Depressive Symptoms Quality Measures Skilled Nursing Facility Setting

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1 Depressive Symptoms Quality Measures Skilled Nursing Facility Setting Prepared for: CMS Quality Measures Work Group Forum 21 June 2012

2 Moderate/Severe Depressive Symptoms Care Plan Measure (long-stay; #0690a) I. Measure Title: Percentage of residents with moderate to severe depressive symptoms who received a care plan (long-stay) II. Description: This measure is based on data from MDS 3.0 assessments of nursing home residents and indicates the percentage of residents who had the Mood State Care Plan addressed (score=01; i.e., in Section V0200 CAAs and Care Planning; subsection A. CAA Results) for those residents who received a score of 10-27/30 moderate to severe depressive symptoms on the PHQ-9. III. Numerator Statement: The numerator is the total number of long-stay residents who had Care Area 08. Mood State Care Planned Addressed (score =1; see image on next page) in the Care Area Assessment (CAA) Summary Section V, V0200, CAAs and Care Planning; A. CAA Result. IV. Denominator Statement: The denominator is the total number of all long-stay residents in the nursing facility who have received an annual MDS assessment during the selected quarter (3- month period). Using the PHQ-9 items in the MDS 3.0, the total sum severity score of 10-27/30 (D0300, D0500) on the most recent annual MDS assessment in the selected quarter. VII. Information on the Impact: Depression is a very expensive, complicating, and treatable factor for nursing facility residents. The total economic cost of depression in the U.S. in CY 2000 was $83.1 billion, including $26.1 billion in direct medical costs (#0690). The prevalence of moderate to severe depressive symptoms among nursing facility residents as of the most recent MDS 3.0 quality indicator was 7%. Therefore, depression among the nursing home residents is a significant clinical issue. VIII. Guidelines which Support Measure: Described elsewhere (#0690) are guidelines for screening, evaluation (including: changes in social or family situation, new stressors or situational factors such as changes in staff, availability of social and meaningful activities, availability of positive [reinforcing] experiences and unmet needs), and treatment (including non-pharmacological and pharmacological interventions effectiveness).

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4 Mild Depressive Symptoms Measure (long-stay; #0690b) I. Measure Title: Percentage of residents who have mild depressive symptoms (long-stay) II. Description: This measure is based on data from MDS 3.0 assessments of nursing home residents and indicates the percentage of resident by resident interview or staff assessment that Patient Health Questionnaire (PHQ-9) depression instrument score in the mild range (5-9). III. Numerator Statement: Using the PHQ-9 items in the MDS 3.0, the total sum severity score of 5-9 (D0300, D0500) on the most recent MDS assessment in the selected quarter. The total severity score reflects long-stay resident responses to question asking about the frequency of nine symptoms over the last 2 weeks, including interest, mood, energy, appetite, self-value, ability to concentrate, change in responsiveness, or patience. IV. Denominator Statement: The denominator is the total number of all long-stay residents in the nursing facility who have received an MDS assessment (which may be an annual, quarterly, significant change or significant correction assessment) during the selected quarter (3-month period). VII. Information on the Impact: Depression is a very expensive, complicating, and treatable factor for nursing facility residents. The total economic cost of depression in the U.S. in CY 2000 was $83.1 billion, including $26.1 billion in direct medical costs (#0690). The prevalence of moderate to severe depressive symptoms among nursing facility residents as of the most recent MDS 3.0 quality indicator was 7%. In addition, according the PA Sample, another 16% of residents have less severe, but nevertheless clinically significant depression. Therefore, depression among the nursing home residents is a significant clinical issue. VIII. Guidelines which Support Measure: Described elsewhere (#0690) are guidelines for screening, evaluation (including: changes in social or family situation, new stressors or situational factors such as changes in staff, availability of social and meaningful activities, availability of positive [reinforcing] experiences and unmet needs), and treatment (including non-pharmacological and pharmacological interventions effectiveness). IX. Supporting Evidence: An estimated 5 million have subsyndromal depression, symptoms that fall short of meeting the full diagnostic criteria for a disorder (Horwath et al. [1992]). Horwath and colleagues (1992), in an analysis of data from a one-year re-interview-based longitudinal study with focus on DSM-III mental disorders, found that subsyndromal depression is especially common among older persons and is associated with a greater than 4 time risk of developing major depression. In addition, the authors found that approximately 50% of those with new-onset Major Depressive Disorder have subsyndromal depression in the prior year; they recommended behaviorally based programs for depression prevention. In a recent Institute of Medicine report (2009) on the prevention of mental health disorders the authors concluded that the evidence indicates that major depression can be prevented this is a turn-around from as recent as 25 years earlier (1984, NIMH depression pamphlet). In a recent review of the literature, Munoz et al. (2012) conclude from the results of a meta-analysis that 22 38% of major depressive episodes can be prevented.

5 Mild Depressive Symptoms Care Plan Measure (long-stay; #0690c) I. Measure Title: Percentage of residents with mild depressive symptoms who received a care plan (long-stay) II. Description: This measure is based on data from MDS 3.0 assessments of nursing home residents and indicates the percentage of residents who had the Mood State Care Plan addressed (score=01; i.e., in Section V0200 CAAs and Care Planning; subsection A. CAA Results) for those residents who received a score of 5-9 mild depression on the PHQ-9. III. Numerator Statement: The numerator is the total number of long-stay residents who had Care Area 08. Mood State Care Planned Addressed (score =1; see image on next page) in the Care Area Assessment (CAA) Summary Section V, V0200, CAAs and Care Planning; A. CAA Result. Currently the Mood State Care Area Assessment triggers for those residents who score 10-27/30; it would need to be changed to 5-27/30 in order to allow for a response to be indicated in the Addressed in Care Plan section. IV. Denominator Statement: The denominator is the total number of all long-stay residents in the nursing facility who have received an annual MDS assessment during the selected quarter (3- month period). Using the PHQ-9 items in the MDS 3.0, the total sum severity score of 5-9 (D0300, D0500) on the most recent annual MDS assessment in the selected quarter. VII. Information on the Impact: Depression is a very expensive, complicating, and treatable factor for nursing facility residents. The total economic cost of depression in the U.S. in CY 2000 was $83.1 billion, including $26.1 billion in direct medical costs (#0690). The prevalence of moderate to severe depressive symptoms among nursing facility residents as of the most recent MDS 3.0 quality indicator was 7%. In addition, according the PA Sample, another 16% of residents have less severe, but nevertheless clinically significant depression. Therefore, depression among the nursing home residents is a significant clinical issue. VIII. Guidelines which Support Measure: Described elsewhere (#0690) are guidelines for screening, evaluation (including: changes in social or family situation, new stressors or situational factors such as changes in staff, availability of social and meaningful activities, availability of positive [reinforcing] experiences and unmet needs), and treatment (including non-pharmacological and pharmacological interventions effectiveness). IX. Supporting Evidence: An estimated 5 million have subsyndromal depression, symptoms that fall short of meeting the full diagnostic criteria for a disorder (Horwath et al. [1992]). Horwath and colleagues (1992), in an analysis of data from a one-year re-interview-based longitudinal study with focus on DSM-III mental disorders, found that subsyndromal depression is especially common among older persons and is associated with a greater than 4 time risk of developing major depression. In addition, the authors found that approximately 50% of those with new-onset Major Depressive Disorder have subsyndromal depression in the prior year; they recommended behaviorally based programs for depression prevention. In a recent Institute of Medicine report (2009) on the prevention of mental health disorders the authors concluded that the evidence indicates that major depression can be prevented this is a turn-around from as recent as 25 years earlier (1984, NIMH depression pamphlet). In a recent review of the literature, Munoz et al. (2012) conclude from the results of a meta-analysis that 22 38% of major depressive episodes can be prevented with currently available interventions.

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7 Mild Depressive Symptoms Measure (short-stay; #0690d) I. Measure Title: Percentage of residents who have mild depressive symptoms (short-stay) II. Description: This measure is based on data from MDS 3.0 assessments of nursing home residents and indicates the percentage of resident by resident interview or staff assessment that Patient Health Questionnaire (PHQ-9) depression instrument score in the mild range (5-9). III. Numerator Statement: Using the PHQ-9 items in the MDS 3.0, the total sum severity score of 5-9 (D0300, D0500) on the most recent MDS assessment in the selected quarter. The total severity score reflects long-stay resident responses to question asking about the frequency of nine symptoms over the last 2 weeks, including interest, mood, energy, appetite, self-value, ability to concentrate, change in responsiveness, or patience. IV. Denominator Statement: The denominator is the total number of all short-stay residents in the nursing facility who have received an MDS assessment (which may be a 5-day, 14-day, 30-day, 60-day, annual, quarterly, change of therapy, significant change or significant correction assessment, discharge assessment) during the selected quarter (3-month period). VII. Information on the Impact: Depression is a very expensive, complicating, and treatable factor for nursing facility residents. The total economic cost of depression in the U.S. in CY 2000 was $83.1 billion, including $26.1 billion in direct medical costs (#0690). The prevalence of moderate to severe depressive symptoms among nursing facility residents as of the most recent MDS 3.0 quality indicator was 7%. In addition, according the PA Sample, another 16% of residents have less severe, but nevertheless clinically significant depression. Therefore, depression among the nursing home residents is a significant clinical issue. In a recent secondary analysis of the Project Red, randomized controlled trial in the acute setting, Mitchell et al. (2010) found a 73% higher incidence rate for hospital utilization within 30 days of discharge for those with symptoms of depression. This places symptoms of depression on par with frequent prior rehospitalization, advanced age and low social support, as known risk factors for rehospitalization. As short-stay post-acute SNF patients are likely a more clinically compromised sub-population of acute patients, depression is apt to be at least as much of a risk factor if not more than those discharged to home from the hospital. VIII. Guidelines which Support Measure: Described elsewhere (#0690) are guidelines for screening, evaluation (including: changes in social or family situation, new stressors or situational factors such as changes in staff, availability of social and meaningful activities, availability of positive [reinforcing] experiences and unmet needs), and treatment (including non-pharmacological and pharmacological interventions effectiveness). IX. Supporting Evidence: An estimated 5 million have subsyndromal depression, symptoms that fall short of meeting the full diagnostic criteria for a disorder (Horwath et al. [1992]). Horwath and colleagues (1992), in an analysis of data from a one-year re-interview-based longitudinal study with focus on DSM-III mental disorders, found that subsyndromal depression is especially common among older persons and is associated with a greater than 4 time risk of developing major depression. In addition, the authors found that approximately 50% of those with new-onset Major Depressive Disorder have subsyndromal depression in the prior year; they recommended behaviorally based programs for depression prevention. In a recent Institute of Medicine report (2009) on the prevention of mental health disorders the authors concluded that the evidence indicates that major depression can be prevented this is a turn-around from as recent as 25 years earlier (1984, NIMH depression pamphlet). In a recent review of the literature, Munoz et al. (2012) conclude from the results of a meta-analysis that 22 38% of major depressive episodes can be prevented.

8 Moderate-Severe Depressive Symptoms Measure (short-stay; #0690e) I. Measure Title: Percentage of residents who have depressive symptoms (short-stay) II. Description: This measure is based on data from MDS 3.0 assessments of nursing home residents and indicates the percentage of resident by resident interview or staff assessment that Patient Health Questionnaire (PHQ-9) depression instrument score in the moderate-severe range (10-27/30). III. Numerator Statement: Using the PHQ-9 items in the MDS 3.0, the total sum severity score of 10-27/30 (D0300, D0500) on the most recent MDS assessment in the selected quarter. The total severity score reflects long-stay resident responses to question asking about the frequency of nine symptoms over the last 2 weeks, including interest, mood, energy, appetite, self-value, ability to concentrate, change in responsiveness, or patience. IV. Denominator Statement: The denominator is the total number of all short-stay residents in the nursing facility who have received an MDS assessment (which may be a 5-day, 14-day, 30-day, 60-day, annual, quarterly, change of therapy, significant change or significant correction assessment, discharge assessment) during the selected quarter (3-month period). VII. Information on the Impact: Depression is a very expensive, complicating, and treatable factor for nursing facility residents. The total economic cost of depression in the U.S. in CY 2000 was $83.1 billion, including $26.1 billion in direct medical costs (#0690). The prevalence of moderate to severe depressive symptoms among nursing facility residents as of the most recent MDS 3.0 quality indicator was 7%. Therefore, depression among the nursing home residents is a significant clinical issue. In a recent secondary analysis of the Project Red, randomized controlled trial in the acute setting, Mitchell et al. (2010) found a 73% higher incidence rate for hospital utilization within 30 days of discharge for those with symptoms of depression. This places symptoms of depression on par with frequent prior rehospitalization, advanced age and low social support, as known risk factors for rehospitalization. As short-stay post-acute SNF patients are likely a more clinically compromised sub-population of acute patients, depression is apt to be at least as much of a risk factor if not more than those discharged to home from the hospital. VIII. Guidelines which Support Measure: Described elsewhere (#0690) are guidelines for screening, evaluation (including: changes in social or family situation, new stressors or situational factors such as changes in staff, availability of social and meaningful activities, availability of positive [reinforcing] experiences and unmet needs), and treatment (including non-pharmacological and pharmacological interventions effectiveness).

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