Mental Health Module“Making It Real”

Learning Session 1

[date]

Making It REAL....My Reflections

Johanna JohnsVanderhoof, British Columbia

Ask the Questions

(Show Patient Video)

The Model for Improvement

What are we trying toaccomplish?

How will we know that achange is an improvement?

What changes can we make thatwill result in improvement?

Model for Improvement

Act Plan

Study Do

Characteristics of the Model for Improvement

• Action-oriented – “What are you going to test next Tuesday?”

• Rapid-cycle testing of changes• Evaluation and revision of all changes

before implementation• Testing and implementing the changes in

small populations, then spreading then spreading to the larger population

• Impact evaluated using annotated run charts

• Monthly reporting of tests and outcomes

The Total Population of Trainer GPs and MOAs and Patients with mental health problems in BC (spread sites)

Small-scale tests of change

Pilot Population: Mental Health Trainers: GP and MOA population and office patients with mental health problems. Focus for the Collaborative (Aim defines)

A PS D

A PS D

A PS D

Utilize Pilot Populations to test the Program

The Fundamental Questionsfor Improvement

1. What are we trying to accomplish?

2. How will we know that a change is an improvement?

3. What changes can we make that willresult in an improvement?

What are we trying to accomplish?

Aim Statement Characteristics• States that we are going to “improve” care for patients

(knowledge, skills, and resource availability related to management of mental health problems in GP offices).

• Describes the target “population” for improvement (GP) • Describes in general terms “changes” we are going to

use to improve care for the population (Mental Health Change Package and Expanded Chronic Care Model)

• Describes the most important outcomes (measures)that we want to improve for the population that defineour success (Use of screening, diagnostic, support mechanisms, etc.).

What are we trying to accomplish?

Office Aim Statement • Aim: The care for patients with mental health

problems in _______ GP office will be redesigned using the mental health change package so that GPs use depression screening tools, the CBIS Assessment tools such as the Diagnostic Assessment Interview, Problem List Action Plan, Resource list and Self Assessment Questionnaire, and CBT options such as the CBIS Handouts, Antidepressant Skills Workbook and Bounceback tools/support

The Fundamental Questions for Improvement

1.What are we trying to accomplish?

2.How will we know that a change isan improvement?

3.What changes can we make that will result in an improvement?

1) Use PHQ-9 screening tool with at least20 patients with potential mental health problems

2) Conduct a second PHQ-9 assessment within 3-6 months for 95% of those patients in this group

3) Use the Diagnostic Assessment Interview for at least 10 patients with positive PHQ-9

Measures

…/

Measures (cont’d)

4) Document suicide risk assessment in the patient chart if the suicide question on the PHQ-9 or Diagnostic Assessment Interview was positive

5) Develop a problem list for 10 patients with an Axis I diagnosis

6) Develop a resource list for 10 patients with an Axis I diagnosis

…/

Measures (cont’d) 7) Develop an action plan from the problem

list for 10 patients with an Axis I diagnosis.

8) Use skills from the CBIS Manual with 10 patients with mental health problems.

9) Refer 10 patients screened as having mild/moderate depression to the Bounce Back Program

10) Offer Anti-depressant Skills Workbook (ASW) and provide some coaching to 10 patients screened as having depression

Measurement

• The purpose of measurement in the collaborative is for learning not judgment

Fundamental Questions for Improvement

1. What are we trying to accomplish?

2. How will we know that a change is an improvement?

3. What changes can we make that will result in an improvement?

Mental Health Change Package

• Screening Tools• Diagnostic Assessment Interview• Problem List & Action Plan• Mental Health Care Plan • Resource List • CBIS Skills • Bounce Back program • Antidepressant Skills Workbook

What are we trying toaccomplish?

How will we know that achange is an improvement?

What changes can we make thatwill result in improvement?

Model for Improvement

Act Plan

Study Do

The PDSA Cycle

Act

• What changes are to be made?• Next cycle?

Plan• Objective• Questions and predictions (why)• Measure of success• Plan for the cycle (who, what, where, when)

Study• Complete the analysis of the data

•Compare data to predictions

•Summarize what was learned

Do• Carry out the plan• Document problems and unexpected observations• Begin analysis of the data

Aim: To improve the care of patients with mental health problems

Use of mental health screening tools will help identify patients needing support.

Improved outcomes

A P

S D

APS

D

A PS D

D SP A

DATAD S

P A

Cycle 1: Test use of PHQ9 with patient A on Tuesday

Cycle 2:

Cycle 3:

Cycle 4:

Cycle 5: Test 3 ways to access skills in CBIS manual

Test the use of the PHQ9 with patients B and C on Wednesday.

Test Diagnostic Assessment Interview (Patient B) -Hand out Problem List

Test (Patient B) + Problem List/Action Plan

http://www.impactbc.ca/Local%20Settings/Temporary%20Internet%20Files/OLK12E/CBIS_Linked_042209_secure.pdf

http://www.impactbc.ca/Local%20Settings/Temporary%20Internet%20Files/OLK12E/antidepressant%20algorithm%20with%20links.20.may.09.pdf

Context / History

23

Depression used as Lens

Source: Descriptive Epidemiology of Major Depression in Canada. Patten, SB; Wang, JL; Williams, JVA et al. Canadian Journal of Psychiatry; Feb 2006; 51, 2; 84.

Lifetime prevalence of Major Depressive Episode: 12.2%Past-year episodes: 4.8%

Past-month episodes: 1.3%

Why

Picture in BC:• 2008 733,982 receiving services• 638,208 by a GP• 108,810 by a psychiatrist• 104,441 in a community MH center• 20,378 hospitalized

Why

• 2003 module developed for Health Transition Fund -75 GPs

• GP numbers made consultation liaison model impossible

• Module developed to enhance GP skills in real time

• Made every mistake possible • DID, 18 GPs until project ended (now 30

GPs)

Why

• GPSC after GP survey, assessing our module, new fee incentive

• Funded this rollout

Why

• Shift from ‘acute’ to ‘planned pro-active’ MH care

• Focus on efficient office time management

• Bridge with Mental Health and Addictions

27

MOA Role

• Understand module• Take CMHA course on Mental Health• Feel comfortable with mental health

patients• Heightened awareness• Know scheduling required• Know the materials needed• Have materials prepared/placed

Compensation

• Case examples

What’s Real

• YOU...are the experts in your practice…integrate into your practice..

• Focus is adults…not directly applicable for C/Y and elderly….your judgment

Overview of Mental Health Module

Show Overview Video

PHQ-9

34

PHQ-2 & PHQ-9

35

PHQ-2

36

PHQ-99 questions used in scoring depression severity

Functional impairment question

37

PHQ-9 ScoringStep 1:Need one or both questions endorsed as “2” or “3”(“More than half the days” or “Nearly every day”)

38

PHQ-9 ScoringStep 2:Major Depressive Disorder: Need 5 or more questions endorsed as “More than half the days” or “Nearly every day” (i.e. in shaded areas)

Step 3:Total score: Calculate score for columns 1,2 and 3

18

8 91

39

PHQ-9 Scoring

Guide for Interpreting PHQ-9 Scores

Score Provisional Diagnosis

05-09 Minimal symptoms (*)

10-14 Minor depression (††)

Dysthymia(*)

Major depression, mild

15-19 Major depression, moderately severe

≥20 Major depression, severe

Step 4:Interpret results

(*) If symptoms present ≥ two years, then probable chronic depression.(††) If symptoms present ≥ one month or severe functional impairment,

consider active treatment

40

PHQ-9 Scoring

Step 5:Is functional impairment endorsed as “Somewhat difficult” or greater?

18

8 91

What is CBIS?

• Cognitive• Behavioural• Interpersonal• Skills

Manual Layout

• Introduction• Flow charts• Assessment• Education• Activation• Cognition• Relaxation• Lifestyle

Introduction

TIPS• Teaching• Implementing• Planning• Supporting

Flow Charts

• When in doubt – go with the flow

• This directs you to the appropriate treatment strategies in the manual

Assessment

• Diagnostic screening interview• Screening worksheet• Problem list• Problem list action plan• Resource list• Self-assessment questionnaire• Self-assessment profiles

Education

• Understanding depression

• Frequently asked

questions• Signs and symptoms• Medication?

Activation

• Daily activities• Energize• Small goals• Problem solving• Chunking time• Improving mood• Self supportive

Cognition

• Changing behaviour• Changing thinking• Changing feeling

Relaxation

• Benefits• Stress management• Breathing• Grounding• Relaxation• Mindfulness• Meditation

Lifestyle

• Sleep• Nutrition• Substances• Exercise• Wellness

Navigating the Skills Manual

Three ways to begin:• Problem list action plan• Symptoms • Self-assessment questionnaire

Problem List Action Plan

No job – I’m too old to retrain

ACTIVATION RELAXATION

COGNITION LIFESTYLE

MEDICATION REFERRAL

No job – job coachBankruptcy – debt counselling

I feel tired all the time

Tired all the time

I don’t want to do anythingIrritable – tense

Drinking more coffeeHaving a few beers

Not interested in seeing friends

I overreact

I overreact

I feel like a failure – I’ll never get a job Stay up late watching TV

Sleeping during the day

Sleeping during the day

Arthritis – pain

Arthritis – Bounce Back

Flow Chart

Healthy Habits For Sleeping, pg 68It’s True: You Are What You Eat, pg 69Physical Activity, pg 71The Wellness Wheel, pg 72

Anti-Depression Activities, pg 31Depression’s Energy Budget, pg 32Small Goals, pg 34Problem Solving, pg 36Opposite Action Strategy, pg 37Chunk The Day, pg 38Improve The Moment, pg 39Appreciation Exercise, pg 40

ACTIVATION

LIFESTYLE

Flow Chart

NEGATIVE THINKINGCOGNITIVE

DISTORTIONS

COGNITION MODULEThe Circle Of Depression, pg 42Common Thinking Errors, pg 44Thought Change Process, pg 45Self Talk (Mean Talk), pg 47Thought Stopping, pg 48Good Guilt / Bad Guilt, pg 50Is Anger A Problem For You, pg 54

PANICKY

RELAXATION MODULEAbdominal Breathing, pg 57Grounding, pg 58Passive Relaxation, pg 61Mindfulness, pg 64

Self-assessment Questionnaire

0 = never or rarely true to me; 1 = somewhat true; 2 = quite a bit true; 3 = very true of me

1. ____ It’s hard for me to say no to people even if I don’t want to agree or don’t have the time or energy

2. ____ I will do almost anything to avoid hurting people’s feelings, whatever the cost to myself

3. ____ I do lots of things for others, even at the expense of meeting my own needs

Flow ChartACTIVATION MODULEAnti-Depression Activities, pg 31Depression’s Energy Budget, pg 32Small Goals, pg 34Problem Solving, pg 36

ACTIVATION

OVER-THINKER PROFILE

ASSESSMENT MODULEOver-thinker Profile, pg 24

RELAXATION MODULEAbdominal Breathing, pg 57Grounding, pg 58Passive Relaxation, pg 61Mindfulness, pg 64

PANICKY

Questions and Discussion

Diagnostic Assessment Interview

Teaching Points

Diagnostic Assessment Interview

Show Video

Diagnostic Assessment Interview

Frequently Asked Question #1

Diagnostic Assessment Interview

Frequently Asked Question #2

Diagnostic Assessment Interview and Handing Out the Problem List (20 min practice & 10 min debrief)

GP Skills Practice Session

Organizing the Problem List into a Problem Action Plan

Show Video

Problem/Resource List Action Plan

Frequently Asked Questions

Questions and Discussion

Develop Problem List Action Plan

(20 min & 10 min debrief)

GP Skills Practice Session

Fee Codes

Case Study #2

Meet Mrs. J

• 47 yrs. old; married, school age children• SSRI for depression (laid off a year ago)• 1 previous episode, also situational• Mother had depression requiring treatment• Osteoarthritis; diabetes and hypertension• Not interested in old hobbies, no energy,

crying frequently • Bitter, worried; napping much of the day

January

• Headaches, not sleeping well, “blowing up” at even small irritants

• Not eating regularly; has lost weight • Initial neurologic examination is normal• You spend 20 minutes counselling her on

the probable diagnosis of depression

Counselling #1 Fee Code 00120

Diagnostic Code 311

One Week Later…

• Labs normal; PHQ9 = 17• CBIS Diagnostic Assessment

Interview confirms diagnosis of recurrent depression, and

• You spend 30 minutes counselling her alcohol, caffeine; problem list; SAQ

Counselling #2 Fee Code 00120

Diagnostic Code 311

Another Week Later…

• Problem list and the SAQ• Problem List Action Plan (CBIS)• BounceBack Referral• You spend 30 minutes counselling

Counselling #3 Fee Code 00120

Diagnostic Code 311

Mental Health Planning Visit…

• Review diagnosis, Problem List Action plan, Resource List

• Reassess emotional and mental status• Jointly develop a plan• CBIS activation skills (2) • 30 minutes MH Planning Visit

MH Plan (30 min) Fee Code 14043

Diagnostic Code 311

Follow-Up…• Telephone Follow-up (Day 3 and 1 week)• Regular office visits (2)

• MH Follow-up Calls #1 and #2• Office Visit #1and #2

Phone F/U #1 Fee Code 14079 Diagnostic Code 311Phone F/U #2 Fee Code 14079 Diagnostic Code 311

Office Visit #1 Fee Code 00100 Diagnostic Code 311Office Visit #2 Fee Code 00100 Diagnostic Code 311

Unplanned Visit…• Panic / overwhelmed • Takes :15 min to settle her• Office Visits #3• Community Patient Conference #1

Office Visit #3 Fee Code 00100 Diagnostic Code 311

Comm. Pt. Conf #1 Fee Code 14077 or 14016Diagnostic Code 311 (Units x1)

Over next 6 months …• CBIS – working on skills• ASW – coaching• PHQ9 down to 7 • Follow up on diabetes, etc• Office Visits #4 thru 9

Office Visit #4 Fee Code 00100 Diagnostic Code 311

Same for Office Visits # 5, 6,7,8,9 (note: #6 = code 250)

Physical and CDM …

• Time for complete physical examination due to diabetes• Review CDM • Discuss mental health plan

• Physical Exam• CDM review

CPX Fee Code 00101 Diagnostic Code 250

CDM Diabetes Fee Code 14050Diagnostic Code 250

Follow-up…

• Telephone follow-up• MH Follow-up Call #3

Phone F/u # 3 Fee Code 14079 Diagnostic Code 311

Next Visits (over 3 months…)

• Counselling visits• Office visit; coaching ASW & CBIS skills

• 20 minutes counselling sessions (#4&5)• Office Visit #10

Counselling #4 Fee Code 00120Diagnostic Code 311

Counselling #5 (GPSC) Fee Code 14044Diagnostic Code 311

Office Visit #10 Fee Code 00100Diagnostic Code 311

Total Billing

• $ 912.04

http://www.impactbc.ca/Local%20Settings/Temporary%20Internet%20Files/OLK12E/CBIS_Linked_042209_secure.pdf

Bounce Back (Overview)

• Funded to support Family Practice• Where it fits• DVD versus telephone coaching• Coach is available to give overview at

learning sessions• Feedback loop• Research stream• 1-866-639-0522

81

Bounce Back

Show Bounce Back Video

Tasks – Action Period 1• Conduct initial chart review – target

patients with chronic conditions, thick charts, chronic pain, etc.

• Use PHQ-9 screening tool with at least 20 patients with potential mental health problems

• Conduct a 2nd PHQ-9 assessment within 3-6 months for 95% of those patients in this group

• Use the Diagnostic Assessment Interview for at least 10 patients with positive PHQ-9

• Document suicide risk assessment in the patient chart if the suicide question on the PHQ-9 or Diagnostic assessment Interview was positive

…/

Tasks – Action Period 1• Develop a problem list for 10 patients with

an Axis I diagnosis• Develop a resource list for 10 patients with

an Axis I diagnosis• Develop an action plan from the problem

list for 10 patients with an Axis I diagnosis• Use skills from the CBIS Manual with 10

patients with mental health problems• Refer 10 patients screened as having

mild/moderate depression to the Bounce Back Program

• Offer Anti-depressant Skills Workbook (ASW) and provide some coaching to 10 patients screened as having depression

…/

Tasks – Action Period 1 (cont’d)

• Report data results with monthly narrative report

• Follow up with patients (MOA can follow up with patients on homework and goals agreed to in action plans)

• Identify changes to work processes and office re-design

• Records PDSA tried with plans, predictions, analysis, etc.

• Record overall progress towards aims• Participate in team calls with support teams

and peers