Overview

This quality improvement project aimed to improve depression management by offering both universal screening in several languages and additional tools for treatment decision-making and follow-up tracking.

Organization Name

Harrisonburg Community Health Center (HCHC) in Harrisonburg, Virginia

Organization Type

• Community health center

National/Policy Context

• Depression is the leading cause of disability worldwide. Depression screening and follow-up ranks among the lowest-reported measures of the Medicaid Adult Core Set, despite being a measure endorsed by the National Quality Forum and Healthy People 2020.
• Screening for and treating depression in a multicultural patient population requires more nuance, and this population can experience underdiagnosis and/or undertreatment.

Local/Organizational Context

• Harrisonburg Community Health Center (HCHC) is a Federally Qualified Health Center (FQHC), and approximately half of all patients speak a first language other than English.
• A 2016 internal audit showed that depression screening and follow-up occurred in <10% of clients at HCHC.

Patient Population Served and Payor Information

• HCHC has three clinic sites that serve 12,000 patients in rural central Virginia. The city serves as a major site of refugee resettlement, and there are many multilingual members of the clinic team. FQHCs such as HCHC typically serve more Medicaid and uninsured patients.

Leadership

• The project was led by a nurse midwife who coordinated a multidisciplinary group of providers across two teams.
• Support for the second team was provided by a physician who also served as the medical director for the clinic.

Funding

• HCHC’s operating budget
• Minimal funds from the project leader herself

Research + Planning

• A complete analysis of the gaps between best practices per the United States Preventive Services Task Force (USPSTF) and pre-project practices at HCHC was conducted. Current practices at HCHC were compared to USPSTF best practices and key areas for improvement were highlighted – details can be found in Table 1 here.
• The Plan-Do-Study-Act cycle format was utilized to implement this project. This is a staged roll-out where a project is gradually introduced over two-week cycles. During each subsequent cycle, there was an increase in the number of team members involved or tools used, with opportunities for nudges to ensure that the project stays on track. Adjustments were made as needed from cycle to cycle. This allowed for a flexible and gradual implementation of the project.

Tools or Products Developed

• This project utilized the Screening, Brief Intervention, and Referral to Treatment (SBIRT) framework, which was initially designed for treatment of substance use disorders but has recently been used in other chronic conditions such as depression. The SBIRT principles were used to craft the four aspects of the project: screeners, decision tools, tracking logs, and team meetings.
  • Screener: A positive PHQ template was designed for the EHR to improve documentation of the results and cue the provider to discuss the PHQ with the patient.
  • Decision Tool: An Option Grid ™ tool (from EBSCO health) was used to guide the conversation with patients about options for follow-up. Option Grids ™ are shared decision-making tools that compare choices and potential outcomes of those choices in an easy-to-understand grid format that allows patients to explain and apply their personal values. This tool was then translated by the clinic into English, Spanish, and Arabic, the three most commonly spoken languages at HCHC.
  • Tracking Log: The “right care” tracking log was based on the Community Care of North Carolina (CCNC) toolkit. It included tracking for behavioral health and social work referrals and weekly follow-up phone calls.

Training

• Biweekly training meetings were held to build capacity among the providers and other staff involved in this project.
• Providers were given tools to trigger screening and were trained to provide the paper PHQ form, evaluate it, conduct a discussion about follow-up using the Option Grid ™, and document follow-up in the log.

Tech Involved

• Electronic medical record
• Excel database

Team Members Involved

• LPNs
• MAs
• NPs
• Physicians
• RNs

Workflow Steps

• The intervention took place as follows:
  • A standardized Patient Health Questionnaire (PHQ) screener in seven different languages (English, Spanish, Arabic, Russian, Kurdish, Swahili, and Tigrinya) was provided to patients in clinic. The minority of patients who could not complete a written PHQ were given a verbal version. Any patient screening with a score >0 was considered to be positive. Screening did not exclude anyone with a prior or current diagnosis of depression. Point-of-care notebooks with all of the resources (e.g. PHQ, Option Grid ™, tracking log, etc.) called “Blue Books” were used to serve as visual triggers in clinic rooms to remind providers to screen for depression.
  • Patients who screened positive were further engaged with the Option Grid ™ shared decision-making tool. This allowed patients to consider several options for depression follow-up and their sequelae, aiding patients in applying their own values to make a choice for follow-up.
  • All screen-positive patients were eligible for the “right care” treatment tracking log. It recorded behavioral health appointments, weekly phone follow-ups, and any handoff to licensed clinical social workers.
  • Team meetings were conducted every two weeks to train team members and provide support. Constant feedback was sought and incorporated throughout the PDSA cycles.
• Implementation of the project was evaluated through a tally of completed paper PHQ forms, chart audits to track referrals and other follow-up metrics, and a tally of staff participating in the biweekly meetings. The teams also filled out daily evaluation of teamwork, pre-visit depression screening planning, and level of provider satisfaction. The teamwork scores were adapted from resources at the Agency for Healthcare Research and Quality (AHRQ). These metrics were recorded in a spreadsheet.

Budget Details

• Approximately 240 hours of APRN time were used for project support and implementation.

Where We Are

• The pilot program ran from June to September 2017.
• Project techniques and lessons learned continue to be spread and implemented throughout the 3 clinic sites.

Outcomes

• Patients Served: A total of 237 unique clients were served over the 90-day project timeline. One provider saw patients under age 12, who were excluded from the project.
• PHQ Screening Rate: PHQ screening rates increased from 32.5% at baseline to 85.2% at the end of the project.
• Option Grid ™ Utilization Rate: Of the screen positive patients, 87.5% used the Option Grid ™ with the provider, and 85.7% had a choice of care plan documented in EHR, up from 35.0% at baseline.
• Logging of Screening Results: All screen-positive patients were entered into the “right care” treatment log, and 75.0% had the correct documentation and follow-up in the log.
• Adherence to Follow-up Plans: Patient adherence to follow-up plans improved from 33.3% at baseline to 60.0% during the project.
• Depression Remission Rates: Over the first three PDSA cycles, 15.5% of patients were able to achieve complete remission of symptoms of depression, likely due to the follow-up care.
• Composite Screening and Follow-up Rates: At the end of the project, >70% of patients were receiving screening and follow-up as needed, up from <10% at baseline.

Future Outcomes

• While not necessarily planned by the clinic, future studies to evaluate the PHQ-2 and PHQ-9 scores and their relation to response to treatment over time would be beneficial to understand how these metrics track with therapy.

Benefits

• Standardization of screening across providers, visual triggers to remind providers to use the screener, and provision of paper screeners in multiple languages improved rates of depression screening.
• Depression follow-up was improved via shared decision-making tools to determine any treatment and logs for follow-up via phone or referrals.

Unique Challenges

• While the options in the shared decision-making tools were well-received by patients, there was uncertainty about the purpose of a referral to behavioral health.
• The clinic care coordinator resigned mid-project, leading to decreased pre-visit planning services. The project lead ultimately took on this role. Fluctuations in other clinic staff also affected project training and continuation.
• Generalizability to a less diverse patient population may be limited.

Glossary

• Medicaid Adult Core Set: A set of quality metrics for adults receiving Medicaid.

Sources

• Schaeffer, Ann M., and Diana Jolles. “Not Missing the Opportunity: Improving Depression Screening and Follow-Up in a Multicultural Community.” The Joint Commission Journal on Quality and Patient Safety, vol. 45, no. 1, 2019, pp. 31–39., doi:10.1016/j.jcjq.2018.06.002.