Justin Coffey, MDBehavioral Health Services

Terri Robertson, PhDCenter for Clinical Care Design

Perfect Depression Care

Objectives

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Recognize the value of including depression care into chronic disease care models

1. Understand the key components of evidenced-based treatment for clinical depression

1. Understand the key components of evidenced-based treatment for clinical depression

Enhance knowledge of suicide prevention strategiesEnhance knowledge of suicide prevention strategies

Discuss the benefits of using standardized depression

screening tools, such as the PHQ-2 and PHQ-9

Develop several strategies for integrating depression screening and treatment into clinical practice

5

4

3

2

1

Suicide Statistics

There is a suicide every 15 minutes in the US

90% of people who die by suicide have a diagnosable and treatable psychiatric disorder at the time of their death

70% of patients committing suicide have seen their primary care provider within 6 weeks of the suicide

….. There is an opportunity here!!

Number of suicides per 100,000 US general population

0

50

100

150

200

250

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Su

icid

es p

er

100,0

00

Number of suicides per 100,000 US general population

Suicides per 100,000 HMO Patients

Number of suicides per 100,000 US general population

Expected suicide rate for patients with an active mood disorder (21X)Expected rate for euthymic patients with mood disorder (4-10X)

Number of suicides per 100,000 HAP-HFMG patients

Q3YTD

Suicidality in Primary Care is Palpable

% of Primary Care Patients with a Positive Q9 on PHQ9

0

5

10

15

20

25

2006 2007 2008 2009 2010 2011YTD

Suicide Ideation Trends- HFMG

Depression in Primary Care Model

Registry (DocSite) to identify eligible patients

Standardized, evidenced-based toolsPHQ2PHQ9

Automated toolsEmbedded in EHR

SimpleSelf-scoresProvides interpretationLinks to treatment guidelines

Evidenced-based treatment menu based on patient preference

Medication managementPsychotherapy (CBT)Problem-solving therapy (PST)

Utilize MA’s to “tee up” process

Use Psychiatric NP’s and/or Clinical Psychologist to spread tools/ train clinic staff

Cross trained Diabetes Care Center and RN Case Managers (collaborative care)

HFHS DST

PHQ-2 branches when positive (> 3) to full 15-item DST

Depression Screening Tool

Alerts at top of patient record:1 D= DST score is > 10, alert is removed after DST is signed by Responsible Staff2 S= Suicide risk question(s) answered positively, alert is removed when DST is repeated and suicide risk questions are negative

1

2

Safety Visual Management

Diabetes Care Center-2011 Depression Screening Rates

15%

52%

85%

97%

0

10

20

30

40

50

60

70

80

90

100

% p

ts w

/ fo

llow

-up

DS

T

(wh

en P

HQ

-2+

)

Beforeprocesschange2009*

Afterprocesschange2009**

2010 2011-Q3

2011 Goal=85%

DST Rates

70% 72%

83%

97%

50

60

70

80

90

100

% o

f el

igib

le p

atie

nts

sc

reen

ed

2008 2009 2010 2011-Q3

PHQ-2 Rates

2011 Goal=83%

Continuous Improvement

Realized that clinics needed more education/ tools specific to handling a potentially suicidal patient

Solution:1) Developed a suicide triage protocol 2) Partnered with the DCC staff, who selected this as their 2011 safety goal

Diabetes Care CenterResponse to Q9 for Suicide

11%

7%

59%

7%

7%

7%

BHS Referral

No info ondispositionPCP Referral

Outside BHSproviderSent toED/hospitalizedDCC MLP treated

52%

21%

27%

no info fordisposition

BHS referral

Refused orMissedappointment

Pre suicide safety goal (2010) Post suicide safety goal (2011)

N=33 N=27

Celebrate the (Not So) Small Successes!Recent case example from DCC49 yo, AF-AM female with multiple medical conditions and known psychiatric historyActive in psychiatric treatment, medications recently changedSeen for diabetes education, completed DST as part of standard process

Skipped suicidal ideation question, but said “YES” to plan for self harm and skipped intent question

On questioning, disclosed was feeling depressed for over a month, was having suicidal thoughts and planned to take an overdose of pills (had access)Admitted to purposefully lying to her mental health provider a few days prior out of fear that they would “lock her up” Symptoms: feeling depressed, tearful, hopeless, insomnia, loss of appetite with unintentional weight loss, rapid and pressured speech, flight of ideas, hearing voicesRisks identified by DCC staff: history of Bipolar I Disorder, history of depression with suicidal thoughts, very limited social support, comorbid anxiety, access to pills, possible mania/ psychosisOutcome: relocated patient to the internal medicine clinic where clinic RN could assist with sitting with patient; in consultation with BHS, petition was completed and patient was triaged to the ER for IPD Psychiatric admission; police assisted (at request of EMS) without incident

THANK YOU

Questions??

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