Pre- and Post-MIDUS Workflow

MIDUS_HIV_collective-care-3

Post-MIDUS Workflow

Prior to implementing a collaborative care model, a Medical Assistant (MA) would call the patient to a room and perform vital signs. System-wide screening questions were asked and recorded prior to the. An HIV physician would meet with the patient.

HIV patients with depressive symptoms were only identified if:

A) the patient mentioned issues
B) the provider inquired about symptoms
C) an external person, such as the medical case manager or a significant other, raised concerns.

The provider would then:

A) initiate treatment
B) refer to psychiatry
C) do both
-or-
D) do nothing

Being referred to psychiatric care came with a long wait. Patients referred to psychiatry may wait 6 weeks to 3 months for an initial appointment.

Prior to receiving behavioral health services, patients are required to get a mental health assessment and these assessment times were often limited or were completed on a walk-in basis.

Once a patient completes the evaluation, they are then scheduled to see a Master’s or Ph.D. level therapist and/or a mid-level prescriber or physician based on the results.

Finally, the psychiatry department has had a “no-show policy” which impacts future scheduling for no-show patients. These barriers add time to the process of initiating behavioral health services and our HIV patients were often “getting lost” in the system.

Post-MIDUS Workflow

Healthcare providers at the MetroHealth HIV Clinic implemented a collaborative care model to improve the identification and treatment of depressive symptoms among people living with HIV. This model has been used in primary care settings to bridge the gap in depression care and has been shown to improve access to care, processes, and outcomes.

At MetroHealth today, all HIV patients complete a PHQ-2/9 annual screening to identify depressive symptoms and medical assistants (MAs) enter results into the electronic health record (EHR).  Scores >10, initiate the collaborative care model. Re-measurement algorithms are used to determine the effectiveness of treatment plans and augment treatment when a patient has not responded adequately. An electronic registry is used to access population health information at a glance, determine who is due or overdue for remeasurement. And, a systematic case consultation provides treatment recommendations for depressed patients with HIV.

Behavioral Health Care Managers (BHMs) offer support to the patient, encourage self-management including establishing a behavioral activation plan . BHMs also assess “readiness” to make use of psychotherapy. BHMs complete mental health assessments (rather than being done in psychiatry) and those are reviewed with the Consulting Psychiatrist (CP) to determine a treatment plan. Notes are made in the patient’s Electronic Medical Record (EMR) detailing a treatment plan. The HIV care physician prescribes psychiatric medication along with HIV care while the  BHM ensures patients are aware of recommendations and assist with entry into psychotherapy or medication initiation.


Next: MIDUS Model Workflow Chart