creening for depression has been recommended at least yearly for all patients, but screening rates still lag, and when screening is conducted, there is often a lack of follow up on positive screens. Within our medical group, we track analytics on many different aspects of quality care, including the use of depression screenings. Using this data, we found that only 41% of University of Utah Health patients received depression screening within the previous 9 months. This number was far lower in specialty clinics, where only 19% of patients received a screening.
Even after patients in these clinics screened positive for depression, we saw a lack of follow-up care for them. When patients did schedule a mental health appointment after a positive screen, it took up to 20 weeks to get scheduled with a clinician. Based on our data, we knew we needed to make a change to ensure our patients were getting timely access to the care they needed.
Our goal for this initiative was to offer a depression screening to 100% of specialty care clinic patients and respond rapidly after a positive screening without increasing the workload of our staff.
Innovative Workflow and Process
We created a workflow that made it easy to administer a depression screen through MyChart with the help of our IT team. If they did not have a depression diagnosis, no mental health appointments in our system, and had not received a screen in the last 9 months, Epic would automatically send patients the Patient Health Questionnaire (PHQ) through MyChart with two initial questions on depressed mood and a loss of interest.
If the patient scores below a certain threshold, the questionnaire ends, and patients are thanked for their time completing the survey. But if the patient answers yes, they receive 7 more questions (full PHQ-9). After answering all questions, a calculated score based on their responses would indicate next steps for the patient:
- Patients with a score below 10 (none to mild): the screening ended with a thank you.
- Patients with a score between 10 and 19 (moderate): patients are told they may be suffering from symptoms related to depression and given options, such as scheduling an appointment. They receive more follow-up through MyChart.
- Patients with a score at 20 or above (severe) or had any indication they were having suicidal ideation despite level of their initial scoring: they receive a phone call from a behavioral health analyst on the Behavioral Health Integration team at HMHI.
The Profound Impact on Patients
This initiative had an immediate and profound emotional impact, both for us and patients. As a Case Analyst, I (Josi) have been able to show patients that we are listening and really care. We’ve been able to cut out the frustration of having to find a provider and get the patient the help they needed when they needed and wanted it. It is extremely humbling to offer this relief and hope to them.
On the first day we went live, we had a patient score a 26, which is high, and a 3, the highest score, on the question about suicidal ideation. When we called this patient, they said they didn’t really think anyone would reach out to them and that no one really cared.
We were able to get the patient in with a Behavioral Health Integration (BHI) clinician the next day by calling them and offering an appointment, rather than waiting for them to call us and ask for help.
We’ve had a patient who was actively suicidal, who had a plan and means to carry this out. Josi was able to connect with them, escalate them to a phone call with a social worker who provided crisis management, create a safety plan with patient, and schedule patient for follow up visit with them as well. We offered lifesaving care when it was needed most.
Positive Outcomes for Patients and Providers
Before our initiative, wait times from a positive depression screen to being scheduled with a social worker was 20 weeks. Now, if patients are interested, Josi can reach out for a brief follow up and assessment, pend a referral to their provider and get the patient scheduled within 1-5 days.
In our primary care clinics we have implemented the collaborative care model. Patients identified in the depression screening program who also have a primary care physician within the University Health system can be referred back to their respective clinics for enrollment in the collaborative care program to receive psychotherapy and medication management services when appropriate with psychiatric consultation with a goal to reduce their depression systems, provide access to medication management, and provide necessary skills to support their mental health. This is just one more way to help reduce barriers and provide timely access to needed care.
So far, our behavioral health analyst has successfully contacted 538 patients by phone after they had a positive score. This is 86% of all patients who scored in the severe range for depression or indicated possible suicidal ideation. For the few patients we were unable to reach, we provide our contact information asking them to call us.
Serving the questionnaire through MyChart has multiple benefits. Patients can answer more honestly because they are answering privately. They can be given options to consider on their own time and in their own space. This outreach works to streamline the time a patient has with their provider, works behind the scenes to implement the behavioral health resources and management prior to the appointment (or shortly after) to help reduce in clinic crisis needs that may arise.
Challenges and Future Considerations
Though this initiative has had huge successes, it’s not without its challenges or drawbacks. We are finding that we must continually advocate for our patients to get them the care they need. We have to be proactive in our approach and provide as much support as possible so the barriers to overcome are not all left to the patient who may be struggling.
We are also finding that most patients who scored positive but in the moderate range (79%) are declining further help or a clinical assessment. Some of this may be due to patients already receiving mental health treatment outside of our health system, but there are likely still existing barriers present such as cost of care, insurance barriers, a lack of motivation for treatment that can accompany depression, and stigma.
Expanding the Reach
With the success of this program in the specialty clinics, we are now strategically expanding into primary care in the community clinics and other areas in our system. With so many patients being screened, there is a need for more staff to continue outreach and follow-up.
In the future, we are looking to expand this program system-wide, to offer this support to all our patients, intervene early to potentially change the course of depression, and advance improved mental health for our all of our community.
Stories of impact
Patient had PHQ of 27 (very high). Patient wanted to schedule therapy but ran into many barriers in the community and University of Utah Health. Patient had given up hope. Patient defined the MyChart questionnaire as one last shot to let people know their situation. Patient had an appointment with a therapist two days later.
Elderly patient’s PHQ score was 26 (very high) with suicidal ideation. Patient didn’t have transportation to/from appts and was uncomfortable with public transport. Analyst was able to get patient virtual therapy that hadn’t be offered previously.
Patient has chronic condition with profound impact on mental health. The patient has tried therapy in the community, but no one seemed to understand their medical condition. Analyst was able to let them know we had experienced clinicians familiar with their condition. Therapy was scheduled immediately.