oakland county health division nurse-family partnership ... · cycle 1 study summary 45% 44% 11%...

Oakland County Health Division Nurse-Family Partnership

Maternal Depression

Quality Improvement Team

Marcy Raska Program Coordinator/Supervisor

Leanora Gray Nurse Home Visitor

Sue Martinez Nurse Home Visitor

Katie Smedley Nurse Home Visitor

Angela Varela Nurse Home Visitor

Women

Enrolled in HV

Depression

Screen

Negative No referral

To mental

health services

Screen at

recommended

intervals and PRN

Positive score greater

than or equal to 10

Is she already

receiving EB MHS?

Yes

No

Referral

Rescreen

in 30 days

No

Is the client

receptive to

the MH

referral?

Yes

Refer to EB

mental Health

Services

Did she have her

1st contact with

MH provider?

No Is client receptive

to M & B course

provided by HV??

No

HV use MI techniques to

encourage client to

access services.

Yes

NHV delivers

M & B

session

during HV.

No

Investigate

reason why

client did not

Yes

Did she have

improve-

ment in

depression

symptoms?

No

Encourage

client to dis-

cuss follow up

with MH pro-

vider.

Yes

Improved

Maternal

Mental

Health

This point in the process needs

improvement. More women

can be receiving screening

within 3 months of enrollment.

Oakland NFP—Process Map for Maternal Depression Screening, Referral, and Treatment

112 women enrolled

83 women screened with-

in 3 months of enrollment

1 woman screened positive

1 woman with positive

screen not already receiving

EB services

0 woman had 1st

contact with provider

and improved

0 woman with positive screening referred to

services with a 1st contact

1 woman with positive

screen referred to EB

services

Baseline Data from Process Mapping

• 112 women enrolled September 2015 • 83 women screened within 3 months of enrollment • 1 woman screened positive • 1 woman with positive screen not already receiving EB

services • 1 women with positive screen referred to EB services • 0 women referred who had a 1st contact with a MH

provider • 0 women who had 1st contact with MH provider whose

symptoms improved (e.g. Screener score decreased)

Why our Team continued in the HV CoIIN…

Our experience working with the CoIIN study since May of 2014 has made an impact on how we approach our clients as a team. We have all discovered that all of our clients are engaging in more of an open dialogue to discuss their maternal depression. We have learned as a team how to integrate the PDSA process into our nursing practice as a way of looking at the data to see what improvements can be made. It is impacting the outcomes for our clients with each successful change that we implement. It has created a structure for us to use as a method of improvement. We are now able to measure the effectiveness of our interventions and make modifications based on data. It validated that are agency has many great practices in place and that our clients do have successful outcomes.

Change Package

Your Team Name: Oakland NFP

Topic Area: Maternal Depression

Name of the Intervention: if home visitors used Motivational Interviewing techniques to revisit screening results with mothers screening positive, will this create an open dialogue and cause some mothers to reconsider seeking treatment?

Primary Driver 3: Standardized processes for referral, treatment and follow up

Definition of the Intervention What is the intervention? Include a short definition of the intervention (1-2 sentences)

if home visitors used Motivational Interviewing techniques to revisit screening results with mothers screening positive, will this create an open dialogue and cause some mothers to reconsider seeking treatment?

Model for Improvement’s Three Fundamental Questions

What are we trying to accomplish?

• By January 2015 85% of Mothers who screened positive with a >9 on the Edinburgh and refused a behavioral health referral will be rescreened and provided with a subsequent referral if needed within 30 days.

How will we know that a change is an improvement?

• A greater number of clients will accept and follow up with their Physician or behavioral health referral for their elevated Edinburgh score. (% referrals offered that are accepted / acted on)

What changes can we make that will result in an improvement?

• A process will be standardized for all Nurse Home Visitors to use when the client refuses a referral on the initial Edinburgh assessment.

The team ran 3 consecutive Plan-Do-Study-Act (PDSA) Cycles,

each one incorporated the learning from the previous cycles to

make an adjustment to the intervention

PLAN Who will implement the change?

Nurse Home Visitors

When will this change happen?

November 17, 2014 to November 24, 2014

What will take place?

5 nurse home visitors identify 2 clients each who screened >9 & declined MH referral 30

days ago and will

•Create opportunity for open dialogue

•refer to a question client had difficulty with or scored with a concern.

•use one Motivational Interviewing (MI) technique in the home visit.

Where will this change occur? During home visits

Tasks/Tools Needed to Support the Change: Develop simple data collection tool: 3x5

index card

•Client name;

•Edinburgh Postnatal Screen (EPDS) Date & score;

•Question they re-assessed with the client;

• MI technique to be used;

•Client's impression;

•Nurse's impression.

Each nurse will fill in after HV & turn in to supervisor: expect 10 responses PREDICTION 100 % of women rescreened will engage in open dialogue about MH status. One or more

will access treatment options.

DO 5 Nurses carried out the test with 9 clients. There were no difficulties carrying out the test.

Oakland Cycle #1: Plan & Do

Client 1 2 3 4 5 6 7 8 9

NHV SM SM TW TW TW AV LG-2 LG-2 LG-1

Date EPDS 10/13/2014 10/29/2014

3/25/2014,

5/6/14,

11/19/14

6/24/14,

10/2/14

7/9/14, 8/14/14,

10/9/14

10/24/2014,

11/21/14 10/10/2014 9/19/2014 10/9/2014

EPDS Score 10 10 19,11,19 11,3 21, 8, 5 10,7 9 10 10

Question Discussed 3 4 6

9 4,5 8 8 10 5,3,6

MI Technique

Reframing

Scaling Question Reframing Reframing

Scaling Question Reframing Reframing Reframing Reframing

Client's Impression

Client was

given

numbers by

Dr. K,

tested at

hospital

and is good

now.

Doesn't

need

counseling

now.

Client accepted

mental health

provider, said

she will call for

appointment

Aware that she

is depressed

but doesn't

want

counseling

Sometimes

feels the same,

thinks she

would benefit

from

counseling but

has a high

copay that is

an issue

Continues to

feel anxious

Circumstances

are getting

better

Things are much

better now, was

stressed in

relation to baby

and finances

Feeling much

better now, was

feeling out of

control. Stress

related to

wanting to

move and

mother's

smoking.

Things are

better, able to

handle

situation.

Nurse's Impression

Client's

mood much

improved,

no

appointmen

t made but

will

monitor.

Client using

"change talk,"

planning to

make

appointment.

Client has

history of

emotional

illness and

would benefit

from

counseling

Client would

benefit from

counseling.

Stress is

situational,

helped by open

discussion.

Client has

some coping

skills but needs

evaluation.

Client has

appointment

with OB doctor,

will discuss

getting on

medication first

and then will

find a therapist.

Client has

some

situational

stressors in her

life that are

now improving.

Client states

she still has

PHN referral,

states a friend

has a therapist

she likes and

that she is

thinking about

calling that

therapist.

Situational

stress related

depression. 2nd

pregnancy,

communication

concerns with

FoC, Full Time

student, works 2

jobs

Situational vs.

endogenous

depression.

Client lives with

mother who

smokes in

home and

ignores client's

request to stop.

Client has

made progress

to secure

additional

housing,

pending

applications.

Working more

hours, not at

home to smell

smoke. Client

feels more in

control.

Referred to

services,

depression is

situational.

Open dialogue

with client was

positive. Client

lacks

transportation,

potential

barrier.

Oakland Cycle #1: STUDY

Cycle 1 Study summary

45%

44%

11% Improvement insymptoms

Active symptoms, awarethey are depressed &don't want counseling

Still depressed &anxious, ready to followup

• Our results show that we

did create an opportunity

for open dialogue.

• As we predicted, 100%

engaged in open dialogue

about depressive

symptoms and interest in

accessing support

services / activating a

referral increased.

• We learned that several of

our clients had situational

depression. 3/9. Due to a

life event or major change.

• The clients were receptive

to this approach.

ACT The team will do a second cycle with the same 9 clients, and we added new Motivational Interviewing questions:

1. How are you feeling now?

2. What are you doing to feel better?

3. If you are not feeling better, have you reconsidered following up with the referrals we discussed?

Oakland Cycle #1: Act


Nurse Home Visitors


12-1-14 to 12-24-14,

Study will happen at a team meeting on Monday, January 26, 2015


Each of the 5 nurse home visitors will create a second opportunity for an open

discussion with the same 9 clients’ who declined a mental health referral 30

days ago and reassess at this subsequent Home visit. They will ask the client 3

additional questions and again use one MI technique in the home visit.


Tasks/Tools Needed to Support the Change:

Staff will gather responses to the following questions:

1. How are you feeling now?

2. What are you doing to feel better?

3. If you are not feeling better, have you reconsidered following up with the

referrals we discussed?

DO We carried out this test with the same 9 clients

Oakland Cycle #2: Plan & Do

STUDY

What was unique about this study was that all of the Nurse Home visitors asked

the same questions.

The clients did not mind talking about their concerns.

Over the months most of the clients stated that they felt better.

Two clients obtained medication.

Our client population does not seem to like going to therapy or counseling. Many

have a negative stereotype against it. If we address our prediction;

We predicted that using this technique would provide an opportunity to create an

open dialogue with the clients who refused to seek medical care for an elevated

Edinburgh. This prediction was true and we did create an open dialogue.

Oakland Cycle #2: Study

7

1 1

Client Responses (9)

Feeling better, improvingw/ own skills

Still anxious

Unable to locate

7

1

1

2

Medical Care

Didn't engage withmedical care

Engaged w/ medicalcare

Couldn't fillprescription b/c ofinsurance

ACT All of the Nurses will continue to use MI techniques and can ask the same assessment questions. This test was successful and the clients verbalized improvement. We will continue to repeat the elevated EPDS 30 days later.



Nurse Home Visitors


March 1, 2015 to March 31, 2015


Each of the 5 nurse home visitors will create a third opportunity for an open

discussion with the same 9 clients’ who declined a mental health referral 30

days ago and reassess at this subsequent Home visit. During their home visits

in March they will ask the client additional questions on how they are

coping. Each Home visitor will use one MI technique in the home visit.


Tasks/Tools Needed to Support the Change:

A team meeting will be held on Monday, April 13, 2015 to discuss the results

of the 9 clients. Staff will gather responses to the following questions:

DO We carried out this test with the same 9 clients

Oakland Cycle #3: Plan & do

Oakland Cycle #3: Study

2

5

2

7

Cycle 3 Study

Left program

Improved w/ointervention beyond HV

Improved w/ medication

One client left because of

work/school commitments and

no longer had mental health

concerns. One client showed

improvement in cycle 2 and

was no longer available to stay

in the program.

• Client 8: EPDS 1 with no

intervention beyond HV.

• Client 1: EPDS 0. did not

follow thru on

recommendations or

referrals, the NHV continues

MI techniques. Well

attached, going to school.

• Client 6: Last EPDS was a 3, gaining support from family. No medications, no f/u with

referral. The NHV Faxed the EPDS scores to the client’s OB.

• Client 7: with an EPDS of 7, continues to refuse therapy but is looking & feeling much

improved.

• Client 3: with an EPDS score of 7, accepted referral but precontemplative (didn’t act on it)

throughout intervention.

• Client-5 with an EPDS score of 8, in therapy & on medication, coping well with her anxiety.

• Client 2: Last EPDS was an 8. The client is taking Effexor, seeing psychiatrist. Verbalizes

goal starting counseling next 6 months.

ACT The team will implement this approach with all women

who screen >10 on EPDS or the PHQ-9 at any point in

time. There are several clients who have screened

positive since this test started.

The Supervisor will develop materials to train new

Home Visitors on this approach to monitoring women

with depressive symptoms.

The next cycle will test use of these training materials

with a new NHV who will begin seeing clients next

month.


Lessons Learned: CQI Team Reflections

HV: “Intervention and follow up seems positive. Even

though there is some element of social desirability to

answering the EPDS – for example, I have a client who

scored 0 on her EPDS and filled it out very quickly – is

probably not a zero, but she is doing better and she knows

I’m checking in with her.”

Client: “My nurse encouraged me to follow through with my

doctor and now I am feeling better. She told me that I

deserve to feel better and she helped me to realize that I can

make small changes”.


HV: “Some clients are getting better, it is attesting to our

relationship with them & our continued support. I think

especially in cases of situational depression, our support

lends to symptoms getting better. If we were not there,

things would be profoundly worse. Also, I'm looking at my

practice, I'm looking at these young women, I'm doing this

differently. I really like this.”

“for 2/9 women who have more endogenous depression, we

facilitated getting access to treatment that they might not

have accessed on their own.”


Supervisor:

“Everyone feels like there is a systematic process for follow

up of women with depressive symptoms. We have a

consistent process and procedure when the EPDS is >10. All

Nurse Home Visitors know what's expected, they know what

to do. All 5 NHV are using the same process.”

Plans for the Future

• We will continue to participate in Hv CoIIN

Phase 2 for 2016

• We will have the NFP team trained in the

Mother’s and Babies program so we can

use evidenced based interventions with our

clients

• We will continue with monthly PDSA cycles

Contact Information

Marcy Raska BSN, RN

Oakland County Nurse-Family Partnership

[email protected]

248-858-1380

oakland county health division nurse-family partnership ... · cycle 1 study summary 45% 44% 11%...

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