Quality Improvement in Practice: Screening for Depression in the Chronically Ill ANNIE RUTTER, MD, MS & ELIZABETH MEZA, MD UNC-CHAPEL HILL FAMILY MEDICINE RESIDENCY IN COLLABORATION WITH: DANA NEUTZE, MD, PhD KHALILAH DANN, MD, MPH KRISTINE ROSS CARPENTER MD, MS RONALD LANEY, MD, MPH EMMA WILLIAMS, MD CALEB PINEO, MD, MPH

Objectives Implement quality improvement initiatives among residents teaching how to use the Plan-Do-Study-Act (PDSA) cycles to assess effectiveness Understand the importance of screening for depression in patients with chronic disease and have a model for doing so Recognize the value in letting residents help achieve Patient Centered Medical Home (PCMH) goals within the clinic

Quality Improvement Curriculum Resident driven practice redesign Ongoing senior chronic disease project Senior resident class identifies clinical focus for their 3rd year Leading the Chronic Care Team Senior residents are “Steering Committee” for project Experiential learning: carry out series of PDSA cycles Residents have 4-8 hours per week

Deming cycle

PDSA Transitions Resident 4 Resident 3 Resident 2 Resident 1

Landscape Registry system for tracking patients with chronic diseases Developed out of previous resident-lead QIP project 3 Chronic diseases Diabetes Mellitus Heart Failure Coronary Artery Disease

Current QI Project Goal Incorporate depression screening for chronically ill into clinical practice Depression associated with poorer outcomes Majority of depression is treated in primary care setting Behavioral medicine as part of PCMH

Project Structure Resident 1: Resident 2: Resident 3: Resident 4: Identified screening tool Resident 2: Incorporated screening tool into chronic disease registry Educated clinic staff Resident 3: Clinic wide implementation of screening Resident 4: Initial chart audit of clinic wide implementation

Project Structure Resident 5: Resident 6: Resident 7: Resident 8: Second chart audit, evaluated documentation of positive PHQ-9 in clinic visit note Resident 6: Changed registry template to clarify provider responsibilities, audit to assess effectiveness Resident 7: Chart review for new diagnoses of depression Resident 8: Plan to aggregate data, compare data to national averages

QI Project: Depression Screening Chose standardized instrument for screening PHQ-2  PHQ-9 Provided in service for clinicians and support staff Added screening protocol to current registry forms Pilot on 2 of 4 clinical teams Initial chart review 87-100% screened if chief complaint (CC) was follow-up for chronic disease Then launched clinic-wide

Example of registry with new sections for depression screening

QI Project: Depression Screening Screening rate was 58% 80% when CC was DM, CHF, or CAD 18% when presented for different CC Next PDSA cycle: ensure screening at ALL visits Goal of printing registry forms for all visits Chart review: to assess documentation of screening Changed registry form for ease of provider documentation at point of care

Results Number of Patients

Lessons Learned Residents can drive QI in academic settings Residents develop tool set for use in future practice Quality improvement PCMH model Information technology with support is critical Registry as point of care reminder Systematic screening for important conditions Effective communication between residents

Thank you! emeza@unch.unc.edu Arutter@unch.unc.edu