Collaborating Across Disciplines: Screening for Peri-Partum Depression

1. Collaborating Across Disciplines, Departments and Across Houston: Screening for and Addressing Peri-Partum Depression Stephanie Marton, MD MPH, Jill Roth MD and Stephanie Chapman, PhD

2. Objectives • Recognize signs and symptoms of postpartum depression that would warrant further evaluation by the behavioral health team. •  Describe the benefits of an integrated OB-pediatric-behavioral health care model when screening for peripartum depression.   • Identify how patient centered medical homes can effectively care for families affected by peripartum depression.

3. Brief Outline • How does the Center for Children and Women function as a patient centered medical home? • Who is our population? • Why is peripartum depression a significant concern for our patient population? • How are women with peripartum depression identified? • How does behavioral health assist with diagnosis, treatment and provide community referrals? • Example of recent quality improvement in screening for postpartum depression • Case study • Future directions

4. TCHP The Center for Children and Women at Greenspoint and Southwest Southwest: Opened November 2014 Greenspoint: Opened August 2013

5. Patient Centered Medical Home • Pediatrics: National Committee for Quality Assurance (NCQA) Level 3 Patient-Centered Medical Home • OB: NCQA Level 3 Patient-Centered Specialty Practice • Multiple integral teams

6. The center departments:Integrated Care = Easy Access

7. Pediatric Team at the Centers • 12 pediatricians, 8 nurse practitioners, RNs and MAs • Scheduled appointments • Newborns, ADHD medication, Well-child checks • Walk-in availability for sick visits • Same day lab and Xray services • Real time consultation with other Center departments • Continuity of care • Teaching facility for pediatric residents and medical students • Continuity clinic • Underserved rotations • Capstone projects

8. OB Team at the Centers • 12 MDs, 6 midwives  • Clinic care • Centering pregnancy • 24-hour coverage at 2 community hospitals • Teaching site for students

9. THE CENTER: Pediatric Patient Access Hours Pediatric Hours: Sunday 9 AM – 7 PM Monday 7 AM – 11PM Tuesday 7 AM – 11PM Wednesday 7 AM – 11PM Thursday 7 AM – 11PM Friday 7 AM – 11PM Saturday 9 AM – 7 PM 100

10. The Center: Patient Demographics

11. Percent of Patients Engaged in Behavioral Health Care 4% of TCHP membership engaged in BH as of 8/15; 14% of patients seen at Center engage in BH care as of 4/16

12. The Center for Children and Women – A Hybrid Model 1) Independent outpatient behavioral health services 2) Just in time behavioral health services during medical appointments

13. Integrated Care • No offices • Team huddles • Voalte communication • Just-in-time consults • Care coordination

14. Open Access Appointment Scheduling • No referral process • No intake paperwork • Just in time services – medical screens and consults • Open scheduling –all team members can put a patient in an appointment slot for Behavioral Health

15. Interdisciplinary Behavioral Health (BH) Team

16. Bilingual Clinical Team (70% speak Spanish fluently) All services available in Spanish All handouts available in Spanish Telephone interpretation services always available Focus on Language Access

17. Flexible BH Service Delivery • Just in time services – medical screens and consults • Therapy (individual and family) • Groups (e.g., social skills and assertiveness training groups) • Telehealth between Centers • Social work resourcing

18. Treatment of Maternal Depression

20. The AAP Task Force on Mental Health and the Committee on the Psychosocial Aspects of Child and Family Health have promoted collaborative, colocated, and integrated models for mental health services within primary care medical homes. In such settings, social work staff or mental health providers, who are colocated in the practice as part of the care team, can provide immediate triage for positive screening results, support and follow-up for mothers, and linkage and referral for more specialized services. -Pediatrics, 2010

21. Risk Factors for Maternal Depression Lancaster et al., 2010

22. Maternal Depression Screening - EDINBURGH Center Screening Points: OB/GYN Clinic At first visit 36 weeks 4-6 week postpartum visit PEDIATRIC Clinic At 2 week well-check At 2 month well-check

23. BH Diagnostic Intake • Psychosocial interview • Clinical observations • Assessment measures • Broadband measure administered (e.g., SCL-90 or BASC-2) • Other measures administered specific to individual and identified concerns (e.g., Hamilton Anxiety Rating, UCLA Trauma Rating, Mood Disorder Questionnaire) • Feedback/ Treatment Plan

24. Evidence-Based Treatments For Perinatal Depression

25. Medication Management 1) BH Clinicians and PEDI/OBGYN physicians partner to manage the majority of psychotropic medication 2) Psychiatry -patients with complex medications - lack of progress with first line treatment -consult role – provider to provider support to BH, OB and PEDI teams

26. 2015 Top 10 OB Diagnosis Seen in Center BH Department

27. Recent Quality Improvement in Maternal Depression Screening OB-Pediatric-Behavioral Health Initiatives

28. QI Project – Paper to Pencil Depression Screening History: • Peri-partum depression screens conducted via verbal report • Concern regarding underreporting of symptoms QI Initiative: implementation of paper-to-pencil depression screening in both PEDI and OB clinics

29. Results – Percent of Screens with Significant Scores

30. Unexpected Impact of QI Change 1. Spanish translation issue • Question #8 “Me he sentidotriste y desgraciadas” • “Desgraciadas” has negative connotations in parts of Mexico and Central America • MAs were uncomfortable presenting paper/pencil questionnaire with desgraciadas

32. Unexpected Impact of QI Change 1. Spanish translation issue Results: • Great call out for cultural improvement of screener • Updated screeners of the Spanish Edinburgh are now being used at the Center, the Pavilion and some TCPs.

33. Positive Depression Screens – Provider Level Utilized Total Patients with + Screens= 294, 2015

34. Reasons for No BH Contact After + Depression Screen

35. Fishbone Analysis • No Just in time service available • Patient left without appt; unable to reach by phone • BH appt different day – no show • BH appt at next OB appt but services ran late • No follow-up scheduled; score “drops off” • Stigma of BH • Misunderstanding of BH services • Appointment taking too long • Family pressure to decline • Patient doesn’t perceive need • Provider forgot • Provider unclear on cut score • Provider read score incorrectly • Provider determined lack of need

36. QI Project – Postpartum Depression Screening in Pediatrics Department History: • Concern that postpartum depression was not being identified by the pediatrics team • Concern that positive EPDS screens were not being recognized QI Initiative: • Provider education

37. QI Project – Postpartum Depression Screening in Pediatrics Department Provider Education: Email, Huddles, Provider Meeting • Pediatrics • Reminder to team that Edinburgh is to be done at 2 weeks and 2 months • Defined a positive screen as an Edinburgh score of 11 or higher, or any score on suicidal question • Reminder to providers that even if the score is missed in “real time”, if caught later when reviewing chart, order can still be placed to SW to follow up via phone.  • Behavioral Health • BH to link infant and mother’s charts to document cross-departmental care.

39. Potential QI Interventions • Concern: Pediatric provider not recognizing positive screens • MA can directly place BH referral for positive EPDS screen (MAs enter the score into EMR) • Concern: OB team receiving higher percentage of positive screens than pediatric team • Develop MA scripting when providing the questions to normalize mom’s feelings

40. Treatment – Case Study

41. Case Study - Laura 24 y.o. Latina and bilingual female seen in OB at 18 weeks gestation Psychosocial: lived alone with 2 children domestic violence underemployed limited social support

42. Case Study - Laura Diagnostic presentation: • EDPS Screen – 23, frequent suicidal ideation endorsed • Sleep disturbances • Low weight gain; reduced appetite • Anhedonia • Sleeps most of day; difficulty caring for kids • Shame, guilt, belief family better off without her • Passive suicidal ideation (hanging) – waiting for a time when kids would be on vacation • History of suicidal attempts – last 2 years ago

43. Case Study - Laura

44. Results • At 6 weeks postpartum, remission of all depressive sxs achieved • EDPS score = 3 • Violent relationship ended • Increased connection with social support system • Increased engagement in parenting • Laura continued maintenance dose of antidepressant • Successfully transferred care out of clinic at end of pregnancy medicaid term • Baby is now cared for in pediatric clinic

45. Summary • Patient centered medical homes have great ability to identify, care for and initiate referrals for peri-partum depression • Expanded access • Screening of patients • Integrated services • Coordinated care