Slide 2 / / Instructions to view video embedded in slide:
- slide presentation with embedded videos may be played directly from the DVD – if you choose to copy to your personal computer, please note that all videos and the slide presentation must be copied together to the same folder or to your desktop
- to play video embedded in slide, click on the picture of the video (automatically full screen format)
- to pause the video, click anywhere on the screen
- note: there is no rewind or fast forward capability for viewing this video when it is embedded within the slide
- video will automatically ‘rewind’ at end
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Slide 4 / / The BTS Model for Improvement was first developed by Tom Nolan and colleagues, and is described in detail in The Improvement Guide (Langley, Nolan, Nolan, Norman, and Provost, Jossey-Bass, 1996).
The Model for Improvement is based on the idea that every system is designed to give you exactly the results you get. To get different or improved results, you have to change the system. We already discussed the three fundamental questions for improvement. The action part of the model is the Plan, Do, Study, Act Cycle; it gives you a method to learn how to make the changes that will result in improvement.
Slide 5 / / The Model for Improvement is action-oriented, with immediate planning and testing of changes. “What are you going to test next Tuesday?” is the mantra. This is much different than earlier models of quality improvement that involved months of planning and D-day the “Do- It Day,” followed by almost immediate failure of the new system.
The Model for Improvement is characterized by rapid-cycle testing of changes and all changes are evaluated and revised if necessary prior to change implementation. Changes are tested in small pilot populations before they are spread to a larger population. The impact of changes is defined by improvement in data; measures are tracked using a run chart and changes are annotated. Tests of change along with outcome data are recorded on monthly basis.
Slide 6 / / In this Train-the-trainer session, you as a Trainer, are a member of the pilot population. The patients with mental health problems that you work with during this collaborative are also members of a pilot population within the province. Changes within primary care that produce a new system of mental health care need to be tested and adapted in small populations, then spread to larger populations.
Point out the pilot populations (trainers and patients) and the total population.
Slide 7 / / The Model for Improvement contains three questions that any successful improvement effort must address.
1. The first question “What are we trying to accomplish?” is about creating an aim statement that focuses our improvement work. The aim statement should be measurable, specific, and should require taking the status quo off the table in order to achieve it.
2. The second question “How will we know that a change is an improvement?” requires that the team decide on how it will measure its progress in reaching the aim. For example: you don’t know whether your golf game is improving unless you keep track of the number of strokes per round.
3. The last question, “What changes can we make that will result in an improvement?” helps us consider the set of changes that will lead toward improvement, toward the aim. We are not making change for the sake of change, we need to utilize a set of evidence-based changes have been shown to be effective in improving the measures?. This question is based on the assumption that all improvement requires change, but not all changes lead to improvement.
So let’s look at each of the questions more specifically
Slide 8 / / In order to answer the question “What are we trying to accomplish?” , we need to develop an aim statement. The characteristics of an aim statement are:
1) that an action word like “change” or “improve or “redesign” is used to denote a change from the status quo; 2) that the population targeted for change or impacted by the set of changes is identified in the statement; 3) that the set of changes being used to improve care is identified (in this scenario the Mental Health Change Package and Expanded Chronic Care Model); and
4) that the most important outcome measures are listed in the statement (i.e. use of the CBIS manual).
Slide 9 / / So an office aim statement that might be something like this (read the aim statement). Each GP office should design its own aim statement and it should include all of the bolded characteristics:
Redesigned = change
Physicians = population of focus
Mental health change package = set of changes
Depression screening tools, etc. = outcomes
Slide 10 / / Let’s look closer at the second question “How will we know that a change is an improvement?”
Slide 11 / / These are important process measures for the Train-The-Trainer mental health collaborative. They have been selected because they are important to the care of patients with mental health problems and are therefore important skills for GPs caring for patients with mental health problems.
Note that the Practice Guide refers to both the outcome and process aims and measures – both should be addressed.
Read the measures (continued on next page)
Slide 12 / / Continue to read the measures
Slide 13 / / Continue to read the measures
Slide 14 /
Slide 15 / / The last question of the Model for Improvement is “What changes can we make that will result in an improvement?”
What is the evidence-based set of changes we need to implement to reach our aim?
Slide 16 / / The mental health change package lists the changes that will be tested and implemented in the care of patients with mental health problems.
These changes have been previously piloted in physician offices.
Slide 17 / / The BTS Model for Improvement was first developed by Tom Nolan and colleagues, and is described in detail in The Improvement Guide (Langley, Nolan, Nolan, Norman, and Provost, Jossey-Bass, 1996).
The Model for Improvement is based on the idea that every system is designed to give you exactly the results you get. To get different or improved results, you have to change the system. We already discussed the three fundamental questions for improvement. The action part of the model is the Plan, Do, Study, Act Cycle; it gives you a method to learn how to make the changes that will result in improvement.
Slide 18 / / Four parts of the cycle:
Plan:
Decide what change you will make, who will do it, and when it will be done. Formulate an hypothesis about what you think will happen when you try the change. What do you expect will happen?
Identify data that you can collect (either quantitative or qualitative) that will allow you to evaluate the result of the test.
Do:
Carry out the change.
Study:
Make sure that you leave time for reflection about your test. Use the data and the experience of those carrying out the test to discuss what happened. Did you get the results you expected? If not, why not? Did anything unexpected happen during the test?
Act:
Given what you learned during the test, what will your next test be? Will you make refinements to the change? Abandon it? Keep the change and try it on a larger scale?
Slide 19 / / This is an example of the PDSAs tested to implement the use of the PHQ-9 and additional mental health tools in the physician office practice.
The first cycle of change is the use of the depression screening tool, PHQ-9, with patient A on Tuesday. Cycle 2 is the additional testing of the PHQ-9 with two additional patients (B and C) on Wednesday.
Cycle 3 is the testing the use of the Diagnostic Assessment Interview and handing out the Problem List to the patient B who had a moderate PHQ-9 score either the same day or at a follow-up visit.
Cycle 4 is the development of the care plan according to the Problem List when patient B comes in for a follow-up visit.
Finally cycle 5 is the testing of 3 ways to access skills that inform patient care in the CBIS manual.
These five PDSA cycles demonstrate the process of care for patients with mental health problems (Axis 1) from screening to diagnosis to problem identification and care planning to use of intervention skills.
Slide 20 / / Here is your hyperlinked algorithm
It shows you all the ways you can flow to use the module tools.
We will be demonstrating all the pieces, but know that this is the integrated flow.
You can point, click and bring up, print anything here, single pages as you like…
In teaching this we will follow the flow, starting with the PHQ-9, then the CBIS manual…
First the overview, then the Diagnostic Assessment, then the problem List Action plan, then the CBT skills…
Then Bounce Back, then the Antidepressant Skills Workbook…
So let’s get started.
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Slide 23 / / The above source shows the prevalence of depression in Canada, based on a 2006 study
Depression is the number one serious mental illness in terms of societal and economic burden
These stats are based on diagnosed cases of depression
Higher among people with a chronic disease
According to studies cited in The Journal of the American Medical Association (JAMA), depression is often under-diagnosed in primary care settings, and if recognized, is often not treated according to evidence-based, standardized guidelines (2)
We decided to use Depression as the lens through which we are going to do this….because it is the highest prevalence disorder….much like Diabetes was used in CDM.
Sources:
(1)Patten Scott B; Wang Jian Li; Williams Jeanne V A; Currie Shawn; Beck Cynthia A; Maxwell Colleen J; El-Guebaly Nady. Descriptive epidemiology of major depression in Canada. Canadian journal of psychiatry. Revue canadienne de psychiatrie2006;51(2):84-90.
(2)Glass. Awareness about depression. Journal of the American Medical Association. 2003; 289(23): 3169.
Slide 24 / / Why are we doing a MH module?
In BC, over 700,000 people receive mental health services
Over 600,000 receive them from a physician
Over 100,000 from a Psychiatrist
100,000 in a community MH center
Only about 20,000 require and receive hospital treatment
There is some overlap between the two groups as some patients are seen by both GPs and psychiatrists.
Source: MoHS ; Focus on Innovation Forum , Mar 2009
Slide 25 / / Back in 2003 a VIHA team got involved with the HTF focused on Depression, 75 GPs involved.
No way could they see all the patients of so many docs.
So they decided to use a module that would enhance their skills, and that was really practical, being able to be used in realistic time……
They made every mistake possible……..and kept learning
They finally did it in 18 GP offices with good results in the limited evaluation, Then the project ended under the HTF. Then some GPs volunteered anyway, or they were able to get grants to work with others.
Docs from the IHN already in teams to treat Chronic diseases were especially interested…..so they were able to continue to do it with up to 30 docs offices
Slide 26 / / They had a chance to present this to the GPSC, who then did a survey that rated mental health as one of the top requests for more knowledge.
New fee incentives had also been created.
They joined with the BB program, and the SSM, ASW added some needed components and GPSC funded this rollout using the PSP to roll it out.
Slide 27 / / We hope to provide you the tools that you can confidently use to shift from acute to proactive MH care
We know these tools have to be used in an efficient time frame
We also wanted to facilitate a bridge with MH and Addictions…enhancing this relationship and building a base for further collaboration and so have invited Psychiatrists and MH clinicians in from each of the HA…
Although there are no MH clinicians here today, know that they were at the first TTT session.
The Psychiatrists and MH clinicians who are here are here to support you throughout the action periods. They can be a coach, a mentor, can help you know who to refer, where and can help you navigate the mental health system. Contact numbers are in your package.
Slide 28 / / The MOAs are the most crucial part of your office practice.
In order for this module to work, they have to understand what it is, why and the different components of it.
They will be away for some of this time, taking a CMHA course on mental health that will help them feel comfortable with mental health patients, and give them a heightened awareness of what to look for.
This will help them flag patients that need your followup for mental health problems.
They are also vital to make sure patients are scheduled correctly to take advantage of this module
Finally they need to make sure all materials are present and ready to go for you.
Slide 29 / / In your package are 2 case studies, demonstrating how to make the best use of the mental health fee codes.
One of them, Case #2 fits this module exactly and will be presented in detail later
Slide 30 / / Although there are other so called “experts” here, we are acutely aware that YOU are the experts in your own practices……..so part of your work will be to learn and practice what you learn here today, and find your unique ways of integrating the various pieces into your practice.
Remember, this module applies to adults and is not directly applicable for C/Y and elderly.
Slide 31 / / Video is approximately 5 minutes long
Instructions to view video embedded in slide:
- slide presentation with embedded videos may be played directly from the DVD – if you choose to copy to your personal computer, please note that all videos and the slide presentation must be copied together to the same folder or to your desktop
- to play video embedded in slide, click on the picture of the video (automatically full screen format)
- to pause the video, click anywhere on the screen
- note: there is no rewind or fast forward capability for viewing this video when it is embedded within the slide
- video will automatically ‘rewind’ at end
Slide 32 / / Here is your hyperlinked algorithm
It shows you all the ways you can flow to use the module tools.
We will be demonstrating all the pieces, but know that this is the integrated flow.
You can point, click and bring up, print anything here, single pages as you like…
In teaching this we will follow the flow, starting with the PHQ 9, then the CBIS manual…
First the overview, then the Diagnostic Assessment, then the problem List Action plan, then the CBT skills
Then Bounce Back, then the Antidepressant Skills Workbook
So let’s get started.
Slide 33 /
Slide 34 / / The PHQ-2 and PHQ-9
A valid and practical tool for depression screening
Uses a symptom-based rating scale (PHQ-9) to establish a baseline
This form is on and another version is on GPAC website (part of guidelines for MDD)
Guideline applies only to adults between the ages of 19 and 65 and should not be extrapolated to children, adolescents or geriatric populations.
Both presentation and treatment of major depressive disorder may differ in these populations.
Slide 35 / / Depression Screening: PHQ-2
A physician can quickly screen for depression by asking 2 questions:
Over the last 2 weeks, how often have you been bothered by any of the following problems:
1) little interest or pleasure in doing things?
2) feeling down, depressed, or hopeless?
(These are the first 2 questions on the questionnaire)
A positive response to either question requires follow-up with PHQ-9
Source: Patient Health Questionnaire – PHQ-9(
Slide 36 / / PHQ-9
A 9-item, self-administered questionnaire
Can be completed by the patient before, during, or after the office visit
Can be given to patient for completion by MOA, physician, RN or other clinical staff
Corresponds with the 9 signs and symptoms of the DSM-IV
Used as a screening tool; not a diagnostic tool
Quantifies the severity of depression (gives a number)
Additional question (10) to rate functional impairment level
Provides measurement over time
GPAC version also available in GPAC Full Guidelines for MDD (on website)
Available in multiple languages (access them at pFizer’s website:
Strong evidence of reliability and validity
Sensitivity = 88% for Major Depression
Specificity = 88% for Major Depression
Slide 37 / / If the patient answers either of the first two questions with