Depression and 2 Week Follow-Up Phone Calls. Sarina Pasricha February 2011 QI Project

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1 Depression and 2 Week Follow-Up Phone Calls Sarina Pasricha February 2011 QI Project

2 Diagnosis of Depression- SIGECAPS 5 out of the 9 symptoms experienced majority of the days in 2 week time frame Sleep (insomnia/hypersomnia) Interests (diminished interest or pleasure from activities) Guilt (excessive guilt or feelings of worthlessness) Energy (loss of energy/fatigue) Concentration (diminished concentration/indecisiveness) Appetite (decrease or increase in appetite) Psychomotor retardation/agitation Suicide

3 Background One third of depressed adults who receive an accurate diagnosis in primary care discontinue their antidepressant medication during the first month of treatment. As many as one half of depressed patients who receive mental health referrals for psychiatric and/or other mental health services (e.g., problemfocused psychotherapy) fail to complete the referral. Katon W, Von Korff M, Line E, Bush T, Ormel J. Adequacy and duration of antidepressant treatment in primary care. Med Care. 1992;30:67-76.

4 Telephone Counseling as an Adjunct to Antidepressant Treatment in the Primary Care System: A Pilot Study. Effective Clinical Practice. July/August Steve Tutty, Greg Simon, MD, Evette Ludman. ACP. Patients: 28 adult primary care pts starting antidepressant treatment (telephone counseling group) compared with 94 pts receiving usual care (control group). Intervention: Telephone counseling pts received written educational material addressing depression followed by 6 wkly counseling sessions via phone by a master s level therapist

5 Results from ACP study Results: 93% of telephone counseling participants contacted agreed to participate 92% completed the intervention. Telephone counseling pts had sig lower depressive sx at 3 month follow up (0.89 vs 1.13) and 6 month follow up (0.79 vs 0.95) Telephone counseling pts were 2x as likely to adhere to antidepressant meds Total outpatient visits did not change

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7 UNC IM Clinic System Nursing staff performs PHQ-2 prompt. If score 3, prompts patient and MD to fill out completed PHQ-9 Score (nurses often assist filling out PHQ-9). If PHQ-9 score is greater than 15, Cole manually records the patient into the Internal Medicine Depression Program Access Database Cole completes 2 week follow up phone call to all pts with PHQ

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9 Depression Follow-Up Phone Call Script

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11 Documentation For each phone call that is attempted, the conversation is documented in: 1. Depression Binder 2. Depression Database online 3. Webcis Phone Call Note

12 Objectives How successful are we in contacting pts? How much time is invested in making phone calls? Are patients who receive phone calls more likely to show up to their next scheduled appointment? Does PHQ-9 score change in patients who receive a phone call?

13 2 Week Follow Up Depression Phone Calls

14 # of Patients 2 week Follow Up Phone Calls in a Day Time Period in Feb Completed Phone Calls Skipped Phone Calls Not Completed Phone calls

15 Breakdown of Total Time Spent Making 2 week Follow up Phone Calls Total Preparation Time (Min) Total Time Contacting Pts (Min) Total Time Documenting (Min) Total Encounter Time (Min) 43 Patients (All pts) Patients (Completed Phone Calls)

16 Average Time Breakdown Average Prep Time (Min) Average Time Contacting Pts (Min) Average Time Documenting (Min) Average Encounter Time Total (Min) Completed Phone Calls Call Attempted but Encounter Not Completed FYI: Anti-Coagulation Clinic has 15 min blocks scheduled for patients Diabetes Care Clinic has 30 min blocks scheduled for patients

17 Database for Upcoming Results Data was analyzed from the Internal Medicine Depression Program Access Database Data was analyzed from October 2010 in order to have 3 months worth of follow up data 78 pts were in the database of which 32 had completed phone calls

18 Follow Up Appointments in Pts Who Did NOT Receive Phone Call No follow up appt scheduled 7% Did not keep appt but don't know if cancelled or no show 3% Completed next appt 39% No show 17% Cancelled next appt 34% Cancelled next appt No show Completed next appt Did not keep appt but don't know if cancelled or no show No follow up appt scheduled Follow Up Appointments in Pts Who DID Receive Phone Call No follow up appt scheduled 6% Did not keep appt but don't know if cancelled or no show 0% Cancelled next appt 26% Cancelled next appt No show Completed next appt 58% No show 10% Completed next appt Did not keep appt but don't know if cancelled or no show No follow up appt scheduled

19 Days Average Time Frame in Days from Expected Phone Call to Completed Appointment * * p< Pt who did NOT receive phone call Pts who DID receive phone call

20 PHQ-9 Score Before and After Anticipated 2 wk Follow Up Phone Call * Average PHQ 9 score 1before exp phone call Average PHQ 9 score 2 after exp phone call Pts w ho did NOT receive phone call: Pts w ho DID receive phone call: * p< pts who did not receive phone call had clinical significant PHQ-9 score changes 15 pts who did receive phone call had clinically significant PHQ-9 score changes

21 Medication Adjustments in MD Visit Prior to 2 Wk Follow-Up Phone Call Percentage of pts who did NOT receive phone call: Percentage of pts who DID receive phone call: 10 0 No Medication Changes New Medication Added Medication Dose Increased No Documentation Sent to the ED

22 Results On average, 20 min is spent on completed 2 wk follow up phone calls and 15 min on phone calls attempted but pt not reached Nearly 50% of the total time is spent on documentation 39% of pts who did not receive 2-wk phone call completed their next clinic visit compared to 58% of pts where phone call was completed Average time from scheduled 2 wk phone call to completed clinic visit was 47 days in pts with no phone call and 22 days in pts who had completed call 15 out of 32 pts (48%) who had completed phone calls and 10 out of 20 (50%) of pts without completed phone calls had clinically significant improvements in their PHQ-9 scores (PHQ-9 score change > 5) 51% who had completed phone calls and 45% of pts without completed phone calls had medication additions/increase at MD visit prior to follow-up phone call

23 SUCCESS We need to continue to collect data to further analyze long-term outcomes of 2 week follow ups.

24 Future We spent roughly 11 hrs trying to get in touch with 43 pts of whom 21 had completed phone calls Should we have 2 wk follow up Depression Clinic (similar to Coag/DM clinic)?

25 2 Wk Depression Clinic? Pros: Scheduled time for pts Can double book pts Not wasting prep time for pts we don t get in touch with Cons: Pts seen in person will often require more than allotted time Require clinic staff personnel and room Greater cost Challenging for pts (requires time and money)

26 Future Should follow- up phone call time and date be established at prior visit (ie scheduled)?

27 Future Do any of our pts have and can follow-up exchange be done via for at least some pts? Can we speed line the documentation process to decrease time? Can we schedule follow-up time post pain/coags/dm clinic (in pts who follow up in these clinics)?

28 Special thanks to: Dr. Amy Weil Diane Dolan-Soto Cole Andrew Kim Young-Wright

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