Development, Implementation and Evaluation of a Psychiatric Home Care Evidence Based Practice. Rose Madden-Baer DNP MHSA BC-PHCNS CPHQ, CHCE, COS-C

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1 . Development, Implementation and Evaluation of a Psychiatric Home Care Evidence Based Practice Rose Madden-Baer DNP MHSA BC-PHCNS CPHQ, CHCE, COS-C

2 Why develop a depression care model? Prevalence of depression in the homebound elderly ranges from 13.5% to 46%. Homebound elderly patients are twice as likely to have depression compared to those in primary care. (Bruce, 2002) Estimates of the direct and indirect medical costs of patients with depression were approximately 83.1 billion in the year (USPSTF, 2009) Lack of screening for patients with depression and under treatment of their diagnosis and symptoms. Bruce et.al. (2002) (78% of the depressed patients not receiving treatment and 40% receiving inadequate therapy) Carson and Vanderhorst (2010) 36% to 38% mortality rate in two year period with depression and Diabetes. Depression associated with medical and functional disabilities and increased risk for falls even when controlling for antidepressant use. (Byers et al., 2008; Sheeran, Byers, & Bruce, 2010) Raue and colleagues--continued persistence of depression even after one month receipt of standard home care services. (Raue et al., 2003) Valente (2005) -25% incidence rate of depression in the homebound elderly. Depression is a prevalent co-morbidity with heart disease, cancer and diabetes Assoc with hastened mortality in these conditions. (Kang-Yi and Gellis, 2010)

3 Consensus on Home Care Challenges Navigating complex regulatory and reimbursement requirements (Zeltzer & Kohn, 2006) Programs and populations are under-reimbursed, expensive in terms of resource utilization and not financially sustainable (Cunningham, 2007; Zeltzer & Kohn, 2006) Processes needed for recruitment and training of qualified, competent staff to deliver psychiatric home care nursing are impractical (Cunningham, 2007; Friedman, Delavan, Sheeran, & Bruce, 2009) Patient level barriers such as a lack of awareness and reluctance, and complexities with the various risk screening tools and assessments (Brown, Raue, Schulberg, & Bruce, 2006; Brown, Raue, Roos, Sheeran, & Bruce, 2010;Brown, McAvay, Raue, Moses, & Bruce, 2003; Bruce et al., 2007; Bruce et al., 2002; Ell, Unutzer, Aranda, Sanchez, & Lee, 2005; Holroyd, 2000; Sheeran et al., 2010) Multidisciplinary approach is required for effective depression treatment: Coordinated care delivery and communication models with primary care physicians, psychiatric specialists and home health nurses can be significant logistical challenges (Sheeran, Byers, et al., 2010; Zeltzer & Kohn, 2006)

4 VNSNY Program Objectives Establishment of eligibility is achieved through an assessment of risk or exhibited signs/symptoms through evidence based valid and reliable tools Interventions are based upon evidence based practice for both diagnosis/symptoms and provision of skilled counseling including behavior therapy techniques Metrics are utilized to evaluate clinical quality, outcomes and financial sustainability

5 Overall Program Structure Team composition: Psychiatrists, Psychiatric Nurse Practitioners, Psychiatric CNS and Psychiatric Home Care Nurses Care planning components are driven by the comprehensive assessment including OASIS C items and specific behavior assessment items Predictive model algorithm for screening under care and EBP tools for evaluation internal/external dependent upon behavior PHQ 2, PHQ9, Hamilton Anxiety, SAD Persons (suicide risk) GDS and Mini Cog and FAST for dementia; MANIA scale for Bi-Polar disorders and BPRS for Schizophrenia. Evidence Based Clinical Protocols & Visit Guidelines are utilized in best practice in psychiatric care management guidelines for homebound individuals : Use of combination therapy including treatment and psychopharmacology consults and CBT counseling

6 Risk and Evaluation Under care internal referrals are received via an initial identification of potential risk as determined by a predictive model algorithm which incorporates various data elements. Positive predictive algorithm has a.78 AUC (area under the curve) for sensitivity and specificity when evaluated in 2011 Secondary assessment utilized to establish the patient s program needs and medical necessity eligibility

7 Practice Design Care plan problems and interventions are then developed according to behavioral health specific assessments: Psychiatric evaluations, Cognitive Behavioral Therapy, Psychopharmacology consultations, Medication management, Primary care physician coordination Patient outcomes measured over time pre-treatment and posttreatment comparison GDS scores or other EBP tools at SOC, recertification and at discharge to evaluate effectiveness.

8 Program Evaluation Design: Used RE-AIM Framework to evaluate DCM EBP Evaluation period: Sept through Sept Data collection & analysis period: Year end 2011 REACH METRICS: Demographic patterns Clinical attributes e.g. Diagnoses Referral volume EFFECTIVENESS METRIC: Change in GDS score ADOPTION METRICS: Referral to admission (yield) metric Team transfer metric

9 Program Evaluation IMPLEMENTATION FIDELITY METRICS: Completion of a pretreatment and post treatment GDS Activated CBT care plans Number of nursing visits per episode MAINTENANCE METRICS: Program/episode margin Success with meeting revenue and budget targets Number of payer denials

10 DATA ANALYSIS & RESULTS of DCM Model REACH METRICS 597 patients were referred for DCM services from Sept through Sept reporting period. Diagnoses: Heart diseases, Diabetes, Neoplasms, Orthopedic disorders Average age 75 80% Female 40% Living alone 2011 referral target 50 per month or 600 as 12 month total The 600 referral target represented an estimated 15% prevalence rate of patients determined at risk who were under care based on a 2009 VNSNY analysis

11 ADOPTION METRICS Referral to Admission (yield rate) 546 of 597 patients referred to DCM were admitted: This number represents that 91% of patients referred were accepted and admitted onto the DCM program Reasons for not accepted (9%): 1. 6% of patients refused services; 2. 2 % patients were already receiving in home community mental health services; 3. <1% other reasons such as moving out of service area

12 Physician adoption: 1% PCP viewed service as not needed COC Adoption: Target transfer rate for COC adoption was 30% Actual adoption rate was 29.2% which varied by region with pilot regions at 35-40% and roll out to subsequent regions at approximately 20%.

13 Implementation Fidelity Implementation Measure Yes No Pre-treatment GDS score 100% 0% Post-treatment GDS score 87% **13% Improvement area Activated CBT care plan 90% 10%** (Note 21 cases CBT noted in free text) for 99% compliance in total

14 Implementation Fidelity Measure Average nursing visits per episode were 8.3. DCM target was 8-10 per episode based on guideline. ** Fidelity measures reached target post pilot when clinical tools migrated from paper to EMR

15 OTHER STUDY MEASURES Change in Depression Score- effectiveness measure: mean reduction 3 points P<.0001 Patient satisfaction: 91% overall satisfaction Employee satisfaction overall engagement 96%

16 Maintenance Metrics 1. 0 Payer denials 2. 17% Contribution margin 3. Positive margin per episode. 4. Exceeded budget targets on revenues and contribution margin

17 Where is Program Now? Top 5 diagnoses in order of frequency Depression Anxiety Dementia (early onset) Bipolar Disorders Schizophrenia 2012 admissions approx 1900 ADC Average daily census is 372 w year end budget target of 400

18 Program Data Average visits per episode for 2012 was for all psych diagnoses Average CMI for BH episodes 1.36 Positive contribution margin and revenues over expenses Testing new frontiers in voice recognition

19 2012 Results The mean level of depressive symptoms at start of care was 7.88 (s = 3.21) points on the 15 point GDS scale and at post treatment the mean was 6.28 (s = 3.35), which was a statistically significant improvement Box-Plot of Pre-and Post-Treatment Scores on the Geriatric Depression Scale

20 Results (continued) Pre- Treatment Post- Treatment Paired Samples Test Outcomes Mean (SD) Mean (SD) p-value Geriatric Depression Scale * 7.88 (3.21) 6.28 (3.35) <.001 Number of Activities of Daily Living Requiring Assistance 3.38 (2.19) 2.10 (2.18) <.001 Frequency of Anxiety 1.24 (0.96) 1.18 (0.70).280 Number of Cognitive, Behavioral, and Psychiatric Symptoms 0.46 (0.81) 0.41 (0.80).266 Frequency of Disruptive Behavioral Symptoms 0.51 (1.34) 0.71 (1.52).017

21 Results (continued) Valid Cases Observed Percent National 2012 Outcomes N % (n) % Hospitalization (Within 60-Days of First GDS (22) 22.0 Assessment) Emergency Room Visit (Within 60-Days of First (22) 14.7 GDS Assessment) Improvement in Score on the Geriatric (301) NA Depression Scale (GDS) Improvement in Number of Activities of Daily (323) NA Living Requiring Assistance Improvement in Frequency of Anxiety (274) 58.3 Improvement in Frequency of Disruptive (324) 70.8 Behavioral Symptoms Improvement in Number of Cognitive, Behavioral, and Psychiatric Symptoms (327) NA

22 Awards and Media NYT, ADVANCE, GEM Excellence Nurse.com, JNCQ, DNP publication, Huffington Post etc. etc.