objective

To use quality improvement (QI) practice facilitators in a community primary care pediatric

practice in Ohio’s Appalachia to increase routine adolescent screening, diagnosis and

management of depression.

Example of a practice-specific aim statement:

Increase use of a validated depression screening tool from 0% to 30%, and for those

diagnosed with depression, the use of a management plan from 43% to 85% by

6/30/2016 and sustain through 12/31/2016.

results

Figure 5. Depression screening performance

Initial interventions: Depression screening increased from 0% to 42%.

Subsequent interventions: Performance increased to 91% and the

centerline shifted to 80%.

background

Depression affects 12% to 20% of adolescents and up to 30% of Appalachian residents.

Universal adolescent depression screening and management is recommended by the

American Academy of Pediatrics. Still, routine depression screening is limited. QI practice

facilitators can help clinicians standardize care, remove unwanted variation and improve

outcomes.

The QI practice facilitation model may improve depression screening and management at

community pediatric practices by:

• Improving screening rates

• Equipping pediatricians to manage mild cases

• Creating referral paths for patients diagnosed with depression

Partners For Kids, an accountable care organization affiliated with Nationwide Children’s

Hospital (NCH), offers practice facilitation services to guide community pediatric practices

through QI projects. Practice facilitation is an evidence-based approach using an external

coach (practice facilitator) to:

• Manage QI projects aimed at improving patient outcomes

• Train staff on QI methods

• Use practice-level data to drive change

• Help practices sustain improvements

conclusion

• Implementing behavioral health recommendations using practice facilitation led to

increased screening, diagnosis and management of depression at an Appalachian primary

care practice.

• Practice facilitation using QI methodology can help community practices effectively

implement evidence-based clinical recommendations.

aim and key driver diagram

Figure 3. Practice-specific aim and key driver diagram

Practice Facilitation to Improve Behavioral Health

Management at a Pediatric Practice in Ohio’s Appalachia

Suzanne Hoholik, MBA, MBOE

Christina Toth, MPH

Mike Fetzer, BSISE

Rebecca Baum, MD

Stephen Cardamone, DO, MS, FAAFP

Sean Gleeson, MD, MBA

In early 2016, a non-NCH-owned practice in Ohio’s Appalachia region initiated a

depression screening and management project with 6 months follow-up.

Practice facilitators trained practices on the IHI Model and led recurring, on-site meetings

where tests of change were discussed.

Figure 1. Depression management tip sheet

Initial interventions:

• Complete

checklist

• Participate in

training with

specialist

Subsequent

interventions:

• Develop

screening

process

• Add dot phrases

to EHR

• Standardized

patient charting

Figure 2. Depression screening process map

methods

Figure 4. Practice depression management performance

Documentation of evidence-based management of patients with

depression increased from 43% to 85%.

Depression Management Project Tip Sheet

Screening checklist Things to have in place before your office begins universal screening. Processes:

Scoring and documentation process

Management of confidential concerns

Crisis plan — staff trained on what to do in emergency

Skills:

Performing an assessment

Recommending interventions

Managing emergencies

Resources:

Patient handouts

Referral sources

Consultation tools

Components of an Effective Management plan Things to document in the chart to meet the quality metric definition. All criteria should be completed within 1 month

of the visit.

Screening results

Safety assessment (if positive for self-

harm questions on PHQ-9; if negative,

don’t need additional discussion)

Interventions (first line advice, referral,

consultation or medication)

Follow up plan (can be PRN, esp. if they

refer out)

Process map for Depression Screening June 2016

Pat

ien

t Fl

ow

Phase

Yes

Provider takes chart, PHQ-9 from

outguide, reviews/adds

score

Provider starts exam. During

exam, asks parent to leave, if present

Patient fills of PHQ-9

When rooming pt.,

MA/nurse takes form and adds to

chart, puts in outguide

outside of room.

Provder reviews with pt.

Asks if they want this

shared with parent

Patient decides

Parent asked back in, PHQ-9 reviewed. Provider

discusses next steps, if necessary and notes in

EMR and on PHQ-9

Yes

Provider discusses next steps

with patient, if necessary, adds notes to EMR and

PHQ-9

No

Exam continues and ends. Provider

puts PHQ-9 with chart

in outguide.

MA takes chart and PHQ-9, leads pt. to

check out. Gives chart/PHQ-9 to front desk

for scanning

When time available, front desk staff scans in PHQ-9 into EMR

Billing office sees code and scanned PHQ-9 in EMR, bills for service

Process ends

PHQ-9 given to pt. at check-in on

clipboard