objective To use quality improvement (QI) practice facilitators in a community primary care pediatric practice in Ohio’s Appalachia to increase routine adolescent screening, diagnosis and management of depression. Example of a practice-specific aim statement: Increase use of a validated depression screening tool from 0% to 30%, and for those diagnosed with depression, the use of a management plan from 43% to 85% by 6/30/2016 and sustain through 12/31/2016. results Figure 5. Depression screening performance Initial interventions: Depression screening increased from 0% to 42%. Subsequent interventions: Performance increased to 91% and the centerline shifted to 80%. background Depression affects 12% to 20% of adolescents and up to 30% of Appalachian residents. Universal adolescent depression screening and management is recommended by the American Academy of Pediatrics. Still, routine depression screening is limited. QI practice facilitators can help clinicians standardize care, remove unwanted variation and improve outcomes. The QI practice facilitation model may improve depression screening and management at community pediatric practices by: • Improving screening rates • Equipping pediatricians to manage mild cases • Creating referral paths for patients diagnosed with depression Partners For Kids, an accountable care organization affiliated with Nationwide Children’s Hospital (NCH), offers practice facilitation services to guide community pediatric practices through QI projects. Practice facilitation is an evidence-based approach using an external coach (practice facilitator) to: • Manage QI projects aimed at improving patient outcomes • Train staff on QI methods • Use practice-level data to drive change • Help practices sustain improvements conclusion • Implementing behavioral health recommendations using practice facilitation led to increased screening, diagnosis and management of depression at an Appalachian primary care practice. • Practice facilitation using QI methodology can help community practices effectively implement evidence-based clinical recommendations. aim and key driver diagram Figure 3. Practice-specific aim and key driver diagram Practice Facilitation to Improve Behavioral Health Management at a Pediatric Practice in Ohio’s Appalachia Suzanne Hoholik, MBA, MBOE Christina Toth, MPH Mike Fetzer, BSISE Rebecca Baum, MD Stephen Cardamone, DO, MS, FAAFP Sean Gleeson, MD, MBA In early 2016, a non-NCH-owned practice in Ohio’s Appalachia region initiated a depression screening and management project with 6 months follow-up. Practice facilitators trained practices on the IHI Model and led recurring, on-site meetings where tests of change were discussed. Figure 1. Depression management tip sheet Initial interventions: • Complete checklist • Participate in training with specialist Subsequent interventions: • Develop screening process • Add dot phrases to EHR • Standardized patient charting Figure 2. Depression screening process map methods Figure 4. Practice depression management performance Documentation of evidence-based management of patients with depression increased from 43% to 85%. Depression Management Project Tip Sheet Screening checklist Things to have in place before your office begins universal screening. Processes: Scoring and documentation process Management of confidential concerns Crisis plan — staff trained on what to do in emergency Skills: Performing an assessment Recommending interventions Managing emergencies Resources: Patient handouts Referral sources Consultation tools Components of an Effective Management plan Things to document in the chart to meet the quality metric definition. All criteria should be completed within 1 month of the visit. Screening results Safety assessment (if positive for self- harm questions on PHQ-9; if negative, don’t need additional discussion) Interventions (first line advice, referral, consultation or medication) Follow up plan (can be PRN, esp. if they refer out) Process map for Depression Screening June 2016 Patient Flow Phase Yes Provider takes chart, PHQ-9 from outguide, reviews/adds score Provider starts exam. During exam, asks parent to leave, if present Patient fills of PHQ-9 When rooming pt., MA/nurse takes form and adds to chart, puts in outguide outside of room. Provder reviews with pt. Asks if they want this shared with parent Patient decides Parent asked back in, PHQ-9 reviewed. Provider discusses next steps, if necessary and notes in EMR and on PHQ-9 Yes Provider discusses next steps with patient, if necessary, adds notes to EMR and PHQ-9 No Exam continues and ends. Provider puts PHQ-9 with chart in outguide. MA takes chart and PHQ-9, leads pt. to check out. Gives chart/ PHQ-9 to front desk for scanning When time available, front desk staff scans in PHQ-9 into EMR Billing office sees code and scanned PHQ-9 in EMR, bills for service Process ends PHQ-9 given to pt. at check-in on clipboard