SCREENING FOR DEPRESSION IN ADOLESCENTS PROJECT FROM QUALITY GOAL TO IMPLEMENTATION

Transcription

1 SCREENING FOR DEPRESSION IN ADOLESCENTS PROJECT FROM QUALITY GOAL TO IMPLEMENTATION

2 ABOUT WOODCREEK HEALTHCARE Washington State Pediatric Private Practice, Urgent Care, Allergy & Asthma & Behavioral Health 3 clinics in the south Puget Sound 40 Providers 170 total employees CPS

3 BACKGROUND In 2014 the American Academy of Pediatrics began recommending annual screening for depression at ages In 2014 CMS added NQF 0418, Screening for Clinical Depression and Follow- Up Plan, to their list of recommended core quality measure for pediatrics (CMS2v1) Woodcreek Healthcare partnered with a collaborative group of area providers to review depression screening recommendations Woodcreek Healthcare Medicine Committee voted to add this screening to the adolescent well care standard visit; this committee created and approved Screening for Depression in Adolescents Practice Guideline

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5 RECOMMENDED SCREENS Based on AAP recommendations, depression collaboration group work and literature review the Woodcreek guideline recommended the use of the following tools Patient Health Questionnaire 2 (PHQ-2) for ages Patient Health Questionnaire 2A (PHQ-2A) for ages (adolescent version) Patient Health Questionnaire 9 (PHQ-9) for ages Patient Health Questionnaire 9A (PHQ-9A) for ages (adolescent version) Columbia Suicide Severity Rating Scale (CSSRS)

6 PROJECT Woodcreek Healthcare EMR team was asked to review guidelines and to assist with implementation by creating electronic tools to both capture data and guide provider work flow EMR Committee assigned a small team to this project that included: Christine Bozich, MD (EMR Chair and Urgent Care Med Director) Kathleen Figetakis (Clinical Application Administrator and VFE Form Writer) AnnMarie Marzano (EMR Trainer and Provider Workflow Support) The evolving goal of this project became a desire to create an electrically driven work flow that would have recommended interventions and scoring logic directly embedded within the forms

7 ALGORITHMS Scoring algorithms were used to guide our form writer s work With MultiCare's permission the PHQ-2, PHQ-9 and the Columbia-Suicide Severity Rating algorithms outlined in the MultiCare Adolescent Depression Screening Guidelines, were used as starting reference points These algorithms evolved overtime as they often had incomplete end points Additions to algorithm, clinical decision support and scoring options were researched and then discussed with both Medicine Committee and EMR Committee prior to project team implementation into form work

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10 RESOURCES FOR VFE FORM WORK PHQ-9 form work was launched off form work completed by Latha Kirubakaran from Austin Diagnostic who kindly shared their work and form logic with the CHUG website The Quality Measures form that we edited for this purpose has been in use for many years in our practice and has undergone multiple revisions to meet quality measure needs. This form was originally designed by University Ob/Gyn Associates

11 CSSRS RECOURSES The CSSRS form work was developed from scratch by Kathleen Figetakis In addition to the expanded flow algorithm created for this project additional scoring logic algorithms were created and carefully reviewed by team See scoring logic algorithm example in screen shot below

12 QUALITY MEASURES 1.4 AND PHQ-2/2A Quality Measures form was updated with PHQ-2 screen This two question screen for depression can be used on any patient When patient is in recommended annual screening age appropriate PHQ-2 for age is offered and highlighted

13 PROVIDER PROMPT The highlighted PHQ-2/2A button prompts provider to review the screening recommendation for age The last screening date is displayed Per guideline recommendations if the patient has not had a depression screen within the last year the provider should launch the PHQ-2 through this highlighted button

14 The PHQ-2/2A The PHQ-2 screen asks the first 2 questions of the PHQ-9 The Adolescent version phrases the second question just slightly different Appropriate versions are launched automatically based on age

15 SCORING THE PHQ-2/2A The form auto-calculates the score as you make your selections and then gives you an interpretation. Scores < 3 do not require any additional action and are considered a negative screen for depression

16 PHQ-2/2A Positive Screen For Depression When a patient scores 3 or greater on the PHQ-2/2A it is considered a positive screen for depression Any score greater than 3 will prompt the provider to launch the age appropriate PHQ-9/9A

17 The PHQ-9/9A The answers from the PHQ-2/2A will auto populate the PHQ-9/9A and then the additional 7 questions can be addressed The screen shot below is the PHQ-9, the PHQ-9A has similar questions with slight variation in wording for age

18 PHQ-9/9A SCORING PHQ-9/9A form auto-calculates and interpretation adjusts based on built in scoring algorithm. In screen shot below the additional questions were all negative so the built in Clinical Decision Support (CDS) within this form tells the provider that this is a negative depression screen

19 PHQ-9/9A SCORE OF 5-9 PROMPTS AND RECOMMENDATIONS As score changes the built in CDS adjusts to reflect recommendations for any given score A score in the 5-9 range is positive for depression Built in algorithm tells the provider that a score of 9 is consistent with Mild Depression and offers the provider some possible interventions for care as well as some short cuts to additional forms

20 PHQ-9/9A SCORE OF PROMPTS AND RECOMMENDATIONS A score of moves pt into the Moderate to Severe Depression category In screen shot below pt now has a score of 11 and so diagnosis has updated and interventions have adjusted Form is now prompting provider to make a referral to Behavioral Health Prompt has changed from to There is a new prompt to this links to CCC-Antidepressant medication list where an antidepressant med can be ordered if clinically indicated

21 PHQ-9/9A SCORE OF AND > 19 PROMPTS AND RECOMMENDATIONS A score of per algorithm is still consistent with a diagnosis of Moderate to Severe Depression, but prompts have changed. Per recommendations of our working algorithm the launch to the CCC-Antidepressant medication custom list has changed names from to A score of >19 adds in the prompt to contact the county crisis team

22 PHQ-9/9A QUESTION NINE SCORING Question 9 in the PHQ-9/9A is a screen for suicide risk Any positive response to question 9 requires an evaluation of patient s possible risk for suicide A positive response to question 9 triggers form logic to prompt the provider to perform a complete Columbia Suicide Severity Rating Scale regardless of the overall PHQ-9/9A score, see examples below Overall score of 5 Overall score of 22

23 THE COLUMBIA SUICIDE SEVERITY RATING SCALE (CSSRS) The CSSRS is a complicated rating scale with a complex algorithm Questions adjust depending on results to initial questions and there are 4 levels of risk with associated possible interventions defined within the algorithm The CSSRS loads with 3 screening questions This screen shot is the initial launched blank CSSRS form

24 LEVEL 1: NO EVIDENT RISK OF SUICIDE

25 LEVEL 2: LOWER RISK A positive response to question 1 has increased risk to Level 2 and provider is being prompted to consider possible interventions based on this response

26 CSSRS QUESTION TWO A positive response to question 2 opens up an additional 3 questions (3-5) If questions 3-5 are all no the overall risk and recommended interventions do not change

27 LEVEL 3: MODERATE RISK Positive responses to questions 3-5 start to modify level of risk A positive response to question 3 increases risk from Level 2 to Level 3 Moderate risk category triggers a modified list of possible interventions

28 LEVEL 4: HEIGHTENED RISK Positive responses to questions 4 and/or 5 increase risk to Level 4 with changed recommended interventions per algorithm

29 CSSRS QUESTION SIX: A FORM WRITERS NIGHTMARE Question 6 carries independent risk A positive response to question 6 increases level of risk even with answers of no to other questions Question 6 is most significant if occurred within the last 3 months

30 QUESTION SIX AND SYMPTOM HISTORY TIMING Question 6 with remote history of between 3 months and a year ago reduces risk to Moderate risk

31 QUESTION SIX AND SYMPTOM HISTORY TIMING Question 6 with remote history of over a year ago reduces risk to Lower risk

32 QUALITY REPORTING DEPRESSION SCREENING Launching the PHQ-2/2A form automatically creates the SNOMED-CT order for Depression Screening that is needed for quality reporting

33 SCREENING FOR DEPRESSION IS BILLABLE Decision was made to bill if full PHQ-9/9A was administered The launching of the PHQ-9/9A automatically generates the CPT order for this screening

34 QUALITY REPORTING SUICIDE SCREENING The launching of the CSSRS automatically adds the SNOMED-CT code for Suicide risk assessment The SNOMED-CT codes are set to go to Complete status as soon as order has been signed

35 DEPRESSION SCREENING POST PRODUCTION STATUS Provider reception Billing for PHQ-2/2A verses full PHQ-9/9A Work flow options for PHQ-2 screen Possible future electronic completion of PHQ-2/2A by patient Patient resources

36 LESSONS LEARNED: FUTURE PROJECT APPLICATIONS A working algorithm that is updated as needed throughout process is essential to form design When form writer identifies that algorithm is breaking down or logic is incomplete they must seek collaboration and consultation Collaboration on more complex logic decisions enables form writer and project team to be more comfortable with high risk end points High level clinical supervision and involvement is critical to form development when form is incorporating clinical decision support

37 LESSONS LEARNED: FUTURE PROJECT APPLICATIONS CONTINUED Consultation with all departments affected by form is essential to successful implementation and design (billers, referral coordinators, nurses, and providers) Extensive testing and honest communication regarding form design is needed to maximize usefulness of final tool Automate as much of your work flow as possible keeping in mind that provider judgement and clinical review is still essential to final decision making and documentation of any patient care interaction

38 FINAL PARAGRAPH FOUND IN WOODCREEK S SCREENING FOR DEPRESSION IN ADOLESCENTS GUIDELINE The PHQ-2, PHQ-9 and CSSRS are tools that providers should use to assist with the screening of depression in adolescents and for assistance in determining possible increased risk of suicide, but the provider should not rely completely on these tools. Clinical judgement and patient presentation should factor into final recommendations when determining patient disposition and plan of care. Providers should have a low threshold for calling the crisis team or seeking expert consultation when patient s presentation is concerning.

39 QUESTIONS?