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Justin Coffey, MDBehavioral Health Services
Terri Robertson, PhDCenter for Clinical Care Design
Perfect Depression Care
Objectives
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Recognize the value of including depression care into chronic disease care models
1. Understand the key components of evidenced-based treatment for clinical depression
1. Understand the key components of evidenced-based treatment for clinical depression
Enhance knowledge of suicide prevention strategiesEnhance knowledge of suicide prevention strategies
Discuss the benefits of using standardized depression
screening tools, such as the PHQ-2 and PHQ-9
Develop several strategies for integrating depression screening and treatment into clinical practice
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4
3
2
1
Suicide Statistics
There is a suicide every 15 minutes in the US
90% of people who die by suicide have a diagnosable and treatable psychiatric disorder at the time of their death
70% of patients committing suicide have seen their primary care provider within 6 weeks of the suicide
….. There is an opportunity here!!
Number of suicides per 100,000 US general population
0
50
100
150
200
250
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Su
icid
es p
er
100,0
00
Number of suicides per 100,000 US general population
Suicides per 100,000 HMO Patients
Number of suicides per 100,000 US general population
Expected suicide rate for patients with an active mood disorder (21X)Expected rate for euthymic patients with mood disorder (4-10X)
Number of suicides per 100,000 HAP-HFMG patients
Q3YTD
Suicidality in Primary Care is Palpable
% of Primary Care Patients with a Positive Q9 on PHQ9
0
5
10
15
20
25
2006 2007 2008 2009 2010 2011YTD
Suicide Ideation Trends- HFMG
Depression in Primary Care Model
Registry (DocSite) to identify eligible patients
Standardized, evidenced-based toolsPHQ2PHQ9
Automated toolsEmbedded in EHR
SimpleSelf-scoresProvides interpretationLinks to treatment guidelines
Evidenced-based treatment menu based on patient preference
Medication managementPsychotherapy (CBT)Problem-solving therapy (PST)
Utilize MA’s to “tee up” process
Use Psychiatric NP’s and/or Clinical Psychologist to spread tools/ train clinic staff
Cross trained Diabetes Care Center and RN Case Managers (collaborative care)
HFHS DST
PHQ-2 branches when positive (> 3) to full 15-item DST
Depression Screening Tool
Alerts at top of patient record:1 D= DST score is > 10, alert is removed after DST is signed by Responsible Staff2 S= Suicide risk question(s) answered positively, alert is removed when DST is repeated and suicide risk questions are negative
1
2
Safety Visual Management
Diabetes Care Center-2011 Depression Screening Rates
15%
52%
85%
97%
0
10
20
30
40
50
60
70
80
90
100
% p
ts w
/ fo
llow
-up
DS
T
(wh
en P
HQ
-2+
)
Beforeprocesschange2009*
Afterprocesschange2009**
2010 2011-Q3
2011 Goal=85%
DST Rates
70% 72%
83%
97%
50
60
70
80
90
100
% o
f el
igib
le p
atie
nts
sc
reen
ed
2008 2009 2010 2011-Q3
PHQ-2 Rates
2011 Goal=83%
Continuous Improvement
Realized that clinics needed more education/ tools specific to handling a potentially suicidal patient
Solution:1) Developed a suicide triage protocol 2) Partnered with the DCC staff, who selected this as their 2011 safety goal
Diabetes Care CenterResponse to Q9 for Suicide
11%
7%
59%
7%
7%
7%
BHS Referral
No info ondispositionPCP Referral
Outside BHSproviderSent toED/hospitalizedDCC MLP treated
52%
21%
27%
no info fordisposition
BHS referral
Refused orMissedappointment
Pre suicide safety goal (2010) Post suicide safety goal (2011)
N=33 N=27
Celebrate the (Not So) Small Successes!Recent case example from DCC49 yo, AF-AM female with multiple medical conditions and known psychiatric historyActive in psychiatric treatment, medications recently changedSeen for diabetes education, completed DST as part of standard process
Skipped suicidal ideation question, but said “YES” to plan for self harm and skipped intent question
On questioning, disclosed was feeling depressed for over a month, was having suicidal thoughts and planned to take an overdose of pills (had access)Admitted to purposefully lying to her mental health provider a few days prior out of fear that they would “lock her up” Symptoms: feeling depressed, tearful, hopeless, insomnia, loss of appetite with unintentional weight loss, rapid and pressured speech, flight of ideas, hearing voicesRisks identified by DCC staff: history of Bipolar I Disorder, history of depression with suicidal thoughts, very limited social support, comorbid anxiety, access to pills, possible mania/ psychosisOutcome: relocated patient to the internal medicine clinic where clinic RN could assist with sitting with patient; in consultation with BHS, petition was completed and patient was triaged to the ER for IPD Psychiatric admission; police assisted (at request of EMS) without incident
THANK YOU
Questions??
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