142nd APHA Annual Meeting and Exposition

Annual Meeting Recordings are now available for purchase

310522
Medical home care team optimization to integrate mental/behavioral health in primary care

142nd APHA Annual Meeting and Exposition (November 15 - November 19, 2014): http://www.apha.org/events-and-meetings/annual
Monday, November 17, 2014

Eboni Price-Haywood, MD, MPH , Dept Research & Internal Medicine, Ochsner Health System, New Orleans, LA
Donisha Dunn, MD , Medicine, Tulane University School of Medicine, New Orleans, LA
Jewel Harden-Barrios, MEd , Medicine, Tulane University School of Medicine, New Orleans, LA
Background: Research shows that collaborative care for patients with depression and chronic medical conditions (e.g. hypertension, diabetes) improves disease control; however, depression care alone does not improve these conditions. We implemented a collaborative care model to integrate primary care and mental/behavioral health in a level 3, safety-net, patient-centered medical home. We assess care team adoption of collaborative care strategies and describe lessons learned to improve care integration.

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 prevention

Learning 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

Presenting author's disclosure statement:

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.