Karen Scott Collins, MD, MPHJuly 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 sessions2. 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