310522
Medical home care team optimization to integrate mental/behavioral health in primary care
Methods: Care teams are encouraged to incorporate the PHQ-9 into intake procedures to assess patients for symptoms of depression. Primary care providers are encouraged, per their discretion, to refer patients with PHQ-9 scores >10 to co-located behavioral health (BH) services including community health worker (CHW) depression care management, counseling by a licensed clinical social worker (LCSW), or psychiatrist evaluation. The BH team reviews care plans, educates patients about depression, promotes self-management including behavioral activation, and offers psychotherapy or group peer support as indicated. A lifestyle health coach is also available for tailored counseling on healthy eating, physical activity, and self-monitoring tools for chronic medical conditions. We used descriptive statistics to examine care team adoption of collaborative care strategies and identify patients who may benefit most from the services.
Results: Among 6324 patients seen over 18-months, 12.6% (n=797) were administered the PHQ-9. Seventy-one percent (n=562) of these patients had symptoms of depression (PHQ-9>10). Among patients with depression symptoms, only 4% (n=25) were referred to the CHW for depression care management and 23% (n=131) were referred to a LCSW/psychiatrist. The majority of patients referred to a LCSW/psychiatrist had an average PHQ-9 score of 19 and kept their appointments (81%). Sixty-five percent (n=365) of patients with PHQ-9 scores >10 had a diagnosis of depression. PHQ-9 scores >10 were prevalent among patients who are overweight/obese, 71% (n=399); hypertensive, 39% (n=221); or diabetic, 16% (n=90). Among the hypertensive patients, 57% (n=127) had blood pressures >140/90. Among diabetics, 48% (n=43) had A1C levels >8. Only 8 patients with depression symptoms and chronic conditions were referred for lifestyle health coaching.
Conclusions: Patients with co-morbid depression and medical conditions were likely underdiagnosed. PCPs referred patients with severe symptoms to the LCSW/psychiatrists and underutilized care management and health coaching. We now use the PHQ-2 as a vital sign followed by PHQ-9 if indicated. Clinical decision support tools are needed to risk stratify patients by symptom severity and co-morbid disease control and to prompt PCPs to utilize BH team members to optimize care plans.
Learning Areas:
Chronic disease management and preventionLearning Objectives:
Assess care team adoption of collaborative care strategies for patients with co-morbid depression and chronic physical conditions
Describe lessons learned to improve care integration
Keyword(s): Chronic Disease Management and Care, Community Health Centers
Qualified on the content I am responsible for because: I am a General Internist and health services researcher with a focus on disease risk reduction, patient-centered medical home models of care, and use of health information technology to optimize care and reduce health disparities. I have eight years of experience in health administration and health service delivery re-design. I am principal investigator or co-investigator on a number of private foundation and federally funded research grants
Any relevant financial relationships? No
I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.