Mental Health Module

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Mental Health ModuleMaking It Real

• Learning Session 1
• date

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Making It REAL....My Reflections
Ask the Questions (Show Patient Video)

• Johanna Johns
• Vanderhoof, British Columbia

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The Model for Improvement
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Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
What changes can we make that
will result in improvement?
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Characteristics of the Model for Improvement

• Action-oriented What are you going to test
  next Tuesday?
• Rapid-cycle testing of changes
• Evaluation and revision of all changes before
  implementation
• Testing and implementing the changes in small
  populations, then spreading then spreading to the
  larger population
• Impact evaluated using annotated run charts
• Monthly reporting of tests and outcomes

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Utilize Pilot Populations to test the Program
Pilot Population Mental Health Trainers GP and
MOA population and office patients with mental
health problems. Focus for the Collaborative
(Aim defines)
Small-scale tests of change
The Total Population of Trainer GPs and MOAs and
Patients with mental health problems in BC
(spread sites)
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The Fundamental Questionsfor Improvement

1. What are we trying to accomplish?
2. How will we know that a change is an improvement?
3. What changes can we make that willresult in an
   improvement?

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What are we trying to accomplish?Aim Statement
Characteristics

• States that we are going to improve care for
  patients (knowledge, skills, and resource
  availability related to management of mental
  health problems in GP offices).
• Describes the target population for improvement
  (GP)
• Describes in general terms changes we are going
  touse to improve care for the population (Mental
  Health Change Package and Expanded Chronic Care
  Model)
• Describes the most important outcomes
  (measures)that we want to improve for the
  population that defineour success (Use of
  screening, diagnostic, support mechanisms, etc.).

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What are we trying to accomplish?Office Aim
Statement

• Aim The care for patients with mental health
  problems in _______ GP office will be
  redesigned using the mental health change
  package so that GPs use depression screening
  tools, the CBIS Assessment tools such as the
  Diagnostic Assessment Interview, Problem List
  Action Plan, Resource list and Self Assessment
  Questionnaire, and CBT options such as the CBIS
  Handouts, Antidepressant Skills Workbook and
  Bounceback tools/support

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The Fundamental Questions for Improvement

1. What are we trying to accomplish?
2. How will we know that a change isan improvement?
3. What changes can we make that will result in an
   improvement?

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Measures

• Use PHQ-9 screening tool with at least20
  patients with potential mental health problems
• Conduct a second PHQ-9 assessment within 3-6
  months for 95 of those patients in this group
• Use the Diagnostic Assessment Interview for at
  least 10 patients with positive PHQ-9

/
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Measures (contd)

• Document suicide risk assessment in the patient
  chart if the suicide question on the PHQ-9 or
  Diagnostic Assessment Interview was positive
• Develop a problem list for 10 patients with an
  Axis I diagnosis
• Develop a resource list for 10 patients with an
  Axis I diagnosis

/
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Measures (contd)

1. Develop an action plan from the problemlist for
   10 patients with an Axis I diagnosis.
2. Use skills from the CBIS Manual with 10 patients
   with mental health problems.
3. Refer 10 patients screened as having
   mild/moderate depression to the Bounce Back
   Program
4. Offer Anti-depressant Skills Workbook (ASW) and
   provide some coaching to 10 patients screened as
   having depression

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Measurement

• The purpose of measurement in the collaborative
  is for learning not judgment

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Fundamental Questions for Improvement

1. What are we trying to accomplish?
2. How will we know that a change is an improvement?
3. What changes can we make that will result in an
   improvement?

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Mental Health Change Package

• Screening Tools
• Diagnostic Assessment Interview
• Problem List Action Plan
• Mental Health Care Plan
• Resource List
• CBIS Skills
• Bounce Back program
• Antidepressant Skills Workbook

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Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
What changes can we make that
will result in improvement?
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The PDSA Cycle
Act
Plan

• Objective
• Questions and
• predictions (why)
• Measure of success
• Plan for the cycle (who,
• what, where, when)

• What changes
• are to be made?
• Next cycle?

Study
Do

• Carry out the plan
• Document problems
• and unexpected
• observations
• Begin analysis
• of the data

• Complete the
• analysis of the data
• Compare data to
• predictions
• Summarize what
• was learned

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Aim To improve the care of patients with mental
health problems
Improved outcomes
DATA
Cycle 5 Test 3 ways to access skills in
CBIS manual
Test (Patient B) Problem List/Action Plan
Cycle 4
Cycle 3
Test Diagnostic Assessment Interview (Patient B)
-Hand out Problem List
Use of mental health screening tools will help
identify patients needing support.
Cycle 2
Test the use of the PHQ9 with patients B and C
on Wednesday.
Cycle 1 Test use of PHQ9 with patient A on
Tuesday
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• Context / History

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Depression used as Lens
Lifetime prevalence of Major Depressive Episode
12.2 Past-year episodes 4.8 Past-month
episodes 1.3
Source Descriptive Epidemiology of Major
Depression in Canada. Patten, SB Wang, JL
Williams, JVA et al. Canadian Journal of
Psychiatry Feb 2006 51, 2 84.
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Why

• Picture in BC
• 2008 733,982 receiving services
• 638,208 by a GP
• 108,810 by a psychiatrist
• 104,441 in a community MH center
• 20,378 hospitalized

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Why

• 2003 module developed for Health Transition Fund
  -75 GPs
• GP numbers made consultation liaison model
  impossible
• Module developed to enhance GP skills in real
  time
• Made every mistake possible
• DID, 18 GPs until project ended (now 30 GPs)

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Why

• GPSC after GP survey, assessing our module, new
  fee incentive
• Funded this rollout

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Why

• Shift from acute to planned pro-active MH
  care
• Focus on efficient office time management
• Bridge with Mental Health and Addictions

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MOA Role

• Understand module
• Take CMHA course on Mental Health
• Feel comfortable with mental health patients
• Heightened awareness
• Know scheduling required
• Know the materials needed
• Have materials prepared/placed

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Compensation

• Case examples

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Whats Real

• YOU...are the experts in your practiceintegrate
  into your practice..
• Focus is adultsnot directly applicable for C/Y
  and elderly.your judgment

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Overview of Mental Health Module

• Show Overview Video

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PHQ-9
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PHQ-2 PHQ-9
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PHQ-2
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PHQ-9
9 questions used in scoring depression severity
Functional impairment question
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PHQ-9 Scoring
Step 1Need one or both questions endorsed as
2 or 3(More than half the days or Nearly
every day)
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PHQ-9 Scoring
Step 2Major Depressive Disorder Need 5 or more
questions endorsed as More than half the days
or Nearly every day (i.e. in shaded areas)
Step 3Total score Calculate score for columns
1,2 and 3
8
9
1
18
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PHQ-9 Scoring
Step 4Interpret results
Guide for Interpreting PHQ-9 Scores Guide for Interpreting PHQ-9 Scores
Score Provisional Diagnosis
05-09 Minimal symptoms ()
10-14 Minor depression () Dysthymia() Major depression, mild
15-19 Major depression, moderately severe
20 Major depression, severe
() If symptoms present two years, then
probable chronic depression. () If symptoms
present one month or severe functional
impairment, consider active treatment
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PHQ-9 Scoring
Step 5Is functional impairment endorsed as
Somewhat difficult or greater?
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What is CBIS?

• Cognitive
• Behavioural
• Interpersonal
• Skills

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Manual Layout

• Introduction
• Flow charts
• Assessment
• Education
• Activation
• Cognition
• Relaxation
• Lifestyle

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Introduction

• TIPS
• Teaching
• Implementing
• Planning
• Supporting

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Flow Charts

• When in doubt go with the flow
• This directs you to the appropriate treatment
  strategies in the manual

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Assessment

• Diagnostic screening interview
• Screening worksheet
• Problem list
• Problem list action plan
• Resource list
• Self-assessment questionnaire
• Self-assessment profiles

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Education

• Understanding depression
• Frequently asked
• questions
• Signs and symptoms
• Medication?

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Activation

• Daily activities
• Energize
• Small goals
• Problem solving
• Chunking time
• Improving mood
• Self supportive

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Cognition

• Changing behaviour
• Changing thinking
• Changing feeling

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Relaxation

• Benefits
• Stress management
• Breathing
• Grounding
• Relaxation
• Mindfulness
• Meditation

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Lifestyle

• Sleep
• Nutrition
• Substances
• Exercise
• Wellness

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Navigating the Skills Manual

• Three ways to begin
• Problem list action plan
• Symptoms
• Self-assessment questionnaire

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Problem List Action Plan
ACTIVATION RELAXATION
I feel tired all the time
Irritable tense
I dont want to do anything
I overreact
Not interested in seeing friends
Arthritis pain
Sleeping during the day
COGNITION LIFESTYLE
No job Im too old to retrain
Drinking more coffee
I overreact
Having a few beers
I feel like a failure Ill never get a job
Stay up late watching TV
Sleeping during the day
MEDICATION REFERRAL
Tired all the time
No job job coach
Bankruptcy debt counselling
Arthritis Bounce Back
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Flow Chart
Healthy Habits For Sleeping, pg 68 Its True You
Are What You Eat, pg 69 Physical Activity, pg
71 The Wellness Wheel, pg 72
LIFESTYLE
Anti-Depression Activities, pg 31 Depressions
Energy Budget, pg 32 Small Goals, pg 34 Problem
Solving, pg 36 Opposite Action Strategy, pg
37 Chunk The Day, pg 38 Improve The Moment, pg
39 Appreciation Exercise, pg 40
ACTIVATION
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Flow Chart
RELAXATION MODULE Abdominal Breathing, pg
57 Grounding, pg 58 Passive Relaxation, pg
61 Mindfulness, pg 64
PANICKY

• COGNITION MODULE
• The Circle Of Depression, pg 42
• Common Thinking Errors, pg 44
• Thought Change Process, pg 45
• Self Talk (Mean Talk), pg 47
• Thought Stopping, pg 48
• Good Guilt / Bad Guilt, pg 50
• Is Anger A Problem For You, pg 54

• NEGATIVE THINKING
• COGNITIVE DISTORTIONS

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Self-assessment Questionnaire

• 0 never or rarely true to me 1 somewhat
  true 2 quite a bit true 3 very true of me
• ____ Its hard for me to say no to people even
  if I dont want to agree or dont have the time
  or energy
• ____ I will do almost anything to avoid hurting
  peoples feelings, whatever the cost to myself
• ____ I do lots of things for others, even at the
  expense of meeting my own needs

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Flow Chart
ACTIVATION MODULE Anti-Depression Activities, pg
31 Depressions Energy Budget, pg 32 Small Goals,
pg 34 Problem Solving, pg 36
ACTIVATION
RELAXATION MODULE Abdominal Breathing, pg
57 Grounding, pg 58 Passive Relaxation, pg
61 Mindfulness, pg 64
PANICKY
OVER-THINKER PROFILE
ASSESSMENT MODULE Over-thinker Profile, pg 24
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Questions and Discussion
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Diagnostic Assessment Interview

• Teaching Points

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Diagnostic Assessment Interview
Show Video
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Diagnostic Assessment Interview

• Frequently Asked Question 1

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Diagnostic Assessment Interview

• Frequently Asked Question 2

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Diagnostic Assessment Interview and Handing Out
the Problem List (20 min practice 10 min
debrief)
GP Skills Practice Session
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Organizing the Problem List into a Problem Action
Plan
Show Video
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Problem/Resource List Action Plan

• Frequently Asked Questions

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Questions and Discussion
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Develop Problem List Action Plan(20 min 10 min
debrief)
GP Skills Practice Session
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Fee Codes

• Case Study 2

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Meet Mrs. J

• 47 yrs. old married, school age children
• SSRI for depression (laid off a year ago)
• 1 previous episode, also situational
• Mother had depression requiring treatment
• Osteoarthritis diabetes and hypertension
• Not interested in old hobbies, no energy, crying
  frequently
• Bitter, worried napping much of the day

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January

• Headaches, not sleeping well, blowing up at
  even small irritants
• Not eating regularly has lost weight
• Initial neurologic examination is normal
• You spend 20 minutes counselling her on the
  probable diagnosis of depression

Counselling 1 Fee Code 00120 Diagnostic Code
311 Value 51.32
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One Week Later

• Labs normal PHQ9 17
• CBIS Diagnostic Assessment Interview confirms
  diagnosis of recurrent depression, and
• You spend 30 minutes counselling her alcohol,
  caffeine problem list SAQ

Counselling 2 Fee Code 00120 Diagnostic Code
311 Value 51.32
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Another Week Later

• Problem list and the SAQ
• Problem List Action Plan (CBIS)
• BounceBack Referral
• You spend 30 minutes counselling

Counselling 3 Fee Code 00120 Diagnostic Code
311 Value 51.32
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Mental Health Planning Visit

• Review diagnosis, Problem List Action plan,
  Resource List
• Reassess emotional and mental status
• Jointly develop a plan
• CBIS activation skills (2)
• 30 minutes MH Planning Visit

MH Plan (30 min) Fee Code 14043 Diagnostic Code
311 Value 100.00
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Follow-Up

• Telephone Follow-up (Day 3 and 1 week)
• Regular office visits (2)
• MH Follow-up Calls 1 and 2
• Office Visit 1and 2

MH Phone F/U 1 Fee Code 14049 Diagnostic Code
311 Value 15.00 MH Phone F/U 2 Fee Code
14049 Diagnostic Code 311 Value
15.00 Office Visit 1 Fee Code 00100
Diagnostic Code 311 Value 29.49 Office Visit
2 Fee Code 00100 Diagnostic Code 311 Value
29.49
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Unplanned Visit

• Panic / overwhelmed
• Takes 15 min to settle her
• Office Visits 3
• Community Patient Conference 1

Office Visit 3 Fee Code 00100 Diagnostic Code
311 Value 29.49 Comm. Pt. Conf 1 Fee Code
14016 (Units x1) Diagnostic Code 311 Value
40.00
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Over next 6 months

• CBIS working on skills
• ASW coaching
• PHQ9 down to 7
• Follow up on diabetes, etc
• Office Visits 4 thru 9

Office Visit 4 Fee Code 00100 Diagnostic Code
311 Value 29.49 Same for Office Visits 5,
6,7,8,9 (note 6 code 250)
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Physical and CDM

• Time for complete physical
• Review CDM
• Discuss mental health plan
• Physical Exam
• CDM review

CPX Fee Code 00101 Diagnostic Code
250 Value 65.54 CDM Diabetes Fee Code
14050 Diagnostic Code 250 Value 125.00
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Follow-up

• Telephone follow-up
• MH Follow-up Call 3

MH Phone F/u 3 Fee Code 14049 Diagnostic Code
311 Value 15.00
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Next Visits (over 3 months)

• Counselling visits
• Office visit coaching ASW CBIS skills
• 20 minutes counselling sessions (45)
• Office Visit 10

Counselling 4 Fee Code 00120 Diagnostic Code
311 Value 51.32 Counselling 5 (GPSC) Fee
Code 14044 Diagnostic Code 311 Value
51.32 Office Vist 10 Fee Code
00100 Diagnostic Code 311 Value 29.49
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Total Billing

• 912.04

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Bounce Back (Overview)

• Funded to support Family Practice
• Where it fits
• DVD versus telephone coaching
• Coach is available to give overview at learning
  sessions
• Feedback loop
• Research stream
• 1-866-639-0522

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Bounce Back

• Show Bounce Back Video

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Tasks Action Period 1

• Conduct initial chart review target patients
  with chronic conditions, thick charts, chronic
  pain, etc.
• Use PHQ-9 screening tool with at least 20
  patients with potential mental health problems
• Conduct a 2nd PHQ-9 assessment within 3-6 months
  for 95 of those patients in this group
• Use the Diagnostic Assessment Interview for at
  least 10 patients with positive PHQ-9
• Document suicide risk assessment in the patient
  chart if the suicide question on the PHQ-9 or
  Diagnostic assessment Interview was positive

/
84
Tasks Action Period 1

• Develop a problem list for 10 patients with an
  Axis I diagnosis
• Develop a resource list for 10 patients with an
  Axis I diagnosis
• Develop an action plan from the problem list for
  10 patients with an Axis I diagnosis
• Use skills from the CBIS Manual with 10 patients
  with mental health problems
• Refer 10 patients screened as having
  mild/moderate depression to the Bounce Back
  Program
• Offer Anti-depressant Skills Workbook (ASW) and
  provide some coaching to 10 patients screened as
  having depression

/
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Tasks Action Period 1 (contd)

• Report data results with monthly narrative report
• Follow up with patients (MOA can follow up with
  patients on homework and goals agreed to in
  action plans)
• Identify changes to work processes and office
  re-design
• Records PDSA tried with plans, predictions,
  analysis, etc.
• Record overall progress towards aims
• Participate in team calls with support teams and
  peers