DEPRESSION SCREENING CASE STUDY

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1 DEPRESSION SCREENING CASE STUDY 2017 NICOLAS E. DAVIES COMMUNITY HEALTH AWARD OF EXCELLENCE UNITY HEALTH CARE, INC. WASHINGTON, DC

2 Overview About Unity Health Care Change Management Depression Screening Case Study

3 HIMSS Davies Application Team Catherine Anderton, Associate Director for Quality Improvement and Research Angela Diop, VP of Information Systems Marcia Hinkle, Assistant Director Social Services: Behavioral Health Cherie Jones, Information Systems Manager Andrew Robie, Chief Medical Information Officer

4 About Unity Health Care

5 Unity Health Care Federally Qualified Health Center District of Columbia Over 106,000 patients and 500,000 visits each year Promoting healthier communities through compassion and comprehensive health and human services, regardless of ability to pay.

6 Unity Sites 10 Community Health Centers 10 Medical Sites in Homeless Shelters 2 School Based Health Centers 1 Mobile Van Health Services in DC Jail Homeless Outreach Administrative offices

7 Services Primary care and specialty care Dental care Behavioral health care Care to people experiencing homelessness, HIV, returning citizens, Title X Patient-Centered Medical Home NCQA level 3

8 Unity s Health Information Technology Customized integrated PM, EMR and Dental applications Implemented March December 2009 in a phased approach (6 phases) Over 260 licensed providers Over 900 staff 6 applications analysts

9 Change Management Robust system of change management helps to develop and adopt well thought out changes in an organized manner. From Unity s change management Guidelines for Electronic Health Records ~2016

10 Unity Teams Responsible for EHR Governance Team Name Team Lead Other Participants Responsibility Stakeholders EHR Analyst EHR Analysts, Deputy CMO, CNO, VPs of Clinical Services and IS Approve major changes to EHR and workflows. Approve and assign resources needed for change. Implementation team VP of IS Deputy CMO, CNO, VPs of Clinical Services, IS and Grants, EHR, PM, IT and Data Analysts, Lab Mgr., IT, CTO, Dir. Social Services, Revenue Mgr., Help Desk Asst. Track issues and changes to resolution. Assign issues to other teams for solution. Implement and communicate changes. EHR tech team EHR Analyst EHR, PM, IT and Data Analysts, VP IS, CTO, Revenue Mgr. Responsible for managing ongoing maintenance, upgrades and implementations. Joint training team EHR Analyst PM and EHR Trainers, Discipline Subject Matter Experts Develop EHR and PM training. Support team EHR Analyst and Help Desk Asst. EHR, PM, IT and Data Analysts Respond to requests for support. Interface with the EHR vendor to track and resolve vendor related issues. Reports team Data Manager Data and EHR Analysts, Deputy CMO, CNO, VPs of IS and Clinical Services, QI Mgr. Develop EHR reports. Configuration team 10 EHR Analysts EHR Analysts, Deputy CMO, CN0, Dir. Social Services, 10 Medical Directors Manage major configuration and content changes to the EHR

11 Our Approach Develop Workflows Modify EHR Change Train Staff

12 Workflow Development Groups Developing the Workflows QI Department QI Working Groups Configuration team In collaboration with Health Information Technology Team (HIT) and Reports team.

13 Disseminating Change Change is developed Working Groups develop training Multi disciplinary team based training is conducted Training is reinforced CHANGE!

14 Depression Screening Case Study

15 Local Problem

Prevalence of Depression 30% of uninsured patients or those with incomes less than 100% of the Federal poverty level have a mental health problem 29% of Medicaid and

16 Prevalence of Depression 30% of uninsured patients or those with incomes less than 100% of the Federal poverty level have a mental health problem 29% of Medicaid and CHIP patients over age 12 have a mental illness % Uninsured or income < 100% of FPL General Populaion National Survey on Drug Use and Health, 2010

17 Depression Screening Depression screening mostly conducted by 7 of our mental health clinicians (MHCs). There was a significant amount of undiagnosed and untreated depression.

18 Depression Screening Goal Develop a consistent way to screen and document depression at a primary care visit using NQF0418. Tracking measures included the percentage of patients aged 12 years and older who were screened, and if the screen was positive, was there a follow up plan documented on the same day. Baseline in 2014: We documented our baseline score as zero. Screening was occurring, but we had no processes in place to measure it except by manual count.

Administered to every adult patient (age 12+) once a year during primary care visits during intake Inquires about frequency of depressed mood over past two

19 Administered to every adult patient (age 12+) once a year during primary care visits during intake Inquires about frequency of depressed mood over past two weeks Patients screening positive (yes to one or both questions) receive PHQ-9 Configured as a SmartForm in the HPI Adult Behavioral Health folder: PHQ2 Tool

20 PHQ9 Tool The PHQ9 screen opens automatically if the PHQ2 is positive. The MA/Nurse can give the patient a paper copy of the PHQ9 to complete while waiting for the provider, and then transfer the responses into the SmartForm. Or, the MA/ Nurse may ask the questions and complete the PHQ9 while with the patient. Scoring is automatic.

Depression Screening Workflow Chief complaint (every visit) OTC Medications (every visit) Tobacco (annually age 13+) Vitals/Standing orders (every visit) PHQ (Patient

21 Depression Screening Workflow Chief complaint (every visit) OTC Medications (every visit) Tobacco (annually age 13+) Vitals/Standing orders (every visit) PHQ (Patient Health Questionnaire) (annually age 12+ at primary care scheduled visits only) Alcohol and Drug Use (annually age 18+) Provider Documents follow up in Adult Behavioral Health

22 How Health IT Was Used

23 PHQ2 and PHQ9 smart forms purchased from our EHR vendor for depression screening. Calculates score and automatically populates the results in the History of the Present Illness (HPI) section of the patient s progress note. Multi-disciplinary team developed and configured the HPI to include smart form assessment and followup plan and substance abuse documentation. In the preventive section of the progress notes a behavioral health section was added to document follow-up. Configuration is a structured format to track and report it as a quality measure. Smartforms

24 MA Intake flowsheet Indicates date of last screening: Alcohol/Drug PHQ2 SDQ Tobacco Use Due= not done in the last year

Depression HPI HPI was configured based on DSM criteria for diagnosis of depression The goal is to help the provider collect information needed to guide treatment plan Is mood change from

25 Depression HPI HPI was configured based on DSM criteria for diagnosis of depression The goal is to help the provider collect information needed to guide treatment plan Is mood change from baseline? Impaired function (home/school/work)? 5 of 9 symptoms present almost every day? Hx of depression or other mental illness? Hx of substance abuse? Medical illness causing depressed mood?

Suicide Risk Assessment (question 9 on PHQ9) The suicide assessment question: Have you had thoughts of actually hurting yourself? was configured.

26 Suicide Risk Assessment (question 9 on PHQ9) The suicide assessment question: Have you had thoughts of actually hurting yourself? was configured. If Yes, further risk stratification questions appear: Have you ever attempted to harm yourself in the past? (yes/no) Have you ever thought about how you might actually hurt yourself? (yes/no) How likely is it that you would act on these thoughts in the next month? (not at all/somewhat likely/very likely) Is there anything preventing you from hurting yourself? (yes/no) Suicide risk? (minimal risk/higher risk)

27 Order Set: Behavioral Health Order sets were configured, included guidance on common psychotropic medications and referral resources

28 The preventive medicine section was configured for documentation that the depression follow-up plan was discussed Preventive Medicine

Preventive Medicine The preventive medicine section includes patient education and documents evidence based actions the patient can take to improve mood.

29 Preventive Medicine The preventive medicine section includes patient education and documents evidence based actions the patient can take to improve mood. Meet with social services today Make an appointment with the psychiatrist you were referred to Make an appointment with the therapist you were referred to Exercise at least 30 min a day Increase social activity Try to sleep at least 8 hours every night Avoid using drugs and alcohol Fill your depression medicine and take it everyday Call WE HELP if you are thinking of hurting yourself or someone else

Staff Engagement 2014 3 months of site visits were conducted to talk to

30 Staff Engagement months of site visits were conducted to talk to providers about barriers and concerns about screening Jan Training was rolled out

31 Patient Education Jan 2015 In Spanish and English

32 Value Derived

In 2016 44% of patients aged 12 years and older were screened and if positive a follow up plan was documented.

33 In % of patients aged 12 years and older were screened and if positive a follow up plan was documented. In 2016 a total of 30,777 patients had depression screening and follow up as necessary Depression Screening

This initiative has improved coordination of care between the MHC and the Primary Care Physicians (PCP). It has made staff better at connecting patient to resources and support.

34 This initiative has improved coordination of care between the MHC and the Primary Care Physicians (PCP). It has made staff better at connecting patient to resources and support. Patients with mild to moderate depression can be identified and treated in primary care. The screening opens the door for patient and provider to discuss other mental health concerns Diagnosing and treating patients with depression improves patients ability to adhere to treatment protocols for somatic and chronic diseases such as diabetes or hypertension. Soft ROI

Lessons Learned A standard screening tool increased identification of depression symptoms and need for treatment, and increased provider confidence in addressing mental health and substance use

35 Lessons Learned A standard screening tool increased identification of depression symptoms and need for treatment, and increased provider confidence in addressing mental health and substance use Similar to hypertension, training and retraining is key to consistently meeting goals Data strengthens the relationship between the medical provider and the mental health clinicians, providing a common language to talk about symptom improvement or need for changes in treatment

36 Thank you

Collaborative Approach in Managing the High Risk Diabetic Patient in a Patient Centered Medical Home

Collaborative Approach in Managing the High Risk Diabetic Patient in a Patient Centered Medical Home Background Safety net facility serving the community for more than 140 years Employ over 3500 health