1. 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

2. 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?

3. Model for Improvement’s Three Fundamental Questions
What are we trying to accomplish? 
By January % 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

4. Oakland Cycle #1: Plan & Do
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.

5. Oakland Cycle #1: STUDY Client NHV Date EPDS EPDS Score2 3 4 5 6 7 8 9
NHV SM TW AV
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
19,11,19
11,3
21, 8, 5
10,7
Question Discussed  
4,5
5,3,6
MI Technique
Reframing
Scaling Question
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 appointment 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.

6. Cycle 1 Study summary
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.

7. Oakland Cycle #1: Act ACT
The team will do a second cycle with the same 9 clients, and we added new Motivational Interviewing questions:
How are you feeling now?
What are you doing to feel better?
If you are not feeling better, have you reconsidered following up with the referrals we discussed?

8. Oakland Cycle #2: Plan & Do
Who will implement the change?
Nurse Home Visitors
When will this change happen?
to ,
Study will happen at a team meeting on Monday, January 26, 2015
What will take place?
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.
Where will this change occur? During home visits 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

10. Oakland Cycle #2: Study 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.

11. Oakland Cycle #2: Act 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.

12. Oakland Cycle #3: Plan & do
Who will implement the change?
Nurse Home Visitors
When will this change happen?
March 1, 2015 to March 31, 2015
What will take place?
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.
Where will this change occur? During home visits 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

13. My First Template

14. Oakland Cycle #3: Study
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.

15. Oakland Cycle #3: Act 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.

16. 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”.

17. Lessons Learned: CQI Team Reflections
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.”

18. Lessons Learned: CQI Team Reflections 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.”

19. 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

20. Oakland County Nurse-Family Partnership
Contact Information
Marcy Raska BSN, RN
Oakland County Nurse-Family Partnership