Depression cdss
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Depression CDSS. Charles Kitzman , Barbary Baer, Sudha Poosa. The Project. To maximize BH efficiencies while maintaining quality care Workflow optimization FQHC integrated BH m odel Strategic partnership Continuity of care/chart sharing Advanced primary care practice.

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Depression cdss

Depression CDSS

Charles Kitzman, Barbary Baer, SudhaPoosa


The project

The Project

  • To maximize BH efficiencies while maintaining quality care

  • Workflow optimization

  • FQHC integrated BH model

  • Strategic partnership

  • Continuity of care/chart sharing

  • Advanced primary care practice


Environment

Environment

  • FQHC northern CA county

  • Woefully inadequate BH services

    • PH contractual outpatient

  • Demand > Access

  • Obligation to have streamlined services

  • Filter inadequate referrals

  • Time for appropriate patients


Backdrop

Backdrop

Higher rates for Suicide

>50% 65 or older


Conditions leading to death rates in shasta county

Conditions leading to death -rates in Shasta County


County crisis stabilization

County crisis stabilization


Rank by county

Rank by county


Bottling the ends

Bottling the ends

  • Our approach sought to narrow scope

    • Why? It’s a diverse field with lots of variability. Makes it difficult to study

    • Many tools, many interpretations

    • Depression is our focus

    • PQH-9 and lab results respectively


Rationale for screening

Rationale for screening

  • Only half of depressed patients are diagnosed by their primary care physician

  • Patients with serious mental illness are 23% more likely to have a non-psychiatric hospitalization compared to the rest of the population. At $6000/admission, this adds $16 million to California’s Medi-Cal program

  • Depression is associated with greater health service use, greater morbidity & mortality, increased medical costs, not to mention unnecessary suffering


Screening triggers

Screening Triggers


Depression cdss

PHQ-9

  • Advantages

    • Self-administered

    • Freely available

    • Short (9 items)

    • Has been validated in Spanish

  • Sensitivity: from 94.4% (cutoff point >= 9) to 88.9% (cutoff point >= 13)

  • Specificity: from 73.3% (cutoff point >= 9) to 86.7% (cutoff point >= 13)

  • Original study:

    • Sensitivity for major depression: 88% for scores > 10

    • Specificity for major depression: 88%

    • Scores of 5, 10, 15, 20 represented mild, moderate, moderately severe, severe depression respectively


Depression cdss

PHQ-9 Questionnaire


Depression cdss flowchart

Depression CDSS flowchart


Depression cdss mindmap

Depression CDSS Mindmap


System input

System : Input

  • Demographics

  • Chief complaint

  • HPI (History of present illness)

  • Other illnesses

  • Medications

  • Life events


System architecture and interface

System : Architecture and Interface

  • Enterprise wide client-server based architecture

  • Architecture will comprise database and the rules engine

  • Compliant with standards – HIPAA, LOINC, HL7, etc.

  • Use of drop menus and logic checks

  • Use of clinic reminders and alerts

  • Capability of creating individual care plans with self-management information and disease severity rating

  • Linked with, but not a substitute for electronic medical records. Will be integrated at the point of care

  • PHQ-9 entry can be made by the patient, nurse or the clinician


System output workflow

System : Output & Workflow

  • Context-specific decision support in real time

  • Test score & risk stratification

  • Treatment regimen

    • Whom to refer the patient to (level of BH clinician)

    • When should the patient be tested / re-evaluated

    • When to administer medications to the patient

  • Treatment options

    • No treatment

    • Watchful waiting

    • Psychotherapy / counseling

    • Anti-depressant medication

    • Combination therapies


System output workflow1

System : Output & Workflow


Evaluation

Evaluation

  • Audit of inappropriate referrals with an expectation of declining numbers

  • Increased access or an increase in encounters per clinic hour for BH staff

  • Increase in consistent use of screening tools by PC staff

  • Log trigger results to check provider compliance with tool suggestions

  • Better outcomes


Conclusions

Conclusions

  • Difficult to separate operations from clinical decision piece

  • BH is very complex field to understand

  • Actually will beta-test in the clinic with a few providers


Depression cdss

Q & A


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