DEPRESSION SCREENING CASE STUDY

2017 NICOLAS E. DAVIES COMMUNITY HEALTH AWARD OF EXCELLENCE

UNITY HEALTH CARE, INC.WASHINGTON, DC

Overview

• About Unity Health Care• Change Management• Depression Screening Case Study

HIMSS Davies Application Team

• Catherine Anderton, Associate Director for Quality Improvement and Research

• Angela Diop, VP of Information Systems

• Marcia Hinkle, Assistant Director Social Services: BehavioralHealth

• Cherie Jones, Information Systems Manager

• Andrew Robie, Chief Medical Information Officer

About Unity Health Care

Federally Qualified Health Center 

District of Columbia

Over 106,000 patients and 

500,000 visits each year

Federally Qualified Health Center 

District of Columbia

Over 106,000 patients and 

500,000 visits each year

Promoting healthier communities through compassion and comprehensive health and human services, 

regardless of ability to pay.

Unity Health Care

Unity Sites

10  Community Health Centers

10 Medical Sites in Homeless Shelters

2 School‐Based Health Centers

1  Mobile Van

Health Services in DC Jail

Homeless Outreach

Administrative offices

Services

• Primary care and specialty care

• Dental care• Behavioral health care• Care to people experiencing

homelessness, HIV, returning citizens, Title X

• Patient-Centered Medical Home NCQA level 3

Unity’s Health Information Technology

Customized integrated PM, EMR and Dental applications

Implemented March –

December 2009 in a phased approach (6 phases) 

Over 260 licensed providers

Over 900 staff6 applications 

analysts 

Change Management

Robust system of change management helps to develop and adopt well thought‐out changes in an organized manner.

From Unity’s change management Guidelines for Electronic Health Records ~2016 

Unity Teams Responsible for EHR Governance

Team Name Team Lead Other Participants Responsibility

Stakeholders EHR Analyst EHR Analysts, Deputy CMO, CNO, VPs of Clinical Services and IS 

Approve major changes to EHR and workflows. Approve and assign resources needed for change.

Implementation team

VP of IS Deputy CMO, CNO, VPs of Clinical Services, IS and Grants, EHR, PM, IT and Data Analysts, Lab Mgr., IT, CTO, Dir. Social Services, Revenue Mgr., Help Desk Asst.

Track issues and changes to resolution. Assign issues to other teams for solution. Implement and communicate changes. 

EHR tech team EHR Analyst EHR, PM, IT and Data Analysts, VP IS, CTO, Revenue Mgr.

Responsible for managing ongoing maintenance, upgrades and implementations.

Joint training team  EHR Analyst PM and EHR Trainers, Discipline Subject Matter Experts

Develop EHR and PM training.

Support team EHR Analyst and Help Desk Asst.

EHR, PM, IT and Data  Analysts Respond to requests for support. Interface with the EHR vendor to track and resolve vendor related issues. 

Reports team Data Manager Data and EHR Analysts, Deputy CMO, CNO, VPs of IS and Clinical Services, QI Mgr.

Develop EHR reports.

Configuration team EHR Analysts EHR Analysts, Deputy CMO, CN0, Dir. Social Services,  10 Medical Directors

Manage major configuration and content changes to the EHR

10

Our ApproachDevelop Workflows

Modify EHR

Train Staff

Change

Workflow Development

Groups Developing the Workflows• QI Department• QI Working Groups• Configuration team

In collaboration with Health Information Technology Team (HIT) and Reports team.

Disseminating Change

Change is developed

Working Groups develop training

Multi‐disciplinary team based training is conducted

Training is reinforced CHANGE!

Depression ScreeningCase Study

Local Problem

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Uninsured orincome < 100%of FPLGeneralPopulaion

Prevalence of Depression

• 30% of uninsured patients or those with incomes less than 100% of the Federal poverty level have a mental health problem

• 29% of Medicaid and CHIP patients over age 12 have a mental illness

National Survey on Drug Use and Health, 2010

Depression Screening

• Depression screening mostly conducted by 7 of our mental health clinicians (MHCs).

• There was a significant amount of undiagnosed and untreated depression.

Depression Screening Goal• Develop a consistent way to screen

and document depression at a primary care visit using NQF0418.

• Tracking measures included the percentage of patients aged 12 years and older who were screened, and if the screen was positive, was there a follow up plan documented on the same day.

• Baseline in 2014: We documented our baseline score as zero. Screening was occurring, but we had no processes in place to measure it except by manual count.

PHQ2 Tool

• Administered to every adult patient (age 12+) once a year during primary care visits during intake

• Inquires about frequency of depressed mood over past two weeks

• Patients screening positive (yes to one or both questions) receive PHQ-9

• Configured as a SmartForm in the HPI Adult Behavioral Health folder:

PHQ9 Tool

• The PHQ9 screen opens automatically if the PHQ2 is positive.

• The MA/Nurse can give the patient a paper copy of the PHQ9 to complete while waiting for the provider, and then transfer the responses into the SmartForm.

• Or, the MA/ Nurse may ask the questions and complete the PHQ9 while with the patient. Scoring is automatic.

Depression Screening Workflow

Chief complaint (every visit)

OTC Medications (every visit)

Tobacco (annually age 13+)

Alcohol and Drug Use                                               (annually age 18+)

PHQ (Patient Health Questionnaire)                                                     

(annually age 12+ at primary care scheduled 

visits only)

Vitals/Standing orders (every visit)

Provider Documents  follow‐up  in Adult Behavioral Health

How Health IT Was Used

Smartforms• PHQ2 and PHQ9 smart forms

purchased from our EHR vendor for depression screening.

• Calculates score and automatically populates the results in the History of the Present Illness (HPI) section of the patient’s progress note.

• Multi-disciplinary team developed and configured the HPI to include smart form assessment and follow-up plan and substance abuse documentation.

• In the preventive section of the progress notes a behavioral health section was added to document follow-up.

• Configuration is a structured format to track and report it as a quality measure.

MA Intake flowsheet

• Indicates date of last screening:– Alcohol/Drug– PHQ2– SDQ– Tobacco Use

• Due= not done in the last year

Depression HPI

• HPI was configured based on DSM criteria for diagnosis of depression

• The goal is to help the provider collect information needed to guide treatment plan

Is mood change from baseline?Impaired function (home/school/work)?5 of 9 symptoms present almost every day?Hx of depression or other mental illness?Hx of substance abuse?Medical illness causing depressed mood?

Suicide Risk Assessment (question 9 on PHQ9)

• The suicide assessment question: “Have you had thoughts of actually hurting yourself”? was configured.

• If “Yes”, further risk stratification questions appear:

Have you ever attempted to harm yourself in the past? (yes/no)Have you ever thought about how you might actually hurt yourself? (yes/no)How likely is it that you would act on these thoughts in the next month? (not at all/somewhat likely/very likely)Is there anything preventing you from hurting yourself? (yes/no)Suicide risk? (minimal risk/higher risk)

Order Set: Behavioral Health

• Order sets were configured, included guidance on common psychotropic medications and referral resources

Preventive Medicine

• The preventive medicine section was configured for documentation that the depression follow-up plan was discussed

Preventive Medicine

• The preventive medicine section includes patient education and documents evidence based actions the patient can take to improve mood.

Meet with social services todayMake an appointment with the psychiatrist you were referred toMake an appointment with the therapist you were referred toExercise at least 30 min a dayIncrease social activityTry to sleep at least 8 hours every nightAvoid using drugs and alcoholFill your depression medicine and take it everydayCall 1‐888‐7WE‐HELP if you are thinking of hurting yourself or someone else

Staff Engagement

• 2014 – 3 months of site visits were conducted to talk to providers about barriers and concerns about screening

• Jan 2015- Training was rolled out

Patient Education

Jan 2015

In Spanish and English

Value Derived

• In 2016 44% of patients aged 12 years and older were screened and if positive a follow up plan was documented.

• In 2016 a total of 30,777 patients had depression screening and follow up as necessary.

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Depression Screening

201420152016

Soft ROI• This initiative has improved

coordination of care between the MHC and the Primary Care Physicians (PCP).

• It has made staff better at connecting patient to resources and support.

• Patients with mild to moderate depression can be identified and treated in primary care.

• The screening opens the door for patient and provider to discuss other mental health concerns

• Diagnosing and treating patients with depression improves patients’ ability to adhere to treatment protocols for somatic and chronic diseases such as diabetes or hypertension.

Lessons Learned• A standard screening tool

increased identification of depression symptoms and need for treatment, and increased provider confidence in addressing mental health and substance use

• Similar to hypertension, training and retraining is key to consistently meeting goals

• Data strengthens the relationship between the medical provider and the mental health clinicians, providing a common language to talk about symptom improvement or need for changes in treatment

Thank youwww.unityhealthcare.org

@UnityHealthCare