Adolescent Depression Screening O C T O B E R 7 , 2 0 1 5 S H R - - PowerPoint PPT Presentation

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Adolescent Depression Screening O C T O B E R 7 , 2 0 1 5 S H R - - PowerPoint PPT Presentation

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Adolescent Depression Screening O C T O B E R 7 , 2 0 1 5 S H R I N E R S H O S P I T A L F O R C H I L D R E N 1 3 1 0 P U N A H O U S T . H O N O L U L U , H I 9 6 8 2 6 /. Disclosures There are no relevant financial or

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Adolescent Depression Screening

O C T O B E R 7 , 2 0 1 5 S H R I N E R S H O S P I T A L F O R C H I L D R E N 1 3 1 0 P U N A H O U S T . H O N O L U L U , H I 9 6 8 2 6

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Disclosures

There are no relevant financial

  • r nonfinancial relationships in

the tools or services described, reviewed, evaluated or compared in this presentation.

Development of this material is supported in part by HMSA and grants administered by the U.S. Department

  • f Health and Human Services,

Maternal and Child Health Bureau.

This work is licensed under the Creative Commons Attribution‐ NonCommercial‐ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by‐nc‐sa/4.0

10/7/2015

/.

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Screening

Annual depression screening 12‐21 years of age Validated tool

  • Reliability (consistent results)
  • Validated (true results)
  • Sensitivity (probability of correctly identifying condition)
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DSM 5 Major Depressive Episode

> 5 Symptoms during same 2 week period that is a change from previous functioning:

1. Depressed mood 2. Markedly diminished interest or pleasure 3. Loss of appetite & weight 4. Insomnia, hypersomnia 5. Fatigue, loss of energy 6. Psychomotor retardation or agitation 7. Low‐self esteem or guilt 8. Diminished ability to think or concentrate 9. Recurrent thoughts of death, suicidal ideation

Results in distress or disability Not due to a substance or medical condition

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Depression in Children & Adolescents 2009

“The USPSTF recommends screening of adolescents (12‐18 years of age) for major depressive disorder (MDD) when systems are in place to ensure accurate diagnosis, psychotherapy (cognitive‐behavioral or interpersonal), and follow‐up.” Draft revision 2015

  • “when adequate systems are in place for diagnosis, treatment, and

monitoring.” http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStat ementFinal/depression‐in‐children‐and‐adolescents‐screening

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2015 AAP Periodicity Schedule

11 y

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Why Screen?

Significant adolescent issue Bright Futures & USPSTF Recommendation Affordable Care Act Health Plan Benefit Queen’s Clinically Integrated Physician Network (QCIPN) Year 2 pediatric metric

  • 1000 screenings by July 1, 2016

Mahie 2020: HMSA Payment Transformation

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Validated Screening Tools 1

Center for Epidemilogic Studies Depression Scale

  • http://cesd‐r.com

Mood and Feelings Questionnaire

  • http://devepi.mc.duke.edu/mfq.html

PHQ‐2

  • http://www.cqaimh.org/pdf/tool_phq2.pdf

PHQ‐A

  • http://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_

DSM5_Severity‐Measure‐For‐Depression‐Child‐Age‐11‐to‐17.pdf

  • http://www.ncfhp.org/Data/Sites/1/phq‐a.pdf
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Validated Screening Tools 2

PHQ‐9 http://www.integration.samhsa.gov/images/res/PHQ%20‐ %20Questions.pdf http://impact‐uw.org/tools/phq9.html 88% Sensitivity 88% Specificity DSM‐IV

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PHQ‐9

Over the last 2 weeks, how often have you been bothered by any of the following problems? 0 = Not At all 1 = Several Days 2 = More Than Half the Days 3 = Nearly Every Day How difficult have those problems made it for you to do your wok, take care of things at home, or get along with other people? Not difficult Somewhat difficult Very difficult Extremely difficult

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Scoring PHQ‐9

Questions 1‐9

  • > 5 scored in shaded area
  • 2 = More than Half the Days or
  • 3 = Nearly Every Day

Questions 1 or 2 required Question 9:

  • 1= several days
  • or 2 or 3
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Scoring PHQ‐9

Question 10 Add total points = Severity Score

X X X

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PHQ‐9 Severity Score

PROVISIONAL DIAGNOSIS 1‐4 Minimal 5‐9 Mild 10‐14 Moderate 15‐19 Moderately severe 20‐27 Severe ACTION 1‐9 Support, educate, call if worse, fu 1 month > 10 Psychotherapy and/or antidepressant

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Android & iPhone app

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PHQ‐A

10/8/2015

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PHQ‐9 or PHQ‐A?

PHQ‐9

1. Little interest or please in doing things 2. Feeling down, depressed or hopeless 3. Trouble falling or staying asleep, or sleeping too much 4. Feeling tired or having little energy 5. Poor appetite 6. Feeling bad about yourself‐or that you are a failure or have let yourself

  • r your family down

PHQ‐A

1. Feeling down, depressed, irritable,

  • r hopeless?

2. Little interest or pleasure in doing things? 3. Trouble falling asleep, staying asleep

  • r sleeping too much?

4. Poor appetite, weight loss or

  • vereating?

5. Feeling tired, or having little energy? 6. Feeling bad bout yourself‐or feeling that you are a failure, or that you have let yourself or your family down?

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PHQ‐9 or PHQ‐A?

PHQ‐9

7. Trouble concentrating on things, such as reading the newspaper

  • r watching television

8. Moving or speaking so slowly that other people could have noticed? Or the opposite‐being so fidgety or restless that you have been moving around a lot more than usual 9. Thoughts that you would be better off dead or hurting yourself in some way

PHQ‐A

7. Trouble concentrating on things like school work, reading or watching TV? 8. Moving or speaking so slowly that other people could have noticed? Or the opposite‐being so fidgety or restless that you were moving around a lot more than usual? 9. Thoughts that you would be better off dead, or of hurting yourself in some way?

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PHQ‐9 or PHQ‐A?

PHQ‐9 If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? PHQ‐A

In the past year have you felt depressed

  • r sad most days, even if you felt okay

sometimes? If you are experience any of these problems on this form, , how difficult have these problems made it for you to do your work, take care of things at home or get along with other people? Have there been a time in the past month when you have had serious thoughts about ending your life? Have you EVER, in your whole life, tried to kill yourself or made a suicide attempt?

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Introduction to the screen

Many middle‐schoolers and high schoolers report being under stress. Sometimes stress may affect how you feel. Please fill out this form that will help us understand how you are dealing with the stresses you face.

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Tracking / Billing

Screening for Depression

  • ICD‐9: V79.0

Screening for other condition

  • ICD‐10: Z13.89

CPT: 96127

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99401 – 99404: Not depression screening codes

Counseling risk factor reduction and Behavioral change intervention services for the purpose of promoting health and preventing illness Provided at a separate encounter where the patient came in only for this preventive counseling and has no health issues.

  • E.g. Family problems, diet, exercise

99401 = 15” 99402 = 30” 99403 = 45” 99404 = 60”

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99420: Not depression screening code

Administration and interpretation of Health Risk Assessment instruments

  • Lead Risk assessment
  • Tb exposure assessment
  • Edinburgh Postnatal Depression Scale when reported under baby’s claim
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Screen is +: ICD‐10

F32.0 ‐ Major depressive disorder, single episode, mild F32.1 ‐ Major depressive disorder, single episode, moderate F32.2 ‐ Major depressive disorder, single episode, severe without psychotic features F32.3 ‐ Major depressive disorder, single episode, severe with psychotic features

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Screen is +: ICD‐10

F32.8 ‐ Other depressive episodes F32.9 ‐ Major depressive disorder, single episode, unspecified F43.21(Adjustment disorder with depressed mood) F06.31 ‐ Mood disorder due to known physiological condition with depressive features F06.32 ‐ Mood disorder due to known physiological condition with major depressive‐like episode

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Is this youth positive or negative for the screen? Why or Why not?

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PHQ‐9 Severity Score

PROVISIONAL DIAGNOSIS 1‐4 Minimal 5‐9 Mild 10‐14 Moderate 15‐19 Moderately severe 20‐27 Severe ACTION 1‐9 Support, educate, call if worse, fu 1 month > 10 Psychotherapy and/or antidepressant

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What is this youthʻs severity score? Is the youth positive or negative for major depressive episode? Why or Why not?

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PHQ‐9 Severity Score

PROVISIONAL DIAGNOSIS 1‐4 Minimal 5‐9 Mild 10‐14 Moderate 15‐19 Moderately severe 20‐27 Severe ACTION 1‐9 Support, educate, call if worse, fu 1 month > 10 Psychotherapy and/or antidepressant

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What is this youthʻs severity score? Is the youth positive or negative for major depressive episode? Why or Why not?

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PHQ‐9 Severity Score

PROVISIONAL DIAGNOSIS 1‐4 Minimal 5‐9 Mild 10‐14 Moderate 15‐19 Moderately severe 20‐27 Severe ACTION 1‐9 Support, educate, call if worse, fu 1 month > 10 Psychotherapy and/or antidepressant

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Now What Do I Do?

SCREENING IS POSITIVE, NOW WHAT?

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What To Do When

Score Severity Proposed Treatment Actions What Does That Look Like?

0‐4 None‐ minimal None None 5‐9 Mild Watchful waiting; repeat screen at follow‐up Normalize, discuss sleep, family, activities, consider counseling 10‐14 Moderate Treatment plan, consider counseling, follow‐up and/or pharmacotherapy Psychotherapy, consider medication 15‐19 Moderately Severe Active treatment with pharmacotherapy and/or psychotherapy Conduct safety assessment, consider crisis services, refer out 20‐27 Severe Immediate initiation of pharmacotherapy and, if severe impairment or poor response to therapy, expedited referral to a mental health specialist for psychotherapy and/or collaborative management

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And of Course...

Score Severity Action

“Yes” answer

  • n any suicide

question Immediate follow up

From Kroenke K, Spitzer RL, Psychiatric Annals 2002;32:509‐521 Committee on Substance Abuse (2011). Substance Use Screening, Brief Intervention, and Referral to Treatment for Pediatricians. Pediatrics 2011;128;e1330

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Things to Consider: Guiding Principles

Depression is a continuum To best optimize your resources, you must have a continuum of resources Not all professional organizations promote their members to the general community

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Things to Consider: Service System

Child/Youth

School Based Behavioral Health Child & Adolescent Mental Health Division Intensive Services FQHCs Community Providers

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Things to Consider: Financing

No Entitlement

Health Plan Network Providers – Commercial & QUEST Integration ‐ FQHCs

CAMHD

Moderate Severe‐Severe Mild‐Moderate + Risk Factors

Medicaid

Health Plan CAMHD

Public School

No Insurance Mild: Consider School Based Behavioral Health

Is There an Entitlement?

Public School Medicaid

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Things to Consider: Referral Mechanism

Child/Youth

School Based Behavioral Health Child & Adolescent Mental Health Division Intensive Services FQHCs Community Providers General Referral Provider Match

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General Referral

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Entitlements

DOE

SBBH

School Counselor or Administrator

504 Accommodation

Student Services Coordinator or Administrator

DOH

Child and Adolescent Mental Health Division

SEBD – Support for Emotional and Behavioral Development Program Medicaid Juvenile Justice

Child/Youth

School Based Behavioral Health Child & Adolescent Mental Health Division Intensive Services

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FQHCs

Sliding Fee Scale Typically Training Sites Geographically Distributed

Kalihi‐Pālama Behavioral Health Kōkua Kalihi Valley Koʻolauloa Community Health and Wellness Center Waiʻanae Coast Comprehensive Health Center Waikīkī Health Center Youth Outreach Teen Clinic Waimanalo Health Center

Child/Youth

FQHCs

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Provider Match

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Community Providers

Therapeutic Interventions Provider Preferences Provider Availability

Child/Youth

Community Providers

  • Health Plan

Network

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Therapeutic Interventions

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Depressive or Withdrawn Behaviors

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Assess Existing Referral Network

Do I have a list more than 5 providers long? Am I aware of the therapeutic interventions offered? Am I aware of their expertise and preferred age range? Are my psychiatrists first line who arrange for psychotherapy with

  • ther providers?

Are my psychiatrists more inclined to wait 3 months and see how “therapy goes” before being introduced to the youth, let alone the discussion of medication? Whoʻs my support for curbside consults? How successful have I been in accessing health plan provider resources to identify available providers?

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Starting Somewhere

1,550

  • PsyD
  • PhD
  • LCSW
  • MFT
  • MHC

235

  • Psychiatrists

HMSA Provider Registy – Oʻahu # of Service Locations by Type

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HELP!

FOR YOU TO HELP YOUR PATIENTS

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HELP 1: Hawaii Psychological Association

http://hawaiipsychology.org/

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HELP 2: PMAG PCMH

Kapili Kōkua

Hawaiʻi Integrated Care Model @ PMAG Care Coordinators

  • Michelle Quensell
  • mquensell@pqhhawaii.com
  • Becca Hartman
  • rhartman@pqhhawaii.com
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HELP! 3: QCIPN

691‐7735 Erica Hoapili, clinical care associate 691‐4053 fax QCIPN Referral Form

  • http://queenscipn.org/images/OtherHelpfulDocs/ClinicalTeamReferralForm_

2015.pdf

QCIPN Website

  • http://queenscipn.org/cipn‐contact‐us
  • Clinical Care Coordination

HealtheNet

  • QCIPN Clinical Care Coordination
  • Social Work tab
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Fax 691‐4053 QCIPN Referral Form

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HELP! 4: HMSA

Beacon Health Strategies http://www.hmsa.com/PORTAL/PROVIDER/FM.Substance_Abuse_Refer ral_Form.pdf 695‐7700, 1‐855‐856‐0578, Fax 695‐7799 http://beaconhealthstrategies.com/pcp_toolkit/pcp_toolkit.aspx Psychiatric Decision Support Line

  • Discuss behavioral health issues such as psychopharmacology, treatment

alternatives and when to refer for psychiatric assessment

  • Telephone:

808‐695‐7700 / 1‐855‐856‐0578

  • Fax: 1‐808‐695‐7799
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http://www2.aap.org/commpeds/ dochs/mentalhealth/keyResource s.html

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Evidence‐Based Psychosocial Interventions

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https://www.aap.org/en ‐ us/Documents/CRPsych

  • socialInterventions.pdf

https://www.aap.org/en‐ us/advocacy‐and‐policy/aap‐ health‐initiatives/Mental‐ Health/Pages/Primary‐Care‐ Tools.aspx

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References

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2016 Quality Improvement Plan

Can I routinely screen 12‐21 years olds annually for Depression?

  • Validated tool
  • Office Flow
  • Billing
  • Tracking

Can I diagnosis & treat depression? Do I have an adequate referral list?

  • Psychiatrists
  • Psychologists

Can I track referrals? Do I receive consult reports? Is my patient improved?

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QI Plan Preparation

October – November 2015

  • Choose Validated Screener and photocopy
  • Office work flow
  • Set up Tracking / Data software
  • Referral process and tracking
  • Begin QI Write‐up
  • Staff Training: 10/27/15 @ 1230 Webinar
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Tracking/Data Spreadsheet

PCP Followup Psychiatry Psychology Agency Other

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QI Plan Cycle #1

December 2015 2 weeks:

  • 1 screeners /day Any HMSA patient aged 12‐21
  • Review success of implementation & results
  • Any +’s?
  • Referral?
  • Tracking?
  • Submit data sheet to Ka Huliau via Wufoo Form
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QI Plan Cycle #2

January 2016

  • 2 weeks
  • 2 screeners /day for any patient 12‐21 years of age
  • Review success of implementation & results
  • Any +’s?
  • Referral?
  • Tracking?
  • Submit data sheet to Ka Huliau
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QI Plan Cycle #3

January 2016

  • 2 weeks
  • 4 screeners /day for any patient 12‐21 years of age
  • Review success of implementation & results
  • Any +’s?
  • Referral?
  • Tracking?
  • Submit data sheet to Ka Huliau
  • Finish QI Write‐up
  • Routine screening of all patients 12‐21 years of age
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Staff Engagement/Training #1

  • December 2015
  • Office meeting for Staff Quiz facilitated by PCP
  • http://www.webmd.com/depression/rm‐quiz‐depression‐tmp
  • $10 Gift card/participant
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http://www.webmd.com/depressi

  • n/rm‐quiz‐depression‐tmp
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Staff Engagement/Training #2

  • January 2016
  • Office meeting for Staff Quiz facilitated by PCP
  • https://www.lifeline.org.au/Content/Default.aspx?PackageID=17
  • $10 Gift card/participant
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https://www.lifeline.org.au/Content/Default.aspx?PackageID=17

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Staff Engagement/Training #3

  • January 2016
  • Office meeting for Staff Quiz facilitated by PCP
  • http://www.medicinenet.com/happiness_quiz/quiz.htm
  • $10 Gift card/participant
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http://www.m edicinenet.co m/happiness_ quiz/quiz.htm

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References

Ader, J. “The Medical Home and Integrated Behavioral Health: Advancing the Policy Agenda”, Pediatrics, 135 (5) May 2015, 1‐9 Weitzman, C. “Promoting Optimal Development: Screening for Behavioral and Emotional Problems”, Pediatrics 2015;135:384‐395 “Policy Statement‐The Future of Pediatrics: Mental Health Competencies for Pediatric Primary Care” Pediatrics 2009: 124; 411‐ 421. Southammakosane, C., “Pediatric Psychopharmacology for Treatment of ADHD, Depression, and Anxiety”, Pediatrics 136(2) August 2015; 351‐ 359