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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

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
slide11
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
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
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
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