Overview

Implementing universal depression screening using PHQ-9 in a primary care setting

Organization Name

University of California San Francisco, Division of General Internal Medicine

Organization Type

• Academic Hospital
• Academic Medical Center
• Community outpatient clinic
• Integrated healthcare system/network

National/Policy Context

• UCSF Health is an academic medical center health system serving patients in San Francisco and Northern California.
• In 2014-15, 3.8% of adults aged 18 or older in California had serious thoughts of suicide. (SAMHSA, Center for Behavioral Health Statistics and Quality, National Surveys on Drug Use and Health, 2011–2012 to 2014.
• 36.4% of adults in California who reported a major depressive episode did not receive treatment for depression, according to data from 2011-2014.

Tools or Products Developed

• The team created an infographic detailing steps for providers to access itemized PHQ-9 during charting.

Training

• The team set up a Provider Education Seminar to teach providers skills in discussing suicidality and facilitating conversations about mental health.

Tech Involved

• Epic

Team Members Involved

• Administrative Assistant
• MAs
• NPs
• Physicians

Workflow Steps

• Patient checks in and receives PHQ-9 form.
• Medical assistant inputs PHQ-9 scores into APeX (Epic-based EHR at UCSF).
• If PHQ-9 is greater than 9 or patient scores positive for suicidality, the behavioral health integration team sends direct messages to the patient’s provider (MD/NP).
• Provider can then:
  • Discuss depression/suicidal ideation.
  • Potentially prescribe antidepressant.
  • Refer to behavioral health/psychiatric department.

Budget

Where We Are

This project is currently ongoing.

• The innovators plan to change the workflow so that medical assistants seeing patients’ positive screen would add “suicidal intent” as a chief complaint so that providers can decide how to address the results.
• In future iterations, the innovators may implement a best practice alert in the EHR for providers (MD/NP) instead of having the behavioral health integration team send direct messages to providers.

Outcomes

• Significant increase in number of patients with suicidal ideation confirming suicidal ideation after intervention to attending physicians from 29% to 81% (p<0.001)
• Increase in proportion of charts addressing depression, documenting suicidal ideation, and documented plan around depression.

Benefits

• A major benefit was that providers and patients had more discussions around depression and mental health.

Unique Challenges

• Providers found it difficult to access details of PHQ-9 scores, which meant they lacked context for positive screens.
• Time is a barrier to discussing depression and suicidal ideation.

Glossary

1. SAMHSA, Center for Behavioral Health Statistics and Quality, National Surveys on Drug Use and Health, 2011–2012 to 2014. Retrieved from https://store.samhsa.gov/shin/content//SMA17-BAROUS-16/SMA17-BAROUS-16-CA.pdf).
2. California Health Care Foundation, Mental Health in California: For Too Many, Care Not There. 2018. Retrieved from: https://www.chcf.org/wp-content/uploads/2018/03/MentalHealthCalifornia2018.pdf

Metrics

2018 MIPS Quality Payment Program (QPP) Measures: Providers participating in the QPP are required to report their performance on at least six metrics chosen from a list provided by CMS. Providers may be able to improve their performance on a number of these metrics by integrating behavioral health programs into primary care. Sample metrics include:

•  Depression Remission at Twelve Month
  • The percentage of patients 18 years of age and or older with major depression or dysthymia who reached remission 12 months (+/- 30 days) after an index visit
• Screening for Clinical Depression and Follow-Up Plan
  •  Percentage of patients aged 12 years and older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen

More details about measures included in the QPP set can be found here.

Medicare Shared Savings Program (MSSP) ACOs: Clinics associated with an MSSP ACO are required to report their performance on measures for Depression Remission at Twelve Months and Screening for Clinical Depression and Follow-Up Plan. More information about these measures and requirements can be found here.

Patient Centered Medical Home (PCMH): Integrating a behavioral health program such as Collaborative Care for Depression into primary care may help practices meet a number of NCQA Patient Centered Medical Home 2017 Standards. Potential opportunities include:

•  KM-03- Conducts depression screenings using a standardized tool
• KM-04- Conducts behavioral health screenings or assessments for at least 2 of the following: anxiety, alcohol use disorder, substance use disorder, pediatric BH screening, post-traumatic stress disorder, ADHD, postpartum depression
• CM-04- A person-centered care plan is established for care management patients.
• CC-10- A behavioral health provider is integrated into the practice’s delivery system

More information can be found here.

HEDIS Depression-Related Measures:Related HEDIS measures for 2018 include:

•  Depression Screening and Follow-up for Adolescents and Adults
• Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults
• Depression Remission or Response for Adolescents and Adults
• Unhealthy Alcohol Use Screening and Follow-Up

More information can be found here for depression measures and here for the alcohol use measure.

NYS Medicaid Collaborative Care Quality Metrics: For providers interested in further assessing the quality of their Collaborative Care for Depression and Anxiety programs, New York State’s Office of Mental Health has a robust set of measures for tracking the quality of these programs that is larger than other measure sets listed here. Among others, metrics for programs include a population screening rate, clinical improvement rate, and change in treatment or psychiatric consultation rate (for patients not showing clinical improvement).  More information about the 2018 metrics can be found here.

Direct Billing: Providers may be able to directly bill for many of the services provided through Collaborative Care for Depression programs.  For example, as of 2017, providers can bill CMS for counseling and care management services using BHI-specific codes (more information available here).

Other Opportunities:Providers may be able to improve performance on chronic disease control measures through behavioral health integration efforts.  For example, a 2014 BMJ Open systematic review and meta-analysis found that participation in collaborative care programs targeting comorbid depression and diabetes significantly improved patients’ depression scores as well as their HbA1c levels.  In addition, behavioral health integration may represent an opportunity for providers to improve patient satisfaction.  A 2010 NEJM randomized, controlled trial of Collaborative Care found that participating patients were significantly more satisfied with the care they received through the program for diabetes, coronary heart disease, and depression than controls.