Depression Screening in Primary Care

1. Depression Screening in Primary Care Kristen Palcisco, BA, MSN The MetroHealth System

2. The MetroHealth System • MetroHealth is an integrated health system with an acute care hospital housing a Level I Adult Trauma and Burn Center, a skilled nursing facility. • More than 25 locations throughout Cuyahoga County with more on the way.

3. Depression Facts - Epidemiology • Lifetime prevalence of 10-24% in women and 5-12% in men • 19 million Americans diagnosed each year • 151 million people affected worldwide • 2nd leading cause of disability by 2020 • Depressive disorders are 2-fold more prevalent in patients with diabetes, CAD, HIV, and stroke • Depression associated with 2x increase in risk of type 2 diabetes • Depression associated with 64% increase in risk of CAD • Untreated symptoms of depression exacerbate chronic illness

4. Background and Purpose • Better Health Greater Cleveland reporting on depression screening , beginning with 2012. Full reporting in January 2014. • Meaningful Use: 11 NQF 0105 PQRI 9 Title: Anti-depressant medication management: (a) Effective Acute Phase Treatment,(b)Effective Continuation Phase Treatment Description: The percentage of patients 18 years of age and older who were diagnosed with a new episode of major depression, treated with antidepressant medication, and who remained on an antidepressant medication treatment. • Medicarecovers annual depression screening for adults in the primary care setting.

5. What we know about Ohio • 1,639,270 Medicare Fee-for-Service (FFS) beneficiaries in provider practices across Ohio • CMS data indicate for Ohio FFS beneficiaries: • Only 1.8 percent were screened for depression **For providers, this is approximately $56,445,600 in lost revenue. **

6. PHQ-2 (Patient Health Questionnaire-2) • It is the first 2 questions of the PHQ-9, asked as “yes/ no.” • Inquires about the frequency of depressed mood and anhedonia (lack of interest or pleasure) over the preceding 2 weeks. • The PHQ-2 is a first step in screening and is not for diagnosis or monitoring. • Patients who screen positive (i.e. answer “yes” to either question) should be evaluated further with a PHQ-9, to determine whether they meet criteria for a depressive disorder diagnosis.

7. Primary Care • Only30-50% of patients with depression are recognized by PCPs. • Only 50% of patients with depression receive treatment.

8. Who are we screening? • Once annual screening for all patients ages 18 and older who are seen in primary care clinic, and do not currently have a diagnosis of depression. • Patients without an ICD-9 related code for depression in their problem list • Successfully implemented at Broadway Family Practice (Dec 4, 2012) and WestPark clinic (March 18, 2013).

9. What happens? • Population: annual screening of all adult patients without an ICD-9 diagnosis of depression on their Problem List. • Outpatient primary care clinics. • PHQ-2 and PHQ-9 printed on pre-visit summary (PVS). • The patient completes PHQ in waiting room.IF the PHQ-2 is positive, they complete the PHQ-9. • The MTA/RN (non-physician) enters the PHQ-2 and/or PHQ-9 data into the PHQ tab in the Epic nursing navigator. • For positive screens: The Best Practice Alert (BPA) fires for the Provider. A positive PHQ-2 screening = answering “yes” to either or both questions. • Negative screens: Repeat Screening in ONE YEAR.

10. Intake form

11. Pilot Results (one month) • 1) Number of alerts fired/triggered since December 4, 2012: 137 Alerts triggered at Broadway. • 2) The number of PHQ-2's and PHQ-9's completed: 653 PHQs completed – 460 with 0 score (i.e. PHQ-2 Negative), 192 with score greater than 0, and 1 with a blank score (most likely data entry error). • 3) Diagnoses given as a result of completing the PHQ: 26 depression diagnoses new to problem list. • 4) Number of positive PHQ screenings per week or month, per provider - Average 13.7 positive PHQ-9 per provider for 9 weeks =1.5 positive PHQ-9/ week/ provider. • 5) Diagnosis made – average 1.8 per provider for 9 weeks = 0.2 per week per provider(total of 14 providers).

12. EVERYONE: Workflow

13. PSR • Patient checks-in. • PHQ-2/9 and General Screening questions print on the Pre-Visit Summary for appropriate patients. Medications print with PVS, as usual. • PSR hands all of these to patient, and states “please answer the questions on these forms.” The PHQ is pre-printed and available to you other languages. • The PHQ-2 is to be completed (2 questions). IF the patient answers “yes” to either question, they must fill out the entire PHQ-9 (9 questions, includes the PHQ-2 questions).

14. Pre-Visit Summary (PVS)

15. MTA and Nurse • When the patient is called back, they should have reviewed: Medications, General Screening Questions, and the PHQ-2/9 depression screening. • The Medications and General Screening Questions responses are entered in the same place in the Epic navigator. • The PHQ-2/9 will be entered in the new “PHQ” tab in the current navigator. • Simply ask the patient “Did you answer all of the questions?”

16. PHQ-9 Navigator • PHQ-2/9 is built into Nursing/MTA and Provider navigators. • Enter PHQ-2 answers as “yes” or “no.” • If either question is answered as “yes,” the patient must complete the full PHQ-9.

17. Provider • Best Practice Alert will fire for positive screens. • Education for diagnosing depression: Please add to the PROBLEM LIST.

18. Providers: BPA Smartset

19. Providers: BPA SmartSet SmartSet contains the following options: • Diagnoses • Antidepressant medication • Referral Options – Current • AVS/charting notes

20. Providers: Best Practice Alert

21. Sample BPA Message: Severe Depression • “Your patient completed a PHQ-9 depression screening today. He/She scored ___ , which indicates Severe depression. You may: 1. Click ACCEPT SmartSet for diagnosis, medication, and referral information, or 2. If SmartSet not accepted - please choose appropriate Reason. Please review the following treatment algorithm for a score of >20 Severe depression. Treatment options: 1) Patient education, 2) Initiate or adjust antidepressant therapy, 3) Alert Social Work for visit support, 4) Refer to Mental Health specialist. Follow-up: 2-4 weeks, repeat PHQ-9.”

22. PHQ data stored in a PHQ-9 Doc Flow Sheet

23. Providers: Depression Treatment Algorithm

24. After Visit Summary (AVS) “Today you completed a PHQ-9 screening for depression. Please follow the plan of care as instructed by your provider.  If your symptoms become worse before your next appointment, please call the MetroHealth nurse hotline at 216-778-7878, or the 24-Hour Mental Health Crisis Hotline 216-633-6888 for help.”

25. Evidence Based Resources

26. Depression doesn’t discriminate! PHQ Available in Other Languages • http://www.mmhrc.ca/en/content/phq-9-multiple-languages • http://www.phqscreeners.com/overview.aspx

27. Education We created 3 webinars on depression education for you! Please visit http://betterhealthcleveland.org/Home/Events/webinars_depression_1112.aspx Please Note: These are no longer valid, but were used during the implementation

28. Next • What: Go-Live with PHQ in Epic. • Where: MetroHealth – All primary care ambulatory clinics. • When: June 3, 2013! • Exceptions: Main Campus Family Medicine and Main Campus Internal Medicine (Go-live will be August, 2013).

29. NCQA PCMH Criteria KM 03 (Core): Conducts depression screenings for adults and adolescents using a standardized tool. • Evidence of implementation AND • Report or • Documented process PCMH Standards and Guidelines (2017 Edition, Version 1) April 3, 2017

30. Questions?

31. Contact • Kristen Palcisco, APRN at Kpalcisco@Metrohealth.org

32. THANK YOU!