Improvements in Depression Screening, Care Sustained in NRN Project

Involvement of Both Physician, Nonphysician Leaders Aids Change Process

September 21, 2010 04:15 pm David Mitchell

The AAFP's National Research Network, or AAFP NRN, and the American College of Physicians, or ACP, Research Network set out in 2005 to help primary care practices make and sustain changes in the way they screen for depression and provide better quality care for patients with depression disorders. Now, a study( recently published in the Journal of the American Board of Family Medicine, or JABFM, shows that practices that participated in the research collaborative did, in fact, demonstrate long-term improvements in care.

Moreover, an accompanying article( details how including both a physician and a nonphysician staff member as co-leaders on a process improvement team can facilitate progress in both clinical care and change management.

"The idea then, as now, is that there is a lot of interest in how practices can best implement activities that will help them deliver better quality care," said Donald Nease Jr., M.D., associate professor in the department of family medicine at the University of Michigan, Ann Arbor, and lead author of the article about sustaining improvements in care. "There has been a lot of work in depression in clinical trials, and it's been shown that physicians can change the way they screen for depression, deliver better quality care and improve outcomes.

"But once the studies end, things go back to the way they were before."

Sustained Clinical Care and Practice Change Improvements

Nease said the researchers sought to intervene in a way that would allow practices to implement change on their own and do it in a way that could be sustained. A key tool in that change was the nine-item Patient Health Questionnaire, or PHQ-9(, that is used for depression screening, diagnosis, treatment and monitoring. The project also taught participating practices how to implement tracking, care management and self-management support.

As important as the depression care improvements were, Nease said a central feature of the project was use of the Reflective Adaptive Process, or RAP(, model for practice change management, which helped practices learn how to implement other improvement changes, as well. The RAP model stresses the following factors:

  • having a vision, mission and shared values to guide the practice through the change and to focus the improvement team on defining what the practice wants to become and how to get there;
  • regular and effective meetings;
  • the ideas that everyone's voice should be heard and that conflicts must be resolved;
  • broad representation on the practice's improvement team; and
  • support and involvement of practice leaders.

Nease and colleagues previously reported in a 2008 article( published in The Joint Commission Journal on Quality and Patient Safety that 15 months after intervention, the primary care practices involved in the study had sustained the majority of changes implemented, including 13 of 16 practices that used the PHQ-9 for depression monitoring.

The current JABFM study report updates the progress of 15 of the 16 practices three years after the project began. Not only were the original 13 practices still using the PHQ-9 for depression monitoring, but one other practice had started using the tool for that purpose since the 15-month report. Additionally, 14 of the 15 practices continued to use PHQ-9 for depression screening and case finding.

More surprising, Nease said, was that use of the PHQ-9 for self-management support continued in two-thirds of the practices at 15-month follow-up, and seven additional practices had initiated self-management support since that time.

"Although practices didn't exactly tell us this, as patient monitoring with the PHQ-9 continued for longer periods, it seemed as if they needed some other tools to help patients," Nease told AAFP News Now, "and that's when they reached back for what we taught them about self management."

Use of tracking systems and case management, however, decreased from eight to four practices.

"The more complicated things were, the more difficult they were to sustain," Nease said.

Use of Physician and Nonphysician Practice Co-Leaders

The lead author of the related JABFM article, Kaia Gallagher, Ph.D., told AAFP News Now that her research team found changes were easier to make and sustain when practices used two co-leaders to champion practice improvements.

In this case, nonphysician leaders were responsible for tasks such as arranging meeting times, facilitating meetings, coordinating the work of the improvement team between meetings and following up on actions that needed to be taken between meetings, said Gallagher, who is president of the Denver-based Center for Research Strategies. The physician co-leaders focused more on clinical issues related to the project and were likely to take responsibility for setting priorities for the improvement team to address.

According to Gallagher, the same concept could be adapted to other practice changes, including moving to the patient-centered medical home model of care.

"Any process of change -- whether it's quality improvement, converting to an electronic medical records system or chronic disease tracking -- is easier in the context of having two co-champions," she said.

The two current JABFM articles are the third and fourth studies published from the joint AAFP NRN/ACP Research Network's Improving Depression Care project. In addition to the 2008 follow-up study cited above, a study( published last year in The Joint Commission Journal on Quality and Patient Safety found that successful quality improvement efforts should address both clinical content and change processes.