Shared Care Collaborative approach for improving the detection, assessment and treatment of depression

1. Shared Care Collaborative approach for improving the detection, assessment and treatment of depression Cheryl Washburn, Ph.D, R.Psych., UBC Counselling Services Patricia Mirwaldt, M.D. CCFP, UBC Student Health Services Whitney Sedgwick, Ph.D, R.Psych., UBC Counselling Services

2. UBC Shared Care Collaborative • community centered collaborative network of primary care providers, working as a multidisciplinary team; enabling sustainable improvement in the primary treatment of depression at UBC and the surrounding community

3. Learning Objectives This workshop will: • Describe the key features involved in the development and implementation of a shared care collaborative model for the treatment of depression • Present data reflecting established stretch goals • Outline some of the challenges and benefits of a shared care collaborative for the treatment of depression • Discuss the applicability of a shared care model in your respective communities

4. The UBC Collaborative UBC Student Health Services Patient UBC Urgent Care UBC Health Clinic University Village Medical Clinic UBC Counseling Services UBC Community VancouverCoastal Health

6. Time Line Sept/03: position paper Jun/04: Initial stakeholders meeting Aug/04: Planning session (i.e. conceptual models) Oct/04: Funding proposal submitted March/05: Funding approved June/05: Planning session (i.e. scope, membership)

7. Time Line (cont.) Oct/05: Learning session (i.e. reviewed best practice models) Nov/05: Planning session (stretch goals) Jan/06: Learning session part I (Suicide assessment) March/06: Learning session, part II (Suicide assessment) March/06: Progress report submitted to VCH

8. Time Line (cont.) June, Oct, Dec 06: ongoing: data review and tech. consultations re: data input March/07: Modification to stretch goals March/07: Flowsheet revision Ongoing: Consideration of sustainability post-funding

9. 2004 NCHA Undergraduate student data: Gaps in care

10. 2006 NCHA Graduate student data: Gaps in care

11. Gaps in care Public: • Lack of awareness of signs/symptoms, prevention and available resources and services • Stigma associated with depression and treatments that prevent people from receiving help. • Failure to comply with treatment. Service Delivery • Failure to recognize/assess depression, educate patients and families about nature of depression and support self management • Failure to recommend evidence-based psychotherapy • Inadequate dosage and duration of meds • Lack of time and compensation • Limited access to mental health professionals • Lack of ongoing monitoring and maintenance of change despite high rates of relapse and recurrence • Lack of integration among multiple existing primary health care services

12. Key features of models to address gaps in depression care • Managed (chronic) care • Evidence based stepped care approach that implements enhanced tools, decision supports, and established core measures 3. Capacity building and sustainable: both in numbers served and in physicians’ capacity to recognize and treat mental health issues (ie; education). • Collaborative: Integrating the services of primary care physicians and mental health practitioners. • Model for improved service delivery

13. Framework for change: The Care Model Adapted from Glasgow, R., Orleans, C., Wagner, E., Curry, S., Solberg, L. (2001). Does the Chronic Care Model also serve as a template for improving prevention? The Milbank Quarterly, 79(4), and World Health Organization, Health and Welfare Canada and Canadian Public Health Association.(1986).Ottawa Charter of Health Promotion.

14. Framework for Change: Model for ImprovementInstitute for Healthcare Improvement Aims Measures Changes Test Changes Implement changes more broadly

15. Framework for change: Breakthrough Series Learning Model

16. The UBC Collaborative UBC Student Health Services Patient UBC Urgent Care UBC Health Clinic University Village Medical Clinic UBC Counseling Services UBC Community VancouverCoastal Health

17. Aims of Collaborative • Improve health outcomes specific to depression • Develop and implement more effective suicide risk assessment practices • Facilitate patient self-management skills • Improve access to treatment for depression for members of the UBC and University neighborhood communities • Develop the primary healthcare network in the UBC community

18. BC Provincial Depression Strategy Recommended Approaches (2002) • Early intervention • Collaborative care • Stepped care • Chronic disease management model

19. Standardized Approach-PHQ-9

20. Stretch Goals/Results: N= 170 (Nov 1, 2006) • % patients given PHQ-9 (Patient Health Questionnaire) at, or within 10 days of, diagnosis Stretch goal: 85%  Results: 137/170=80.6% • % patients given second PHQ-9 within 8 weeks of diagnosis Stretch goal: 85%**Results: 30/137= 21.9% • % patients given third PHQ-9 within 16 weeks of diagnosis Stretch goal: 75%** Results: 12/30 = 40% (** of those who completed initial assessment(s))

21. Stretch Goals/Results: • % patients who have completed a PHQ-9 between 6-12 months post-diagnosis Stretch goal: 50% Results**: 164/170= 96.5% • % patients with PHQ-9 score reduced to < 5 (or in remission) by 16 weeks Stretch goal: 50% (of depression register population of patients) • % patients with PHQ-9 score reduced to <5 (or in remission) within 6-12 months post-diagnosis Stretch goal: 50%(of depression register population of patients) Results:** 36/170= 21.2% **(collapsed over 12 months)

22. Stretch Goals/Results: • % patients who had a suicide risk assessment at, or within, 10 days of diagnosis. Stretch goal: 100%Results = 62.4% • % patients who had second suicide risk assessment within 8 weeks of diagnosis Stretch goal: 70% (of those who completed first assessment) Results: 30/137= 21.9% • % patients who had shird suicide risk assessment within 6 months of diagnosis Stretch goal: 50% (of those who completed second assessment) Results: 12/30 = 40.0% • % patients who had a self-management goal documented Stretch goal: 50% Results: 111/170= 65.3%

23. Additional Stretch Goals: • % patients with second contact within 8 weeks of diagnosis Stretch goal: 85% ** • % patients with third contact made within 16 weeks of diagnosis Stretch goal: 85% ** • % patients with PHQ-9 score between 5-19 with no exclusionary co-morbid conditions who have been offered mood management group Stretch goal: 90% • % patients who have been offered psycho-educational material Stretch goal: 50% (** of those who completed initial assessment(s))

24. Group counselling -A key treatment option: -detailed referral form and FAQ sheet -6 week, psychoeducational CBT groups entitled “Mood management” -positive self-report re: mood (based on 18 groups): Pre-group PHQ-9 mean score=12.1 Post-group PHQ-9 mean score= 5.9

25. Initial Challenges • Recruitment: • Motivation to join • Time commitment • Compensation – salaried and fee for service considerations • Consent Issues: • Designing an informed consent form considering: • BC Health • BC Privacy Commissioner • VCHA • UBC Freedom of Information Coordinator • Confidentiality

26. Initial Challenges • Group Counseling: • Who’s patient is this? (physician and/or counselor) • Counselor acceptance and management of non-students (ex. UBC faculty and staff) in groups. • “Buy In” - physician and patient (acceptance as valid treatment option)

27. Ongoing Challenges • Data base: • Electronic medical records and linkages • Primary care provider inclusion in registry (ex. Non-MD) • Data and file management (time, data configuration, flowsheets) • Self-care: • Physician confidence in guiding patients in self care of depression management • Follow-up: • High attrition with this population including practitioners’ reticence to contact patients who missed last appointment • Lack of systematic follow-up of patients who have completed care to ensure healthy outcomes

30. Benefits • Patients get better from depression-symptoms recede!! • Improved education and awareness of community, practitioners and affiliated health care providers. • Early and accurate diagnosis with step-wise application of evidence based care. • Sustainable network infrastructure provides improved access to existing resources and increased practitioner capacity.

31. 2006 NCHA Female undergraduate students

32. 2006 NCHA Male undergraduate students

33. 2006 NCHA Male graduate students

34. 2006 NCHA Female graduate students

35. Benefits 5. Clear focus on group counseling and improved community access to groups. 6. Self management tools developed and utilized as the cornerstone of care. 7. Shared community of care = healthier campus and community.

36. Questions: In what ways could a shared care model have applicability on your campus? In what ways would a shared care model apply to other health issues on your campus?

37. Questions and Feedback Thank you!

38. Reference list • Bilsker, D., & Paterson, R. (2005). Antidepressant Skills Workbook. Mental Health Evaluation and Community Consultation Unit, University of British Columbia. • British Columbia Provincial Depression Strategy Phase 1 Report, October 2002. http://www.healthservices.gov.bc.ca/mhd/pdf/depressionstrategy.pdf • British Columbia Treatment Guidelines and Protocols for Diagnosis and Management of Major Depressive Disorder: http://www.healthservices.gov.bc.ca/msp/protoguides/gps/depression.pdf (contains references, p.9 and 10). • Fisher, L., & Ransom, D.C. (1997). Developing a strategy for managing behavioural health care within the context of primary care. Archives of Family Medicine, 6, 324- 333. • Iglehart, J.K. (2004). The mental health maze and the call for transformation. The New England Journal of Medicine, 350, 507- 514. • Innes, G. (1999). The health transition fund and the future of Canadian health care delivery. Journal of Emergency Medicine, 17, 157-158. • Kates, N., Craven, M., Bishop, J., Clinton, T., Kraftcheck, D., LeClair, K., Leverette, J., Nash, L., & Turner, T. (1997). Shared mental health care in Canada. The Canadian Journal of Psychiatry, 42(8). • Kates, N. & Craven, M. (1998). Managing mental health problems. A practical guide for primary care. Seattle: Hogrefe & Huber Publishers. • Katon,W., Rutter,C., Ludman, E.J. et al. (2001). A randomized trial of relapse prevention of depression in primary care. Archives of General Psychiatry, 58 (3), 241-247. • Kroenke K, Spitzer R L, Williams J B. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9): 606-613 • Lam, W.R., (2004). Targeted Resources to Improve Primary Care Outcomes in Depression (TRIPOD): An Educational Intervention for Implementing BC Depression Guidelines. • MacMillan, H.L., Patterson, C.J.S., & Wathen, C.N. and The Canadian Task Force on Preventive Health Care. (2005). Screening for depression in primary care: recommendation statement from the Canadian Task Force on Preventive Health Care. Canadian Medical Association Journal, 172, (1). • Paterson, R. (1997). Changeways Core Programme Trainer’s Manual. Vancouver, B.C. • Price, J.R. (2000). Managing physical symptoms: The clinical assessment as treatment. Journal of Psychosomatic Research. 48, 1-10. • Whooley, M.A., Avins, A.L., Miranda, J., & Browner, W.S. (1997). Case-finding instruments for depression. Two questions are as good as many. J. Gen. Intern. Med, 12, 439-445. • World Health Organization. (2000). Towards Unity for Health: Challenges and opportunities for partnership in health development.