Mental Health Module “Making It Real”

1. Mental Health Module“Making It Real” Learning Session 1 [date]

2. Making It REAL....My Reflections Johanna Johns Vanderhoof, British Columbia Ask the Questions (Show Patient Video)

3. The Model for Improvement

4. Act Plan Study Do Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement?

5. Characteristics of the Model for Improvement • Action-oriented – “What are you going to test next Tuesday?” • Rapid-cycle testing of changes • Evaluation and revision of all changes before implementation • Testing and implementing the changes in small populations, then spreading then spreading to the larger population • Impact evaluated using annotated run charts • Monthly reporting of tests and outcomes

6. A A A P P P S S S D D D Utilize Pilot Populations to test the Program Pilot Population: Mental Health Trainers: GP and MOA population and office patients with mental health problems. Focus for the Collaborative (Aim defines) Small-scale tests of change The Total Population of Trainer GPs and MOAs and Patients with mental health problems in BC (spread sites)

7. The Fundamental Questionsfor Improvement • What are we trying to accomplish? • How will we know that a change is an improvement? • What changes can we make that willresult in an improvement?

8. What are we trying to accomplish?Aim Statement Characteristics • States that we are going to “improve” care for patients (knowledge, skills, and resource availability related to management of mental health problems in GP offices). • Describes the target “population” for improvement (GP) • Describes in general terms “changes” we are going touse to improve care for the population (Mental Health Change Package and Expanded Chronic Care Model) • Describes the most important outcomes (measures)that we want to improve for the population that defineour success (Use of screening, diagnostic, support mechanisms, etc.).

9. What are we trying to accomplish?Office Aim Statement • Aim: The care for patients with mental health problems in _______ GP office will be redesigned using the mental health change package so that GPs use depression screening tools, the CBIS Assessment tools such as the Diagnostic Assessment Interview, Problem List Action Plan, Resource list and Self Assessment Questionnaire, and CBT options such as the CBIS Handouts, Antidepressant Skills Workbook and Bounceback tools/support

10. The Fundamental Questions for Improvement • What are we trying to accomplish? • How will we know that a change isan improvement? • What changes can we make that will result in an improvement?

11. Measures • Use PHQ-9 screening tool with at least20 patients with potential mental health problems • Conduct a second PHQ-9 assessment within 3-6 months for 95% of those patients in this group • Use the Diagnostic Assessment Interview for at least 10 patients with positive PHQ-9 …/

12. Measures (cont’d) • Document suicide risk assessment in the patient chart if the suicide question on the PHQ-9 or Diagnostic Assessment Interview was positive • Develop a problem list for 10 patients with an Axis I diagnosis • Develop a resource list for 10 patients with an Axis I diagnosis …/

13. Measures (cont’d) • Develop an action plan from the problemlist for 10 patients with an Axis I diagnosis. • Use skills from the CBIS Manual with 10 patients with mental health problems. • Refer 10 patients screened as having mild/moderate depression to the Bounce Back Program • Offer Anti-depressant Skills Workbook (ASW) and provide some coaching to 10 patients screened as having depression

14. Measurement • The purpose of measurement in the collaborative is for learning not judgment

15. Fundamental Questions for Improvement • What are we trying to accomplish? • How will we know that a change is an improvement? • What changes can we make that will result in an improvement?

16. Mental Health Change Package • Screening Tools • Diagnostic Assessment Interview • Problem List & Action Plan • Mental Health Care Plan • Resource List • CBIS Skills • Bounce Back program • Antidepressant Skills Workbook

17. Act Plan Study Do Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement?

18. The PDSA Cycle Act Plan • Objective • Questions and • predictions (why) • Measure of success • Plan for the cycle (who, • what, where, when) • What changes • are to be made? • Next cycle? Study Do • Carry out the plan • Document problems • and unexpected • observations • Begin analysis • of the data • Complete the • analysis of the data • Compare data to • predictions • Summarize what • was learned

19. D S P A A P S D D S P A A P S D A P S D Aim: To improve the care of patients with mental health problems Improved outcomes DATA Cycle 5: Test 3 ways to access skills in CBIS manual Test (Patient B) + Problem List/Action Plan Cycle 4: Cycle 3: Test Diagnostic Assessment Interview (Patient B) -Hand out Problem List Use of mental health screening toolswill helpidentify patients needing support. Cycle 2: Test the use of the PHQ9 with patients B and C on Wednesday. Cycle 1: Test use of PHQ9 with patient A on Tuesday

22. Context / History

23. Depression used as Lens Lifetime prevalence of Major Depressive Episode: 12.2% Past-year episodes: 4.8% Past-month episodes: 1.3% Source: Descriptive Epidemiology of Major Depression in Canada. Patten, SB; Wang, JL; Williams, JVA et al. Canadian Journal of Psychiatry; Feb 2006; 51, 2; 84. 23

24. Why Picture in BC: • 2008 733,982 receiving services • 638,208 by a GP • 108,810 by a psychiatrist • 104,441 in a community MH center • 20,378 hospitalized

25. Why • 2003module developed for Health Transition Fund -75 GPs • GP numbers made consultation liaison model impossible • Module developed to enhance GP skills in realtime • Made every mistake possible • DID, 18 GPs until projectended (now 30 GPs)

26. Why • GPSC after GP survey, assessing our module, new fee incentive • Funded this rollout

27. Why • Shift from ‘acute’ to ‘planned pro-active’ MH care • Focus on efficient office time management • Bridge with Mental Health and Addictions

28. MOA Role • Understand module • Take CMHA course on Mental Health • Feel comfortable with mental health patients • Heightened awareness • Know scheduling required • Know the materials needed • Have materials prepared/placed

29. Compensation • Case examples

30. What’s Real • YOU...are the experts in your practice…integrate into your practice.. • Focus is adults…not directly applicable for C/Y and elderly….your judgment

31. Overview of Mental Health Module Show OverviewVideo

33. PHQ-9

34. PHQ-2 & PHQ-9 34

35. PHQ-2 35

36. PHQ-9 9 questions used in scoring depression severity Functional impairment question 36

37. PHQ-9 Scoring Step 1:Need one or both questions endorsed as “2” or “3”(“More than half the days” or “Nearly every day”) 37

38. PHQ-9 Scoring Step 2:Major Depressive Disorder: Need 5 or more questions endorsed as “More than half the days” or “Nearly every day” (i.e. in shaded areas) Step 3:Total score:Calculate score for columns 1,2 and 3 8 9 1 18 38

39. PHQ-9 Scoring Step 4:Interpret results (*) If symptoms present ≥ two years, then probable chronic depression. (††) If symptoms present ≥ one month or severe functional impairment, consider active treatment 39

40. PHQ-9 Scoring 8 9 1 18  Step 5:Is functional impairment endorsed as “Somewhat difficult” or greater? 40

41. What is CBIS? • Cognitive • Behavioural • Interpersonal • Skills

42. Manual Layout • Introduction • Flow charts • Assessment • Education • Activation • Cognition • Relaxation • Lifestyle

43. Introduction TIPS • Teaching • Implementing • Planning • Supporting

44. Flow Charts • When in doubt – go with the flow • This directs you to the appropriate treatment strategies in the manual

45. Assessment • Diagnostic screening interview • Screening worksheet • Problem list • Problem list action plan • Resource list • Self-assessment questionnaire • Self-assessment profiles

46. Education • Understanding depression • Frequently asked questions • Signs and symptoms • Medication?

47. Activation • Daily activities • Energize • Small goals • Problem solving • Chunking time • Improving mood • Self supportive

48. Cognition • Changing behaviour • Changing thinking • Changing feeling

49. Relaxation • Benefits • Stress management • Breathing • Grounding • Relaxation • Mindfulness • Meditation

50. Lifestyle • Sleep • Nutrition • Substances • Exercise • Wellness