1
|
Chavez B, Sullivan J, Portela P. Improving Adolescent Depression in Primary Care: A Quality Improvement Initiative. J Nurse Pract 2023; 19:104503. [PMID: 36721626 PMCID: PMC9881523 DOI: 10.1016/j.nurpra.2022.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The coronavirus disease 2019 pandemic has exacerbated and increased the prevalence of depression in adolescents. There is significant evidence supporting best practices for treating adolescent depression; yet, many adolescents remain unidentified or untreated by their primary care provider. For this quality improvement initiative, the Guidelines for Adolescent Depression in Primary Care (GLAD-PC) were implemented in a primary care setting. After GLAD-PC implementation, 90% of participants identified as having depression received an intervention compared with 60% of patients in the baseline group. The results showed that implementing GLAD-PC led to a significant increase in the treatment of adolescent depression in primary care.
Collapse
|
2
|
van Venrooij LT, Rusu V, Vermeiren RRJM, Koposov RA, Skokauskas N, Crone MR. Clinical decision support methods for children and youths with mental health disorders in primary care. Fam Pract 2022; 39:1135-1143. [PMID: 35656854 PMCID: PMC9680662 DOI: 10.1093/fampra/cmac051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Mental health disorders among children and youths are common and often have negative consequences for children, youths, and families if unrecognized and untreated. With the goal of early recognition, primary care physicians (PCPs) play a significant role in the detection and referral of mental disorders. However, PCPs report several barriers related to confidence, knowledge, and interdisciplinary collaboration. Therefore, initiatives have been taken to assist PCPs in their clinical decision-making through clinical decision support methods (CDSMs). OBJECTIVES This review aimed to identify CDSMs in the literature and describe their functionalities and quality. METHODS In this review, a search strategy was performed to access all available studies in PubMed, PsychINFO, Embase, Web of Science, and COCHRANE using keywords. Studies that involved CDSMs for PCP clinical decision-making regarding psychosocial or psychiatric problems among children and youths (0-24 years old) were included. The search was conducted according to PRISMA-Protocols. RESULTS Of 1,294 studies identified, 25 were eligible for inclusion and varied in quality. Eighteen CDSMs were described. Fourteen studies described computer-based methods with decision support, focusing on self-help, probable diagnosis, and treatment suggestions. Nine studies described telecommunication methods, which offered support through interdisciplinary (video) calls. Two studies described CDSMs with a combination of components related to the two CDSM categories. CONCLUSION Easy-to-use CDSMs of good quality are valuable for advising PCPs on the detection and referral of children and youths with mental health disorders. However, valid multicentre research on a combination of computer-based methods and telecommunication is still needed.
Collapse
Affiliation(s)
- Lennard T van Venrooij
- Corresponding author: Department of Research and Education, Academic Center for Child and Youth Psychiatry, Curium-LUMC, Endegeesterstraatweg 27, Oegstgeest, 2342 AK, the Netherlands.
| | | | - Robert R J M Vermeiren
- Department of Research and Education, Academic Center for Child and Youth Psychiatry, Curium-LUMC, Oegstgeest, the Netherlands
- Youz, Parnassia Psychiatric Institute, the Hague, the Netherlands
| | - Roman A Koposov
- Regional Centre for Child and Youth Mental Health and Child Welfare, Northern Norway, UiT, The Arctic University of Norway, Tromsø, Norway
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - Norbert Skokauskas
- Regional Centre for Child and Youth Mental Health and Child Welfare, IPH, Faculty of Medicine and Health Sciences, NTNU, Trondheim, Norway
| | - Matty R Crone
- Department of Public Health and Primary Care, Leiden University Medical Center (LUMC), Leiden, the Netherlands
| |
Collapse
|
3
|
McLeigh JD, Malthaner L, Winebrenner C, Stone KE. Paediatric integrated care in the primary care setting: A scoping review of populations served, models used and outcomes measured. Child Care Health Dev 2022; 48:869-879. [PMID: 35288973 DOI: 10.1111/cch.13000] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 02/17/2022] [Accepted: 03/10/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Paediatric integrated care (PIC), which involves primary care and behavioural health clinicians working together with patients and families, has been promoted as a best practice in the provision of care. In this context, behavioural health includes behavioural elements in the care of mental health and substance abuse conditions, chronic illness and physical symptoms associated with stress, and addressing health behaviours. Models of and contexts in which PIC has been applied vary, as do the outcomes and measures used to determine its value. Thus, this study seeks to better understand (1) what paediatric subpopulations are receiving integrated care, (2) which models of PIC are being studied, (3) what PIC outcomes are being explored and what measures and strategies are being used to assess those outcomes, and (4) whether the various models are resulting in positive outcomes. These questions have significant policy and clinical implications, given current national- and state-level efforts aimed at promoting integrated health care. METHODS This study utilized Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews to identify relevant articles published between January 1994 and 30 June 2020. The search utilized three databases: PubMed, PsycInfo and CINAHL. A total of 28 articles met the eligibility criteria for inclusion. RESULTS Overall, acceptability of PIC appears to be high for patients and providers, with access, screening and engagement generally increasing. However, several gaps in the knowledge base on PIC were uncovered, and for some studies, ascertaining which models of integrated care were being implemented proved difficult. CONCLUSION PIC has the potential to improve access to and quality of behavioural health care, but more research is needed to understand what models of PIC prove most beneficial and which policies and conditions promote cost efficiency. Rigorous evaluation of patient outcomes, provider training, institutional buy-in and system-level changes are needed.
Collapse
Affiliation(s)
- Jill D McLeigh
- Children's Health, Rees-Jones Center for Foster Care Excellence, Dallas, Texas, USA.,Department of Epidemiology, Human Genetics, and Environmental Sciences, UT Health School of Public Health, Dallas Campus, Dallas, Texas, USA
| | - Lauren Malthaner
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UT Health School of Public Health, Dallas Campus, Dallas, Texas, USA
| | | | - Kimberly E Stone
- Children's Health, Rees-Jones Center for Foster Care Excellence, Dallas, Texas, USA.,University of Texas Southwestern Medical Center, Dallas, Texas, USA
| |
Collapse
|
4
|
Pfoh ER, Hohman JA, Alcorn K, Vakharia N, Rothberg MB. Linking Primary Care Patients to Mental Health Care via Behavioral Health Social Workers: A Stepped-Wedge Study. Psychiatr Serv 2022; 73:864-871. [PMID: 34991343 DOI: 10.1176/appi.ps.202100322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Demand for systematic linkage of patients to behavioral health care has increased because of the widespread implementation of depression screening. This study assessed the impact of deploying behavioral health social workers (BHSWs) in primary care on behavioral health visits for depression or anxiety. METHODS This quasi-experimental, stepped-wedge study included adults with a primary care visit between 2016 and 2019 at Cleveland Clinic, a large integrated health system. BHSWs were deployed in 40 practices between 2017 and 2019. Patients were allocated to a control group (diagnosed before BHSW deployment) and an intervention group (diagnosed after deployment). Data were collected on behavioral health visits (i.e., to therapists and psychiatrists) within 30 days of the diagnosis. Multilevel logistic regression models identified associations between BHSW deployment period and behavioral health visit, adjusted for demographic variables and clustering within each group. RESULTS Of 68,659 persons with a diagnosis, 21% had a depression diagnosis, 49% an anxiety diagnosis, and 31% both diagnoses. In the period after BHSW deployment, the proportion of patients with depression who had a behavioral health visit increased by 10 percentage points, of patients with anxiety by 9 percentage points, and of patients with both disorders by 11 percentage points. The adjusted odds of having a behavioral health visit was higher in the postdeployment period for patients with depression (adjusted odds ratio [AOR]=4.35, 95% confidence interval [CI]=3.50-5.41), anxiety (AOR=4.27, 95% CI=3.57-5.11), and both (AOR= 3.26, 95% CI=2.77-3.84). CONCLUSIONS Integration of BHSWs in primary care was associated with increased behavioral health visits.
Collapse
Affiliation(s)
- Elizabeth R Pfoh
- Center for Value-Based Care Research (Pfoh, Rothberg), Cleveland Clinic Community Care (Hohman, Vakharia), and Department of Psychology (Alcorn), Cleveland Clinic, Cleveland
| | - Jessica A Hohman
- Center for Value-Based Care Research (Pfoh, Rothberg), Cleveland Clinic Community Care (Hohman, Vakharia), and Department of Psychology (Alcorn), Cleveland Clinic, Cleveland
| | - Kathleen Alcorn
- Center for Value-Based Care Research (Pfoh, Rothberg), Cleveland Clinic Community Care (Hohman, Vakharia), and Department of Psychology (Alcorn), Cleveland Clinic, Cleveland
| | - Nirav Vakharia
- Center for Value-Based Care Research (Pfoh, Rothberg), Cleveland Clinic Community Care (Hohman, Vakharia), and Department of Psychology (Alcorn), Cleveland Clinic, Cleveland
| | - Michael B Rothberg
- Center for Value-Based Care Research (Pfoh, Rothberg), Cleveland Clinic Community Care (Hohman, Vakharia), and Department of Psychology (Alcorn), Cleveland Clinic, Cleveland
| |
Collapse
|
5
|
Blackmore MA, Patel UB, Stein D, Carleton KE, Ricketts SM, Ansari AM, Chung H. Collaborative Care for Low-Income Patients From Racial-Ethnic Minority Groups in Primary Care: Engagement and Clinical Outcomes. Psychiatr Serv 2022; 73:842-848. [PMID: 35139653 DOI: 10.1176/appi.ps.202000924] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess model impact and opportunities for improvement, this study examined collaborative care model (CoCM) engagement and clinical outcomes among low-income patients from racial-ethnic minority groups with depression and anxiety. METHODS Starting in 2015, the CoCM was implemented in seven primary care practices of an urban academic medical center serving patients from racial-ethnic minority backgrounds, predominantly Medicaid beneficiaries. Eligible individuals scored positive for depressive or anxiety symptoms (or both) on the Patient Health Questionnaire-2 (PHQ-2) and PHQ-9 and the Generalized Anxiety Disorder Scale-2 (GAD-2) and GAD-7 during systematic screening in primary care settings. Screening rates and yield, patient characteristics, and CoCM engagement and outcomes were examined. Clinical improvement was measured by the difference in PHQ-9 and GAD-7 scores at baseline and at 10-to-14-week follow-up. RESULTS High rates of screening (87%, N=88,236 of 101,091) and identification of individuals with depression or anxiety (13%, N=11,886) were observed, and 58% of 3,957 patients who engaged in minimally adequate CoCM treatment had significant clinical improvement. Nevertheless, only 56% of eligible patients engaged in the model, and 25% of those individuals did not return for at least one follow-up appointment. Being female with clinically significant comorbid anxiety and depressive symptoms and having Medicaid or commercial insurance increased the likelihood of CoCM engagement. CONCLUSIONS CoCM can help engage vulnerable patients in behavioral health care and improve clinical symptoms. However, significant opportunity exists to advance the model's impact in treating depressive and anxiety disorders and decreasing health disparities by addressing engagement barriers.
Collapse
Affiliation(s)
- Michelle A Blackmore
- Montefiore Care Management Organization (Blackmore, Ricketts), Einstein College of Medicine (Patel, Chung), and Montefiore Medical Group (Ansari), Montefiore Health System, Yonkers, New York; CareMount Medical, Population Health (Stein), and Mantra Health (Carleton), New York City
| | - Urvashi B Patel
- Montefiore Care Management Organization (Blackmore, Ricketts), Einstein College of Medicine (Patel, Chung), and Montefiore Medical Group (Ansari), Montefiore Health System, Yonkers, New York; CareMount Medical, Population Health (Stein), and Mantra Health (Carleton), New York City
| | - Dana Stein
- Montefiore Care Management Organization (Blackmore, Ricketts), Einstein College of Medicine (Patel, Chung), and Montefiore Medical Group (Ansari), Montefiore Health System, Yonkers, New York; CareMount Medical, Population Health (Stein), and Mantra Health (Carleton), New York City
| | - Kelly E Carleton
- Montefiore Care Management Organization (Blackmore, Ricketts), Einstein College of Medicine (Patel, Chung), and Montefiore Medical Group (Ansari), Montefiore Health System, Yonkers, New York; CareMount Medical, Population Health (Stein), and Mantra Health (Carleton), New York City
| | - Sarah M Ricketts
- Montefiore Care Management Organization (Blackmore, Ricketts), Einstein College of Medicine (Patel, Chung), and Montefiore Medical Group (Ansari), Montefiore Health System, Yonkers, New York; CareMount Medical, Population Health (Stein), and Mantra Health (Carleton), New York City
| | - Asif M Ansari
- Montefiore Care Management Organization (Blackmore, Ricketts), Einstein College of Medicine (Patel, Chung), and Montefiore Medical Group (Ansari), Montefiore Health System, Yonkers, New York; CareMount Medical, Population Health (Stein), and Mantra Health (Carleton), New York City
| | - Henry Chung
- Montefiore Care Management Organization (Blackmore, Ricketts), Einstein College of Medicine (Patel, Chung), and Montefiore Medical Group (Ansari), Montefiore Health System, Yonkers, New York; CareMount Medical, Population Health (Stein), and Mantra Health (Carleton), New York City
| |
Collapse
|
6
|
Sarakbi D, Groll D, Tranmer J, Sears K. Achieving Quality Integrated Care for Adolescent Depression: A Scoping Review. J Prim Care Community Health 2022; 13:21501319221131684. [PMID: 36345229 PMCID: PMC9647275 DOI: 10.1177/21501319221131684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Introduction: While primary care is often the first point of contact for adolescents with
depression, more than half of depressed adolescents are either untreated or
undertreated. A scoping review had been completed to summarize approaches
for achieving quality integrated care in primary care focused on adolescent
depression. Methods: The scoping review followed the methodological framework for scoping studies
from Arksey and O’Malley. Articles were grouped into themes and mapped to 6
quality domains for integrated care from the practice integration profile
survey and 3 levels of stakeholders based on WHO’s definition for health
systems (patient/family, primary care team, and national/sub-national health
system). Results: A total of 868 records were screened resulting in 22 articles at the
patient/family-level (5/22), the primary care team-level (18/22), and the
national/sub-national health system-level (16/22). The results highlighted
multilevel approaches to support the delivery of quality integrated care for
adolescent depression in primary care: (1) population-focused using patient
registries, routine screening based on standardized algorithms, and
patient-centered strategies, (2) team-driven where primary care clinicians
collaborate with mental health clinicians as part of a primary care team,
(3) evidence-based delivery of mental health services across the integrated
care pathway from screening to follow-up visits, and (4) measurement-guided
by leveraging the electronic health record infrastructure to learn from
patient outcomes. Conclusion: More research is needed on how to provide quality integrated care for
adolescent depression, specifically on patient engagement and retention,
grounded in the frontline experiences of patients, families, and clinicians
and supported by national and/or sub-national guidelines. A learning system
could help integrate mental health services in primary care in a way that is
consistent across the national and/or sub-national health system.
Collapse
Affiliation(s)
| | | | | | - Kim Sears
- Queen’s University, Kingston, ON, Canada
| |
Collapse
|
7
|
Gorman DC, Ham SA, Staab EM, Vinci LM, Laiteerapong N. Medical Assistant Protocol Improves Disparities in Depression Screening Rates. Am J Prev Med 2021; 61:692-700. [PMID: 34284914 PMCID: PMC8627913 DOI: 10.1016/j.amepre.2021.05.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 04/16/2021] [Accepted: 05/05/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Depression is a prevalent condition for which screening rates remain low and disparities in screening exist. This study examines the impacts of a medical assistant screening protocol on the rates of depression screening, overall and by sociodemographic groups, in a primary care setting. METHODS Between September 2016 and August 2018, a quasi-experimental study of adult primary care visits was conducted at an urban academic clinic to ascertain the change in the rates of completion of the Patient Health Questionnaire-2 after the implementation of a medical assistant protocol (intervention) versus that of physician-only screening (control arm). Analyses were conducted between April 2019 and April 2020 and used interrupted time-series models with generalized estimating equations. RESULTS A total of 45,157 visits by 21,377 unique patients were included. Overall, screening increased from 18% (physician-only screening) to 57% (medical assistant protocol) (p<0.0001). Screening increased for all measured demographics. With physician screening, depression screening was less likely to occur at visits by women (than at visits by men; OR=0.91, 95% CI=0.85, 0.98) and at visits by Black/African American patients (than at visits by White; OR=0.91, 95% CI=0.84, 0.99). However, with the medical assistant protocol, depression screening was more likely to occur at visits by women (than at visits by men; OR=1.07, 95% CI=1.0002, 1.14) and at visits by Black/African American patients (than at visits by White; OR=1.11, 95% CI=1.02, 1.20). In addition, age-related disparities were mitigated for visits by patients aged 40-64 and ≥65 years (e.g., age ≥65 years: physician, OR=0.66, 95% CI=0.59, 0.73; medical assistant protocol, OR=0.78, 95% CI=0.71, 0.85), compared with visits by patients aged 18-39 years. CONCLUSIONS Implementation of a medical assistant protocol in a primary care setting may significantly increase depression screening rates while mitigating or removing sociodemographic disparities.
Collapse
Affiliation(s)
- Deirdre C Gorman
- Pritzker School of Medicine, The University of Chicago, Chicago, Illinois
| | - Sandra A Ham
- Center for Health and The Social Sciences, The University of Chicago, Chicago, Illinois
| | - Erin M Staab
- Department of Medicine, The University of Chicago, Chicago, Illinois
| | - Lisa M Vinci
- Department of Medicine, The University of Chicago, Chicago, Illinois
| | - Neda Laiteerapong
- Department of Medicine, The University of Chicago, Chicago, Illinois.
| |
Collapse
|