Depression "nudge"
Location
Depression screening test scores recorded as lab values in an electronic health record “nudge” primary care providers to prioritize depression care.
About You
Location
Project Street Address
16 locations in NYS
Project City
Project Province/State
New York
Project Postal/Zip Code
Project Country
United States
Your idea
Year organization founded:
1983
Year initiative began:
2004
Service/activity focus:
Other
If Service/activity focus is "other" please define in 1-2 words below:
Depression
YouTube Upload
Project URL
Name Your Project
Depression "nudge"
Describe Your Idea
Depression screening test scores recorded as lab values in an electronic health record “nudge” primary care providers to prioritize depression care.
Innovation
What is your signature innovation, your new idea, in one sentence?
Depression screening test scores recorded as lab values in an electronic health record “nudge” primary care providers to prioritize depression care.
Describe what makes your idea unique--different from all others in the field.
The Institute uses its fully-integrated electronic health record system to facilitate the identification and treatment of depression in the context of the primary care relationship. The use of the EHR has enabled us to make depression screening and treatment a routine part of primary care across our network of 16 health centers.
While the integrated care model is gaining in popularity, the Institute’s use of the electronic health record to support its implementation has enabled us to dramatically reduce instances of untreated depression through annual, routine screening of adult patients. Though seemingly simple, the Institute’s decision to record the depression screening score as an abnormal lab value was a key innovation: since primary care providers are accustomed to responding quickly to abnormal lab values, recording the score in this way fosters an appreciation of depression as an actionable, treatable condition like any other—one that can be managed in the primary care setting.
Do you have any existing partnerships, and if so, how did you create them?
The nudge described here was the result 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’s collaborative depression care model is based on the evidence-based Project IMPACT: Improving Mood, Promoting Access to Collaborative Treatment.
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.
In which sector do these partners work? (Check all that apply)
Citizen sector (non profits, NGOs) .
Impact
Provide one sentence describing your impact/intended impact.
The Institute’s goal is to make depression screening a routine part of primary care; and make it easy for patients to access treatment.
Please list any other measures of the impact of your innovation.
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.
Is there a policy intervention element to your innovation?
The Institute supports changes to insurance reimbursement structures that will support full integration of behavioral health and primary care services. Fortunately, some New York State officials are advocating for increased integration of primary care and mental health services, and are seeking ways to enhance reimbursement for providers who are offer coordination of care.
How many people does your innovation serve or plan to serve? Exactly who will benefit from your innovation?
Institute health centers currently serve nearly 54,000 adult patients annually; the vast majority are low-income and have limited access to health services. By implementing routine depression screening at our health centers, we can identify patients early on, and offer them onsite treatment services that are managed collaboratively by their primary care physician, a mental health clinician, and a psychiatrist.
What is the key decision that you are trying to influence through your innovation/design?
The Institute’s innovative recording of the depression screening score as a lab value influences two key decisions. The first is the decision on the part of the primary care provider to incorporate depression care into their practice, and into the patient’s treatment plan. The second is the patient’s decision to accept and participate in treatment.
What have you learned about how people respond to your innovation/design?
We have found that a system-level support, such as the electronic “nudge” provided by the abnormal lab value, can help providers to incorporate new care processes into their practices. We have also found that involving the primary care provider, and locating behavioral health staff at the health center, greatly increases the likelihood that patients will participate in treatment for depression.
This Entry is about (Issues)
Sustainability
How is your initiative financed (or how do you expect your initiative will be financed)?
Initially, staff training, as well as the modifications to the EHR system, were financed through grant funding. Now that the model has been implemented, depression screening has become a normal part of everyday clinical activities, and is financed through ordinary patient care revenues.
Financing source
Annual budget
$46.5 million
Annual revenue generated
$46.5 million
Number of staff (full-time, part-time, volunteers)
600
What are the main financial barriers, and how do you plan to address them?
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 hopes that successful, collaborative depression care models like ours will “nudge” insurers to increase payments for these valuable health services!
Aside from financial sustainability, how do you plan to grow and scale the initiative?
The Institute has already grown the initiative from a pilot project at one health center in the Bronx to a network-wide program implemented at each of our 16 full-time health centers in New York State. We regularly take advantage of opportunities to promote the model to the health provider community.
The Story
What was the motivation or defining moment that led to the creation of this innovation? Tell the story.
Institute health centers are located in high-need, medically underserved areas, and our patients face many barriers to accessing behavioral health services. In some communities, the social stigma attached to mental health diagnoses contributes to a reluctance to seek help. Furthermore, there is a shortage of mental health workers, particularly from minority groups.
To address this, the Institute develops models to integrate mental health care at its community health centers. In 2001, the Institute embarked on an ambitious initiative to identify and treat patients suffering from undiagnosed depression. Our goal was to make depression screening a routine part of primary care, and to facilitate a team approach to managing depression in patients.
“If it wasn't for my doctor 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.”
The Institute’s efforts to ensure that primary care providers were “on board” with the project was a key to success. Dr. Eric Gayle, medical director at the Parkchester Family Practice, where the depression care integration project was piloted, notes, “Once you start treating patients with depression, you see improvements in the rest of their well-being as well."
Please name and provide a personal bio of the social innovator behind this initiative.
Neil Calman, MD, president and CEO, is a board-certified practicing family physician, who has led the Institute since its founding in 1983. Virna Little, LCSW-r, Psy D, vice president for psychosocial services, is responsible for the delivery of mental health and social work services at all Institute health centers. 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.
At what stage is this initiative?
Implemented with replication and scale-up.
What resources would you need to take your initiative to the next stage?
The Institute hopes that the success of this model of care will prompt increased reimbursement from insurers, which will in turn lead to wider availability of integrated care for underserved patients.
How did you hear about this contest and what is your main incentive to participate? (Confidential)
We heard about the contest from the New York City Department of Health. We are pleased to share this simple innovation with other providers to help increase access to integrated mental health care.
- Login to post new content in this forum.
Comments
Maxine,
Correct me if I am mistaken, but this idea sounds like it fits under the category of evidence-based health care that some medical professionals and economists are hoping to build on. Could you explain to me more about how screening for depression usually works and what kind of biases in judgment are made? Is your idea more accurate? Does it save time? What kinds of feedback mechanisms can you build into procedures for displaying and using the depression screening score so that it will not be easily ignored?
John
----------
John Balz
Changemakers Featured Commentator
Hi Maxine-
I actually have a similar question to that which was posed by John. For those who may be unfamiliar with how depression issues are currently handled in doctor's offices, can you explain a bit about what the standard practice is and how this is different? Also, I assume the behavior change then happens with the doctors more than the patients. Is that true?
This sounds very promising and I'm excited to learn more!
Thanks!
-Chloe Feinberg
Ashoka
Full Economic Citizenship
Thanks for the great questions, Chloe and John. Current practices for depression screening and treatment in medical settings vary widely, and there is not one clear standard. Traditionally, there has been a divide between “medical” and “mental” health care, and this plays out in all kinds of ways. Providers may or may not feel equipped, or be willing, to recognize depression in their patients. Patients may not be inclined to report symptoms of depression to their medical doctor, because of embarrassment, fear, or because they don’t know if it is an appropriate topic to bring up with their doctor. Patients may speak up about “medical” symptoms like fatigue, insomnia, or chronic pain, but not report feelings of sadness or hopelessness.
That paradigm is now shifting, thanks to a number of individuals and institutions who are advocating for, and implementing, integrated service delivery. Some of these models are indeed evidence-based: the one we are most familiar with is the IMPACT model, which the Institute piloted at its Bronx health centers a few years ago, to great success. But there are lots of folks across the country who are working to diminish the stigma associated with a “mental health” diagnosis, and increase access to effective treatments. Access to depression care in the primary care setting is especially important because for most people, the primary care office is their “entry point” to the health care system. Routine screening in the context of primary care could prevent many patients with depression from slipping through the cracks.
(Response continued in next message.)
(Response continued from previous message.)
Chloe, to answer your question, we have found that the behavior change occurs on both the patient and provider levels. Though they may not raise the subject themselves, patients are generally willing to report symptoms of depression if they are specifically asked about them. This is why regular, routine screening is so important: it “nudges” the patient to consider that depressive symptoms are a health concern, and are treatable. The Institute for Family Health's signature innovation (recording a high depression screening score as a “lab value” in the electronic health record) tackles the other side, and is oriented towards the providers. Even providers who feel well-equipped to identify and treat depression in their patients benefit from the “nudge” of the lab value, because it mimics the way they track and respond to patients’ other needs. It puts depression in the realm of other, more familiar, concerns. For example, elevated cholesterol levels are also recorded as abnormal lab values in the EHR, and providers know immediately how to respond to this clinical information. The Institute’s “depression nudge” is fostering that same capacity with depression screening scores, so that we can provide better care to patients experiencing depression.
The other advantage of recording the screening scores as lab values is that we can then use the EHR to graph the scores over time, and to generate reports (for example, a phone list of patients with high screening scores who have not had a follow-up visit) . This makes it easy for providers to see how patients are doing, and to coordinate outreach to at-risk patients. John, I think this gets at your question as to how we’ve been able to use the “depression nudge” to give feedback to providers, and make sure we don’t ignore the screening results.
I hope I’ve answered your questions—thanks again for the great feedback!
Congratulations! On behalf of RWJF and the Changemakers team, we are honored to declare you a winner of the Early Entry Prize for the “Designing for Better Health” collaborative competition! As a reward, you will receive a camcorder and a digital camera!
We hope that by submitting your innovation early, you have been able to generate feedback, dialogue, and insight about your initiative. Showcasing your blueprint and the challenges involved in creating social impact advises potential investors about how best to improve funding/investing patterns for the sector and to maximize the strategic impact and effectiveness of their future investments.
Please remember that your selection as an Early Entry Prize winner does not preclude you from winning the competition in any way, or guarantee finalist status—all entries will be equally evaluated per the Changemakers criteria at the completion of the entry period.
Congratulations, again!
Best wishes,
The Changemakers Team
----------
The Changemakers Team
Ashoka's Changemakers
On May 11, 2009, the judges reviewed the entries for the Changemakers “Designing for Better Health” competition and would like to pass on the following feedback (listed below) for your entry. Thank you for applying and for your hard work in the field. We are excited to archive your entry to serve as a leading solution for the worldwide community of innovators who are seeking solutions that help people make better choices regarding their health and the health of others. We wish you continued luck with your innovative, sustainable, and socially impactful initiatives.
All the best, The Changemakers Team
“ Good example of data-driven medicine. But if insurance companies don’t fully reimburse physicians and patients for mental health costs will your program still be able to gain traction? Also, can you provide more information about the rigor in which the algorithm works within the referral process? If this is included as an option, could it lead to over-diagnosis?”
“Interesting idea with demonstrated impact, has already scaled up to involve all clinics in their system. A lot happens in a medical visit and doctors don’t always take into account that depression is under diagnosis.”
- Changemakers “Designing for Better Health” Judges: Doutores da Alegria, The Robert Wood Johnson Foundation, Cornell Food and Brand Lab: Cornell University, Innovations in Health @ Massachusetts Institute of Technology, Department of Pediatrics: University of California San Francisco.