Implementing the collaborative care model required a change in the workflow at the clinic:
- The medical technical assistant (MTA) ensures the patient completes the PHQ 9 and enters the results into the electronic medical records (EMR) during intake.
- For PHQ 9 scores > = 10, the BHCs is notified by the MTA, and the chart is flagged on the schedule in the EMR.
- The BHC meets with the patient during the clinic visit to review current symptoms, assess for suicidality, provide education on depression, and encourage personalized behavioral activation strategies.
- BHCs encourage patients to schedule a complete mental health assessment to ensure accurate diagnosis of depression and other comorbidities. When these occurred, they use a structured standardized assessment tool (MINI 6.0) and Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM 5) criteria. (Patients with schizophrenia, schizoaffective disorder, dementia, or cognitive impairment were excluded from the new workflow when it was determined by the treatment team that it would affect their ability to participate. Those with bipolar disorder and other mental health disorders such as post traumatic stress disorder were not excluded from the collaborative care intervention since it was felt that these individuals could benefit from certain aspects of collaborative care such as care coordination and self-management strategies.)
- The treatment algorithm determines when a patient should be re-measured for depression, as well as when depression treatment needs to be augmented based on their PHQ 9 score. Re-measurement is scheduled every three months until patients reached remission (< 5) at which time re-measurement was scheduled every six months for a year. For PHQ 9 < 5 patients remains in remission for a year, annual screening resumes.
- BHCs attempts to meet with patients at each follow-up visit to discuss adherence to previous recommendations, barriers to recommendations, and to assess symptoms. Treatment plans are reviewed and modified. BHCs contacts patients on a bi-weekly basis (either by phone or a message through the patient portal of the EMR) to maintain contact and provide support and advice for the patient on how to best follow their treatment plan.
- The consulting psychiatrist reviews select cases weekly with the BHCs. Treatment augmentation is indicated upon re-measurement for patients who do not experience response or remission in depressive symptoms (PHQ 9 score decreased by 50% or total score < 5) since their last PHQ 9 measurement. Treatment augmentation is defined as either an increase or change in psychiatric medication or referral to psychotherapy or referral to a psychiatrist. If augmentation is needed at three consecutive re-measurements and no adequate response is observed, the patient is formally referred to a psychiatrist. When a change is recommended, the psychiatrist makes a note in the EMR detailing the change in treatment and forwards this note to the patient’s primary care physician, who administers the change. The BHC ensures patients are aware of recommendations and changes.