SPIRIT CMTS Registry Example Patient for Care Manager Training
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- Willis Ellis
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1 SPIRIT CMTS Registry Example Patient for Care Manager Training Getting Started The following scenario is designed to help you learn how to use the Care Management Tracking System (CMTS) registry to facilitate delivery of high quality evidence-based mental health care. Checklists at the end of each section indicate CMTS skills learned. This scenario should be used alongside the SPIRIT CMTS Care Manager User Guide, which contains further instructions for each checklist item. Setting the Scene Dr. Anderson approaches you in the clinic. She explains that a new patient, Emily Richards, came to the clinic reporting fatigue, upset stomach, and headaches. She has a PHQ-9 score of 18 and a positive CIDI bipolar screen (score = 8), and a negative PTSD screen (PCL-6 score = 11). You step into the exam room to introduce yourself. Emily explains she is a student at a local community college. She has been having difficulties managing the stress of school, can t sleep at night, and is not sure if she can go on with her degree. She is the first person in her family to go to college and she tells you that she fears being a disappointment to everyone in her family if she cannot stay in school. Emily had treatment for depression in the past at another clinic but stopped because the medication wasn t helping and she didn t want her friends at school to think she is crazy. Emily agrees to start treatment at the clinic. You explain SPIRIT to her and she agrees to participate. You consent her and tell her that she will be placed into one of two treatment interventions (Collaborative Care or Telehealth Referral) after she completes an initial research interview by phone. Each morning you log in to SPIRIT CMTS to check for new patients. The following week you see that Emily has been randomized into the Collaborative Care intervention. You call Emily to schedule her for her initial visit. 1/7/2015
2 Emily comes into the clinic for her Initial Assessment. While in the waiting room she completes a PHQ-9, SPIRIT Mania Rating Scale, and PCL-5 and gives them to you as you walk to a consultation room. When you get to the consultation room you log in to the SPIRIT CMTS registry, find Emily on your caseload, and tell Emily that the clinic uses a computer program that helps the clinic make sure that patients are getting the most effective treatment and helps the clinic know when it s time to consider making a change in treatment. You normalize for Emily that MOST patients need at least 1 change in the treatment plan before they get better and that it s not uncommon to make 2, 3, or more changes in treatment to get a patient completely better. This doesn t mean that the treatments or the patient are bad-- it s a normal part of the treatment process. You explain that she will also have the opportunity to meet with the psychiatrist via video to talk about treatments that may be recommended for her. You let Emily know that one of the ways that everyone on the team-- her, you, Dr. Anderson, and the psychiatric consultant-- will know whether or not the treatment is working is to keep measuring her symptoms with the PHQ-9, the SPIRIT Mania Rating Scale, and the PCL-5. As part of today s assessment, you will determine which of these symptoms and measures will be the focus for her care. You let her know that you re going to re-measure her symptoms each time you meet or talk on the phone so that you can use the information to make sure she gets the best possible results from treatment. You reiterate that you will keep in touch with by phone between in-person visits to see how she s doing and to follow-up on the things that you discuss when you see each other in person. You collect information from Emily to complete the essential elements of the Initial Assessment. NOTE: You should complete the PHQ-9 and at least one of the other measurement tools (SPIRIT Mania Rating Scale or PCL-5) on every visit. You do NOT need to complete every section/field. Complete the required fields (marked with an asterisk) and those that are clinically useful to you. Emily tells you that her greatest concern is that she may have to drop out of school if her depressive symptoms don t improve. Emily explains she was briefly in treatment for depression in the past and was given Celexa in March She doesn t remember the dose. She stopped taking the medication that summer because she couldn t sleep well while taking it and she felt more irritable. In the fall, she began experiencing depression symptoms again. Emily is not doing well in school because it s hard for her to get motivated to do homework or go to class and she is having a hard time concentrating. She was recently let 2
3 go from her job as a hostess because she kept cancelling her shifts. Emily explained: I was too tired and didn t think it was worth it and I m not good with people anyway. At school Emily has a close group of friends but she said she fell out of contact with them in the last few months. She usually enjoys playing piano and running but now has little interest in these activities. Emily lives with her parents. Her mother has told Emily that she has struggled with depression off and on over the course of her adult life and is currently taking medication but Emily doesn t know which kind. You enter the PHQ-9 and SPIRIT Mania Rating Scale Emily completed in the waiting room into the registry and tell her that the score indicates severe depressive symptoms and moderate symptoms of mania. PHQ-9 1. Little interest or pleasure in doing things: Nearly every day 2. Feeling down, depressed, or hopeless: Nearly every day 3. Trouble falling or staying asleep, or sleeping too much: More than half the days 4. Feeling tired or having little energy: Nearly every day 5. Poor appetite or over eating: More than half the days 6. Feeling bad about yourself-or that you are a failure and letting yourself or your family down: More than half the days 7. Trouble concentrating on things, such as reading the newspaper or watching television: Nearly every day 8. Moving or speaking so slowly that other people could have noticed. Or the opposite, being so fidgety or restless that you have been moving around a lot more than usual: Not 9. Thoughts that you would be better off dead, or hurting yourself in some way: Not 10. If you checked off any problems on this questionnaire so far, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Somewhat difficult Total Score: 18 (Severe Depressive Symptoms) Emily reports she has never been suicidal. SPIRIT Mania Rating Scale 1. Felt easily irritated: Nearly every day 2. Had racing thoughts : Nearly every day 3. Felt overactive: Several days 4. Acted impulsively or done things without thinking about consequences: Not 3
4 5. Felt sped up or restless: More than half the days 6. Felt argumentative: More than half the days 7. Felt pressure to keep talking or been told by someone you are more talkative: Several days 8. Been easily distracted: More than half the days 9. Had little or no sleep, and still felt energized: Not Total Score: 14 PCL-5 1. Repeated, disturbing, and unwanted memories of the stressful experience?: Not at all. 2. Repeated, disturbing dreams of the stressful experience?: Not 3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?: Not 4. Feeling very upset when something reminded you of the stressful experience?: A little bit 5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?: A little bit 6. Avoiding memories, thoughts, or feelings related to the stressful experience?: Not 7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?: Not 8. Trouble remembering important parts of the stressful experience?: Not 9. Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)?: Quite a bit 10. Blaming yourself or someone else for the stressful experience or what happened after it? : Moderately 11. Having strong negative feelings such as fear, horror, anger, guilt, or shame? : Extremely 12. Loss of interest in activities that you used to enjoy?: Quite a bit 13. Feeling distant or cut off from other people? : Moderately 14. Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?: Quite a bit 15. Irritable behavior, angry outbursts, or acting aggressively? : Quite a bit 16. Taking too many risks or doing things that could cause you harm? : Not 17. Being superalert or watchful or on guard? : Not 18. Feeling jumpy or easily startled?: Not 19. Having difficulty concentrating?: Moderately 20. Trouble falling or staying asleep?: Moderately 4
5 Total Score: 26 Now you talk with Emily about the options for treatment. You let her know that the clinic can offer medication and/or counseling. If the first treatment doesn t work there are many other treatments to try. There are many FDA approved medications available and counseling is also helpful. You explain that treatment guidelines suggest a combination treatment (mood stabilizing medications plus counseling) is the best approach for bipolar depression but that her preferences are very important in deciding where to start. You ask Emily if she has a preference for medication, counseling, or both. Emily says that she had a lot of difficulty with Celexa the last time she was depressed, and she is reluctant to try a medication. On the other hand, she says that she s so busy with school that she is concerned that the time commitment necessary for counseling would add to her stress rather than help with it. You tell her that it is OK that she hasn t decided on an initial approach and that you will review her care with the psychiatric consultant. You also schedule her video visit and let her know that this will give her the opportunity to talk directly with the psychiatrist about the treatment that is best for her. You ll let Dr. Anderson know she will be meeting with you regularly and with the psychiatrist to develop a treatment plan. Next, you let Emily know that although she hasn t decided yet on a medication, if she does start one, it often takes time for the medication to start working. You also orient Emily to behavioral activation, explaining the association between participating in valued activities and mood. Emily shares that she values creativity and artistic expression, citing her past experiences with playing piano as an example of a creative outlet, and noting that playing music has typically improved her mood. Emily reports that it has been over a year since she has played the piano but also expresses a desire and willingness to restart her piano playing as a means to coping with her depressive episodes. You agree that she will start with 10 minutes of piano playing on Saturday morning and 10 minutes of piano playing on Wednesday evening, days that she has access to her roommate's electronic keyboard. You are concerned with the severity of Emily s symptoms and want to schedule an appointment with her for the following week. However, Emily says that she doesn t have time to come in again next week because of her school schedule but she does agree to come the following week to meet jointly with the psychiatrist by video. You agree to talk with her by phone next week to see how she s doing and to check-in on progress toward activating the treatment plan. 5
6 You give Emily a blank copy of the PHQ-9 and the SPIRIT Mania Rating Scale to take home to use as a reference when you talk on the phone because it s easier to do the measures over the phone if you have them to look at for reference. You flag Emily for Psychiatric Consultation so you can get discuss her presentation with the psychiatrist in advance of the video visit. CMTS Skills: Initial Assessment Entering Biopsychosocial Treatment Plan SPIRIT Mobile App Registration Flag for Psychiatric Consultation 1/9/2015 During your weekly caseload review with Dr. Fernandez, the psychiatric consultant, she recommends that Dr. Anderson order some blood work to be done for Emily when she comes in for her video follow up visit. Dr. Fernandez enters that recommendation into CMTS and the clinic s EMR. Note: Your specific test patient will not have psychiatric consultant notes entered for her, but please check the treatment history for test patient EXAMPL in SPIRIT CMTS to see sample Psychiatric Consultant Notes for Emily. Locating Psychiatric Consultant Note 1/16/2015 At the video follow-up visit, Dr. Fernandez discusses the recommendation that if today s labs are normal, that Dr. Anderson prescribe lithium 300mg at night, with a schedule to titrate the medication and then check a blood level. Dr. Fernandez enters that recommendation into CMTS and the clinic s EMR. Note: Your specific test patient will not have psychiatric consultant notes entered for her, but please check the treatment history for test patient EXAMPL in SPIRIT CMTS to see sample Psychiatric Consultant Notes for Emily. Locating Psychiatric Consultant Note 6
7 1/19/2015 After the lab results are back, you call Emily and let her know that Dr. Anderson reviewed the psychiatrist s recommendations and wrote a prescription for lithium and that it is waiting for her at the pharmacy. She does not answer. You leave a message on her voic reminding her about your phone appointment and encouraging her to call if she has any questions. 1/28/2015 When you log in to CMTS, you notice that Emily is listed on your Reminders Page. She never called back. You call Emily again and this time she answers. She tells you that she picked up the prescription and started taking it but doesn t feel much better yet. You confirm that she has increased her dose from 300mg to 600mg as prescribed and reports that she started taking the medication the day after your message and hasn t missed any doses. You ask to complete the PHQ-9 and SPIRIT Mania Rating Scale over the phone but she declines and she sounds quite depressed. Emily reports that she played the piano on Saturday morning and enjoyed the experience but didn't play on Wednesday evening because she felt tired and because her roommate seemed annoyed by the idea of Emily playing music when the two of them would typically would be watching TV. After some problem-solving, Emily agrees to try again next Thursday when her roommate will be out. She agrees to come in on Friday, 2/6/2015. You remind her that she should have her lithium level checked as soon as possible and check the clinic EMR to verify that Dr. Anderson has already placed the order. Reminder Page Follow-Up Contact Update Biopsychosocial Treatment Plan 2/6/2015 Emily completes the PHQ-9 and SPIRIT Mania Rating Scale in the waiting area before her appointment. PHQ-9 1) Little interest or pleasure in doing things: More than half the days 2) Feeling down, depressed, or hopeless: More than half the days 7
8 3) Trouble falling or staying asleep, or sleeping too much: More than half the days 4) Feeling tired or having little energy: More than half the days 5) Poor appetite or over eating: Several days 6) Feeling bad about yourself-or that you are a failure and letting yourself or your family down: Several days 7) Trouble concentrating on things, such as reading the newspaper or watching television: More than half the days 8) Moving or speaking so slowly that other people could have noticed. Or the opposite, being so fidgety or restless that you have been moving around a lot more than usual: Not 9) Thoughts that you would be better off dead, or hurting yourself in some way: Not 10) If you checked off any problems on this questionnaire so far, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Somewhat difficult Total Score: 12 (Moderate Depressive Symptoms) SPIRIT Mania Rating Scale 1. Felt easily irritated: More than half the days 2. Had racing thoughts : More than half the days 3. Felt overactive: Not 4. Acted impulsively or done things without thinking about consequences: Not 5. Felt sped up or restless: Several days 6. Felt argumentative: More than half the days 7. Felt pressure to keep talking or been told by someone you are more talkative: Not 8. Been easily distracted: More than half the days 9. Had little or no sleep, and still felt energized: Not Total Score: 9 Emily reports that she doesn t feel much better yet. You acknowledge that she still feels pretty bad and still has moderately high symptoms but also point out that some of her symptoms have gotten a little bit better since last time. She is surprised by this and says, Maybe the medicine is starting to help. I don t know. Emily confirms that she is still taking the 600mg dose of lithium daily, and that she has not missed any doses. You look in the computer and see she had a level drawn yesterday and it is reported to be 0.31, which is below the range that Dr. Fernandez recommended. You let her know that you will review her labs with Dr. Fernandez and Dr. Anderson to determine next steps with the medication. 8
9 You check in with Emily about her behavioral activation activity of playing the piano. She says that it was helpful for you to ask about that last time when you spoke on the phone and that she has played again a few more times but not as consistently as she would like. She reports that she still doesn t really feel like playing piano when she thinks about it but finds that she enjoys it once she begins. You give her reinforcement for pushing herself to do something for herself even when she didn t feel like it and remind her that behavioral activation is an "outside in" approach which emphasizes trying out new behaviors without the precondition of high motivation at the outset. Emily comments on her feelings of social isolation and the contrast between her isolation and the high value she placed on relationships. You ask her to add an action step and reach out to one of the friends that she used to hang out with. She makes a plan to send her a text message immediately after this appointment, suggesting that she and her friend get together over the weekend for coffee. You problem-solve around potential barriers to meeting her friend for coffee (travel time), identifying a location that might be convenient for both her and her friend. Emily schedules a phone appointment in two weeks on 2/18/2015. After the visit you confirm with Dr. Fernandez that Emily should increase her lithium to 900mg at night and check with Dr. Anderson who also agrees with this plan. Dr. Fernandez sends the recommendation to Dr. Anderson who updates Emily s prescription. Emily still has pills from the initial prescription so you call her back advise her about the recommendation to increase to 900mg and re-check her level in a week. Follow Up Note Update Biopsychosocial Treatment Plan 2/18/2015 At her phone follow-up, Emily explains she has been feeling much better and doesn t think she needs to continue treatment. She plans to continue the medication but she is really busy with school and doesn t want more things on her plate. She confirms she is taking 900mg of lithium and has not skipped any doses and that she had her level checked after a week. You check her labs and see her level is 0.82 which is in the range that Dr. Fernandez recommended. She completes the PHQ-9 and SPIRIT Mania Rating scale with you over the phone: PHQ-9 1) Little interest or pleasure in doing things: Not 2) Feeling down, depressed, or hopeless: Several days 9
10 3) Trouble falling or staying asleep, or sleeping too much: Several days 4) Feeling tired or having little energy: Several days 5) Poor appetite or over eating: Not 6) Feeling bad about yourself-or that you are a failure and letting yourself or your family down: Not 7) Trouble concentrating on things, such as reading the newspaper or watching television: Several days 8) Moving or speaking so slowly that other people could have noticed. Or the opposite, being so fidgety or restless that you have been moving around a lot more than usual: Not 9) Thoughts that you would be better off dead, or hurting yourself in some way: Not If you checked off any problems on this questionnaire so far, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Somewhat difficult Total Score: 4 (Mild Depressive Symptoms) SPIRIT Mania Rating Scale 1. Felt easily irritated: Several days 2. Had racing thoughts : Not 3. Felt overactive: Not 4. Acted impulsively or done things without thinking about consequences: Not 5. Felt sped up or restless: Several days 6. Felt argumentative: Several days 7. Felt pressure to keep talking or been told by someone you are more talkative: Not 8. Been easily distracted: Several days 9. Had little or no sleep, and still felt energized: Not Total Score: 4 Since Emily s PHQ-9 and SPIRIT Mania Rating scores are under 5 you suggest that the two of you complete a Relapse Prevention Plan over the phone right now and then let her know that you ll call her once a month for the rest of the year to check in with her to see how she s feeling. She agrees to this. Emily plans to continue taking her medication. You provide some psycho-education about the importance of taking maintenance medication for bipolar disorder to decrease the risk of relapse of mood symptoms. You review the benefits of engaging in regular social activities on Emily's mood, as well as the improvements in her self-esteem since restarting the piano. You also ask Emily to 10
11 identify future behavioral activation targets, including her longer-term goal of becoming a piano teacher, asking her to outline some initial steps she might take toward offering lessons to high school students in the months ahead. Emily reports that her personal warning signs of depression relapse are feeling tired, eating less, and spending more time alone. To minimize her symptoms, Emily will reduce her time spent alone or online, spend more time doing physical activity and playing piano, and be sure to stay in contact with her friends. Follow Up Note Update Biopsychosocial Treatment Plan Relapse Prevention Plan March December 2015 You call Emily monthly to check-in with her to see how she s doing. She continues to report doing well. 1/7/2016 You discharge Emily from your caseload list, as it has been 12 months since she was randomized into the Collaborative Care arm of the SPIRIT study. Discharge a Patient 11
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