Collaborative Family Healthcare Association 14 th Annual Conference

Building the Behaviorally Enhanced PCMH: The Development and Implementation of an EHR-Based System for the Screening and Management of Depression in Primary Care

Collaborative Family Healthcare Association 14th Annual ConferenceOctober 4-6, 2012 Austin, Texas U.S.A.

Session #F3bOctober 5, 2012

UCSD Division of Family Medicine

Building the Behaviorally Enhanced PCMH: Building the Behaviorally Enhanced PCMH: The Development and Implementation of an EHR-Based System for the The Development and Implementation of an EHR-Based System for the Screening and Management of Depression in Primary CareScreening and Management of Depression in Primary Care

Zephon Lister, PhD, LMFTWilliam Sieber, PhD

Rusty Kallenberg, MDKurt Lindeman, PhD


Learning ObjectivesLearning ObjectivesAt the conclusion of this presentation participant will be

able to:

1. Describe the process and conceptual underpinnings of developing an EHR-based office visit screening system

2. Identify and list the implementation steps and components of an EHR-based office visit screening system

3. Discuss a more generalized template for implementation of this process in a range of primary care environments

4. Describe the challenges and clinical pearls identified through the development and implementation of a universal screening process.


UCSD Primary CareUCSD Primary CareProviders

◦40+ Physicians◦1 Psychiatrist◦2 Licensed Mental Health Providers and

12 Mental health providers in training Services 35,000+ patientsEach clinic experiences 120-160

daily patient encounters Population:

◦Payors from low SES and Medi-Cal to PPO


Literature: Universal Literature: Universal Depression Screening in Depression Screening in Primary CarePrimary Care Roughly one third to one half of non-elderly adults and

almost two thirds of older adults who are treated for depression are treated in primary care1-3.

Recent research estimates that mental health screening rates may be as high as 74 percent in primary care4, and once a primary care provider has identified a patient as depressed, almost 90 percent patient receive some level of provider intervention5,6.

One study found that 30 to 40 percent of cases of depression may be missed PCP’s who rely solely on provider recognition7.

The USPSTF conclude that mass screening in primary care may help clinicians identify missed depression cases and initiate appropriate treatment. Screening may help clinicians identify patients earlier in their course of depression8.


BackgroundBackground UCSD Family Medicine building toward PCMH

since 2004

2011 NCQA PCMH standards◦ PCMH 3: Plan and Manage Care- One of three clinically

important conditions identified by the practice must be a condition related to unhealthy behaviors (e.g., obesity) or a mental health or substance abuse condition.

U.S. Preventive Services Task Force (USPSTF)◦ screening adults for depression when staff-assisted

depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up.

◦ against routinely screening adults for depression when staff-assisted depression care supports are not in place.


Background cont.Background cont.UCSD Electronic Health Record EHR EPIC Systems electronic medical record (EHR),

now used throughout the UCSD Healthcare System. EPIC provides a complete view of all visits — from ER to primary care to specialty to inpatient — and all laboratory, radiology, and special testing results.

EHR allows providers to develop patient registries for special groups of patients with particular diseases (e.g. depression) or particular needs (e.g. care management) so that we can more easily follow up on those who are not doing as well as they could.


ImplementationImplementation


ImplementationImplementation


Provide patient standard PCP interpersonal support and education

1.Provide Patient Information Sheet on Stress Management Groups and Collaborative Care 2.Assess for T-Care referral/follow-up 3.Assess for Collaborative Care referral 4.Assess benefit of meds and other PCP intervention

1.On-site T-Care trainee or intern assesses pt. to inform PCP intervention plan 2. Patient referral to Collaborative Care 3.Assess benefit of meds and other PCP intervention

1.(a) Immediate on-site assessment and intervention by T-Care trainee or intern to inform PCP intervention plan, (b) access any CC staff in clinic to assess patient at earliest opportunity (c) if no CC staff is available send stat EPIC message to Lead Therapist or Supervisor or page for immediate support 2.See PHQ-9 >20 protocol

PHQ-9 (#9 positive endorsement)

PHQ-Score 2 or more

Depression Screening Clinical Protocol


Descriptive and Prevalence DataDescriptive and Prevalence Data

male female

% all FM patients seen in clinic (10/07 – 3/09; n =

27,964)

42.8 57.2

% FM patients referred to CC (n = 1040)

24.6 75.4

Mean age referred to CC 41 39

% of referred patients seen by CC (n = 533)

36 31



Diagnosis (DSM code) # FM patients w/ diagnosis

# FM patients w/ diagnosis Rx’d psych

meds

# FM patients referred to CC

w/ Dx (% of Dx’d patients)

# FM patients seen by CC therapist w/ Diagnosis

Anxiety (300) 2137 1625 569 (26%) 218 (38%)

Depression (311) 1910 1542 498 (26%) 173 (35%)

Abuse of drugs (305) 906 485 89 (10%) 32 (36%)

Special symptoms NOS (307)

506 364 63 (13%) 16 (25%)

Episodic mood (296) 370 201 88 (24%) 55 (63%)

Adjustment reaction (308)

104 50 38 (37%) 20 (53%)



Initial estimates are that 26% of patients with Initial estimates are that 26% of patients with anxiety or depression are being referred to CC anxiety or depression are being referred to CC

Patients abusing substances are less often Patients abusing substances are less often referred to CC programreferred to CC program

Well over 1 of every 3 patients referred to CC are Well over 1 of every 3 patients referred to CC are seen by a therapistseen by a therapist

Patients with cardiovascular, metabolic, or Patients with cardiovascular, metabolic, or musculoskeletal pain are referred only 4.3 %, musculoskeletal pain are referred only 4.3 %, 4.0%, and 7.4% of the time, respectively4.0%, and 7.4% of the time, respectively


Questions & SuggestionsQuestions & Suggestions


ReferencesReferences1. Kessler RC, Berglund P, Demler O et al. The epidemiology of major

depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA. 2003;289:3095-3105.

2. Pincus HA, Tanielian TL, Marcus SC et al. Prescribing Trends in Psychotropic Medications: Primary Care, Psychiatry, and Other Medical Specialties. JAMA: The Journal of the American Medical Association. 1998;279:526-531.

3. Harman JS, Veazie PJ, Lyness JM. Primary care physician office visits for depression by older Americans. J Gen Intern Med. 2006;21:926-930.

4. U.S.Department of Health and Human Services. Mental Health and Mental Health Disorder. 2nd ed ed. Washington, D.C.: U.S. Governement Priting Office; 2000.

5. Robinson WD, Geske JA, Prest LA, Barnacle R. Depression treatment in primary care. J Am Board Fam Pract. 2005;18:79-86.

6. Dobscha SK, Gerrity MS, Corson K, Bahr A, Cuilwik NM. Measuring adherence to depression treatment guidelines in a VA primary care clinic. General Hospital Psychiatry 2003 Aug; 25(4):230-7.

7. Simon GE, VonKorff M. Recognition, management, and outcomes of depression in primary care. Arch Fam Med. 1995;4:99-105.

Please complete and return theevaluation form to the

classroom monitor before leaving this session.

Thank you!

Documents

Collaborative Family Healthcare Association 14 th Annual Conference