quality improvement part 2
TRANSCRIPT
Karen Scott Collins, MD, MPHJuly 2008
Public Benefit Corporation Governing:
11 Acute Care Facilities Four Long Term Care
Facilities Six Diagnostic & Treatment
Centers Over 80 Community Health
Clinics A Managed Care
Organization (240,000 Enrollees)
A Certified Home Health Care Agency
◦ Racially, ethnically Diverse, Low Income population◦ Large population covered by Medicaid; ◦ Uninsured population◦ Immigrant◦Multi- lingual; LEP◦ Low health literacy
Additional tasks/measures for diabetes and heart failure teams:◦ Start PHQ screening for depression◦ Develop management of patients with depression
within primary care
3 component model:
AHRQ/MacArthur Initiative
Physician knowledge and skills on management
Collaboration with Psychiatry
Care Management
CCM:
Self management support
Delivery system design Decision support Clinical information
systems Community resources Health system
Screening Management Communication Self management
1. Learning sessions2. Primary Care physician/psychiatrist
teams= depression champions “Train the trainers”◦ Regular conference calls and breakout sessions
at learning sessions◦ Support for trainers
◦ Coaching/consultation with primary care◦ Review PHQ scores and cases with MD’s◦ Based in ambulatory medicine/cardiology clinic a
few hours/month◦ Joint development protocols for management and
referrals◦ Jointly see patients during HF clinic
◦ Training ambulatory care nursing and social workers◦ Early follow-up; ◦ telephone support; ◦ self management support
PHQ incorporated into EMR reports Link to chronic disease registry Brief decision support Links to decision support Next: ◦ creation of dedicated field for followup;◦ Determine suicide assessment tool for EMR
Screening◦ PCA (MA) administer PHQ-2/9◦ PCA gives PHQ 2/ nurse or MD gives PHQ9
Treatment◦ Primary care MD starts Rx; determines referrals◦ Self management support: goal setting tools Case Manager = team effort ◦ MD, psychologists, social worker, volunteers◦ Various team members making follow-up phone calls
and consulting MD to make management decisions
Moderate- significant assistance reportedly required for patients to complete;
PCA’s being tasked to assist patient with PHQ2/ some places with PHQ9 (some resistance)
PDSA in progress: Literacy Assistance Center drafted a brief script/explanation of terms for PCA’s and pts.
PHQ screening rates (POF) 65-75% in ¾ teams PHQ>/= 10 12%-17% among diabetes and HF
teams
492 pts. in diabetes registry 2/05-10/05 screening found 9.4% pts PHQ>10 Increasingly, primary care management Strong psychiatry liaison
Care Model Components◦ BPHC/ change packages
Depression analysis tool*:◦ Standard approach to assessing practice and
planning PDSAs◦ Review 4-5 patients for:
Did the pt have a f/u visit or call within 1-3 weeks of starting treatment?
Did the pt have a repeat PHQ within 4-8 weeks of starting treatment?
Did the pt have a self-management plan in the last six months?
Was there a clinically significant improvement (5 pt drop in PHQ) within 3 months? If not, any ideas why?
*S.Cole, MD
Psychiatry liaison◦ Communication/ access◦ Availability
Clinical information system◦ PHQ score/ recommended steps◦ Links to resources
◦ Reminders/tools