Justin Coffey, MD Behavioral Health Services Terri Robertson, PhD Center for Clinical Care Design

1. Perfect Depression Care Justin Coffey, MD Behavioral Health Services Terri Robertson, PhD Center for Clinical Care Design

2. Objectives Recognize the value of including depression care into chronic disease care models 1 Discuss the benefits of using standardized depression screening tools, such as the PHQ-2 and PHQ-9 2 3 Understand the key components of evidenced-based treatment for clinical depression Enhance knowledge of suicide prevention strategies 4 5 Develop several strategies for integrating depression screening and treatment into clinical practice Your Logo

3. Suicide Statistics There is a suicide every 15 minutes in the US 90% of people who die by suicide have a diagnosable and treatable psychiatric disorder at the time of their death 70% of patients committing suicide have seen their primary care provider within 6 weeks of the suicide ….. There is an opportunity here!!

4. Expected suicide rate for patients with an active mood disorder (21X) Expected rate for euthymic patients with mood disorder (4-10X) Number of suicides per 100,000 HAP-HFMG patients Suicides per 100,000 HMO Patients Q3 YTD Number of suicides per 100,000 US general population

5. Suicidality in Primary Care is Palpable Suicide Ideation Trends- HFMG

6. Depression in Primary Care Model Registry (DocSite) to identify eligible patients Standardized, evidenced-based tools PHQ2 PHQ9 Automated tools Embedded in EHR Simple Self-scores Provides interpretation Links to treatment guidelines Evidenced-based treatment menu based on patient preference Medication management Psychotherapy (CBT) Problem-solving therapy (PST) Utilize MA’s to “tee up” process Use Psychiatric NP’s and/or Clinical Psychologist to spread tools/ train clinic staff Cross trained Diabetes Care Center and RN Case Managers (collaborative care) HFHS DST

7. PHQ-2 branches when positive (> 3) to full 15-item DST Depression Screening Tool

9. Safety Visual Management 1 2 Alerts at top of patient record: 1D= DST score is > 10, alert is removed after DST is signed by Responsible Staff 2 S= Suicide risk question(s) answered positively, alert is removed when DST is repeated and suicide risk questions are negative

10. Diabetes Care Center-2011 Depression Screening Rates DST Rates 2011 Goal=85% PHQ-2 Rates 2011 Goal=83%

11. Continuous Improvement Realized that clinics needed more education/ tools specific to handling a potentially suicidal patient Solution: 1) Developed a suicide triage protocol 2) Partnered with the DCC staff, who selected this as their 2011 safety goal

13. Diabetes Care CenterResponse to Q9 for Suicide Pre suicide safety goal (2010) Post suicide safety goal (2011) N=27 N=33

14. Celebrate the (Not So) Small Successes! Recent case example from DCC 49 yo, AF-AM female with multiple medical conditions and known psychiatric history Active in psychiatric treatment, medications recently changed Seen for diabetes education, completed DST as part of standard process Skipped suicidal ideation question, but said “YES” to plan for self harm and skipped intent question On questioning, disclosed was feeling depressed for over a month, was having suicidal thoughts and planned to take an overdose of pills (had access) Admitted to purposefully lying to her mental health provider a few days prior out of fear that they would “lock her up” Symptoms: feeling depressed, tearful, hopeless, insomnia, loss of appetite with unintentional weight loss, rapid and pressured speech, flight of ideas, hearing voices Risks identified by DCC staff: history of Bipolar I Disorder, history of depression with suicidal thoughts, very limited social support, comorbid anxiety, access to pills, possible mania/ psychosis Outcome: relocated patient to the internal medicine clinic where clinic RN could assist with sitting with patient; in consultation with BHS, petition was completed and patient was triaged to the ER for IPD Psychiatric admission; police assisted (at request of EMS) without incident

16. THANK YOU

17. Questions?? Your Logo