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2012 MFMER | slide-1 EMERALD A pilot collaborative program in primary care for teens with depression May 1, Minneapolis Hot Topics in Pediatrics Mark Williams, MD

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2012 MFMER | slide-2 Disclosures Nothing to disclose

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2012 MFMER | slide-3 Objectives Describe what changed in care delivery with EMERALD at a pediatric clinic Review outcomes and reasons why this model has been so popular

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2012 MFMER | slide-4 Outline Background Conceptualization of the model Implementation Outcomes Future directions

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2012 MFMER | slide-5 Primary Care at Mayo Three groups before (Rochester campus) Community Pediatrics Family Medicine Primary Care Internal Medicine Measures = Fee for Service Psychiatric care = consultation Currently (140,000 patients in PC panels) Employee and Community Health Improve quality and lower cost Integrated Behavioral Health

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2012 MFMER | slide-6 Integrated Behavioral Health Staff Psychiatrists Psychologists APRNs LICSW Nurses Charge Provide care and backup to PCP for their panels of 140,000 primary care patients (40,000 kids)

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2012 MFMER | slide-7 Look to translate evidence into practice Care coordination programs Adult depression (IMPACT model) DIAMOND program Adolescent depression (built on DIAMOND) EMERALD Adults with depression and diabetes and/or cardiovascular disease CMS grant built on model of TEAMcare Adult anxiety and depression CBT (CALM model) Adult addiction (SBIRT)

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2012 MFMER | slide-8 Change process for translating/developing a new model of care 1.Evidence of a need for a new approach Usual care data + Lack of existing success 2.Evidence of a better model Allows for a benchmark from research 3.Measurement tools available 4.Readiness for change Leadership ability to commit resources 5.Multiple stakeholders in steering process 6.Learning collaborative approach 7.Collect outcomes and learn from them Adapted from similar list from ICSI

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2012 MFMER | slide-9 Evidence of a need Need 14% of ages 13-18 in the US meet criteria for a mood disorder 40% of those individuals received no treatment Suicide is the third leading cause of death among adolescents Systemic challenges Short visits in primary care Difficult to attend to mood issues Insurance and stigma barriers to go to Psych Black box warnings Merikangas et al. Oct 2010 Costello EJ Mar 1, 2014

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2012 MFMER | slide-10 Looking for better ideas example in adult world Build it from what has been shown to work IMPACT model (2001) Adult depression care coordination Currently over 75 RCTs supporting better outcomes for this approach Institute for Clinical Systems Improvement (ICSI) Developed stakeholders group to implement this model in >80 clinics in MN starting 2008

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2012 MFMER | slide-11 Collaborative Care for Depression Key components of collaborative care model: 1.Screening and monitoring instrument PHQ-9 in adults PHQ-9M in adolescents 2.Systematic tracking and monitoring of patients Use of a registry 3.Care coordinator trained in motivational interviewing and about depression 4.Consulting psychiatrist consultation and caseload review

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2012 MFMER | slide-12 The DIAMOND Model Consistent with evidence on collaborative care: Four Processes: 1.Consistent assessment/monitoring (PHQ-9) 2.Presence of tracking system (registry) 3.Stepped care approach to intensify/modify treatment (supervision of care coordinators) 4.Relapse prevention Two Roles: 1.Care manager for follow up, support, coordination 2.Consulting psychiatrist for caseload review and recommendations

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2012 MFMER | slide-13 DIAMOND: From a Patient/Provider perspective Any patient meeting criteria Age 18 PCP diagnosed dysthymia or major depression Score on PHQ-9 of 10 or more Introduced to DIAMOND care manager Screen - alcoholism, anxiety, bipolar disorder Clinical scenario gathered along with past history Presented weekly to psychiatrist for recommendations. PCP writes all prescriptions, patient management

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2012 MFMER | slide-14 Collaborative care (DIAMOND) was better than practice as usual at 3 & 6 months Shippee et al. 2013 J Ambulatory Care Manage Vol. 36, No. 1, pp. 1323

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2012 MFMER | slide-15 What about adolescent depression? Richardson, McCauley & Katon Study (2009) IMPACT model applied to adolescent patients 49% of patients activated Average Age 15 74% of youth (12-18) had at least 50% reduction in symptoms at six months Baseline PHQ-9 mean (SD) versus final = 14 (4.5) vs. 5.7 (4.1)

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2012 MFMER | slide-16 EMERALD - Early Management and Evidence-based Recognition of Adolescents Living with Depression

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2012 MFMER | slide-17 EMERALD pilot team members: Requires a multidisciplinary effort Dr. Billings, MD pediatrician champion Dr. Huxsahl MD child psychiatrist Roxie Brennan, RN Care coordinator Denese Lecy desk coordinator Ellen Johnson, LICSW - psychotherapist Hannah Mulholland, LICSW - psychotherapist Isaac Johnson computer programer (for registry) Dr. Leffler, PhD child psychologist Angela Kaderlik, RN nursing leadership Whitney Votava quality office

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2012 MFMER | slide-18 Goals Operationalize a collaborative care model for adolescent depression management Satisfaction Improve provider confidence and satisfaction in managing adolescent depression Increase patient and parent/guardian satisfaction in the management of adolescent depression Identify, monitor, and treat depressed adolescents Develop a viable staffing model for dissemination

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2012 MFMER | slide-19 Process Interviewed family physicians and pediatricians on level of interest Reviewed examples of models in the literature Explored learnings from DIAMOND with pediatric champions and child psychiatry/psychology colleagues Regular meetings of multidisciplinary group to discuss option of new model Borrowed experienced care coordinator from DIAMOND with child psych background for pilot PDSA cycles on components of the model

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2012 MFMER | slide-20 Collaborative care model adapted Components IBH Care Coordinator (IBH CC) PCP (pediatrician) Adapted screening/monitoring tools Child and Adolescent Psychiatrist LICSW (Psychotherapy) Registry for tracking patients

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2012 MFMER | slide-21 Eligibility & Exclusion Criteria Adolescents Ages 13-17 or 18 years old and still in high school Paneled to Community pediatric providers Diagnosis of: Major Depression (296.2x or 296.3x) OR Dysthymic Disorder (300.4) Mood Disorder Depressive Mood PHQ-9 M than 10 Exclusion Criteria Bipolar Diagnosis

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2012 MFMER | slide-22 Tools for monitoring outcomes Depression PHQ-9M Anxiety SCAS-A and SCAS-P Substance abuse CRAFFT ADHD Vanderbilt Bipolar disorder MDQ-A

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2012 MFMER | slide-23 How it works for adolescent patients Six steps 1.Identification and referral 2.Linking up with the care coordinator 3.Intake process 4.Systematic Case Review 5.Care coordinator puts the plan in place 6.Continuos feedback cycle

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2012 MFMER | slide-24 Step one: Identification and referral Two pathways 1.Patient seen somewhere and found to have a PHQ-9M of 10 or more computer identification 2.Pediatrician visiting with a patient and suspects depression gives PHQ-9M and if score 10 or more, decides if this might be depression Discussion of options with the patient for next steps options include EMERALD

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2012 MFMER | slide-25 Step two: link with Care Coordinator Ideal option = warm handoff The patient meets the care coordinator in person while in the primary care clinic Either does an intake then (if time permits) Or, sets up a time to do the intake. Alternative option = phone contact or appointment The patient is given a time to meet with the care coordinator or is called for the intake

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2012 MFMER | slide-26 Step three: Intake process Care coordinator gathers information from the patient and the family Depression (PHQ-9M) Anxiety (SCAS-A and SCAS-P) Substance abuse (CRAFFT) ADHD (Vanderbilt) Bipolar disorder (MDQ-A) Also gathers information about the current life situation, past history, medical issues, meds

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2012 MFMER | slide-27 Step four: Systematic Case Review Weekly meeting with blocked time on both schedules (can be in person or by phone) Psychiatrist and RN review all new patients Also any ongoing patients in program Recommendations clarified Need for more information, referral needs and where, treatment suggestions Recommendations provided to PCP All scripts written by pediatrician

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2012 MFMER | slide-28 Step five: CC putting plan into place Contacts patient to review recommendations Is the patient open to these suggestions? Contacts PCP to review recommendations Starts process if orders needed Assists with scripts, etc. Motivational interviewing, set behavioral action goals, arrange for regular contact, monitor change Assists in linking patient up to resource needs

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2012 MFMER | slide-29 Step six: Continuous feedback cycle Care coordinator maintains patient contact Regular phone calls Face-to-face visits Updates to pediatrician and psychiatrist Adjusts the plan to the patient Tolerating/affording/taking the medication? Going to therapy is it helping? New stressors, etc.

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2012 MFMER | slide-30 Highlighting the importance of a registry All the patients of a care coordinator Psychiatrist can use the registry in weekly meetings Sort by the sickest patient Which person is not progressing? Also can sort by primary care provider Who is making referrals, How are my patients doing? Can ask questions about the program Are we efficient? Who does best/worst?

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2012 MFMER | slide-31 Outcomes (first 125 patients) Acceptance -patients 68% agree to participate Adolescent generally deciding to say no Those entering program initial dropout rate high (63%) Not returning calls most common graduated at time of evaluation (13 patients) 90% reduction in PHQ9M Using Intent to treat metrics (48 patients) 52% reduction in PHQ9M

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2012 MFMER | slide-32 PHQ-9M Total Scores *4 patients missing last PHQ-9M score (3 inactivated for no contact, 1 dropped out)

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2012 MFMER | slide-33 Number of Patients with Suicidal Thoughts in the Past Month *4 patients missing last PHQ-9M score (3 inactivated for no contact, 1 dropped out)

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2012 MFMER | slide-34 Provider Satisfaction & Confidence Comfort Diagnosing Depression in Adolescents

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2012 MFMER | slide-35 Satisfaction & Confidence comments Provider Satisfaction and Confidence Feeling that I can focus on my role as primary care pediatrician with regard to depression and differential diagnosis vs. having to 'manage' and coordinate the connections between family between visits Patient & Parent/Guardian Satisfaction The IBH case manager & MD truly were dedicated to my daughter's well being. This was displayed in every communication with us. Thanks for helping me & my daughter. Both were very knowledgeable about adolescent emotional/developmental stages

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2012 MFMER | slide-36 Staffing Model for Expansion Caseload Size 2012 tracking of workload data showed EMERALD patients take twice as much effort as DIAMOND patients 50 active patients 1.0 FTE IBH Care Coordinator 0.1 FTE Child & Adolescent Psychiatrist 0.2 FTE Pediatric Social Worker

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2012 MFMER | slide-37 Changes at the end of the pilot - 2013 Adolescent depression screening PHQ-9 M MNCM announcing plan to track this Increased attention to screening at well child visits Age Criteria - include 12 year olds Result of presentation to leadership spread to rest of primary care when resources available

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2012 MFMER | slide-38 Some of our lessons and questions Its difficult for care coordinators to reach patients by phone Wish for ability to use various media resources popular with adolescent patients. The additional family component in caring for an adolescent results in increased time commitment per patient compared to adults Attention to reasons for dropouts Would showing eligible patients and families results keep more in treatment? How does the model need to be tweaked for family medicine and rural areas?

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2012 MFMER | slide-39 Thanks to my IBH colleagues Questions?? Williams.mark@mayo.edu