Alliance Health Conf

8/9/2019 Alliance Health Conf

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Improved Screening andManagement of Depression in the

Skilled Nursing Facility andLong-Term Care Setting

Center for Medicare Medicaid Services!CMS" Special Study

#resented $y% &icki 'oyle( )N( 'SN( #ro*ect Manager

To the +lliance for ,ealth


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#resentation utline

#ro*ect $ackground #ro*ect o$*ectives

#ro*ect design

M#) interventions Data analysis and findings

.uestions and discussion


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#ro*ect 'ackground

ne of t/o CMS pro*ects a/arded to .ualityImprovement rgani0ations !.I" on thetopic of Depression in 1223

Michigan .I !M#)" is /orking in the nursinghome setting

Ne/ 4ork .I !I#)" is /orking in the cardiacreha$ setting

#ro*ects $egan 5uly 1223


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Incidence and Significance of

Depression in the 6lderly 789 million !3:;" of +mericans older than :eriatric Depression% Lack of

)ecognition 50% of depressed nursing homeresidents are not appropriately

diagnosed

Less than 25% of depressed elderlyreceive adequate treatment

?,4@


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)easons for Missed Diagnosis

Depression symptoms are attri$uted to age(other physical illness( $ereavement( ordementia

Stigma associated /ith mental illness Depression is masked $y somatic symptoms

#atients deny psychiatric symptoms

InadeAuate assessment of elderly in nursinghomes

Depressed patients often present nomanagement pro$lems


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ConseAuences of Missed Diagnosis

or InadeAuate TreatmentSuicide 3B; of suicides occur in patients :< and older

(allahan , 2&&&)

lder adults account for 31; of the S

population $ut 12; of the more than =2(222suicide deaths annually (allahan , 2&&&)

6lderly /hite men age 9< and older suiciderate is : times higher than the generalpopulation (/$yert et al, 1999)

B2; of suicides see their primary carephysician /ithin one month of suicide($n0ell 199")


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ConseAuences !continued"

>reater Mor$idity

Impaired a$ility to manage other illnesses

Decreased Auality of life

Strain on family and health care /orkers

Decreased compliance /ith medical treatment

Depression increases mor$idity and mortality

in patients /ith congestive heart failure !C,F" Depression /orsens mor$idity post-stroke

and myocardial infarction !heart attack"


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Increased Mortality

Increased risk of death $y


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CoEt

Increased use of medical services

Chronicity% 1 in 4 depressed patients will be ill for

> 2 years

)ecurrence% ore than 50% will have arecurrence

#remature placement in nursing facilities Increased risk of hip fracture due to falls


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#revalence of Depression as a#revalence of Depression as a

ConcomitantConcomitant Condition

&1

21

&1

Cancer Dia$etes #ost-

#artum

#ost-

Stroke

#ost MI

assie /$llan, 199' 4ustman et al, 199' 5$*ie 6al+er,

1992' $rris et al, 199&


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#ro*ect $*ectives

Long-term $*ective

Improvement in depressive symptoms for theresident /ith an increase in daily function

Improve systems for depression management


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M#) Interventions )eadiness assessment of the facilities to determine

characteristics and resources

6ducational sessions !C6s for nursesHassistantsJ CM6for physicians( familyHresident education"

#ro*ect toolkit

n-site visitsHtechnical assistance

C.I consultation and tools

Data collection and analysisHDevelop data collection tool

Data reports and discussion !May 1221 and Novem$er1221"

+ssist facilities to develop a systematic process fordepression screening( assessment( and treatment

Interdisciplinary approach


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Development of Indicators

sing eisting literature and practiceguidelines( M#) developed o$*ectives forthe pro*ect

These o$*ectives /ere then revie/ed /ith

the Technical 6pert #anel !T6#"J dataavaila$ility from the MDS /as investigated


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.uality Indicator 3a and )esults

Proportion of newly admitted residents who areassessed for depression using the Geriatric

Depression Scale (GDS) by day 7 of stay

DK +ll residents /ho fulfill the inclusion and eclusioncriteria K 939

NK Those in the denominator /ith assessment done $y dayB K B3

)ate K ;


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.uality Indicator 3$ and )esults

Proportion of newly admitted residents who

are assessed for depression using the GDS by

day 14 of stay

DK +ll residents /ho fulfill the inclusion and eclusioncriteria K 939

NK Those in the denominator /ith assessment done $yday 37 K 1

)ateK 33;


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.uality Indicator 1a and )esults

Proportion of depressed residents who

receive depression treatment by day 7 of stay

DK )esidents /ith symptoms andHor a diagnosis of

depression $y day B of stay K 1:

NK Those in the denominator /ho receive depressiontreatment $y day B of stay K 12=

)ate K B


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.uality Indicator 1$ and )esults

Proportion of depressed residents who receive

depression treatment by day 14 of stay

DK )esidents /ith symptoms andHor a diagnosis of

depression $y day 37 of stay K =3=

NK Those in the denominator /ho receive depressiontreatment $y day B of stay K 179

)ateK B;


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Criteria for .Is 1a and 1$

Depression diagnosisHsymptoms may $e foundin the chart or MDS

Depressed residents must ehi$it symptomsincluding sad mood and t/o or more of the

follo/ing% Negative statements

+gitation or /ithdra/al

?aking /ith an unpleasant mood or not $eing a/ake

for most of the day and not comatose

'eing suicidal or having recurrent thoughts of death

?eight loss


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Criteria for .Is 1a and 1$

Treatment includes !any of the follo/ing" +ntidepressant medication

#sychological therapy $y any licensed mentalhealth professional

>roup therapy


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#revalence of Depression andTreatment

5e7resse 7ri$r t$

amissi$n

31

n821$t e7resse

-

n8"9

e0 ly ia:n$se

13

n81&(

#; 7ri$r t$

amissi$n

(1n82&3

$ #; 7ri$r t$

amissi$n

19

n8"(


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.uality Indicator = and )esults

Proportion of residents assessed positivefor depression by the GDS by day 14 who are alsoassessed positive for depression by the DSassessment

DK )esidents /ho /ere positive for depression $y the >DS!score < or more" $y day 37 of stay K 71

NK Those in the denominator /ith symptoms andHor a diagnosisof depression noted in either the MDS < day or 37 dayassessment K 1:

)ateK :1;

Di th t + M ft i


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Diseases that +ppear More ften in)esidents /hose Symptoms

Did Not Improve

34%

27%

52%

38%

27%

15%

23%

8%

35%41%

18%

57%49%

36%

19%23%

7%

40%

0%

20%

40%

60%

80%

100%

Allergies Seizure disorder Osteoporosis Emphys!O"# A$emi Arthritis

Symptoms &mpro'ed Symptoms #id (ot &mpro'e Smple


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Diseases that +ppear More ften in)esidents /hose Symptoms Improved

46%

38%

85%

31% 31%

46%

16%

23%25%

66%

20%

27%

27%

13%16%

73%

30%

22%

0%

20%

40%

60%

80%

100%

#i)etes !*+ Stro,e *yperte$sio$ "eriph 's- dis *emiplgi

Symptoms &mpro'ed Symptoms #id (ot &mpro'e Smple


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?hat ,appens to )esidents

/ho are Treated@


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?hat ,appens to )esidents /hoare Treated@

TI 1 indicated that =1 out of =< people /ho aretreated and /hose condition /orsened /erereassessed $y day :2 of stay

Diagnosis confirmedHresponse evaluated K 3!


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Conclusions

.I 3% The >DS is not consistently used $y the37 participating facilities to screen fordepression

.I 1( TI% The ma*ority of the residents identified

/ith depression are receiving treatment

.I =% The MDS is not sufficient $y itself toidentify depression

.I 1( TI = 7% +ntidepressant medication is theprevalent method of treatment

TI = 7% The ma*ority of the residents receivingtreatment are not improving $y day :2


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Conclusions

The ma*ority of the =1 residents /ith :2-daystays /ere reassessed after treatment fordepression /as initiated( $ut in


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Interim )emeasurement )esults

9% 11%

75%79%

62%

47%

60%

69%76%

52%

0%

20%

40%

60%

80%

100%

nB=818 nI=586

Assessed by Day7

nB=818 nI=586

Assessed by Day14

nB=269 nI=159

DepressedResidents Treated

by Day 7

nB=313 nI=180

DepressedResidents Treated

by Day 14

nB=42 nI=77

Assessed Psiti!eby "D# a$s

Assessed Psiti!e

by D#

Base$ine

Interi&


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+lgorithm for Treatment of >eriatric

Depression


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+d*usting Treatment of Depression

if Initial )esponse is InadeAuate Increase dose of initial antidepressant

medication

Change to ne/ antidepressant medication

+dd psychosocial interventions

Implement augmentation strategy


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?hen to )efer to a #sychiatrist

)eferral definitely indicated% #sychotic depression

'ipolar disorder

Depression /ith suicidal ideation

)eferral usually indicated%

Depression /ith comor$id su$stance a$use

Depression /ith comor$id dementia

Depression that has not responded to anadeAuate trial of antidepressant medication


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ConclusionsH)ecommendations

It appears that treatment initiation hasimproved from pre-')+ 392s

The current issue may not $e the initiation oftreatment( $ut the algorithm for treatment

The algorithm for treatment should includestrategies to optimi0e treatment and manageresponses in the geriatric resident


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.uestions@

Thank you

Contact Information%

&icki 'oyle( )N( 'SN

B=7-7

Alliance Health Conf

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