Shared Care Collaborative Shared Care Collaborative approach for improving the approach for improving the detection, assessment and detection, assessment and treatment of depressiontreatment of depressionCheryl Washburn, Ph.D, R.Psych., UBC

Counselling ServicesPatricia Mirwaldt, M.D. CCFP, UBC Student

Health ServicesWhitney Sedgwick, Ph.D, R.Psych., UBC

Counselling Services

UBC Shared Care UBC Shared Care CollaborativeCollaborative

community centered collaborative network of primary care providers, working as a multidisciplinary team; enabling sustainable improvement in the primary treatment of depression at UBC and the surrounding community

Learning ObjectivesLearning ObjectivesThis workshop will:

• Describe the key features involved in the development and implementation of a shared care collaborative model for the treatment of depression

• Present data reflecting established stretch goals

• Outline some of the challenges and benefits of a shared care collaborative for the treatment of depression

• Discuss the applicability of a shared care model in your respective communities

UBC Community

Vancouver Coastal Health

The UBC Collaborative

UBC Counseling Services

UBC Urgent Care

UBC Student Health

Services

Patient

UBC Health Clinic

University Village Medical

Clinic

SHARED CARE OF DEPRESSION PROJECT

Input(s)

List Participants Consent _________________________________________________________________Y__________________________________________ N ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Output(s)

PATIENT Request assistance

Patient with concerns

PHYSICIANS

General Screen

Intake Assessment

Diagnosis: Depression

Use evidence – based guidelines to treat depression

• Selfh elpguidelines

• Mood management & Group

• Individual counselling

• Medication • Psychiatry

Tracking &

Assessment Of

Outcomes

COUNSELLORS

OTHERRESOURCES

Other care Or

Referral to other

resources

Patients conce ( ) rn s/is are

addressed

Time LineTime LineSept/03: position paper

Jun/04: Initial stakeholders meeting

Aug/04: Planning session (i.e. conceptual

models)

Oct/04: Funding proposal submitted

March/05: Funding approved

June/05: Planning session (i.e. scope,

membership)

Time Line Time Line (cont.)(cont.)Oct/05: Learning session (i.e. reviewed best practice models)

Nov/05: Planning session (stretch goals)

Jan/06: Learning session part I (Suicide assessment)

March/06: Learning session, part II (Suicide assessment)

March/06: Progress report submitted to VCH

Time Line Time Line (cont.)(cont.)

June, Oct, Dec 06: ongoing: data review and tech. consultations re: data input

March/07: Modification to stretch goals

March/07: Flowsheet revision

Ongoing: Consideration of sustainability post-funding

2004 NCHA Undergraduate student 2004 NCHA Undergraduate student data: data:

Gaps in careGaps in care

0

10

20

30

40

50

60

Female Male

In the last school yearhave you felt sodepressed it was hard tofunction?Have you ever beendiagnosed withdepression?

If yes, have your beendiagnosed in the lastschool yr.?

… in therapy in the lastyr.?

… taking medication inthe last yr.?

2006 NCHA Graduate student data: 2006 NCHA Graduate student data:

Gaps in careGaps in care

0

510

1520

253035

4045

Female Male

In the last school yearhave you felt sodepressed it was hard tofunction?Have you ever beendiagnosed withdepression?

If yes, have your beendiagnosed in the lastschool yr.?

… in therapy in the lastyr.?

… taking medication inthe last yr.?

Gaps in careGaps in carePublic: Lack of awareness of signs/symptoms, prevention and available Lack of awareness of signs/symptoms, prevention and available

resources and servicesresources and services Stigma associated with depression and treatments that prevent Stigma associated with depression and treatments that prevent

people from receiving help.people from receiving help. Failure to comply with treatment.Failure to comply with treatment.

Service Delivery Failure to recognize/assess depression, educate patients and Failure to recognize/assess depression, educate patients and

families about nature of depression and support self families about nature of depression and support self managementmanagement

Failure to recommend evidence-based psychotherapyFailure to recommend evidence-based psychotherapy Inadequate dosage and duration of medsInadequate dosage and duration of meds Lack of time and compensationLack of time and compensation Limited access to mental health professionalsLimited access to mental health professionals Lack of ongoing monitoring and maintenance of change despite Lack of ongoing monitoring and maintenance of change despite

high rates of relapse and recurrencehigh rates of relapse and recurrence Lack of integration among multiple existing primary health Lack of integration among multiple existing primary health

care servicescare services

Key features of models to Key features of models to address gaps in depression address gaps in depression

carecare1.1. ManagedManaged (chronic) care (chronic) care2.2. Evidence based stepped care approachEvidence based stepped care approach that

implements enhanced tools, decision supports, and established core measures

3. 3. Capacity building and sustainableCapacity building and sustainable:: both both in numbers served and in physicians’ in numbers served and in physicians’ capacity to recognize and treat mental capacity to recognize and treat mental health issues (ie; education).health issues (ie; education).

4.4. Collaborative:Collaborative: Integrating the services of Integrating the services of primary care physicians and mental health primary care physicians and mental health practitioners. practitioners.

5.5. Model for improved service deliveryModel for improved service delivery

Adapted from Glasgow, R., Orleans, C., Wagner, E., Curry, S., Solberg, L. (2001). Does the Chronic Care Model also serve as a template for improving prevention? The Milbank Quarterly, 79(4), and World Health Organization, Health and Welfare Canada and Canadian Public Health Association.(1986).Ottawa Charter of Health Promotion.

SelfManagement

DecisionSupport

InformationSystemsDelivery System

Design

Healthy Public Policy

SupportiveEnvironments

CommunityAction

ActivatedCommunity

InformedActivatedPatient

Productive

Interactions &

Relationships

Improved Outcomes

THE CARE MODEL

Prepared,Proactive,Practice

Team

Prepared,Proactive

CommunityPartners

Framework for change: The Care Model

Framework for Change: Model Framework for Change: Model for Improvementfor Improvement

Institute for Healthcare ImprovementInstitute for Healthcare Improvement

Aims

Measures

Changes

TestChanges

Implement changes morebroadly

Framework for change: Breakthrough Series Learning Model

UBC Community

Vancouver Coastal Health

The UBC Collaborative

UBC Counseling Services

UBC Urgent Care

UBC Student Health

Services

Patient

UBC Health Clinic

University Village Medical

Clinic

Aims of CollaborativeAims of Collaborative1.1. Improve health outcomes specific to Improve health outcomes specific to

depression depression 2.2. Develop and implement more effective Develop and implement more effective

suicide risk assessment practices suicide risk assessment practices 3.3. Facilitate patient self-management Facilitate patient self-management

skillsskills4.4. Improve access to treatment for Improve access to treatment for

depression for members of the UBC and depression for members of the UBC and University neighborhood communitiesUniversity neighborhood communities

5.5. Develop the primary healthcare network Develop the primary healthcare network in the UBC communityin the UBC community

BC Provincial Depression BC Provincial Depression Strategy Recommended Strategy Recommended Approaches (2002)Approaches (2002)

• Early intervention Early intervention • Collaborative care Collaborative care • Stepped care Stepped care • Chronic disease management model Chronic disease management model

Standardized Approach-PHQ-9Standardized Approach-PHQ-9

Stretch Goals/Results:Stretch Goals/Results:N= 170 (Nov 1, 2006)

% patients given PHQ-9 (Patient Health Questionnaire) at, or within 10 days of, diagnosis Stretch goal: 85%  Results: 137/170=80.6%

% patients given second PHQ-9 within 8 weeks of diagnosis Stretch goal: 85%** Results: 30/137= 21.9%

% patients given third PHQ-9 within 16 weeks of diagnosisStretch goal: 75%** Results: 12/30 = 40%

(** of those who completed initial assessment(s))

Stretch Goals/Results:Stretch Goals/Results:• % patients who have completed a PHQ-9 between 6-12 months post-

diagnosis

Stretch goal: 50% Results**: 164/170= 96.5%

% patients with PHQ-9 score reduced to < 5 (or in remission) by 16 weeks Stretch goal: 50% (of depression register population of patients)

% patients with PHQ-9 score reduced to <5 (or in remission) within 6-12 months post-diagnosis

Stretch goal: 50% (of depression register population of patients)

Results:** 36/170= 21.2%

**(collapsed over 12 months)

Stretch Goals/Results:Stretch Goals/Results: % patients who had a suicide risk assessment at, or within,

10 days of diagnosis.

Stretch goal: 100% Results = 62.4%

% patients who had second suicide risk assessment within 8 weeks of diagnosisStretch goal: 70% (of those who completed first assessment)

Results: 30/137= 21.9%

% patients who had shird suicide risk assessment within 6 months of diagnosisStretch goal: 50% (of those who completed second assessment)

Results: 12/30 = 40.0%

% patients who had a self-management goal documented

Stretch goal: 50% Results: 111/170= 65.3%

Additional Stretch Goals:Additional Stretch Goals: % patients with second contact within 8 weeks of

diagnosisStretch goal: 85% **

% patients with third contact made within 16 weeks of diagnosisStretch goal: 85% **

% patients with PHQ-9 score between 5-19 with no exclusionary co-morbid conditions who have been offered mood management groupStretch goal: 90%

% patients who have been offered psycho-educational materialStretch goal: 50%

(** of those who completed initial assessment(s))

Group counsellingGroup counselling-A key treatment option:

-detailed referral form and FAQ sheet -6 week, psychoeducational CBT groups entitled “Mood management”-positive self-report re: mood (based on 18 groups):

Pre-group PHQ-9 mean score=12.1

Post-group PHQ-9 mean score= 5.9

Initial ChallengesInitial Challenges Recruitment:

Motivation to join Time commitment Compensation – salaried and fee for service considerations

Consent Issues: Designing an informed consent form considering:

BC Health BC Privacy Commissioner VCHA UBC Freedom of Information Coordinator

Confidentiality

Initial ChallengesInitial Challenges

Group Counseling: Who’s patient is this? (physician and/or counselor)

Counselor acceptance and management of non-students (ex. UBC faculty and staff) in groups.

“Buy In” - physician and patient (acceptance as valid treatment option)

Ongoing ChallengesOngoing Challenges Data base:

Electronic medical records and linkages Primary care provider inclusion in registry (ex. Non-MD)

Data and file management (time, data configuration, flowsheets)

Self-care: Physician confidence in guiding patients in self care of depression management

Follow-up: High attrition with this population including practitioners’ reticence to contact patients who missed last appointment

Lack of systematic follow-up of patients who have completed care to ensure healthy outcomes

BenefitsBenefits1. Patients get better from depression-

symptoms recede!!2. Improved education and awareness of

community, practitioners and affiliated health care providers.

3. Early and accurate diagnosis with step-wise application of evidence based care.

4. Sustainable network infrastructure provides improved access to existing resources and increased practitioner capacity.

2006 NCHA Female undergraduate 2006 NCHA Female undergraduate studentsstudents

0

10

20

30

40

50

60

2004 2006

In the last school yearhave you felt sodepressed it was hardto function?Have you ever beendiagnosed withdepression?

If yes, have your beendiagnosed in the lastschool yr.?

… in therapy in the lastyr.?

… taking medication inthe last yr.?

2006 NCHA Male undergraduate 2006 NCHA Male undergraduate studentsstudents

05

101520253035404550

2004 2006

In the last school yearhave you felt sodepressed it was hard tofunction?Have you ever beendiagnosed withdepression?

If yes, have your beendiagnosed in the lastschool yr.?

… in therapy in the lastyr.?

… taking medication inthe last yr.?

2006 NCHA Male graduate students2006 NCHA Male graduate students

0

510

1520

253035

4045

2004 2006

In the last school yearhave you felt sodepressed it was hard tofunction?Have you ever beendiagnosed withdepression?

If yes, have your beendiagnosed in the lastschool yr.?

… in therapy in the lastyr.?

… taking medication inthe last yr.?

2006 NCHA Female graduate 2006 NCHA Female graduate studentsstudents

0

10

20

30

40

50

60

2004 2006

In the last school yearhave you felt sodepressed it was hard tofunction?Have you ever beendiagnosed withdepression?

If yes, have your beendiagnosed in the lastschool yr.?

… in therapy in the lastyr.?

… taking medication inthe last yr.?

BenefitsBenefits5. Clear focus on group counseling and

improved community access to groups.

6. Self management tools developed and utilized as the cornerstone of care.

7. Shared community of care = healthier campus and community.

Questions:Questions:

In what ways could a shared care model have applicability on your campus?

In what ways would a shared care model apply to other health issues on

your campus?

Questions and FeedbackQuestions and Feedback

Thank you!Thank you!

Reference listReference list Bilsker, D., & Paterson, R. (2005). Bilsker, D., & Paterson, R. (2005). Antidepressant Skills Workbook. Mental Health . Mental Health

Evaluation and Community Consultation Unit, University of British Columbia.Evaluation and Community Consultation Unit, University of British Columbia. British Columbia Provincial Depression Strategy Phase 1 Report, October 2002.British Columbia Provincial Depression Strategy Phase 1 Report, October 2002.

http://www.healthservices.gov.bc.ca/mhd/pdf/depressionstrategy.pdfhttp://www.healthservices.gov.bc.ca/mhd/pdf/depressionstrategy.pdf British Columbia Treatment Guidelines and Protocols for Diagnosis and Management of Major British Columbia Treatment Guidelines and Protocols for Diagnosis and Management of Major

Depressive Disorder: Depressive Disorder: http://www.healthservices.gov.bc.ca/msp/protoguides/gps/depression.pdf (contains http://www.healthservices.gov.bc.ca/msp/protoguides/gps/depression.pdf (contains references, p.9 and 10).references, p.9 and 10).

Fisher, L., & Ransom, D.C. (1997). Developing a strategy for managing behavioural Fisher, L., & Ransom, D.C. (1997). Developing a strategy for managing behavioural health care within the context of primary care. health care within the context of primary care. Archives of Family Medicine, 6, 324- 324- 333.333.

Iglehart, J.K. (2004). The mental health maze and the call for transformation. Iglehart, J.K. (2004). The mental health maze and the call for transformation. The New England Journal of Medicine, 350, 507-, 350, 507- 514.514.

Innes, G. (1999). The health transition fund and the future of Canadian health care Innes, G. (1999). The health transition fund and the future of Canadian health care delivery. delivery. Journal of Emergency Medicine, 17, 157-158. 157-158.

Kates, N., Craven, M., Bishop, J., Clinton, T., Kraftcheck, D., LeClair, K., Leverette, Kates, N., Craven, M., Bishop, J., Clinton, T., Kraftcheck, D., LeClair, K., Leverette, J., Nash, L., & Turner, T. (1997). Shared J., Nash, L., & Turner, T. (1997). Shared mental health care in Canada. mental health care in Canada. The Canadian Journal of Psychiatry, 42(8).

Kates, N. & Craven, M. (1998). Kates, N. & Craven, M. (1998). Managing mental health problems. A practical guide for primary care. Seattle: Hogrefe & Huber Publishers. Seattle: Hogrefe & Huber Publishers.

Katon,W., Rutter,C., Ludman, E.J. et al. (2001). A randomized trial of relapse prevention Katon,W., Rutter,C., Ludman, E.J. et al. (2001). A randomized trial of relapse prevention of depression in primary care. of depression in primary care. Archives of General Psychiatry, 58 (3), 241-247. 58 (3), 241-247.

Kroenke K, Spitzer R L, Williams J B. (2001Kroenke K, Spitzer R L, Williams J B. (2001). The PHQ-9: Validity of a brief depression The PHQ-9: Validity of a brief depression severity measure. severity measure. Journal of General Internal Medicine, 16(9): 606-613 16(9): 606-613

Lam, W.R., (2004). Targeted Resources to Improve Primary Care Outcomes in Depression Lam, W.R., (2004). Targeted Resources to Improve Primary Care Outcomes in Depression (TRIPOD): An Educational (TRIPOD): An Educational Intervention for Implementing BC Depression Guidelines. Intervention for Implementing BC Depression Guidelines.

MacMillan, H.L., Patterson, C.J.S., & Wathen, C.N. and The Canadian Task Force on MacMillan, H.L., Patterson, C.J.S., & Wathen, C.N. and The Canadian Task Force on Preventive Health Care. (2005). Screening for depression in primary care: Preventive Health Care. (2005). Screening for depression in primary care: recommendation statement from the Canadian Task Force on Preventive Health Care. recommendation statement from the Canadian Task Force on Preventive Health Care. Canadian Medical Association Journal, 172, (1)., (1).

Paterson, R. (1997). Changeways Core Programme Trainer’s Manual. Vancouver, B.C.Paterson, R. (1997). Changeways Core Programme Trainer’s Manual. Vancouver, B.C. Price, J.R. (2000). Managing physical symptoms: The clinical assessment as treatment. Price, J.R. (2000). Managing physical symptoms: The clinical assessment as treatment.

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