Transcript of ©2012 MFMER | slide-1 EMERALD A pilot collaborative program in primary care for teens with...
- Slide 1
- 2012 MFMER | slide-1 EMERALD A pilot collaborative program in
primary care for teens with depression May 1, Minneapolis Hot
Topics in Pediatrics Mark Williams, MD
- Slide 2
- 2012 MFMER | slide-2 Disclosures Nothing to disclose
- Slide 3
- 2012 MFMER | slide-3 Objectives Describe what changed in care
delivery with EMERALD at a pediatric clinic Review outcomes and
reasons why this model has been so popular
- Slide 4
- 2012 MFMER | slide-4 Outline Background Conceptualization of
the model Implementation Outcomes Future directions
- Slide 5
- 2012 MFMER | slide-5 Primary Care at Mayo Three groups before
(Rochester campus) Community Pediatrics Family Medicine Primary
Care Internal Medicine Measures = Fee for Service Psychiatric care
= consultation Currently (140,000 patients in PC panels) Employee
and Community Health Improve quality and lower cost Integrated
Behavioral Health
- Slide 6
- 2012 MFMER | slide-6 Integrated Behavioral Health Staff
Psychiatrists Psychologists APRNs LICSW Nurses Charge Provide care
and backup to PCP for their panels of 140,000 primary care patients
(40,000 kids)
- Slide 7
- 2012 MFMER | slide-7 Look to translate evidence into practice
Care coordination programs Adult depression (IMPACT model) DIAMOND
program Adolescent depression (built on DIAMOND) EMERALD Adults
with depression and diabetes and/or cardiovascular disease CMS
grant built on model of TEAMcare Adult anxiety and depression CBT
(CALM model) Adult addiction (SBIRT)
- Slide 8
- 2012 MFMER | slide-8 Change process for translating/developing
a new model of care 1.Evidence of a need for a new approach Usual
care data + Lack of existing success 2.Evidence of a better model
Allows for a benchmark from research 3.Measurement tools available
4.Readiness for change Leadership ability to commit resources
5.Multiple stakeholders in steering process 6.Learning
collaborative approach 7.Collect outcomes and learn from them
Adapted from similar list from ICSI
- Slide 9
- 2012 MFMER | slide-9 Evidence of a need Need 14% of ages 13-18
in the US meet criteria for a mood disorder 40% of those
individuals received no treatment Suicide is the third leading
cause of death among adolescents Systemic challenges Short visits
in primary care Difficult to attend to mood issues Insurance and
stigma barriers to go to Psych Black box warnings Merikangas et al.
Oct 2010 Costello EJ Mar 1, 2014
- Slide 10
- 2012 MFMER | slide-10 Looking for better ideas example in adult
world Build it from what has been shown to work IMPACT model (2001)
Adult depression care coordination Currently over 75 RCTs
supporting better outcomes for this approach Institute for Clinical
Systems Improvement (ICSI) Developed stakeholders group to
implement this model in >80 clinics in MN starting 2008
- Slide 11
- 2012 MFMER | slide-11 Collaborative Care for Depression Key
components of collaborative care model: 1.Screening and monitoring
instrument PHQ-9 in adults PHQ-9M in adolescents 2.Systematic
tracking and monitoring of patients Use of a registry 3.Care
coordinator trained in motivational interviewing and about
depression 4.Consulting psychiatrist consultation and caseload
review
- Slide 12
- 2012 MFMER | slide-12 The DIAMOND Model Consistent with
evidence on collaborative care: Four Processes: 1.Consistent
assessment/monitoring (PHQ-9) 2.Presence of tracking system
(registry) 3.Stepped care approach to intensify/modify treatment
(supervision of care coordinators) 4.Relapse prevention Two Roles:
1.Care manager for follow up, support, coordination 2.Consulting
psychiatrist for caseload review and recommendations
- Slide 13
- 2012 MFMER | slide-13 DIAMOND: From a Patient/Provider
perspective Any patient meeting criteria Age 18 PCP diagnosed
dysthymia or major depression Score on PHQ-9 of 10 or more
Introduced to DIAMOND care manager Screen - alcoholism, anxiety,
bipolar disorder Clinical scenario gathered along with past history
Presented weekly to psychiatrist for recommendations. PCP writes
all prescriptions, patient management
- Slide 14
- 2012 MFMER | slide-14 Collaborative care (DIAMOND) was better
than practice as usual at 3 & 6 months Shippee et al. 2013 J
Ambulatory Care Manage Vol. 36, No. 1, pp. 1323
- Slide 15
- 2012 MFMER | slide-15 What about adolescent depression?
Richardson, McCauley & Katon Study (2009) IMPACT model applied
to adolescent patients 49% of patients activated Average Age 15 74%
of youth (12-18) had at least 50% reduction in symptoms at six
months Baseline PHQ-9 mean (SD) versus final = 14 (4.5) vs. 5.7
(4.1)
- Slide 16
- 2012 MFMER | slide-16 EMERALD - Early Management and
Evidence-based Recognition of Adolescents Living with
Depression
- Slide 17
- 2012 MFMER | slide-17 EMERALD pilot team members: Requires a
multidisciplinary effort Dr. Billings, MD pediatrician champion Dr.
Huxsahl MD child psychiatrist Roxie Brennan, RN Care coordinator
Denese Lecy desk coordinator Ellen Johnson, LICSW - psychotherapist
Hannah Mulholland, LICSW - psychotherapist Isaac Johnson computer
programer (for registry) Dr. Leffler, PhD child psychologist Angela
Kaderlik, RN nursing leadership Whitney Votava quality office
- Slide 18
- 2012 MFMER | slide-18 Goals Operationalize a collaborative care
model for adolescent depression management Satisfaction Improve
provider confidence and satisfaction in managing adolescent
depression Increase patient and parent/guardian satisfaction in the
management of adolescent depression Identify, monitor, and treat
depressed adolescents Develop a viable staffing model for
dissemination
- Slide 19
- 2012 MFMER | slide-19 Process Interviewed family physicians and
pediatricians on level of interest Reviewed examples of models in
the literature Explored learnings from DIAMOND with pediatric
champions and child psychiatry/psychology colleagues Regular
meetings of multidisciplinary group to discuss option of new model
Borrowed experienced care coordinator from DIAMOND with child psych
background for pilot PDSA cycles on components of the model
- Slide 20
- 2012 MFMER | slide-20 Collaborative care model adapted
Components IBH Care Coordinator (IBH CC) PCP (pediatrician) Adapted
screening/monitoring tools Child and Adolescent Psychiatrist LICSW
(Psychotherapy) Registry for tracking patients
- Slide 21
- 2012 MFMER | slide-21 Eligibility & Exclusion Criteria
Adolescents Ages 13-17 or 18 years old and still in high school
Paneled to Community pediatric providers Diagnosis of: Major
Depression (296.2x or 296.3x) OR Dysthymic Disorder (300.4) Mood
Disorder Depressive Mood PHQ-9 M than 10 Exclusion Criteria Bipolar
Diagnosis
- Slide 22
- 2012 MFMER | slide-22 Tools for monitoring outcomes Depression
PHQ-9M Anxiety SCAS-A and SCAS-P Substance abuse CRAFFT ADHD
Vanderbilt Bipolar disorder MDQ-A
- Slide 23
- 2012 MFMER | slide-23 How it works for adolescent patients Six
steps 1.Identification and referral 2.Linking up with the care
coordinator 3.Intake process 4.Systematic Case Review 5.Care
coordinator puts the plan in place 6.Continuos feedback cycle
- Slide 24
- 2012 MFMER | slide-24 Step one: Identification and referral Two
pathways 1.Patient seen somewhere and found to have a PHQ-9M of 10
or more computer identification 2.Pediatrician visiting with a
patient and suspects depression gives PHQ-9M and if score 10 or
more, decides if this might be depression Discussion of options
with the patient for next steps options include EMERALD
- Slide 25
- 2012 MFMER | slide-25 Step two: link with Care Coordinator
Ideal option = warm handoff The patient meets the care coordinator
in person while in the primary care clinic Either does an intake
then (if time permits) Or, sets up a time to do the intake.
Alternative option = phone contact or appointment The patient is
given a time to meet with the care coordinator or is called for the
intake
- Slide 26
- 2012 MFMER | slide-26 Step three: Intake process Care
coordinator gathers information from the patient and the family
Depression (PHQ-9M) Anxiety (SCAS-A and SCAS-P) Substance abuse
(CRAFFT) ADHD (Vanderbilt) Bipolar disorder (MDQ-A) Also gathers
information about the current life situation, past history, medical
issues, meds
- Slide 27
- 2012 MFMER | slide-27 Step four: Systematic Case Review Weekly
meeting with blocked time on both schedules (can be in person or by
phone) Psychiatrist and RN review all new patients Also any ongoing
patients in program Recommendations clarified Need for more
information, referral needs and where, treatment suggestions
Recommendations provided to PCP All scripts written by
pediatrician
- Slide 28
- 2012 MFMER | slide-28 Step five: CC putting plan into place
Contacts patient to review recommendations Is the patient open to
these suggestions? Contacts PCP to review recommendations Starts
process if orders needed Assists with scripts, etc. Motivational
interviewing, set behavioral action goals, arrange for regular
contact, monitor change Assists in linking patient up to resource
needs
- Slide 29
- 2012 MFMER | slide-29 Step six: Continuous feedback cycle Care
coordinator maintains patient contact Regular phone calls
Face-to-face visits Updates to pediatrician and psychiatrist
Adjusts the plan to the patient Tolerating/affording/taking the
medication? Going to therapy is it helping? New stressors,
etc.
- Slide 30
- 2012 MFMER | slide-30 Highlighting the importance of a registry
All the patients of a care coordinator Psychiatrist can use the
registry in weekly meetings Sort by the sickest patient Which
person is not progressing? Also can sort by primary care provider
Who is making referrals, How are my patients doing? Can ask
questions about the program Are we efficient? Who does
best/worst?
- Slide 31
- 2012 MFMER | slide-31 Outcomes (first 125 patients) Acceptance
-patients 68% agree to participate Adolescent generally deciding to
say no Those entering program initial dropout rate high (63%) Not
returning calls most common graduated at time of evaluation (13
patients) 90% reduction in PHQ9M Using Intent to treat metrics (48
patients) 52% reduction in PHQ9M
- Slide 32
- 2012 MFMER | slide-32 PHQ-9M Total Scores *4 patients missing
last PHQ-9M score (3 inactivated for no contact, 1 dropped
out)
- Slide 33
- 2012 MFMER | slide-33 Number of Patients with Suicidal Thoughts
in the Past Month *4 patients missing last PHQ-9M score (3
inactivated for no contact, 1 dropped out)
- Slide 34
- 2012 MFMER | slide-34 Provider Satisfaction & Confidence
Comfort Diagnosing Depression in Adolescents
- Slide 35
- 2012 MFMER | slide-35 Satisfaction & Confidence comments
Provider Satisfaction and Confidence Feeling that I can focus on my
role as primary care pediatrician with regard to depression and
differential diagnosis vs. having to 'manage' and coordinate the
connections between family between visits Patient &
Parent/Guardian Satisfaction The IBH case manager & MD truly
were dedicated to my daughter's well being. This was displayed in
every communication with us. Thanks for helping me & my
daughter. Both were very knowledgeable about adolescent
emotional/developmental stages
- Slide 36
- 2012 MFMER | slide-36 Staffing Model for Expansion Caseload
Size 2012 tracking of workload data showed EMERALD patients take
twice as much effort as DIAMOND patients 50 active patients 1.0 FTE
IBH Care Coordinator 0.1 FTE Child & Adolescent Psychiatrist
0.2 FTE Pediatric Social Worker
- Slide 37
- 2012 MFMER | slide-37 Changes at the end of the pilot - 2013
Adolescent depression screening PHQ-9 M MNCM announcing plan to
track this Increased attention to screening at well child visits
Age Criteria - include 12 year olds Result of presentation to
leadership spread to rest of primary care when resources
available
- Slide 38
- 2012 MFMER | slide-38 Some of our lessons and questions Its
difficult for care coordinators to reach patients by phone Wish for
ability to use various media resources popular with adolescent
patients. The additional family component in caring for an
adolescent results in increased time commitment per patient
compared to adults Attention to reasons for dropouts Would showing
eligible patients and families results keep more in treatment? How
does the model need to be tweaked for family medicine and rural
areas?
- Slide 39
- 2012 MFMER | slide-39 Thanks to my IBH colleagues Questions??
Williams.mark@mayo.edu