Using health information technology to expand depression screening and treatment in primary care
About You
Section 1: About You
Section 2: About Your Organization
Organization Name
Institute for Family Health
Organization Website
Organization Phone
212-633-0800 x1309
Organization Address
16 E 16 Street, New York, NY 10003
Organization Country
United States
Is your organization a
Non‐profit/NGO/citizen sector organization
Your idea
Name Your Project
Using health information technology to expand depression screening and treatment in primary care
Country your work focuses on
United States
Describe Your Idea
Innovation
What makes your idea unique?
In 2004, the Institute for Family Health embarked on an ambitious initiative to increase identification and treatment of patients suffering from undiagnosed depression. Our goal was to achieve universal depression screening of adult patients seeking primary care at the Institute’s health centers.
Since depression identification and treatment has not traditionally fallen within the purview of primary health care, the need to provide systems-level support for this integration was apparent from the outset. To do this, we developed robust functionality within our electronic health record system to facilitate an integrated, collaborative approach to depression care in a medical setting. The result was a cultural transformation among the Institute’s primary care providers and other clinical staff, and depression screening rates as high as 90% at our health centers.
While the integrated primary care/behavioral health care model is gaining in popularity, the Institute’s use of the electronic health record to support its implementation of this model has enabled us to dramatically reduce instances of untreated depression through annual, routine screening of adult patients.
Do you have a patent for this idea?
Impact
This Entry is about (Issues)
What impact have you had?
Currently, nearly 75% of adult patients at Institute health centers are screened at least annually for depression. A 2006 research study of Institute patients enrolled in treatment for depression (medication, counseling, or a combination), conducted with Fordham University, found a statistically significant drop in PHQ9 (an evidence-based depression screening tool) scores between the initial visit and a three month follow-up visit, and between the three and six month follow-up visits.
One of the most profound impacts of the initiative was the cultural change among Institute primary care providers and other clinical staff unaccustomed to providing “mental health” care. “The number one thing was getting the doctors onboard, to buy into the program and recognize how it will help their patients and help the practice,” noted one staff social worker. Depression care integration has helped the Institute to promote a more holistic approach to health services delivery at our centers.
“If it wasn't for my doctor, my psychiatrist and my therapist, I wouldn't be here today,” said a 48-year old African-American/Puerto Rican patient, who did not wish to use her name. “I lost all of my faith when my depression got the best of me, but they believed in me. They called me, got me to come to the office when I felt my worst, and as time went on, I got better. My faith is back and I want to help others who felt like dying like I did.”
Problem
Institute health centers are located in high-need, medically underserved areas, and our patients face many barriers to accessing behavioral health services. The social stigma attached to mental health diagnoses contributes to a reluctance to seek help, and there is a shortage of mental health workers, particularly from minority groups.
To address this, the Institute integrates mental health care at its community health centers. The potential for benefit is well-documented: roughly 50% of mental health care for common disorders is provided in general medical settings and nearly 40% of primary care patients present with at least one mental health diagnosis. Many of these common disorders, notably depression, are under-diagnosed or under-treated. This is especially true for older adults, who are more likely to have undiagnosed depression, and less likely to seek treatment-- nearly half of older adults who committed suicide saw their primary care provider within a week before their death.
Actions
To achieve its success, the Institute convened a team of behavioral health, primary care and information technology staff members to develop systems-level tools that would support the integration of depression care into our practices at every level. We programmed the EHR to automatically prompt the intake nurse to ask all adult patients to complete an evidence-based depression screening tool. We also modified the EHR to include clinical supports such as on-screen assistance with differential diagnosis; additional point-of-care screenings, such as lethality screening; and order a consult with a mental health clinician. Clinicians can also use the EHR to print patient education materials; prescribe an anti-depressant; consult remotely with an offsite psychiatrist; and access a worksheet for developing self-management goals with the patient. To prioritize ongoing, active management of patients’ depression, the Institute developed custom reports which staff use to monitor their patient panels, or identify patients overdue for follow-up.
Results
The Institute’s efforts to ensure that primary care providers were “on board” with the project was key to success. According to Dr. Joseph Lurio, a family physician and the medical director of the Institute’s Amsterdam Center, “One of the issues was how to identify patients with depression early on, and how to provide the best kind of treatment, given the time constraints of primary care.” Dr. Eric Gayle, a family physician and medical director at the Institute’s Parkchester Family Practice, where the depression care integration project was piloted, notes, “Once you start treating patients experiencing depression, you start seeing improvements in the rest of their well-being as well.”
What will it take for your project to be successful over the next three years? Please address each year separately, if possible.
The Institute pilot-tested the collaborative depression care model at one health center in 2001, and has since implemented it at an additional fourteen health centers. Depression screening in the primary care setting is a cost-effective way to identify patients early on, and assist them in accessing needed care in a comfortable manner. Unfortunately, treatment for depression in the primary care setting is inadequately reimbursed by insurers. The Institute supports changes to insurance reimbursement structures that will support full integration of behavioral health and primary care services.
What would prevent your project from being a success?
This project has already been successfully implemented at 15 health centers, and could be replicated at other organizations equipped with electronic health records.
How many people will your project serve annually?
More than 10,000
What is the average monthly household income in your target community, in US Dollars?
$1000 - 4000
Does your project seek to have an impact on public policy?
Yes
Sustainability
What stage is your project in?
Operating for 1‐5 years
In what country?
United States
Is your initiative connected to an established organization?
Yes
If yes, provide organization name.
Institute for Family Health
How long has this organization been operating?
More than 5 years
Does your organization have a Board of Directors or an Advisory Board?
Yes
Does your organization have any non-monetary partnerships with NGOs?
Yes
Does your organization have any non-monetary partnerships with businesses?
Does your organization have any non-monetary partnerships with government?
Yes
Please tell us more about how these partnerships are critical to the success of your innovation.
The depression care project worked because of the collaboration between the Institute’s interdisciplinary team of staff members, including primary care providers, behavioral health staff, information technology staff and administrative staff.
The Institute maintains active linkages with a number of community organizations and agencies that work with the elderly, families, adolescents, children, people with disabilities, and people needing mental health services. These numerous community partnerships help us to ensure that our services are accessible and are relevant to the needs of the communities we serve.
What are the three most important actions needed to grow your initiative or organization?
One of the most profound impacts of the depression care initiative was the cultural change among Institute primary care providers and other clinical staff unaccustomed to providing “mental health” care. “The number one thing was getting the doctors onboard, to buy into the program and recognize how it’s going to help their patients and help the practice,” noted social worker Regina Epperhart, LMSW. Depression care integration has helped the Institute to promote a more holistic approach to health services delivery at our centers.
The Story
What was the defining moment that led you to this innovation?
Beginning in 1993, when we hired our first clinical social worker, the Institute has endeavored to integrate mental health and primary care in each of its health centers. Institute leadership recognized that the separation of mind and body which permeates the entire health care delivery system in the United States resulted in less effective care for many individuals, especially those with co-morbid medical and mental health conditions.
In 2002, the Institute implemented an electronic health record (EHR) and practice management system in all of its practices, becoming the first freestanding ambulatory care network in New York City and one of very few nationally to have a fully integrated EHR system. Since 2003, the Institute has been completely “paperless,” and all chart notes, clinical data, and patient information is stored within the electronic health record system. The full integration of the EHR system presents unparalleled opportunities for data collection and monitoring, and has enabled us to significantly improve the quality of care we provide to our patients.
Once the EHR was fully integrated at all of our health centers, it became clear that we could use the system to support our staff in routinizing depression care screening for adult patients.
Tell us about the social innovator behind this idea.
Neil Calman, MD, president and CEO, is a board-certified practicing family physician, who has led the Institute since its founding in 1983. In 2002, Dr. Calman led the Institute’s efforts to develop and implement an electronic health record (EHR) and practice management system in all of its practices.
Dr. Calman has published on the importance of harnessing the potential of electronic health records to eliminate racial disparities in health outcomes, and has won two prestigious awards from the Healthcare Information and Management Systems Society. In 2005, Dr. Calman earned the Physician’s IT Leadership Award. In 2007, he received the Davies Public Health Award of Excellence, which is awarded to organizations that have made outstanding contributions to public health through the use of health information technology. In 2009, Dr. Calman was appointed to President Obama’s Health Information Technology Policy Panel, where he represents the interests of vulnerable communities.
Virna Little, LCSW-r, Psy D, vice president for psychosocial services, is responsible for the delivery of mental health and social work services at the Institute for Family Health’s 15 full-time and nine part-time federally-qualified health centers in New York State. Dr. Little began her Institute career in 1996 as the organization’s first social worker, and now heads a 150-member staff team that provides over 25,000 behavioral health patient visits annually in diverse, underserved communities across the state.
Dr. Little is a champion of integrated care, and is a leader not only within the Institute, but in local, state and national advocacy efforts to support equity in behavioral health care. She regularly participates in collaborations and research that support community behavioral health care.
Together, Dr. Calman and Ms. Little have championed integrated models of care that expand access to high-quality, comprehensive health services in medically underserved communities.
How did you first hear about Changemakers?
Through another organization or company
If through another, please provide the name of the organization or company
New York City Department of Health
