A Guide to Behavioral Health Screenings: Utilizing Screening tools to Improve Identification of Depression and Alcohol Misuse in Primary Care

A Guide to Behavioral Health Screenings: Utilizing Screening tools to Improve Identification of Depression and Alcohol Misuse in Primary Care

HealthInsight New Mexico Team John Siebel, MD Medical Director Remona Benally Project Manager Licensed and practicing endocrinologist with more than 40 years of experience Past president of the New Mexico Medical Society and an ex-chair of the prestigious Specialty and Service Society (SSS) Caucus of the American Medical Association Health Education in Community Health Patient Navigation Community Organization Edy Taylor Project Coordinator Naval Hospital Corpsman Psychiatric Technician Certified Medical Assistant 2

About HealthInsight It is a private, nonprofit, community-based organization dedicated to improving health and health care, composed of locally governed organizations in four western states: Nevada, New Mexico, Oregon and Utah. HealthInsight also has operations in Seattle, Wash., and Glendale, Calif., supporting End-Stage Renal Disease Networks in the Western United States. We draw upon the unique social and cultural elements of each region, as well as quality improvement expertise that has been developed over four decades. 3

Improving Behavioral Health Our community-based initiative engages primary care providers, behavioral health providers and inpatient psychiatric facilities in community-focused approaches to: Increase primary care screening and referral for depression and alcohol use disorder Reduce readmission rates following discharge from an inpatient psychiatric facility Increase outpatient follow-up and care coordination postdischarge to assist in reducing readmission rates with inpatient psychiatric facility 4

Today s Learning Objectives 1. Recognize depression and alcohol misuse in aging patient population. 2. Identify screening tools available for practices identify depression and alcohol misuse. 3. Apply billing codes that are appropriate for depression and alcohol misuse screening and brief intervention. 5

Why Primary Care? 6

Primary Care More than 1/3 of patients in a primary care receive their behavioral health treatment from their primary care practitioner. Patients prefer to receive behavioral health treatment from their primary care practitioner. Primary care practices must be able to routinely recognize and treat these common behavioral health disorders. Depression and Alcohol Misuse are not a normal part of growing older. "Primary Care Doctors Carrying Heavier Mental Health Load." - Amednews.com. N.p., 25 Oct. 2010. Web. 19 Aug. 2016. 7

Depression 8

Depression Depression is the most prevalent mental health problem in older adults. Of adults older than 50 years, 7.7 percent report currently suffering from depression and 15.7 percent report a lifetime diagnosis of depression. Adults, 65 and older, made up 16 percent of all suicide deaths in 2004. Centers for Disease Control and Prevention and National Association of Chronic Disease Directors. The State of Mental Health and Aging in America Issue Brief 92: Addressing Depression in Older Adults: Selected Evidence-Based Programs. Atlanta, GA: National Association of Chronic Disease Directors; 2009.

Depression and Chronic Disease Management of chronic medical conditions, such as diabetes and hypertension, are complicated when a patient suffers from depression and/or alcohol misuse. Treating the behavioral health symptoms are essential to improving outcomes of the chronic medical condition. Centers for Disease Control and Prevention and National Association of Chronic Disease Directors. The State of Mental Health and Aging in America Issue Brief 102: Addressing Depression in Older Adults: Selected Evidence-Based Programs. Atlanta, GA: National Association of Chronic Disease Directors; 2009.

Claims Data for Depression Screening Number of Depression Screenings 25,000 20,000 15,000 10,000 5,000 0 8,934 10,345 16,816 19,912 17,442 22,236 2014 2015 9,687 NM NV OR UT 11,428 Medicare fee-for-service (FFS) claims data State 2014 2015 Grand Total NM 8,934 10,345 19,279 NV 16,816 19,912 36,728 OR 17,442 22,236 39,678 UT 9,687 11,428 21,115 Grand Total 52,879 63,921 116,800 11

Alcohol Misuse 12

Alcohol Misuse About 2.5 million older adults abuse alcohol or drugs. Between 6 to 11 percent of elderly hospital admissions are due to alcohol or drugs. Widowers, over age 75, have the highest rate of alcoholism. Older adults are hospitalized as often for alcohol related problems as they are for heart attacks. National Council on Alcoholism and Drug Dependence 13

Alcohol and Public Health Excessive alcohol drinking is the third leading cause of preventable death 1. Approximately 88,000 deaths in the U.S. each year 1 Cost the United States $249 billion in 2010 2 Excessive alcohol use includes: Binge drinking Heavy drinking ( 8 drinks/week for women or 15 drinks/week for men) Any drinking by pregnant women or those < 21 years 90 percent of people who excessively drink are not alcohol dependent 3 1. Centers for Disease Control and Prevention (CDC). Alcohol-Related Disease Impact (ARDI). Atlanta, GA: CDC. 2. Sacks JJ, Gonzales KR, Bouchery EE, Tomedi LE, Brewer RD. 2010 National and State Costs of Excessive Alcohol Consumption. Am J Prev Med 2015; 49(5):e73 e79. 3. Esser MB, Hedden SL, Kanny D, Brewer RD, Gfroerer JC, Naimi TS. Prevalence of Alcohol Dependence Among US Adult Drinkers, 2009 2011. Prev Chronic Dis 2014;11:140329. 14

Binge Drinking Alcohol consumption that brings a person s blood alcohol concentration (BAC) level to 0.08% Usually corresponds to 4 drinks per occasion for women or 5 drinks per occasion for men, generally within ~ 2 hours Binge drinking is the most common pattern of excessive alcohol use 92 percent of adults who drink excessively report binge drinking 4 Multiple components to binge drinking: Prevalence: Percent of the population that meets the criteria Frequency: Among those who binge drink, number of occasions Intensity: Among those who binge drink, number of drinks 4. Town M, Naimi TS, Mokdad AH, Brewer RD. Health care access among U.S. adults who drink alcohol excessively: missed opportunities for prevention. Prev Chronic Dis [serial online] April 2006. 15

Alcohol-Attributable Death Rate by State, United States, 2006-2010 1 Stahre M, Roeber J, Kanny D, Brewer RD, Zhang X. Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States. Prev Chronic Dis 2014;11:130293. 16

Claims Data for Alcohol Screening Number of Alcohol Screenings 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 1,510 3,305 611 1,194 6,216 11,441 2014 2015 NM NV OR UT 55 862 Medicare fee-for-service (FFS) claims data State 2014 2015 Grand Total NM 1,510 3,305 4,815 NV 611 1,194 1,805 OR 6,216 11,441 17,657 UT 55 862 917 Grand Total 8,392 16,802 25,194 17

Validated Screening Tools 18

Why Use a Screening Tool? Screening tools are evidence-based and validated for use in the primary care setting. A standardized instrument will quantify baseline intensity and document future progress. Including response and remission rates 1 Agency for Healthcare Research and Quality, Adult Depression in Primary Care, revised 2013 September. 19

Screening Tools as Depression Vital Signs? Hypertension systolic and diastolic blood pressure Diabetes Hgb A1C Asthma peak flow or PEF? Hyperlipidemia LDL, HDL Depression PHQ-9 20

Validated Screening Tools Depression PHQ-2 and PHQ-9 Hamilton Rating Scale for Depression (HAM-D) Beck Depression Inventory Quick Inventory of Depressive Symptomology Self Report (QIDS) Alcohol Misuse AUDIT & AUDIT C (Alcohol Use Disorders Identification Test Consumption CAGE (Screening Test for Alcohol Dependence) Michigan Alcohol Screen Test (MAST) Short Michigan Alcohol Screening Test (SMAST) Agency for Healthcare Research and Quality, Adult Depression in Primary Care, revised 2013 September. 21

Example: PHQ-9 What is the PHQ-9? Patient Health Questionnaire (PHQ) with nine questions Multipurpose instrument for screening, diagnosing, monitoring and measuring the severity of depression Rates the frequency of the symptoms, which factors into the scoring severity index 22

PHQ-9 Advantages Self-reported: Can be done in person, by phone, on-line, interactive voice-response, tablets Available in multiple languages Appropriate for multiple patient populations Over 700 articles published on use of the tool in various settings 23

PHQ-9 tool: Over the last 2 weeks, how often have you been bothered by any of the following problems? Not at all Several days More than half the days 1. Little interest or pleasure in doing things 0 1 2 3 2. Feeling down, depressed, or hopeless 0 1 2 3 3. Trouble falling or staying asleep, or sleeping too much 0 1 2 3 4. Feeling tired or having little energy 0 1 2 3 5. Poor appetite or overeating 0 1 2 3 Nearly every day 6. Feeling bad about yourself or that you are a failure or have let yourself or your family down 7. Trouble concentrating on things, such as reading the newspaper or watching television 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 0 1 2 3 0 1 2 3 0 1 2 3 9. Thoughts that you would be better off dead or of hurting yourself in some way 0 1 2 3 PHQ-9 developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. Reproduced with permission; original content available at www.phqscreeners.com. 24

Example: PHQ-2 Over the last 2 weeks, how often have you been bothered by any of the following problems? Not at all Several days More than half the days 1. Little interest or pleasure in doing things 0 1 2 3 2. Feeling down, depressed, or hopeless 0 1 2 3 Nearly every day Patient Health Questionnaire (PHQ) with two questions Inquires about the frequency of depressed mood over the past two weeks PHQ-2 developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. Reproduced with permission; original content available at www.phqscreeners.com. 25

Example: AUDIT What is the AUDIT? Alcohol Use Disorders Identification Test - 10 Questions Assessing patients' drinking patterns (screening) Providing feedback about the risks of excessive drinking and a short conversation about changing drinking habits to those who screen positive Referral to treatment when appropriate 26

AUDIT tool: Alcohol Use Disorders Identification Test - 10 Questions 0 1 2 3 4 1. How often do you have a drink containing alcohol? Never 2. How many drinks containing alcohol do you have on a typical day when you are drinking? 3. How often do you have six or more drinks on one occasion? Never 4. How often during the last year have you found that you were not able to stop drinking once you had started? 5. How often during the last year have you failed to do what was normally expected from you because of drinking? 6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? 7. How often during the last year have you had a feeling of guilt or remorse after drinking? 8. How often during the last year have you been unable to remember what happened the night before because you had been drinking? 9. Have you or someone else been injured as a result of your drinking? No 10. Has a relative or friend or a doctor or another health worker been concerned about your drinking or suggested you cut down? Less than monthly 2-4 times per month 2-3 time per week 4+ time per week 1-2 3-4 5-6 7-9 10+ Never Never Never Never Never No Less than monthly Less than monthly Less than monthly Less than monthly Less than monthly Less than monthly Monthly Monthly Monthly Monthly Monthly Monthly Yes, but not in the last year Yes, but not in the last year Weekly Weekly Weekly Weekly Weekly Weekly Daily or almost daily Daily or almost daily Daily or almost daily Daily or almost daily Daily or almost daily Daily or almost daily Yes, during the last year Yes, during the last year AUDIT developed by the World Health Organization. Reproduced with permission; original content available at www.who.int. 27

Example: AUDIT-C What is the AUDIT-C? Abbreviated, four question test Consumption and binge drinking questions Alcohol Use Disorders Identification Test - Consumption 0 1 2 3 4 1. How often do you have a drink containing alcohol? Never Less than monthly 2-4 times per month 2-3 time per week 4+ time per week 2. How many drinks containing alcohol do you have on a typical day when you are drinking? 1-2 3-4 5-6 7-9 10+ 3. How often do you have six or more drinks on one occasion? Never Less than monthly Monthly Weekly Daily or almost daily 4. How often during the last year have you found that you were not able to stop drinking once you had started? Never Less than monthly Monthly Weekly Daily or almost daily AUDIT-C developed by the World Health Organization. Reproduced with permission; original content available at www.who.int. 28

Who can administer screening tools? Screening tools can be completed by the patient or a staff member in a few minutes or less. Some screening tools have a few as two questions. Can be scored quickly for provider to determine next steps Easy to integrate into workflow 29

Integrating Screening Tools into Your Workflow 30

Patient Self-disclosure Check-In Prior to Triage Triage Prior to Visit Staff give patient the screening tool Patient completes screening tool MA collects, scores and documents in EHR Provider reviews results/determines next steps Possible Variations: Tool may be paper or electronic Provider may review results in room with patient or prior to visit Patient may forget to complete, requiring MA to interview the patient EHR = Electronic Health Record 31

Patient Interview Triage Triage/Prior to Visit Prior to Visit MA interviews patient using screening tool MA scores and documents in EHR Provider reviews results/determines next steps Possible Variations: Tool may be paper or electronic Provider may review results in room with patient or prior to visit EHR = Electronic Health Record 32

How can my EHR help? Depending on capabilities, your EHR may: Prompt staff to screen Screen further if using PHQ-2 or AUDIT-C Document and/or score automatically Allow you to scan and document paper tools 33

Billing 34

Billing for Depression Screen G0444 Modifier may be necessary depending on the other services provided Screening is a covered Medicare benefit once a year: Each state reimbursement rate varies Separate from the Annual Wellness Visit 35

Billing: Alcohol Misuse Screening G0442 Modifier may be necessary depending on the other services provided Screening is a covered Medicare benefit once a year: Each state may have a higher or lower reimbursement rate Separate from the Annual Wellness Visit 36

Billing: Brief Intervention Additionally, if you provide a brief intervention to a patient who screened positive for alcohol misuse you can bill for it. G0443 15 Minutes or less Have you ever considered decreasing the amount of alcohol you consume? This code can be billed up to 4 times per year, if necessary Reimbursement by state varies 37

National Resources 1. Depression Screening tools: phqscreeners.com 2. Alcohol Misuse Screening Tools: http://apps.who.int/iris/bitstream/10665/67205/1/who_msd_msb_01.6a.pdf 3. Alcohol Screening and Intervention Algorithm: http://pubs.niaaa.nih.gov/publications/practitioner/cliniciansguide2005/clinicians_guide5_help_p.htm 4. CDC.gov: cdc.gov/features/alcoholscreeningintervention/ 38

Plan to attend the rest of this webinar series: A Guide to Behavioral Health Screenings Module 2: August 31, 2016 The ABCs of Scoring and Interpreting Behavioral Health Screens Module 3: September 7, 2016 Monitoring Patients to Symptom Remission Module 4: September 14, 2016 Behavioral Health Referrals and Community Resources All times: 12:30 p.m. - 1:30 p.m. MT / 11:30 a.m. - 12:30 p.m. PT 39

Questions? 40

Contact Information New Mexico Remona Benally (505) 998-9753 RBenally@healthinsight.org Oregon Rebecca Fuller, MA, LPC 503-382-3920 rfuller@healthinsight.org Nevada Jackie Buttaccio 702-933-7322 jbuttaccio@healthinsight.org Utah Janet Tennison, PhD, MSW, LCSW (801) 892-6604 jtennison@healthinsight.org This material was prepared by HealthInsight, the Medicare Quality Innovation Network-Quality Improvement Organization for Nevada, New Mexico, Oregon and Utah, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW-G1-16-19 41