Shared Care Collaborative approach for improving the detection, assessment and treatment of depression

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Shared Care Collaborative approach for improving the detecti...

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1. Shared Care Collaborative approach for improving the detection, assessment and treatment of depression

2. UBC Shared Care Collaborative 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

3. Learning Objectives This 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

5.

6. Time Line Sept/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)

7. Time Line (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

8. Time Line (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

9. 2004 NCHA Undergraduate student data: Gaps in care www.ctfphc.org There is good to fair level I evidence to recommend screening adults in the general population for depression in primary care settings that have integrated programs for feedback to patients and access to case management or mental health care. www.ctfphc.org There is good to fair level I evidence to recommend screening adults in the general population for depression in primary care settings that have integrated programs for feedback to patients and access to case management or mental health care.

10. 2006 NCHA Graduate student data: Gaps in care

11. Gaps in care Public: Lack of awareness of signs/symptoms, prevention and available resources and services Stigma associated with depression and treatments that prevent people from receiving help. Failure to comply with treatment. Service Delivery Failure to recognize/assess depression, educate patients and families about nature of depression and support self management Failure to recommend evidence-based psychotherapy Inadequate dosage and duration of meds Lack of time and compensation Limited access to mental health professionals Lack of ongoing monitoring and maintenance of change despite high rates of relapse and recurrence Lack of integration among multiple existing primary health care services

12. Key features of models to address gaps in depression care Managed (chronic) care Evidence based stepped care approach that implements enhanced tools, decision supports, and established core measures 3. Capacity building and sustainable: both in numbers served and in physicians? capacity to recognize and treat mental health issues (ie; education). Collaborative: Integrating the services of primary care physicians and mental health practitioners. Model for improved service delivery key features of the national and provincial models to improve depression care are: key features of the national and provincial models to improve depression care are:

13. VCHA provided coaching through core renewal project..The Care Model is based on The Chronic Care Model developed by the Institute for Health Improvement. - Illustrates key spheres of influence impacting health and service delivery outcomes: serves as a theoretical framework identifying all levels of care that need to be addressed. VCHA provided coaching through core renewal project..The Care Model is based on The Chronic Care Model developed by the Institute for Health Improvement. - Illustrates key spheres of influence impacting health and service delivery outcomes: serves as a theoretical framework identifying all levels of care that need to be addressed.

14. Framework for Change: Model for Improvement Institute for Healthcare Improvement Provides a practical framework for making specific changes. Model for Improvement asks three questions to focus the area of change and measure change, then provides a model for testing change. Setting Aims Time-specific, measurable; define the specific population affected. Establishing Measures to determine if a specific change actually leads to an improvement. Select Changes that are most likely to result in improvement. Test Changes: The Plan, Do (try it), Study (observe results), and Act (on what?s learned). It is the scientific method used for action-oriented learning. ? Provides a practical framework for making specific changes. Model for Improvement asks three questions to focus the area of change and measure change, then provides a model for testing change. Setting Aims Time-specific, measurable; define the specific population affected. Establishing Measures to determine if a specific change actually leads to an improvement. Select Changes that are most likely to result in improvement. Test Changes: The Plan, Do (try it), Study (observe results), and Act (on what?s learned). It is the scientific method used for action-oriented learning. ?

15. Provides a graphic of the change process ? for those of us who are visually oriented. Provides a graphic of the change process ? for those of us who are visually oriented.

16. Darker circles represent clinics that are less active at present with respect to actively referring patients with depressionDarker circles represent clinics that are less active at present with respect to actively referring patients with depression

17. Aims of Collaborative Improve health outcomes specific to depression Develop and implement more effective suicide risk assessment practices Facilitate patient self-management skills Improve access to treatment for depression for members of the UBC and University neighborhood communities Develop the primary healthcare network in the UBC community

18. BC Provincial Depression Strategy Recommended Approaches (2002) Early intervention Collaborative care Stepped care Chronic disease management model

19. PHQ-9 used as assessment tool-reliable and valid Mild/moderate/severe categories Qualitative item at end PHQ-9 used as assessment tool-reliable and valid Mild/moderate/severe categories Qualitative item at end

20. 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 diagnosis Stretch goal: 75%** Results: 12/30 = 40% (** of those who completed initial assessment(s)) We developed ten stretch goals / indicators that would allow us to evaluate how we were doing. The goals are a combination of process indicators and outcome indicators. Have since elaborated to better capture the mission of the collaborative, and have added 4 goals (have yet to implement the revised flowsheet so do not have reportable data for these new 4 stretch goals-at end of original 10 goals). Beside each stretch goal is measure of status relative to that goal as of early Nov 2006- we have 482 flowsheets in total (from two clinical offices) that remain to be input- these aren?t included here as we?re continuing to better manage and be thorough as possible with data management. Stretch goal #1: .lack of diagnosis date (technician used same date as first PHQ-9 if diagnosis date was missing) #2-had to have had first PHQ-9 in order to have second one #3- this looks inflated because 40% that came back did complete a PHQ-9, but we?re still low on getting people back a third time-rationale to ensure follow up, assess efficacy of treatment, reevaluate diagnosis ** Some might be waiting for a group (chance they are being seen by more than one practitioner)We developed ten stretch goals / indicators that would allow us to evaluate how we were doing. The goals are a combination of process indicators and outcome indicators. Have since elaborated to better capture the mission of the collaborative, and have added 4 goals (have yet to implement the revised flowsheet so do not have reportable data for these new 4 stretch goals-at end of original 10 goals). Beside each stretch goal is measure of status relative to that goal as of early Nov 2006- we have 482 flowsheets in total (from two clinical offices) that remain to be input- these aren?t included here as we?re continuing to better manage and be thorough as possible with data management. Stretch goal #1: .lack of diagnosis date (technician used same date as first PHQ-9 if diagnosis date was missing) #2-had to have had first PHQ-9 in order to have second one #3- this looks inflated because 40% that came back did complete a PHQ-9, but we?re still low on getting people back a third time-rationale to ensure follow up, assess efficacy of treatment, reevaluate diagnosis ** Some might be waiting for a group (chance they are being seen by more than one practitioner)

21. 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) These three goals all involved longer time frames, 16 weeks (4 months) and then having PHQ-9 administered and then hopefully remission within time frame of 6-12 months First one by one year, 96.5% had done a PHQ-9--he went to far end of time scale (1 year) For next two these involve remission, a score of 5 or lower on PHQ-9?again if collapse over a year we?d hoped to have 50% of the patients here and we are at 21.2%These three goals all involved longer time frames, 16 weeks (4 months) and then having PHQ-9 administered and then hopefully remission within time frame of 6-12 months First one by one year, 96.5% had done a PHQ-9--he went to far end of time scale (1 year) For next two these involve remission, a score of 5 or lower on PHQ-9?again if collapse over a year we?d hoped to have 50% of the patients here and we are at 21.2%

22. 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 diagnosis Stretch goal: 70% (of those who completed first assessment) Results: 30/137= 21.9% % patients who had shird suicide risk assessment within 6 months of diagnosis Stretch 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% -if patient indicated any ideation on PHQ-9 (score >0, clinicians must ask additional questions regarding ideation, plan, assess risk)?.important, and too low! again, issue of getting patients to return for follow-up visits --based on the original 137 patients who had first PHQ-9 and were assessed Appears that clinicians are asking about suicidality more frequently in a third visit, but still an issue given low number that come back a third time?.PARALLELS the PHQ-9 results-if patient indicated any ideation on PHQ-9 (score >0, clinicians must ask additional questions regarding ideation, plan, assess risk)?.important, and too low! again, issue of getting patients to return for follow-up visits --based on the original 137 patients who had first PHQ-9 and were assessed Appears that clinicians are asking about suicidality more frequently in a third visit, but still an issue given low number that come back a third time?.PARALLELS the PHQ-9 results

23. Additional Stretch Goals: % patients with second contact within 8 weeks of diagnosis Stretch goal: 85% ** % patients with third contact made within 16 weeks of diagnosis Stretch goal: 85% ** % patients with PHQ-9 score between 5-19 with no exclusionary co-morbid conditions who have been offered mood management group Stretch goal: 90% % patients who have been offered psycho-educational material Stretch goal: 50% (** of those who completed initial assessment(s)) First 2-not yet collecting data on contacts---this will include phone contacts, or condensed sessions Want to ensure that those who are referred to our groups have primary issue of depression, that co-morbid exclusionary issues (such as active mania, or significant eating issues) have been ruled out -will be included material-considering population of students with access to reading material, possibly web-based material Also want to increase some stretch goal percentages (ie. we agreed that self-management should be increased from 50% to 90%) There is acommitted effort to increase followup, enhance tracking?due in part to patient attrition (we need to have patients return in order to track changes) -student population fluctuating visits, may return later in semester Overall, work to be done--hopeful with revised stretch goals and flowsheet will better capture data (consider patients being seen in two offices concurrently)First 2-not yet collecting data on contacts---this will include phone contacts, or condensed sessions Want to ensure that those who are referred to our groups have primary issue of depression, that co-morbid exclusionary issues (such as active mania, or significant eating issues) have been ruled out -will be included material-considering population of students with access to reading material, possibly web-based material Also want to increase some stretch goal percentages (ie. we agreed that self-management should be increased from 50% to 90%) There is acommitted effort to increase followup, enhance tracking?due in part to patient attrition (we need to have patients return in order to track changes) -student population fluctuating visits, may return later in semester Overall, work to be done--hopeful with revised stretch goals and flowsheet will better capture data (consider patients being seen in two offices concurrently)

24. Group 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 -rolling admission, offer groups on varying days/times of the week- -based on Changeways program developed by Dr. Randy Patterson, R. Psych. (Vancouver) -coordinator vets all referrals (exclusionary criteria developed) -where appropriate, individual counselling and referral to psychiatry are also utilized -rolling admission, offer groups on varying days/times of the week- -based on Changeways program developed by Dr. Randy Patterson, R. Psych. (Vancouver) -coordinator vets all referrals (exclusionary criteria developed) -where appropriate, individual counselling and referral to psychiatry are also utilized

25. Initial 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 Recruitment:originally new group, hesitant re:motivation compensation for nonfaculty/non-salaried physicians (not an issue now-not in active practice in collaborative) Consent: various stages-developed form taking these guidelines into consideration confidentiality involved need to store data on a secure site. Use of medical toolkit,while counsellors/non-physicians continue to use paper flowsheets. Questions of encryption and access were imp, here--practices from government technology haven?t caught up with recommendations NOT requiring consent means you get a better, more accurate take on levels of depression, but the downside comes in sharing of information between offices (because with exceptions of signed referrals, we can?t talk among offices about patients and treatment plans)Recruitment:originally new group, hesitant re:motivation compensation for nonfaculty/non-salaried physicians (not an issue now-not in active practice in collaborative) Consent: various stages-developed form taking these guidelines into consideration confidentiality involved need to store data on a secure site. Use of medical toolkit,while counsellors/non-physicians continue to use paper flowsheets. Questions of encryption and access were imp, here--practices from government technology haven?t caught up with recommendations NOT requiring consent means you get a better, more accurate take on levels of depression, but the downside comes in sharing of information between offices (because with exceptions of signed referrals, we can?t talk among offices about patients and treatment plans)

26. Initial 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) -consideration re: if client has a crisis situation while group-practitioner who made referral remains the ?point person? (may have both physician and counsellor at times) -this point has not been an issue as to date we?ve only had 3 non-students in the groups -?buy-in?--we developed FAQ sheet as well as info for physicians re: referral to group-to familiarize with process and clear on exclusionary criteria--this is going well-consideration re: if client has a crisis situation while group-practitioner who made referral remains the ?point person? (may have both physician and counsellor at times) -this point has not been an issue as to date we?ve only had 3 non-students in the groups -?buy-in?--we developed FAQ sheet as well as info for physicians re: referral to group-to familiarize with process and clear on exclusionary criteria--this is going well

27. Ongoing 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 -1 office has EMR, other office in process-non-physicians will not be granted access Next two are together--:non-physicians are still not in the registry--we?re moving ahead with alternate means of collecting data but it is time consuming and a challenge?data entry is becoming more substantial as we have had to use the paper flowsheets as opposed to the secure toolkit--factored this in finances-constraining to an extent, the amount of data presented today!! Self-care-limited here,, and patients don?t return for followup visits on regular basis--makes this challenging Follow-up -will see impact of these bullets on stretch goal slides (is no news good news re: practitioner reticence?) -ongoing follow-up say 6 months later to see if gains are being sustained -1 office has EMR, other office in process-non-physicians will not be granted access Next two are together--:non-physicians are still not in the registry--we?re moving ahead with alternate means of collecting data but it is time consuming and a challenge?data entry is becoming more substantial as we have had to use the paper flowsheets as opposed to the secure toolkit--factored this in finances-constraining to an extent, the amount of data presented today!! Self-care-limited here,, and patients don?t return for followup visits on regular basis--makes this challenging Follow-up -will see impact of these bullets on stretch goal slides (is no news good news re: practitioner reticence?) -ongoing follow-up say 6 months later to see if gains are being sustained

28. Draft flowsheet-1st page with demographics, information gathered in first session (I.e. history of mood, comorbid conditions and disease phase)Draft flowsheet-1st page with demographics, information gathered in first session (I.e. history of mood, comorbid conditions and disease phase)

29. This page would then be used at each visit and reflects the established stretch goals and new 4 goals (I.e. PhQ-9 and contact recording)This page would then be used at each visit and reflects the established stretch goals and new 4 goals (I.e. PhQ-9 and contact recording)

30. Benefits Patients get better from depression-symptoms recede!! Improved education and awareness of community, practitioners and affiliated health care providers. Early and accurate diagnosis with step-wise application of evidence based care. Sustainable network infrastructure provides improved access to existing resources and increased practitioner capacity. !. From the patients that we can followup-particularly in group-their depression recedes 2-skill base, knowledge, learning sessions, and a respect for other practitioners? work 3-with PHQ-9-proactive tool and guidelines-continue to have evidence based care in practice 4-plan to continue post fall 2007-majority of project running on itself with referral network established and ongoing communication between offices, sustain high number of groups etc.!. From the patients that we can followup-particularly in group-their depression recedes 2-skill base, knowledge, learning sessions, and a respect for other practitioners? work 3-with PHQ-9-proactive tool and guidelines-continue to have evidence based care in practice 4-plan to continue post fall 2007-majority of project running on itself with referral network established and ongoing communication between offices, sustain high number of groups etc.

31. 2006 NCHA Female undergraduate students With #3-with NCHA2006 data comparison with 2004 data, ?hard to function and ever diagnosed are similar)?.we see a significant increase number of female undergraduate students reporting they have received treatment for depression within the last school year. (purple and yellow) -would like to believe that some of this positive change could be attributed to the work of this collaborativeWith #3-with NCHA2006 data comparison with 2004 data, ?hard to function and ever diagnosed are similar)?.we see a significant increase number of female undergraduate students reporting they have received treatment for depression within the last school year. (purple and yellow) -would like to believe that some of this positive change could be attributed to the work of this collaborative

32. 2006 NCHA Male undergraduate students Males-up on diagnosis of depression from 2004 and more treatment Males-up on diagnosis of depression from 2004 and more treatment

33. 2006 NCHA Male graduate students Data for graduate students is less pronounced, particularly for male graduate students. Data for graduate students is less pronounced, particularly for male graduate students.

34. 2006 NCHA Female graduate students Slight increase in accessing therapy for female graduate studentsSlight increase in accessing therapy for female graduate students

35. Benefits 5. 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. -18 groups run since beginning of collaborative in May 2005--prior to this, for example, counselling services would run ave of 3 mood management groups/year (?why not group??) -beh.and cog. Strategies as well as social support imp---lower PHq-9 scores and early diagnosis = less acute depression -18 groups run since beginning of collaborative in May 2005--prior to this, for example, counselling services would run ave of 3 mood management groups/year (?why not group??) -beh.and cog. Strategies as well as social support imp---lower PHq-9 scores and early diagnosis = less acute depression

36. 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? 10-15 min to consider application on your campus?--how could you benefit, what might your challenges be? What other issues warrant shared care model?-groups of 3-4 to consider this?less detail, but considering application of the model/aims?10-15 min to consider application on your campus?--how could you benefit, what might your challenges be? What other issues warrant shared care model?-groups of 3-4 to consider this?less detail, but considering application of the model/aims?

37. Questions and Feedback Thank you!

38. Reference list Bilsker, D., & Paterson, R. (2005). Antidepressant Skills Workbook. Mental Health Evaluation and Community Consultation Unit, University of British Columbia. British Columbia Provincial Depression Strategy Phase 1 Report, October 2002. http://www.healthservices.gov.bc.ca/mhd/pdf/depressionstrategy.pdf British Columbia Treatment Guidelines and Protocols for Diagnosis and Management of Major Depressive Disorder: http://www.healthservices.gov.bc.ca/msp/protoguides/gps/depression.pdf (contains references, p.9 and 10). Fisher, L., & Ransom, D.C. (1997). Developing a strategy for managing behavioural health care within the context of primary care. Archives of Family Medicine, 6, 324- 333. Iglehart, J.K. (2004). The mental health maze and the call for transformation. The New England Journal of Medicine, 350, 507- 514. Innes, G. (1999). The health transition fund and the future of Canadian health care delivery. Journal of Emergency Medicine, 17, 157-158. Kates, N., Craven, M., Bishop, J., Clinton, T., Kraftcheck, D., LeClair, K., Leverette, J., Nash, L., & Turner, T. (1997). Shared mental health care in Canada. The Canadian Journal of Psychiatry, 42(8). Kates, N. & Craven, M. (1998). Managing mental health problems. A practical guide for primary care. Seattle: Hogrefe & Huber Publishers. Katon,W., Rutter,C., Ludman, E.J. et al. (2001). A randomized trial of relapse prevention of depression in primary care. Archives of General Psychiatry, 58 (3), 241-247. Kroenke K, Spitzer R L, Williams J B. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9): 606-613 Lam, W.R., (2004). Targeted Resources to Improve Primary Care Outcomes in Depression (TRIPOD): An Educational Intervention for Implementing BC Depression Guidelines. 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: recommendation statement from the Canadian Task Force on Preventive Health Care. Canadian Medical Association Journal, 172, (1). Paterson, R. (1997). Changeways Core Programme Trainer?s Manual. Vancouver, B.C. Price, J.R. (2000). Managing physical symptoms: The clinical assessment as treatment. Journal of Psychosomatic Research. 48, 1-10. Whooley, M.A., Avins, A.L., Miranda, J., & Browner, W.S. (1997). Case-finding instruments for depression. Two questions are as good as many. J. Gen. Intern. Med, 12, 439-445. World Health Organization. (2000). Towards Unity for Health: Challenges and opportunities for partnership in health development.


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