Transcript Building the Behaviorally Enhanced PCMH: The Development and Implementation

Session #F3b
October 5, 2012
Building the Behaviorally
Enhanced PCMH:
The Development and Implementation
of an EHR-Based System for the
Screening and Management of
Depression in Primary Care
Collaborative Family Healthcare Association 14th Annual Conference
October 4-6, 2012 Austin, Texas U.S.A.
Building the Behaviorally Enhanced PCMH:
The Development and Implementation of an EHR-Based System for the
Screening and Management of Depression in Primary Care
UCSD Division of Family Medicine
Zephon Lister, PhD, LMFT
William Sieber, PhD
Rusty Kallenberg, MD
Kurt Lindeman, PhD
Learning Objectives
At the conclusion of this presentation participant will be able to:
1.
Describe the process and conceptual underpinnings of
developing an EHR-based office visit screening system
2.
Identify and list the implementation steps and components of
an EHR-based office visit screening system
3.
Discuss a more generalized template for implementation of
this process in a range of primary care environments
4.
Describe the challenges and clinical pearls identified through
the development and implementation of a universal
screening process.
UCSD Division of Family Medicine
UCSD Primary Care

Providers
◦ 40+ Physicians
◦ 1 Psychiatrist
◦ 2 Licensed Mental Health Providers and 12
Mental health providers in training



Services 35,000+ patients
Each clinic experiences 120-160 daily patient
encounters
Population:
◦ Payors from low SES and Medi-Cal to PPO
UCSD Division of Family Medicine
Literature: Universal Depression
Screening in Primary Care




Roughly one third to one half of non-elderly adults and almost two
thirds of older adults who are treated for depression are treated in
primary care1-3.
Recent research estimates that mental health screening rates may
be as high as 74 percent in primary care4, and once a primary care
provider has identified a patient as depressed, almost 90 percent
patient receive some level of provider intervention5,6.
One study found that 30 to 40 percent of cases of depression may
be missed PCP’s who rely solely on provider recognition7.
The USPSTF conclude that mass screening in primary care may
help clinicians identify missed depression cases and initiate
appropriate treatment. Screening may help clinicians identify
patients earlier in their course of depression8.
UCSD Division of Family Medicine
Background

UCSD Family Medicine building toward PCMH since 2004

2011 NCQA PCMH standards
◦ PCMH 3: Plan and Manage Care- One of three clinically important
conditions identified by the practice must be a condition related to
unhealthy behaviors (e.g., obesity) or a mental health or substance
abuse condition.

U.S. Preventive Services Task Force (USPSTF)
◦ screening adults for depression when staff-assisted depression care
supports are in place to assure accurate diagnosis, effective treatment,
and follow-up.
◦ against routinely screening adults for depression when staff-assisted
depression care supports are not in place.
UCSD Division of Family Medicine
Background cont.
UCSD Electronic Health Record EHR

EPIC Systems electronic medical record (EHR), now used
throughout the UCSD Healthcare System. EPIC provides a
complete view of all visits — from ER to primary care to
specialty to inpatient — and all laboratory, radiology, and
special testing results.

EHR allows providers to develop patient registries for special
groups of patients with particular diseases (e.g. depression)
or particular needs (e.g. care management) so that we can
more easily follow up on those who are not doing as well as
they could.
UCSD Division of Family Medicine
Implementation
UCSD Division of Family Medicine
Implementation
Practice
•Practice Buy-in for concept of Universal
Depression Screening
•Identifying Quality Improvement Measures
•Respecifying EHR Data and System
Parameters
Clinic
•Development of standardized clinic protocol
•Education at clinic management and staff level
•Identification of clinic coordinators to monitor
implementation process and report to PCMH
Depression Screening Coordinators
Provider
UCSD Division of Family Medicine
•Refined focus from clinic with tracking to
identifying and tracking specific provider
teams
•Monthly tracking available to clinic managers
and teams
Patient Given PHQ-2
Depression Screen
Depression Screening
Clinical Protocol
PHQ-Score 2
or more
Full PHQ-9
given to
patient
PHQ-9 Score
(0-9)
Provide patient
standard PCP
interpersonal
support and
education
PHQ-9 Score
(10-19)
1.Provide Patient
Information Sheet on
Stress Management
Groups and Collaborative
Care
2.Assess for T-Care
referral/follow-up
3.Assess for Collaborative
Care referral
4.Assess benefit of meds
and other PCP intervention
UCSD Division of Family Medicine
PHQ-2 Score
less than 2
No further
clinical action
needed
PHQ-9 Score (>20
with no #9
endorsement)
1.On-site T-Care trainee or
intern assesses pt. to inform
PCP intervention plan
2. Patient referral to
Collaborative Care
3.Assess benefit of meds and
other PCP intervention
PHQ-9 (#9
positive
endorsement)
1.(a) Immediate on-site
assessment and intervention by
T-Care trainee or intern to
inform PCP intervention plan, (b)
access any CC staff in clinic to
assess patient at earliest
opportunity (c) if no CC staff is
available send stat EPIC message
to Lead Therapist or Supervisor
or page for immediate support
2.See PHQ-9 >20 protocol
Descriptive and Prevalence Data
male
female
% all FM patients seen in
clinic (10/07 – 3/09; n =
27,964)
42.8
57.2
% FM patients referred to
CC (n = 1040)
24.6
75.4
Mean age referred to CC
41
39
% of referred patients
seen by CC (n = 533)
36
31
UCSD Division of Family Medicine
Descriptive and Prevalence Data
Diagnosis (DSM code)
# FM patients
w/ diagnosis
# FM patients
w/ diagnosis
Rx’d psych
meds
# FM patients
referred to CC
w/ Dx (% of
Dx’d patients)
# FM patients
seen by CC
therapist w/
Diagnosis
Anxiety (300)
2137
1625
569 (26%)
218 (38%)
Depression (311)
1910
1542
498 (26%)
173 (35%)
Abuse of drugs (305)
906
485
89 (10%)
32 (36%)
Special symptoms NOS
(307)
506
364
63 (13%)
16 (25%)
Episodic mood (296)
370
201
88 (24%)
55 (63%)
Adjustment reaction
(308)
104
50
38 (37%)
20 (53%)
UCSD Division of Family Medicine
Descriptive and Prevalence Data
 Initial
estimates are that 26% of patients with
anxiety or depression are being referred to CC
 Patients
abusing substances are less often
referred to CC program
 Well
over 1 of every 3 patients referred to CC are
seen by a therapist
 Patients
with cardiovascular, metabolic, or
musculoskeletal pain are referred only 4.3 %,
4.0%, and 7.4% of the time, respectively
UCSD Division of Family Medicine
Questions & Suggestions
UCSD Division of Family Medicine
References
1.
Kessler RC, Berglund P, Demler O et al. The epidemiology of major depressive disorder: results
from the National Comorbidity Survey Replication (NCS-R). JAMA. 2003;289:3095-3105.
2.
Pincus HA, Tanielian TL, Marcus SC et al. Prescribing Trends in Psychotropic Medications:
Primary Care, Psychiatry, and Other Medical Specialties. JAMA:The Journal of the American
Medical Association. 1998;279:526-531.
3.
Harman JS,Veazie PJ, Lyness JM. Primary care physician office visits for depression by older
Americans. J Gen Intern Med. 2006;21:926-930.
4.
U.S.Department of Health and Human Services. Mental Health and Mental Health Disorder. 2nd
ed ed. Washington, D.C.: U.S. Governement Priting Office; 2000.
5.
Robinson WD, Geske JA, Prest LA, Barnacle R. Depression treatment in primary care. J Am
Board Fam Pract. 2005;18:79-86.
6.
Dobscha SK, Gerrity MS, Corson K, Bahr A, Cuilwik NM. Measuring adherence to depression
treatment guidelines in a VA primary care clinic. General Hospital Psychiatry 2003 Aug; 25(4):2307.
7.
Simon GE,VonKorff M. Recognition, management, and outcomes of depression in primary care.
Arch Fam Med. 1995;4:99-105.
UCSD Division of Family Medicine
Please complete and return the
evaluation form to the classroom
monitor before leaving this session.
Thank you!