Improving Mental Health Screening Rates

1. Improving Mental Health Screening Rates Facilitators: Dan Belanger, NYSAI Quality of Care Director Nanette Brey Magnani, Quality Consultant NYSDOH AIDS Institute September 18, 2009

2. Workshop Outcomes • Understand the importance of mental health care. • Understand changes to Mental Health Indicator for 2008 data collection. • Share HIVQUAL results on the mental health screening indicator 2007. • Select a mental health screening tool to pilot. • Develop a QI Plan from causal analysis to next PDSA cycle to address current implementation issues.

3. Agenda 9:00 Welcome. Review agenda. Assess needs. 9:15 Overview: Importance of Mental Health and QI Project Steps 9:45 2008 MH Indicator and participant exchange of experiences with screening 10:30 Divide into Groups A and B. Group A: Review, discuss and select a screening tool to pilot.

4. Agenda contd. Group B: Problem solve implementation issues. Plan the next PDSA cycle. 11:15 Large group debrief 11:30 Large group: Plan a PDSA to pilot a screening tool and next steps 11:55 Evaluation and feedback 12:00 Adjourn!

5. 9:15 Overview • Importance of Mental Health Care • QI Project Steps

6. Importance of Mental Health Care “Mental health is a state of successful performance of mental function, resulting in productive activities, fulfilling relationships with other people, and the ability to adapt to change and cope with adversity.” United States Surgeon General Report 1999 www.surgeongeneral.gov

7. MENTAL ILLNESS “…A group of brain disorders that cause severe disturbances in thinking, feeling, and relating to other people. They often result in an inability to cope with the ordinary demands of life.” National Alliance for the Mentally Ill (NAMI) www.nami.org

8. Spectrum of Mental Illness In General Primary Care(Not an all inclusive list) • Mood Disorders • Anxiety Disorders • Schizophrenia / Other psychotic disorders • Personality Disorders • Substance Use Disorders • Cognitive Disorders • Attention Deficit Disorders • Eating Disorders American Psychiatric Association. DSM IV: Diagnostic and Statistical Manual of Mental Disorders. 4th ed. 1994.

9. MENTAL ILLNESSES • Affect the patient, family members, friends, neighborhoods and communities • Leading cause of reduced productivity and absenteeism in the work place Mental Health in Adulthood www.surgeongeneral.gov

10. DEPRESSION • Leading cause of disability in developed nations • Will become 2nd leading cause of global disability by 2020 World Health Organization. Global Burden of Disease Study 2001

11. MOOD & ANXIETY DISORDERS • Commonly co-exist (i.e. PTSD and depression) • Commonly co-occur in people with chronic illnesses • Mental Health in Adulthood www.surgeongeneral.gov

12. MOOD & ANXIETY DISORDERS • Concurrent substance use disorder in 24-40% of individuals • Substance abuse worsens course of mental illness Mental Health in Adulthood” www.surgeongeneral.gov

13. ADULT PRIMARY CAREDepression • 1 out of 10 adults • Second most common chronic condition (second to hypertension) Whooley, MA, et al. Managing depression in medical outpatients. NEJ 2000; 1942-1950.

14. ADULT PRIMARY CAREDepression • Patient support necessary • Psychopharmacology and psychotherapy when indicated • 50-60% respond to treatment prescribed • Screening necessary Whooley, MA, et al. Managing depression in medical outpatients. NEJ 2000; 1942-1950.

15. STRESS • Stressful life circumstances exacerbate mood disorders Mental Health in Adulthood” www.surgeongeneral.gov

16. GROUPS WITH GREATER STATISTICAL RISK OF STRESS • Women • African Americans • Young and unmarried people • Lower socioeconomic status Mental Health in Adulthood www.surgeongeneral.gov

17. CHRONIC HEALTH CONDITIONS • Associated with increased rates of mental illness • Diabetes • Hypertension • Heart Disease • Asthma • GI disorders • Soft tissue skin infections • Malignant neoplasm • Acute respiratory disorders • HIV Infection • Substance Use Disorders Dickey, B, Normand S, et al: Medical morbidity, mental illness, and substance use disorders. Psychiatry Serv 53: 861-867, July 2002.

18. Alcohol Substance use Tobacco Poor nutrition Sedentary Lifestyle Poor health literacy Inadequate health insurance Inadequate access to quality care Unstable housing Mental IllnessAssociated with Habits or Circumstances that lead to shortened life spans

19. INCREASED RATES OF MENTAL ILLNESS OBSERVED IN SPECIAL POPULATIONS • Homeless • Incarcerated • Institutionalized • Physically challenged • People with HIV/AIDS www.surgeongeneral.gov

20. About 10% of people with HIV infection have severe mental illness. AIDS INSTITUTE HIV Clinical Guidelines for the Primary Care Practitioner www.hivguidelines.org NYS DOH 1990’s Medicaid Data

21. 50% of the HIV population suffers from some degree of mental illness Wang PS, Berglund P, Kessler RC. Recent care of common mental disorders in the United States: prevalence and conformance with evidence-based recommendations. J Gen Intern Med. 2000;15:284-292 MENTAL ILLNESS

22. Adherence problems Death anxiety Fluctuations in CD4 and VL Poorer outcomes The Differential Impact of PTSD and Depression on HIV Disease Markers and Adherence to HAART in People Living with HIV Boarts JM, Sledjeski EM, Bogart LM, Delahanty DL.  AIDS and Behavior , Vol. 10, No. 3, May 2006, pp. 253- 261. MENTAL ILLNESS ASSOCIATED WITH:

23. Overview of QI Project Steps • Step 1: Collect and Analyze Performance Data • Step 2: Convene a Project Team • Step 3: Investigate the Process • Step 4. Implement PDSA – Plan, Do, Study Act • Step 5: Evaluate Test Result(s) with Key Stakeholders • Step 6: Systematize Change

24. 9:45 2008 HIVQUAL Mental Health Indicator

25. 9:30 Mental Health Indicator • 2008 eHIVQUAL evaluates whether allHIV+ patients have received mental health screening during the 12 month review period. • A patient is deemed to have received a mental health screening if all of the specified components were provided. • Additionally, the need and follow-up for a mental health referral is evaluated.

26. Mental Health Indicator Continued Documentation Guide: Criteria developed by the New York State Quality of Care Advisory Committee include the following components for an annual Mental Health Screening for people with HIV: • Cognitive function assessment, including mental status • Depression screening • Anxiety screening • Psychiatric history • Psychosocial assessment • Sleeping habits assessment • Appetite assessment • Post Traumatic Stress Disorder screening (optional)

27. Mental Health Indicator Continued • Needfor Mental Health Referral. HIVQUAL prompts, "Was a need for mental health referral identified?“ • YES: A need for a mental health referral was documented during the review period (can be independent of mental health screening) (continue to 2.1). • NO: No documentation of the need for a mental health referral (stop).

28. Mental Health Indicator Continued • 1.2) eHIVQUAL prompts, “Referral indicated?” • YES: The problem documented in 1.1 required a referral (continue to 1.2.1) • NO: The problem documented in 1.1 did not require a referral. This is the case if the patient was treated in-house, or was already in care. Also, choose “no” if a referral was not made and it is unclear whether one was indicated (continue to 1.3).

29. Mental Health Indicator Continued • Documentation Guide (suggestions) • Need for Mental Health referral • Patient request • Symptoms identified in formal assessment • Need noted by primary care physician

30. Mental Health Indicator Continued • 1.2.1) eHIVQUAL prompts, “Referral made?” • YES: A mental health referral was documented (continue to screening for other conditions) • NO: No documentation of a mental health referral (continue to screening for other conditions)

31. Mental Health Indicator Continued • For anxiety, depression, and PTSD screening, the following questions apply: • 1.1) eHIVQUAL prompts, “Treatment indicated?” If the patient was not screened, eHIVQUAL will ask whether treatment was indicated based on the patient’s previous history. • YES: There is a documented problem requiring treatment (continue to 1.2). • NO: There is no documented problem that requires treatment (continue to screening for other conditions).

32. Mental Health Indicator Continued • 1.3) eHIVQUAL prompts, “Was the patient given treatment or already in care at the time of the assessment?” • ALREADY IN CARE: Chart documents that the patient was already receiving mental health care during the review period (continue to screening for other conditions) • GIVEN TREATMENT: The patient was treated, but not referred to a psychiatrist. (continue to screening for other conditions). • NO: None of the above options apply. The patient was identified as having the specific mental health condition but no further action was taken. (continue to screening for other conditions)

33. Mental Health Indicator Continued • For appetite assessment, sleep habits assessment, psychiatric history, and psychosocial assessment, eHIVQUAL prompts whether the screening occurred but does not ask follow-up questions.

34. Mental Health Indicator Continued • 2) eHIVQUAL will ask whether there was a needfor mental health referral if one was not previously identified for depression, anxiety or PTSD. HIVQUAL prompts, "Was a need for mental health referral identified?" -YES: A need for a mental health referral was documented during the review period (can be independent of mental health screening) (continue to 2.1). -NO: No documentation of the need for a mental health referral (stop).

35. Mental Health Indicator Continued • 2.1) Mental Health Referral. HIVQUAL prompts, "Was referral to a mental health provider made?“ -YES: A mental health referral was documented (continue to 2.1.1). -NO: No documentation of a mental health referral (stop.)

36. Mental Health Indicator Continued • 2.1.1) Mental Health Appointment HIVQUAL prompts, "Did a mental health appointment occur within 30 days of the referral?” -YES: Documentation of visit for mental health care (stop). -NO: No documentation of mental health care appointment being kept (stop). Currently Receiving Mental Health Care: Chart documents that the patient was already receiving mental health care during the review period (stop).

37. www.hivguidelines.org Clinicians pocket reference for mental health screening. Download from website or contact AIDS Institute to order laminated pocket card. • All updates available • on website.

38. 10:00 Large Group Share Experience with screening tools

39. SCREENING TOOLS • Standardized screening tools • Self-administered patient questionnaires • Administered by appropriate staff www.hivguidelines.org

40. INTERPRETATION OF RESPONSES and TREATMENT PLAN Licensed health care provider: MD PA NP PhD / PsyD CSW

41. Example of Depression Screening Questions Over the past two weeks have you: q Felt down, depressed or hopeless? q Felt little interest or pleasure in doing things? United States Prevention Services Task Force (USPSTF)

42. Example of Anxiety Screening Questions • Do you often feel worried, anxious or nervous? • Do you ever experience your heart racing, shortness of breath all at one time for no reason?

43. Example of PTSD Screening Questions Have you ever had an experience that was so frightening or horrible that you: q Think about it even when you don’t want to? q Have nightmares about it? q Feel numb or detached from others and your surroundings? q Are you easily startled?

44. Screening should include at least: 1. Level of orientation & awareness 2. 3/3 object recall after 5 minutes 3. Naming objects

45. BENEFITS OF ROUTINE SCREENING • Early identification of mental illness • Improved treatment plans for mental illness and substance use disorders • Treatment will improve the quality of life, increase rates of adherence and stabilization of CD4 and VL

46. INTEGRATION OF CARE FOR HIV INFECTED PEOPLEBruce Agins, MD 2001 HIV Medical Care INTEGRATION OF CARE Mental Health Services Substance Use Treatment Services

47. Individual practitioners and larger systems must reassess approach to coordinate, integrate and monitor delivery of effective care. Integration of care will widen the safety net approach for those patients who are most in need. INTEGRATION OF CARE

48. Leadership Strategies • Incorporate mental health and substance use presentations into lecture series • Facilitate communication among all treating providers • Incorporate mental health screening into primary care • Educate all staff • Provide contact information about mental health services in your area • Facilitate referral processes and tracking

49. 10:30 Small Group Work • Group A: Review, discuss and select a screening tool to pilot. • Group B: Problem solve implementation issues. Plan the next PDSA cycle.

50. PDSA Cycle Plan, Do, Study, Act