Care Partners In-Person Training Depression in Late-Life Initiative September 17 & 18, 2015

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1 Care Partners In-Person Training Depression in Late-Life Initiative September 17 & 18, 2015

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3 Site Introductions Vision, Innovation, & Workflow Sharing

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5 Downtown Family Health Center at Connections (DTFHC) Clinic DTFHC resides in the heart of downtown San Diego home to many of San Diego s lowest-income seniors and is co-located within a multi-service residential community designed to help homeless individuals move into permanent housing. Margarita Velosa, LCSW, PhD, Care Manager Steven Ritter, DO, Primary Care Provider Gabrielle Cerda, MD, Psychiatry Consultant Myra Buby, LCSW, Project Lead

6 Serving Seniors- CBO An independent non-profit focused on improving the health and wellbeing of San Diego s low-income seniors through the provision of essential services such as food, healthcare, housing, and social services. Dennis Dearie, MFT, Case Manager Parwin Tahir, MSW, Case Manager

7 FHCSD/SS: Vision Statement Our vision is a community which optimizes mind, body, and spirit one senior at a time.

8 Family Health Centers of San Diego: Innovation and Workflow Patient s Workflow Experience In the course of the primary care visit patients 65 and older with a positive PHQ-9 screening will be identified and referred to the care manager for further assessment. Services will be provided within an integrated approach Comprehensive multidisciplinary assessment of medical, functional and psychosocial needs will be provided with ongoing follow-up of patients; Coordination across providers Intensive health education and support for lifestyle modification; Monitoring of patients progress between office visits Additional skills provided will include: psycho-education, positive coping techniques and development of solid selfmanagement skills.

9 Family Health Centers of San Diego: Innovation and Workflow (continued) Key Points of Workflow Flexible and innovative integrated services for older adults Clarity about responsibilities and accountabilities Key parts of workflow that have been/are expected to be the most challenging Patients not wanting to participate in the program Identifying patient eligibility Fragmented workflow within clinicians and lack of familiarity with the registry

10 Family Health Centers of San Diego: Innovation and Workflow Ideas to overcome challenges Continuous Dissemination of the project to both FHCSD staff and Serving Seniors staff Continued Collaboration between primary care and mental health A collaborative phone conference between Serving Seniors and Family Health Centers

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12 Clinic and CBO Introductions SAC Health System provides comprehensive and low-cost health care services in San Bernardino, California. Team: Tom Bazemore, Adriana Gomez, Jason Lohr, and Brenda Boyle El Sol Neighborhood Educational Center, a community-based organization serving seniors in the city of San Bernardino, California. Team: Oscar S. Bustillos, Alex Fajardo, Angelica Alvarez, Monica Fuentes, and Irma Abaunza

13 Vision Statement El Sol and SAC Health System (SACHS) commit to focus on improving care quality and coordination of care among older adults from various racial and ethnic backgrounds in our community with, or at-risk, for depression through Collaborative Care by comprehensive community-based, family-focused, and patient-centered outreach and education.

14 SACHS & El Sol: Workflow Participants will be recruited through Community outreach events (health fairs, educational presentations held at churches, homes and schools) Medical appointments at SACHS (positive score on the PHQ-2) Potential participants will be asked to complete a screening tool to determine their eligibility Each person approached will receive either verbal or written educational information on Depression, General Anxiety Disorder and its symptoms Patients will be warmly connected between CHW s and Care Manager during treatment process.

15 Workflow & Innovation (cont.) Enrolled patients can expect follow-up home visits from Community Health Workers (CHWs) to assess their needs and develop a plan of action to fill them. Patients will be referred to a Therapist professional for further care. Patients will be educated on Medications (if applicable) during treatment plan. CHW s and Clinic will work closely using CMTS registry as a means of communication and patient evaluation. CBO and Clinic staff (Project Lead, CHW s, Care Manager, Psychiatric Consultant) will have weekly meetings to discuss treatment options and plans. After patient has shown signs of improvement, patient will be assessed once more and follow up calls will occur 1-3 months after last home visit.

16 Workflow & Innovation (cont.) Community Health Workers (CHWs) will: Work individually with each patient and be exceptionally involved in providing the best support to eliminate depression and depressive symptoms Complete home visits to encourage behavior activation that can counteract the client s depressive symptoms. Provide tools that will bring Empowerment to the Patient and work with them to develop their strengths. Provide home-based activities that will vary with each client s response to the PHQ-9, so that they are tailored to address the areas of the screening where a Patient scored the highest and help improve their score.

17 Workflow & Innovation-Potential Challenges Lack of active participation from clinicians (physicians, therapists and psychiatric consults) limited availability to participate in meetings or update a client s chart on the CMTS system Following up with hard to reach clients Unreliable contact information Do not want home visits Partners/caregivers are reluctant to participate in program

18 Workflow & Innovation-Overcoming Challenges Lack of active participation from clinicians Care Manager and the CHW s can consult individually at clinic update clients charts on CMTS and provide updates at weekly meetings Following up with hard to reach clients Collect contact information for participant and several family members/partners in their care Follow-up visits can be completed at location outside home that client feels comfortable with and can easily access (El Sol - CBO), during their medical appointment, at their church, etc). Follow-up can be completed over the phone/

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20 Sonoma Care Collaborative Clinic and CBO Introductions Clinic: Petaluma Health Center - Nurit Licht, M.D., Chief Medical Officer - Todd Finnemore, Psy.D., Geropsychology - Ken Weinstock, Psychiatric Consultant - Vicki Rivera, LCSW CBO: Sonoma County Human Services Department/Adult & Aging Division - Anne Percival, Social Work Supervisor - Diane Camurat, Social Worker/Community Home Visiting Coordinator

21 Sonoma Care Collaborative Vision Statement We envision a Sonoma Care Collaborative with a thoughtful, inclusive, and efficient system of care that is focused on delivering whole person care that incorporates medical and socialenvironmental factors.

22 Sonoma Care Collaborative: Innovation and Workflow Clinic: Petaluma Health Center (PHC) Patient Experience: patients will engage in our collaborative in a team-based and supportive environment.

23 Sonoma Care Collaborative: Innovation and Workflow CBO: Sonoma County Human Services Department (HSD)/Adult & Aging Division - Providers of services to empower, support and protect clients throughout the community - Experts in delivering coordinated care in older adults homes - Experienced in implementing Healthy IDEAS

24 Sonoma Care Collaborative: Innovation and Workflow Innovations: Within PHC, teams are supported by engaged staff and providers, data analytics, and collaborations across family medicine, behavioral health. Multiple avenues exist to engage patients into the program. Collaboration continues beyond PHC to our partnering community-based organization, the Division of Adult and Aging; through this collaboration, we are able to provide comprehensive care located both in the medical home (PHC) and the patient s home.

25 Sonoma Care Collaborative: Innovation and Workflow Challenges: Coordinating care and information across team members who are working for different organizations, and making coordination of care seamless for the patient. Understanding which patients will benefit most from our innovative and collaborative care model.

26 Sonoma Care Collaborative: Innovation and Workflow Overcoming Challenges: Coordinated use of registry, electronic medical record, and meeting time and dedicated support staff to ensure seamless coordination. Patient engagement education and written material to explain the team model and provide consistent contact information to access team members. Scheduled consultations with PHC LCSW will allow for stratification of patients and over time provide information as to which patients will benefit most from our collaborative care model.

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28 Clinic and CBO Introductions Primary Care Clinic LifeLong Medical Care Over 60 Berkeley, CA Team Members: Program Supervisor: Alex Baker PCP: Jennifer Elton Psychiatric Consultant: Megan O Brien Care Manager: Jesse Merjil Community Health Worker: Alexis Bradley Community Based Organization St. Mary s Center Oakland, CA Team Members: Carol Johnson Karla Salazar

29 Clinic Name: Vision Statement Vision Statement LifeLong Over 60 We envision LifeLong Over 60 and St. Mary s center through Collaborative Care will support the identification, engagement and treatment of depression among high risk adults 65 plus. We will improve the access of depression care, which we believe will benefit older adults. Both organizations recognize the importance of developing trust with older adults who face poverty, isolation and often have distrust of the medical system. We will form a strong basis for successful screening, enrollment and patient participation in depression care.

30 LifeLong Medical Care: Innovation and Workflow At LifeLong Over 60 and Saint Mary s we aim to identify and screen between patients ages 65+ per week. How would a patient experience our workflow? Identify and Engage Patients/Establish Diagnosis Meet Mr. Johnson! Mr. Johnson is a 70 year old patient with our Over 60 Health Center Scheduled appointment at Over 60 to discuss managing his diabetes. Prior to his appointment CHW meets with him and introduces the screening process using PHQ-9. Mr. Johnson s PHQ-9 score was a 13, moderate level depression. Receives diagnoses from PCP discuss treatment options.

31 LifeLong Medical Care: Innovation and Workflow How would a patient experience our workflow? Initiate and provide treatment A warm connection made between our PCP and Care Manager/CHW. Allow Mr. Johnson to discuss his concerns. Our team will educate him about depression, Collaborative Care and the treatment options available. Mr. Johnson says no antidepressants! But is interested in therapy sessions and community support group at our CBO (Saint Mary s Center). Here a treatment/care plan will be developed and initiated

32 LifeLong Medical Care: Innovation and Workflow How would our patients experience our workflow? Follow-up Care and Treatment to Target CHW does the first two week follow-up call with Mr. Johnson. Mr. Johnson has been attending his therapy sessions, but hasn t wanted to attend the support group at Saint Mary s. Lack of transportation is keeping him from attending the groups. Transportation resources are arranged. CHW also agrees to meet Mr. Johnson at Saint Mary s as additional support.

33 LifeLong Medical Care: Innovation and Workflow How would our patients experience our workflow? Complete Treatment and Relapse Prevention Over the course of 12 weeks of treatment Mr. Johnson s PHQ-9 score has improved from a 13 to a 5. He is scheduled a follow-up appointment with our CM to discuss the end of his treatment and plan his RPP. He agrees to continue attending his support groups at our CBO and has set goals to ensure no relapse in his symptoms. Mr. Johnson is reassured that he has our entire team as a support system as he continues to recover from his depression.

34 LifeLong Medical Care: Innovation and Workflow A possible challenge we may face Patients may see treatment as a burden or indication that they are suffering from irregular circumstances. Ways to overcome this challenge Ensuring patients that we, as a team, will work through their circumstances to find the best solution for them. Helping patients understand that they have a huge support system through the LifeLong and Saint Mary s Center team. Understanding that this treatment will not be a burden but rather an uplifting, progressive movement toward living a happier and healthier life. As a team LifeLong Medical Care and Saint Mary s Center aim to successfully treat as many patients as possible and provide each with healthy and prosperous lives!

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36 UCSF House Calls and Geriatric Clinic, San Francisco, CA Dr. Helen Kao, UCSF Geriatrics Clinical Program, Medical Director Dr. Meredith Greene, UCSF Geriatrics Clinical Program, Medical Director Dr. Daniel Pound, UCSF Center for Geriatric Care Marisa Guardado, Clinical Social Worker, UC Care at Home Division of Geriatrics Alexis Armenakis, Psychiatric Consultant Institute on Aging Psychology Department, San Francisco, CA Karyn Skultety, Ph.D., Vice President of Health Services Carolyn Stead, Psy.D., Project Director, Director of Psychology and Counseling Services Clare Farrington, Program Coordinator, Psychological and Counseling Services Alyson Madigan, Psy.D. Psychology Post-Doctoral Fellow David Shoup, M.A., Psychology Pre-Doctoral Trainee

37 Vision Statement The vision of our project is to develop a robust, long-term partnership between two organizations that strive to increase the quality of life for isolated, homebound adults in our community. Often times homebound elders face significant barriers in accessing adequate mental health services as it is difficult if not impossible for them to leave their homes and very limited, if any services exist to provide affordable treatment in home. We strive to develop an innovative model that addresses the limited access to mental health services for these older adults. This includes the use of Collaborative Care to increase communication between providers, track treatment outcomes, and prevent clients from falling through the cracks. Our vision is that through our primary care and psychotherapy collaboration, we will provide effective treatment for homebound elders struggling with depression and create a model that is both replicable and sustainable.

38 UCSF & Institute on Aging: Innovation and Workflow Mrs. Anderson has been receiving UCSF primary care services in her home for almost a year now. During a routine home visit, her doctor recognizes some symptoms of depression and suggests to Mrs. Anderson that she might benefit from having someone to talk to. Mrs. Anderson agrees and her doctor makes a referral to IOA. The next week, an IOA clinician knocks on Mrs. Anderson s door to complete a clinical assessment and discuss next steps.

39 UCSF & IOA: Innovation and Workflow Innovation: Patients will be asked by their trusted PCP to agree to have an additional provider come to them in their home instead of being referred to an outside clinic. Challenges: Scheduling warm connections, organizing consistent collaboration with non-traditional physical clinic setting and satellite providers. Plans to overcome challenges: have PCP state which methods of communication they prefer on referral, scheduling regular consultation meetings that overlap with other staff meetings and have a call-in line available, and consistent collaboration w/supervisors

40 Clinic and CBO Introductions USC Dept of Family Medicine, Los Angeles, CA, Sandra Avila, Jennifer Talbot, Camilo Zaks Eisner Pediatrics and Family Medicine: USC- Eisner FMC, Eisner Adult Dept., Los Angeles, CA, Gail Myers, Jose Luevano, Ana Rosas, Eveline Zamora St. Barnabas Senior Services, Los Angeles, CA, John Kotick, Maria De Leon

41 USC/Eisner/SBSS: Vision Statement The USC-Eisner-SBSS BALLAD project will improve the treatment of depression in older adults through a collaborative and comprehensive approach to treatment, using a Collaborative Care model plus integration of a Senior services center and training family members to be part of the care team.

42 USC/Eisner/SBSS: Innovation and Workflow Eisner First Visit Annual depression screening w/ PHQ2 PHQ9 Warm Connection to Case Manager Case Manager does additional screening (Bipolar, etc.) and does intake. Case Manager links to LCSW therapist via EMR Case Manager links to SBSS by telephone during visit. Eisner after First Visit LCSW contacts patient to set up first session. LCSW does therapy PST, following protocol. SBSS liaison contacts patient to set up first session. liaison provides connection to SBSS services. liaison trains family member to be Caregivers Innovations in italics and bold.

43 McClellan Outpatient Clinic Vision & Workflow

44 Clinic Introductions McClellan Outpatient Center Sacramento Team members Angela Araneta, Psy.D. Jane Addagatla, M.D. Brian Dahmen, Ph.D. Ladson Hinton, M.D. Thuc-Nhi Nguyen, Ph.D.

45 Vision Statement To develop and implement a family-centered model of collaborative depression care to advance outcomes for older veterans

46 Innovation and Workflow Patients screened and engaged in family-centered care during regular primary care visits Innovation Family care partners share in multiple collaborative care tasks Using groups to reinforce family-centered care Challenges and solutions Working with PCPs to change practice Engaging patients and family members Negotiating confidentiality concerns

47 BREAK

48 Collaborative Care Jürgen Unützer MD, MA, MPH Professor and Chair Psychiatry & Behavioral Sciences, University of Washington Seattle, Washington

49 Depression More than having a bad day, week, or month Pervasive depressed mood/sadness Loss of interest/pleasure Lack of energy, fatigue, poor sleep and appetite, physical slowing or agitation, poor concentration, physical symptoms (aches and pains), irritability, thoughts of guilt, and thoughts of suicide A miserable state that can last for months or even years

50 What Do Patients Say? I am depressed. My wife thinks I am depressed. or.. I just don t feel right I hurt all over I just don t have any energy it s all getting me down. I just can t sleep. I don t know what hit me I can t do anything I am not crazy Isn t depression just a part of normal aging? Wouldn t you feel this way if you had lost your spouse?

51 Depression is Deadly One suicide every 14 minutes. Older men have the highest rate of suicide.

52 Depression is Usually Not the Only Health Problem Chronic Pain 40-60% Cancer 10-20% Geriatric Syndromes 20-40% Depression Neurologic Disorders 10-20% Heart Disease 20-40% Diabetes 10-20%

53 Depression and Diabetes

54 Effective Treatments for Late-Life Depression Antidepressant Medications Over 25 FDA approved All are effective in 40-50% of patients if taken correctly It often takes several trials to find effective treatment Patients need support during this time Psychotherapy CBT, IPT, BA, PST, etc. Other somatic treatments Electroconvulsive Treatment (ECT) Physical activity/exercise Unützer et al, NEJM 2007

55 BUT: Few Older Adults Get Effective Depression Treatment One in 10 older adults see a psychiatrist Limited access and concerns related to stigma Increasing use of antidepressants in primary care PCPs prescribe % of antidepressants % of older adults are on antidepressants (> 4 million) But treatment is often not effective 30 % drop out of treatment within 4 weeks Only 25 % receive adequate follow-up care Only about 20 % improve substantially over 12 months Limited access to evidence-based psychosocial treatments (psychotherapy)

56 Bridging the Divide Between Mental Health & Primary Care Mental health is part of overall health Treat mental health disorders where the patient is/ feels most comfortable receiving care Established doctor-patient relationship is an important foundation of trust & helps reach more people in need Less stigma Better coordination with medical care

57 IMPACT Study ,801 depressed adults 18 primary care clinics 8 health care organizations in 5 states Diverse health care systems Urban & semi-rural settings Capitated (HMO & VA) & fee-for-service 450 primary care providers Two groups compared: Usual Care Collaborative Care

58 IMPACT Program Measures PCP with Care Manager and Patient Practice Support Registry Tools & Training Consultation

59 Doubles Effectiveness of Care for Depression 50 % or greater improvement in depression at 12 months 70 Usual Care IMPACT % Participating Organizations Unützer et al., JAMA 2002; Psych Clinics North America 2004

60 IMPACT Care Benefits Disadvantaged Populations 50 % or greater improvement in depression at 12 months 60% 54% 50% 40% 43% 42% IMPACT Care 30% 20% 19% 23% 14% Care as Usual 10% 0% White Black Latino Areán et al. Medical Care, 2005

61 IMPACT: Summary 1) Improved Outcomes: Less depression Less physical pain Better functioning Higher quality of life 2) Greater patient and provider satisfaction 3) More cost-effective I got my life back THE TRIPLE AIM

62 Principles of Collaborative Care Patient-Centered Team Population-Based Treatment to Target Evidence-Based Accountable

63 Elizabeth s Story

64 Collaborative Care Delivering Care as a Team

65 Collaborative Care Workflow Identify & Engage Establish a Diagnosis Initiate Treatment Follow-up Care & Treat to Target Complete Treatment & Relapse Prevention System Level Supports

66 Collaborative Care Team Approach PCP Patient Care Manager Community Partner PCC New Roles Psychiatric Consultant University of Washington

67 Collaborative Care Workflow Identify & Engage Establish a Diagnosis Initiate Treatment Follow-up Care & Treat to Target Complete Treatment & Relapse Prevention System Level Supports

68 Identify and Engage Identify people who may need help Help patient understand how depression affects them and instill hope You don t have to feel this way. Identify safety and other concerns Introduce Collaborative Care, engage patient in program, and introduce team

69 PHQ-2 and PHQ-9 as Vital Signs Like screening and monitoring blood pressure! Identify that there is a problem Need further assessment to understand the cause of the abnormality Track to measure response to treatment

70 Collaborative Care Workflow Identify & Engage Establish a Diagnosis Initiate Treatment Follow-up Care & Treat to Target Complete Treatment & Relapse Prevention System Level Supports

71 Provisional Diagnosis Assessment by PCP & CM Screen filled out by patient Psychiatric Consultant Case Review Provisional diagnosis and treatment plan 71

72 Common Medical Causes of Depression Neurological Disorders CVA Parkinson s disease Huntington s disease Multiple sclerosis Cardiovascular disease Vascular depression Obstructive sleep apnea Cancers Pancreatic cancer

73 Collaborative Care Workflow Identify & Engage Establish a Diagnosis Initiate Treatment Follow-up Care & Treat to Target Complete Treatment & Relapse Prevention System Level Supports

74 Patient Education What is depression? Instill hope about treatment: You don t have to feel this way. We have several good treatment options Discuss concerns and anticipate problems Involve significant others Systematically assess and follow Treatment adherence (how are you using the meds?) Depressive symptoms (use a scale such as the PHQ-9)

75 The Cycle of Depression

76 Treatment Options The treatment that WORKS is the best one One size fits few Medication therapy is not right for everyone; often several trials of medications are needed Psychotherapy is not right for everyone; different approaches Supporting during treatment is important Everyone knows the treatment plan, supports patients, and can help identify when treatment is not working and changes should be made.

77 FDA Approved Antidepressants Serotonin Reuptake Inhibitors (SSRIs) fluoxetine (Prozac), paroxetine (Paxil), citalopram (Celexa), escitalopram (Lexapro), sertraline (Zoloft), fluvoxamine (Luvox) Newer Antidepressants (atypical) bupropion (Wellbutrin), mirtazapine (Remeron), venlafaxine XR (Effexor), desvenlafaxine (Pristiq), duloxetine (Cymbalta) Tricyclics (TCAs) secondary amines: nortriptyline, desipramine tertiary amines: imipramine, doxepin, amitriptyline Not recommended as 1 st line for older adults due to side effects.

78 Choosing Antidepressants All FDA approved antidepressants are equally effective (~ 50 % have a substantial response) Considerations in selecting an antidepressant: Prior treatment history in patient / family members Patient preferences Expertise of prescribing provider Side effect profile (sedating or activating) Safety in overdose Availability and costs Drug-drug interactions

79 SSRIs: 1 st Choice Agents Fluoxetine (Prozac ) Sertraline (Zoloft ) Paroxetine (Paxil ) Citalopram (Celexa ) Escitalopram (Lexapro ) Starting Dose/day 5-10mg Qam Qam 10 Qhs 10 Qhs 5-10 Qam Therapeutic Range/day* Generic CYP 450 effects Sideeffects 10-20mg Y +++ +/ Y Y Y N ± ± Espinoza R., Unützer, J. 2013; Mittman 1999; Solai 2001; Sommer 2003; Williams 2000

80 Assure Adequate Medication Trials Follow-up closely to asses progress: Treatment adherence Are you taking medications? How are you taking them? Are you having side effects or concerns? Treatment response Use a scale such as the PHQ-9 to track symptoms Make sure the dose is high enough Start low but make sure you achieve therapeutic dose.

81 Is The Patient at Maximum* Daily Therapeutic Dose? Fluoxetine (Prozac) 40 mg Paroxetine (Paxil) 50 mg Citalopram (Celexa) 20 mg Escitalopram (Lexapro) 20 mg Sertraline (Zoloft) 200 mg Venlafaxine (Effexor) 300 mg Desvenlafaxine (Pristiq) 100 mg Duloxetine (Cymbalta) 60 mg Buproprion (Wellbutrin) 450 mg Mirtazapine (Remeron) 45 mg Nortriptyline 125 mg (check serum level) Desipramine 200 mg (check serum level) * Start all meds low but go to effective or maximum dose as tolerated over 4-12 wks.

82 Adverse Effect Profiles SSRIs: serotonergic; variably anticholinergic, antihistaminergic or antidopaminergic Common nausea loose stools restlessness akathisia insomnia headache sexual dysfunction Less common weight loss / gain hyponatremia (SIADH) sinus bradycardia cardiac arrhythmia bleeding (anti-platelet effect) Parkinsonism Serotonin Syndrome

83 What If Patients Don t Improve? Is the diagnosis correct?? Bipolar depression (manic symptoms: no sleep, excess energy / irritability): use mood stabilizers not antidepressants: lithium, valproate, lamotrigine, quetiapine? Psychotic depression: add antipsychotic (e.g., risperidone, olanzapine, quetiapine); consider ECT? Medical conditions hypothyroidism, sleep apnea, pain, neurological, neurodegenerative disease, vascular disease, chronic conditions / inflammation, geriatric syndromes? Medications: steroids, interferon, hormones? Withdrawal: stimulants, anxiolytics, alcohol, opiates

84 Plan B No response: switch to antidepressant from a different class SSRI, SNRI, Bupropion, Mirtazapine, TCA Partial response: augment antidepressant Other antidepressants (e.g., Bupropion, Nortriptyline) Lithium, Thyroid, Stimulants Psychotherapy Physical Activity / Exercise Social Activity Electroconvulsive therapy Especially if severe, psychotic

85 Dual Action and Atypical Antidepressants Starting Dosage (mg) Range* (mg) Treatment Resistance Drug Interactions Potential SE Venlafaxine (Effexor XR ) Desvenlafaxine (Pristiq ) Mirtazapine (Remeron ) 37.5 Qam Yes Minimal DBP, BP Na, Nausea 50 Qam Unknown Minimal DBP, BP Na, Nausea Qhs Yes Minimal Sedation, wt Dry mouth Duloxetine (Cymbalta ) 20 Qam Unknown Minimal DBP, BP Na, Nausea Nefazodone (^Serzone ) BID Unknown Probable (3A4 inhibition) liver enzymes? Sedation Trazodone (Desyrel ) Bupropion (Wellbutrin XL, SR ) Vilazodone (Viibryd ) Levomilnacipran ER (Fetzima ) Vortioxetine (Brintellix ) Qhs Unknown Minimal BP, sedation, priapism BID Possible Minimal DBP, BP Seizures 10 Qam Unknown Minimal GI upset, insomnia 20 Qam Unknown Unlikley GI distress, BP, HR,constipation 5mg Qam 5-20mg Unknown Possible HA, dizziness, GI upset, constipation * Dosage for Major Depression; ^ Brand not available

86 Psychotherapy Orientation Cognitive-behavioral Interpersonal Problem-solving Dialectical-behavioral Bereavement/Grief Therapy Psychodynamic Therapy Supportive Therapy Reminiscence and life review Bibliotherapy Modality Individual Couple Family Group Practitioners Psychiatrists Psychologists Social Workers Nurse therapists MFTs

87 Communication: Care Manager and Primary Care Provider GOAL: Efficiently communicate about patient care. Specific Question or Request Brief history of problem Current treatment duration, effectiveness, side effects. Psychiatric recommendations PCP Patient Care Manager Role Psychiatric Consultant Community Partner PCC

88 Communication: Care Manager and Psychiatric Consultant PCP Patient Care Manager Role Community Partner PCC GOAL: Provide psychiatric expertise to team Consultation Scheduled As Needed Education Integrated Presentations Psychiatric Consultant

89 Psychiatric Consultation Model Consultation Hour Brief check-in Changes in the clinic Systems questions Identify patients and conduct reviews Requested by CM Not improved Severity of presentation Disengaged from care Wrap-up Confirm next consultation hour Send any educational resources discussed

90 Provider to Provider Communication How and When? Consider modality In person Staff (MA or nurse) Phone Fax (careful with confidential info) EMR Frequency Scheduled As needed

91 Collaborative Care Workflow Identify & Engage Establish a Diagnosis Initiate Treatment Follow-up Care & Treat to Target Complete Treatment & Relapse Prevention System Level Supports

92 Comparison of Contacts in Usual Care vs. IMPACT Usual Care 3.5 PCP Contacts per year* = PCP contact 0 12 months 20% - 40% treatment response/improvement *Based on HRSA report of average PCP visit rates for FQHCs

93 Comparison of Contacts in Usual Care vs. IMPACT Collaborative Care = PCP contact (avg. 3.5 contacts per year) = Contacts with BHP/CM (avg. 10 contacts) = Case reviews from psychiatric consultant to BHP/CM, PCP (avg. 2 case reviews) 0 50% - 70% treatment response/improvement 12 months

94 Collaborative Care Workflow Identify & Engage Establish a Diagnosis Initiate Treatment Follow-up Care & Treat to Target Complete Treatment & Relapse Prevention System Level Supports

95 Typical Course of Care Management: Duration Primary Care Panel Collaborative Care Caseload Referral to Specialty Mental Health Relapse Prevention

96 Questions?

97 Mobilizing Family Support to Advance Collaborative Care for Depression Ladson Hinton, MD University of California Davis

98 Overview Defining family Why involve family? Challenges of involving family Overview of how family can strengthen depression collaborative care Questions/discussion

99 Who is Family? Persons in the older adult s social network who are Present in patient s home or community Acceptable/preferred by patient Motivated to be part of care team Wide range of kin and non-kin Spouses, significant others, children, extended family, friends, neighbors, etc Paid in-home caregivers

100 Why Involve Family? Family members are often already involved! And patients want them involved But they are not well-supported by healthcare systems With recognition, support, and skills, family can be valuable depression care partners Together we have nice opportunity to advance the field

101 Common Challenges Time Confidentiality / privacy issues Family impedes treatment Elder abuse situations Provider comfort in working with family Multiple family members involved Cultural aspects of family caregiving Family unavailable (time, interest, etc..)

102 Role of Family in Collaborative Care Participation in assessment and treatment planning process Psychoeducation Supporting evidence-based care Behavioral activation/problem-solving Medication management Participation in primary care visits Facilitating connection to CBO Relapse and prevention planning

103 Partnering with a CBO and Family PCP Patient (Family) Care Manager Community Partner PCC Psychiatric Consultant

104 Resources All of us! Discussion of family involvement on calls VA workflow document Consultation with UC Davis team Ongoing NIMH funded study on depression and family engagement References

105 Reflection

106 LUNCH

107 Delivering Care as a Team

108 Collaborative Care Workflow Identify & Engage Establish a Diagnosis Initiate Treatment Follow-up Care & Treat to Target Complete Treatment & Relapse Prevention

109 Behavioral Health Measures as Vital Signs Behavioral health measures are like monitoring blood pressure! Identify that there is a problem Need further assessment to understand the cause of the abnormality Help with ongoing monitoring to measure response to treatment

110 Common Measures Depression: PHQ-9

111 Advantages of Using Behavioral Health Measures Objective assessment Creates common language Focuses on function Avoids potential stigma of diagnostic terms Helps identify patterns of improvement or worsening Flexibility of administration

112 PHQ-9: How to Administer In-Person Facilitates assessment AND teaching about depression symptoms Can be administered orally for low literacy patients By phone Send a copy home for patient to follow along Self-administered In clinic or at home

113 PHQ-9: How to Score Adapted from Kroenke K, Spitzer RL, Williams JB. The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16:606-13,

114 Understanding PHQ-9 Score Score Severity 0 4 No Depression 5 9 Mild Depression Moderate Depression 15 Severe Depression

115 Practice: PHQ-9 Each person takes an activity sheet from the envelope. One person plays the Care Manager One person plays patient One person observes (using checklist) and provides feedback to the Care Manager We will switch roles so that each person can practice!

116 Review What went well? What was challenging?

117 Collaborative Care Workflow Identify & Engage Establish a Diagnosis Initiate Treatment Follow-up Care & Treat to Target Complete Treatment & Relapse Prevention University of Washington

118 Introducing Care Partners PCP Patient (Family) Care Manager Role Community Partner PCC Psychiatric Consultant University of Washington

119 Practice Step 1: Personalize your Introduction Use model introduction to get started Keep it short and simple Key points How shared care works and works well! Your role and the team The patient role Next steps to engage in care Step 2: Practice your based on real role on the team Each person practices introducing Care Partner Program Each person plays the patient Patient partner provides feedback If time, practice twice

120 Review What went well? What was challenging?

121 Collaborative Care Workflow Identify & Engage Establish a Diagnosis Initiate Treatment Follow-up Care & Treat to Target Complete Treatment & Relapse Prevention System Level Supports

122 Provider to Provider Communication: How and When? Frequency Scheduled As needed PCP Patient (Family) Consider modality In person Staff (MA or nurse) Phone Fax (careful with confidential info) EMR CMTS! Care Manager Role Community Partner PCC Psychiatric Consultant

123 Planning Activity! Plan YOUR team communication! In you clinic group use Team Communication Planning Worksheet Consider provider to provider communication Consider modality Consider frequency May need to capture which handoffs need further discussion!

124 Review Which handoffs are ready? Which handoffs need some further discussion?

125 BREAK

126 Facilitated Reflection in Teams

127 Brainstorming IdeasGoals Sharing

128 Day 1 Training Feedback

129 ADJOURN

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