

NYT, ADVANCE, GEM Excellence Nurse.com,

JNCQ, DNP publication, Huffington Post etc. etc.