1. Carolina Health Centers, Inc.
Maternal Depression
Intervention
Policy & protocols for urgent & non-urgent care
Primary Driver 1:
Standardized and reliable processes for maternal depression screening and response

2. Definition of the Intervention
Adoption of formal policies for maternal depression screening and for response to a positive screen. Creation of protocols for each policy. Creation of resource materials for home visitors and assurance for easy access.

3. Description of the Intervention
Title: Home Visitation Participant Depression Screen Policy
Category: Policy
Effective Date: January 26, 2014
POLICY: Women enrolled in early childhood home visitation programs will receive screening for depression using standardized depression screening tools and periodicity schedules.
Scope: This policy applies to all early childhood home visitors.
Procedures:
All Prenatal participants shall be screened for depression per home visitation model schedules and as deemed necessary per home visitor judgment.
.The EPDS (Edinburgh Postnatal depression scale) shall be used by HS and HFA on the first prenatal visit, the 36 week prenatal visit and until the participant’s child is 12 months of age for all early childhood home visitation participants.
The PHQ-9 shall be used by the NFP program on the first prenatal visit, the 36 week prenatal visit and until the participant’s child is 12 months of age for all early childhood home visitation participants.
The PHQ-9 shall be used by all programs as needed after the child is age 12 months until completion of the home visitation program for the participant.
At a minimum for all home visitation programs, the EPSD or other approved screening tool must be administered to all early
childhood home visited mothers before 8 weeks postpartum.
7. The home visitors will share the results of the screening with the mother in a timely manner.

4. Description of the Intervention
Title: Policy for a positive depression screen
Category: Policy
Effective Date: January 26, 2014
POLICY: Home visitors will assess for imminent danger and make either a non-emergency or emergency referral
Scope: This policy applies to all early childhood home visitors.
Procedures:
If a screen is not positive (moderate to severe symptoms), the home visitor will re-screen and re-evaluate at the next screening interval or if clinical judgments indicates a need.
If a screen is positive (moderate to severe symptoms) and the PHQ-9 score is less than 10 or the EPDS score is less than 13, the home visitor will document the screen score, discuss the results with the family, staff the family with the supervisor to determine if any interventions are necessary or recommended, and rescreen monthly until the depressive symptoms are gone or decreased to mild levels.
If a screen is positive (moderate to severe symptoms) and the PHQ-9 score is greater than or equal to 10 or the EPDS score is greater than or equal to 13, a referral is required. The home visitor will assess for imminent danger. If there is no threat of imminent danger, the home visitor will make a non-emergency referral to the mother’s OB/MD and to a mental health service provider.
The home visitor will track the referral and document if the mother accesses care.
If the client does not accept the referral or does not access the service, the home visitor will document the refusal of the referrals and/or that the client did not access the services. The home visitor will staff this client with the supervisor, continue to monitor the client status, and use motivational interviewing to discuss options with the client. The home visitor and supervisor will document follow-up screening as needed.
If the client accepts and receives a service, the home visitor will document the service and will do a follow-up screening at 12 weeks from the receipt of the first service contact.

5. 7. When using the PHQ-9 if the participant indicates any potential (score is 1 or above) for self-harm on question #9 and/or
scores 10 or above total score or when using the EPDS if the participant indicates any potential (score is 1 or above) for self-
harm on question# 10 and/or scores 10 or above total score the home visitor must assess if the client is suicidal, homicidal
and/or there is imminent danger. If there is no risk of imminent danger, the home visitor must efer the client to her OB/MD
and to mental health and staff this with the supervisor. Staffing must include a written follow-up plan and refer to the following
document: Management Levels According to Key Symptoms and Behaviors of Parents with a Mental Health Crisis. The
supervisor will notify the Program Manager and the Director.
8. If an emergency response is warranted, the home visitor will call 911 and will stay with the client until resources arrive to
further assist the client. The home visitor will notify the supervisor after calling 911 to discuss further plan of action. A critical
incident report must be completed and the Program Manager and Director notified.
9. If the home visitor deems there is any danger to him/herself, they are to go to a place of safety and call 911, then call
supervisor. A critical incident report must be completed and the Program Manager and Director notified.

6. Description of the Intervention

14. How is the Intervention Carried Out?
Research best practice policy & protocols
Draft policy & protocols
Conduct a focus group with all home visit staff to assess current knowledge & comfort with MD screening, referral, and follow-up.
Formally adopt policy & protocols. Create resource materials according to protocols. Survey home visit staff about knowledge of policy & protocols and need for any additional supports.

15. Intervention continued
Test protocols and materials in the field. 1 home visitor in 1 urgent care situation.
Create new materials as needed.
Test protocols and newly revised materials with another home visitor in another urgent care situation.
When successfully complete testing, create packets of materials for each home visitor to keep in the care for ready access in the field.
Monitor ongoing use of policy & protocols.

16. Changes that Result in Improvements
Cycle 5: Test protocols & materials with another HV in the field. Successful connections. Create MD folder for each HV to keep in cars for ready access in the field.
Cycle 4:Test new protocols & materials 1 HV in 1 urgent care response. Determine need for materials in the field.
Cycle 3: Policy formally adopted by Board. Resource materials created. HV staff surveyed on knowledge of policy & protocols and about need for additional supports.
Cycle2: Review draft documents. Focus group to assess HV knowledge of & comfort with MD screening.
Cycle 1: Create new policy and protocols for urgent and non-urgent care

17. Pre-requisites for the Intervention
Knowledge of agency policy standards
Knowledge of program model guidelines
Knowledge of best practice procedures
Access to standardized screening tools and instructions for use
Advice from behavioral health experts/faculty
Input from direct service providers/home visitors

18. Lessons Learned
Policy needs to be adequate for real life urgent situations.
Procedures need to be examined and reexamined for sufficiency following use in urgent situations
Home visitors need ready access to protocols and tools while in the field
Supervision and concrete supports for home visitors is critical

19. References/Resources
Linda Beeber as faculty advisor
Program model guidelines when available
Substance Abuse and Mental Health Services Administration. Depression in Mothers: More Than the Blues—A Toolkit for Family Service Providers. HHS Publication No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.