Improving Depression

1. Improving Depression Screening & Management in Heart Failure Patients at the Pali Momi Medical Center Final Defense Presentation Erika Jang March 28, 2019 University of Hawai’i at Manoa Doctor of Nursing Practice Committee Members: Dr. Joseph Mobley, Chairperson Dr. Maureen Shannon Cheryl Kozai

2. Iowa Model Determine organizational priority Identify triggers Form a team Search, critique, synthesize evidence Pilot the practice change Implement change Evaluate outcomes • Evidence-based practice framework • Promotes quality care through research & clinical decisions • Used to improve patient care and outcomes within a large organization (Titler et al., 2001)

3. Background • Heart Failure (HF) • 3rd leading cause of cardiovascular deaths in the U.S. • High rates hospitalizations and deaths • Depression • Decreases quality of life • Silent suffering due to stigma and fear

4. Problem-Focused Triggers • Depression is under-recognized and under-treated • Depression screenings are not routinely administered • Co-prevalence of depression and HF is associated with: • Increased risk for cardiovascular events • Increased risk for mortality • Higher healthcare costs • Lower quality of life • Disturbing mental health care crisis in Hawai’i • Lack of psychiatrists/psychologists in the state

5. Problem Focused Triggers cont. Hawai’i: Increasing number of HF diagnoses every year (HI DOH, 2015)

6. Problem Focused Triggers cont. Mental health and HF were the leading causes of preventable hospitalization (PMMC CHNA, 2013)

7. Knowledge Focused Triggers • American Heart Association Guidelines 2013 • Recommend routine annual screening for depression in patients with coronary heart diseases • Significant link between depression and CVD • Supports the use of PHQ-9 • More effective compared to PHQ-2

8. Organizational Priority • Prevention-focused care • Holistic approach to health and wellness • PMMC Quality of Care Initiative: • Improve outpatient care • Decrease mortality rates • 1 of the 4 Heart Centers in Hawaii • Pali Momi services a large number of HF patients in Central Oahu

9. Team Formation • Interdisciplinary Stakeholders • PMMC Outpatient Director (Cheryl) • Heart Center Cardiologists (6) • Quality Control • Clinic Manager (Melissa) • Registered Nurse (Shari) • Quality Improvement • Medical Assistants (8) • Front Desk Secretaries (4)

10. Literature Search & Synthesis • Depression & HF • Depression is present in 10 to 40% of HF patients • Depression Screening Tools • PHQ-9: consistent and reliable depression screening instrument • Depression Management & Treatment • Early diagnosis and treatment are crucial to improve health-related quality of life in elderly patients with HF

11. Project Design • Quality Improvement/Evidence-Based Practice • Systematic and continuous actions that lead to measurable improvement in healthcare services and the health status of targeted patient groups (HRSA, 2015) Consider system-level changes to continue delivering high-quality health care Help organizations recognize areas of improvement Apply recommended practice in real clinical settings Translate the research on depression screening and management

12. PICO Will the implementation of a depression assessment program improve staff knowledge about evidence-based depression screening and management protocols, as well as increase the number of patient screened for depression at the Pali Momi Heart Center?

13. Practice Change A • Educational Presentation • Goal: Improve staff knowledge of depression screening and management • Evaluate: Pre- & post-test to evaluate for knowledge improvement • 30-min Powerpoint presented by DNP candidate • During staff lunch break: food & drinks provided by project stakeholders • 10 staff members participated

14. The Results: Improved Knowledge

15. Practice Change B • Administer PHQ-9 Surveys • Goal: Increase the number of HF patients screened for depression • Objective: Provide appropriate management and measure prevalence of depression • Evaluate: Collect surveys and record PHQ-9 results weekly Designated office area for the “PHQ-9 Collection Drawer” and “Resource folder”

16. Participant Eligibility • Inclusions • Over the age of 18 • Diagnosed with Heart Failure, ICD-10 code in EPIC • English language proficiency • Exclusions • History of depression or other mental health disorder • Screened for depression in the last 6-months by another provider • Diagnosed with cognitive impairment such as Alzheimer’s disease or developmental delay

17. Practice Change B cont. Quality Control Methods: • Formulated list of HF patients scheduled during project pilot period • Audited patient charts to confirm qualification based on the project’s inclusion/exclusion criteria • Prepared a daily patient list for front desk secretaries and MA’s • Printed and attached patient labels to PHQ-9 surveys • Addressed any issues during weekly informal meetings and offer individual support to providers and medical staff • Formulated “office flow chart” and “management algorithm” in collaboration with medical staff to avoid confusion and disruption to office workflow

18. Office Flow-Chart MA Front Desk Secretary Provider Erika Enter exam room. Discuss with patient: 1) PHQ-9 score 2) Severity of depression Ask patient about: 3) Duration of symptoms 4) Functional impairment Every Week: • Print patient labels & attach to forms • Generate weekly list of HF appts each day • Collect completed PHQ-9’s • Refill treat drawer Collect form and review it. Did patient answer all 9 questions? COMPLETE NOT COMPLETE Should the patient be referred to psych? Is the patient open to psych consult? Attempt to complete with patient. If unable to, ask patient for reason & write on the back of the form START YES NO Patient checks in. Check HF appt list for patient’s name. Inform MA to make referral. Calculate total score. Document in writing on form. Complete referral through EPIC. Give PHQ-9 form for patient to complete. Scan form. Upload into patient’s EMR on EPIC. Patient checks out “This is a questionnaire we give out once a year. It is to assess your overall health & well-being. Please complete this by yourself. Give it to your MA in the exam room.” Give the form to MA for data collection. Give form to Provider. Place completed form into drawer. Take a treat. Escort patient to exam room Review PHQ-9 score & severity of depression. *If form is not completed, attempt to go over it with patient if there is concern & time. END

19. PHQ-9 Scoring & Management Algorithm Screen with PHQ-9 If yes to Q.9 “suicidal”, Immediate evaluation for acute suicidality. 10 - 19 Less than 10 > 20 If safe. At risk. Mild to moderate, uncomplicated* Minimal symptoms with short duration Major depressant Emergency department. Support, education, follow-up in 1 month. If symptoms persist or worsen. Refer for more comprehensive clinical evaluation by a professional qualified in the diagnosis and management of depression Follow-up with PCP in 1 month. Depression and Coronary Heart Disease, Volume: 118, Issue: 17, Pages: 1768-1775, DOI: (10.1161/CIRCULATIONAHA.108.190769)

20. Sample Size • Initial start of 152 patients • 21 canceled or rescheduled appt • 15 no current HF diagnosis (excluded HF with preserved ejection fraction) • 4 hx of depression • 5 screened with PHQ-2 or PHQ-9 in the last 6 months • 10 surveys incomplete (patient declined) • 10 front desk forgot to give (workflow got busy, time constraints) • Total number of completed PHQ-9 surveys: 87

21. Participant Characteristics • Average age was 69 years • Patients mostly 70-80 years old • Youngest patient 40 • Oldest patient 96 • Males> Females

22. Participant Characteristics cont. • Majority were F/U appointments • 10% were New Patients visits • 2 Cardiologists saw 50% of the project sample • Dr. Bender • Dr. Szeto-Wong

23. The Results: HF Diagnosis by ICD-10 Codes • Most common: I50.9 (Unspecified HF) • Least common: I50.20 (Systolic HF) & I50.30 (Diastolic HF)

24. Results of the PHQ-9 Scores • 61.7% of patients scored 0 to 4 (none or minimal depression) • 9.3% of patients scored 5 to 10 (mild depression) • 9.3% of patients scored 10 to 14 (mild/moderate depression) • Less than 1% of patients scored 15 to 20 (mod/severe depression) • 0% of patients scored more than 20 (severe depression) • 18% surveys incomplete

25. Patients who scored equal to or greater than 10 Referral initiated Not interested in referral

26. Results & Discussion • Less than 20% of patients had a positive score (>4) • 13.8% scored 10 or more • Provider engaged in discussion to validate score and offer psych referral • Management/Referral • 2 patients were referred to the Psychologist • 1 patient declined referral • More than 60% of patients scored none-minimal depression (< 4)

27. Other Findings • 4 patients: History of depression • Managed appropriately (medications and/or behavioral health therapy) • 5 patients: Screened in the last 6-months by their PCP • PHQ-2 or PHQ-9 results found in EPIC • 5/5 scores were “0” or not depressed

28. Limitation/Barriers • Relatively small sample size • Use of a convenience sample • Inclusion of only English-speaking patients • Individuals with history of depression were excluded • Sample consisted of more men than women • May underestimate the impact of depression • Studies have found depression is more prevalent in women (Son et al., 2012). • Difficult to identify depression • Negative stigma and attitude associated with mental health issues • Overlaps with symptoms with HF (fatigue, weight changes, poor concentration, poor sleep) • 18% of attempted screenings were incomplete at the project’s end • Time constraints attributable to short patient visit times and busy provider schedules • Patient declined to participate

29. Outcome/Accomplishments • Improved staff knowledge • Increased the number of HF patients screened for depression • More than 50% of scheduled HF patients completed PHQ-9 • Found community resources and mental health professional • Referred 2 patients to the Psychologist (Julie) for consult • Measured the prevalence of depression in HF patients

30. Future Studies and Direction • Continue to engage stakeholders • Determine PMMC interest in sustainability • Work on health policies to address “mental health crisis” in Hawaii • Severe lack of mental health professionals • Find ways to improve accessibility to affordable healthcare and resolution to mental health issues • Evaluate inpatient population with HF • Hospitalized patients: more sick, many comorbidities • Increased risk for depression

31. Conclusion/Implications • Chronic diseases such as heart failure are associated with increased risk for depression • Patients are not always screened for depression • Developing a process for depression screening and management is an important aspect of care • More trials and studies are needed for this topic

32. Acknowledgments • University of Hawai’i at Manoa • Dr. Joseph Mobley • Dr. Maureen Shannon • Pali Momi Medical Center • Cheryl Kozai • Melissa Watson • Heart Center • Providers: Kao, Bender, Zaid, Szeto-Wong, Tran, Christella • RN: Shari • Medical Assistants • Front Desk Secretaries • Sandy Tsuha

33. Questions

34. Thank you.

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