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Integrated Care Project Improves Depressive Symptoms in Primary Care Patients

November 05, 2020

A practice improvement project integrating behavioral health care expertise into a San Francisco primary care clinic improved patients’ mental and physical health outcomes, including depressive symptoms, researchers recently reported in The Journal for Nurse Practitioners.

The initiative has also helped primary care providers at the clinic become more comfortable and skilled at treating mental health conditions, study co-author Amanda Ling, MS, RN, PMHNP said.

The project was funded by a $1.9 million grant from the US Department of Health and Human Services’ Health Resources and Services Administration (HRSA). Here, Ling and coauthors Kara Birch, DNP, FNP, PMHNP, and Beth Phoenix, PhD, RN, FAAN, explain the project, its outcomes, and the challenges of implementing integrating behavioral health treatment into primary care settings.

Q: How did this project got started and what were the reasons for it?

Beth Phoenix, PhD, RN, FAAN
Beth Phoenix, PhD, RN, FAAN

A: Beth Phoenix: The impetus for this project was a request for proposals for a grant to increase integration in a primary care clinic by adding behavioral health providers. Kara has a really deep background in the area of collaborative care and using integrated behavioral health into primary care to improve both depression and other medical condition outcomes.

We originally partnered with a different clinic. Then, because of changes in that organization, we switched partners about a year into the project. At the Saint Anthony's Clinic, there were some behavioral health services co-located with the primary care services. What we really wanted our project to do was increase the level of integration and offer more support and consultation for the primary care providers in managing common psychiatric conditions.

Q: Please briefly describe the major points of how the project was carried out.

Kara Birch: For this project, with the goal being improving patients' depression outcomes and enhancing the level of behavioral health integration, the first thing that we did was to partner with the community clinic to do a needs assessment. We worked to determine their current level of integration as well as training, workflow and role development needs. We then partnered with the clinic to provide trainings, plan, implement and evaluate the project. Our psych NP [nurse practitioner] faculty developed workflows for integration, looking at how we can improve their current system to enhance things such as communication, population level tracking, and patient follow up.

Kara Birch, DNP, FNP, PMHNP
Kara Birch, DNP, FNP, PMHNP

In collaborative care, there's a team triad that includes the existing primary care provider, the psychiatric consultant, which we served in as psych NPs, and a care manager. We hired a social work care manager to fill the care manager position and began training and working as a team.

We started routine depression screening in primary care with a PHQ‑9. Then, when patients screened positive for depression and were determined to be eligible for collaborative care, they were, either through warm handoff or through referral, connected with the care manager.

Then, the team triad—the psych NP, the care manager, and the primary care provider—meet weekly to review every patient that is enrolled in collaborative care. That way, the psychiatric consultant can make regular medication or treatment change recommendations as well as provide support and role development for the team.

Q: Did the project change at all after the COVID-19 outbreak? 

Beth Phoenix: I think because the patients who were being managed as part of this collaborative care project were used to having regular telephone check‑ins with the care manager, they were able to be retained in care a lot more easily than some of the other patients in the clinic. That's something that would be great to follow up on more, because there's so much coming out right now about the increase in the number and severity of psychiatric problems related to the conditions that are caused by the COVID pandemic. Although we haven't been accepting more new patients, the contribution of this support to relapse prevention in a population of people who otherwise would have been at great risk for relapsing in terms of their depressive symptoms, that's something that I think would be important to look at.

Q: What would you say were your key findings and outcomes?

Beth Phoenix: One of the really significant findings is that for all the patients who were enrolled in this project, we saw an improvement in their depression scores over time. For some folks, it was pretty rapid. For other people, it took a longer time. But basically, everybody got better.

Amanda Ling, MS, RN, PMHNP
Amanda Ling, MS, RN, PMHNP

Amanda Ling: We also had a number of outcomes that are more difficult to quantify in terms of changes in the clinic, and primary care's experience and comfort in working with patients with depression. For instance, we noticed and got feedback throughout the project that primary care providers' knowledge and comfort in prescribing antidepressants and increasing doses on their own that they might not otherwise have, or in prescribing medications that they wouldn't necessarily have considered before, really changed. Throughout the project, they actually needed less and less consultation on our part.

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