Universal Depression Screen of Ambulatory Heart Transplant Recipients With Referral for Mental Health Intervention: A Quality Improvement Project

A Quality Improvement Project on Team-Based Care for Depression Screening Before and During the COVID-19 Pandemic in a Specialty Clinic

BACKGROUND

Depression screening is an important first step to identifying patients who might benefit from depression treatment. Merit-based incentive payment system (MIPS) quality measures can yield financial benefits or losses for healthcare systems, including depression screening.

OBJECTIVES

This study aims to (1) develop a team-based care workflow to improve MIPS depression screening in a specialty clinic and (2) modify the workflow to include a virtual nursing and behavioral health resource after the COVID-19 pandemic hit.

METHODS

A quality improvement project, utilizing Lean Six Sigma process improvement methods, was implemented to improve team-based depression screening in a specialty clinic. A multidisciplinary team implemented plan-do-study-act cycles, created educational materials tailored to each role, developed electronic medical record (EMR) tools to alert and assist team members in screening, and ensured the EMR aligned with the MIPS criteria. The percentage of eligible visits where depression screening was performed was analyzed across four study periods: pre-intervention, post-intervention, COVID-19, and recovery. Recovery strategies included developing telehealth workflows, establishing centralized registered nurse triage groups, and using phone-based triage and support resources at virtual visits.

RESULTS

Utilizing team-based strategy and available or newly developed tools, the percentage of eligible visits with completed depression screening was as follows: 1.4% pre-intervention, 58.2% post-intervention, 3.5% COVID-19, and 64.0% recovery. With the COVID-19 pandemic outbreak, initially, improved screening performance declined sharply. Recovery was achieved through the revision of workflows, team members, and support tools.

CONCLUSIONS

A team-based care approach can successfully improve and maintain depression screening in a specialty clinic and was versatile enough to be readapted to virtual visits during the COVID-19 pandemic. In addition to impacting MIPS quality incentives, the depression screening workflows described in this article can be adapted to other uses, including virtual and in-person visits and in other specialty or chronic disease settings.

An "Engage to Sustain" Intervention to Improve Process Performance Measures in Ambulatory Care

In ambulatory care, monitoring process performance measures (PPMs) is essential to meet regulatory requirements, establish targets for care, seek reimbursement, and evaluate patient care responsibilities. We implemented a comprehensive program, "Engage to Sustain," for licensed practical nurses (LPNs) and certified medical assistants (CMAs) to practice at the top of their licensure/certification. Screening rates for 4 key PPMs (depression screening, fall risk screening, and tobacco use screening and counseling) markedly increased following this intervention across 18 ambulatory departments with more than 2 million patient visits. These results suggest that shifting responsibilities for patient screening from physicians and advanced practitioners to LPNs and CMAs may improve screening rates.

ACLP Best Practice Guidance: Evaluation and Treatment of Depression in Solid Organ Transplant Recipients

We present Academy of Consultation Liaison Psychiatry best practice guidance on depression in solid organ transplant (SOT) recipients, which resulted from the collaboration of Academy of Consultation Liaison Psychiatry's transplant psychiatry special interest group and Guidelines and Evidence-Based Medicine Subcommittee. Depression (which in the transplant setting may designate depressive symptoms or depressive disorders) is a frequent problem among SOT recipients. Following a structured literature review and consensus process, the Academy of Consultation Liaison Psychiatry transplant psychiatry special interest group proposes recommendations for practice: all organ transplant recipients should be screened routinely for depression. When applicable, positive screening should prompt communication with the mental health treating provider or a clinical evaluation. If the evaluation leads to a diagnosis of depressive disorder, treatment should be recommended and offered. The recommendation for psychotherapy should consider the physical and cognitive ability of the patient to maximize benefit. The first-line antidepressants of choice are escitalopram, sertraline, and mirtazapine. Treating depressive disorders prior to transplantation is recommended to prevent posttransplant depression. Future research should address the mechanism by which transplant patients develop depressive disorders, the efficacy and feasibility of treatment interventions (both pharmacological and psychotherapeutic, in person and via telemedicine), and the resources available to transplant patients for mental health care.

Prevalence and characterization of frailty, depression, and cognitive impairment in patients listed for heart transplantation: Results of the FELICITAR prospective registry

INTRODUCTION

It is recommended to assess frailty prior to heart transplantation (HT). Our objective was to assess the prevalence of frailty in patients listed for HT.

METHODS

The FELICITAR registry (Frailty Evaluation after List Inclusion, Characteristics and Influence on TrAnsplantation And Results) is a prospective registry that includes patients listed for HT in three centers, from January 2017 to April 2019. We assessed the presence of frailty, depression, cognitive impairment, and quality of life when included.

RESULTS

Ninety-nine patients were included. Of this group, 30.6% were frail, 55 (56.1%) had depression (treated only in nine patients), and 51 (54.8%) had cognitive impairment. Compared with non-frail patients, frail patients were more frequently hospitalized when included in HT waiting list (P = .048), had a lower upper-arm circumference (P = .026), had a lower Barthel index (P = .001), more anemia (P = .010), higher rates of depression (P = .001), poorer quality of life (P = .001), and lower hand-grip strength (P < .001). In multivariate analysis hand-grip strength (odds ratio .91; 95% confidence interval .87-.96, P < .001) and Barthel index (odds ratio .90; 95% confidence interval .82-.99, P = .024) were associated with frailty.

CONCLUSIONS

Frailty, depression, and cognitive impairment are common in patients included in HT waiting list. Frailty is strongly associated with hand-grip strength.