DUNIA CAPSTONE PP

Implementation of Standardized Depression Screening 1

Implementation of Standardized Depression Screening

Final Capstone Project Part I, II, III

Student’s name: Dunia Barrueta

Florida National University

Instructor: Dr. Carmen Lazo, DNP, MSN, APRN-BC, APN

Course: Capstone Project

Date: August 10, 2026

Introduction

Depression is one of the most common mental diseases, and also one of the leading contributors to morbidity and poor quality of life, as well as utilization of health services globally. In the U.S., millions of people suffer from depression each year, but a significant percentage have symptoms that are unrecognized or not treated in their routine/primary care visits (Greenberg et al., 2023). A sleep issue can have a bad influence on consuming drugs, managing chronic medical conditions, job fulfillment, relationship achievement, and overall well-being. Depression is a common condition in primary care clinics, and often patients do not have emotional symptoms; it is therefore important that there is systematic screening for its early detection. Primary care physicians with nurse practitioners (NPs) are well placed to identify depression symptoms, as they often have established long-term therapeutic relationships with patients (Trexler, et al., 2023). Use of standardized assessment, such as the Patient Health Questionnaire-9 (PHQ-9), not only increases the likelihood of early identification of depression but also prompts timely referral to behavioral health services. The practice problem that has been considered for this exercise is the lack of consistency about screening for depression in adults accessing treatment in primary care clinics across Miami-Dade County, Florida. The objective of this proposed capstone project is to determine if the standardized use of the PHQ-9 depression screening instrument, coupled with a nurse practitioner (NP) led referral and follow-up program, will increase depression identification and behavioral health referrals of adults receiving primary care within Miami-Dade County over 6 months.

Significance of the Practice Problem

Miami-Dade County has challenges with depression that are related to the County's large and diverse population and its socioeconomic differences. Behavioral healthcare challenges may exist for many residents, including limited insurance coverage, financial strain, transportation issues, language issues, stigma associated with mental illness, and inadequate behavioral health providers (Sulzer, et al., 2024). All these factors often delay the resolution of the problem and lead to a sequence of worsening symptoms until treatment is initiated. If left untreated, depression has high financial costs. Compared to people who do not have depression, individuals with depression suffer from higher health care costs, as a result of multiple primary care visits, utilization of emergency care, hospitalizations, decreased compliance with treatments, and lost time from work. Preventable complications add to the cost burden on healthcare organizations, especially when they lead to complications in patients with chronic health issues. Time-of-treatment and timely intervention can contribute to the prevention of excess utilization of health care services and improve long-term health care outcomes for the patients.

The proposed intervention is realistic and measurable as it features an evidence-based screening instrument that has been in use in healthcare settings. The PHQ-9 has a small number of items, was validated in a wide range of groups, is easily integrated into electronic health records, and only takes a minimal amount of staff training to use (Rahman, et al., 2022). In addition to nurse practitioner-led follow-up, standardized screening could also increase the number of depression cases diagnosed, encourage referrals to be completed, help get treatment started, and enhance continuity of care.

PICOT

“In adults 18 years and older receiving care in primary care clinics in Miami-Dade County, Florida (P), how does implementing a standardized PHQ-9 depression screening protocol with a nurse practitioner-led referral and follow-up program (I), compared with usual care without standardized screening (C), affect depression identification and behavioral health referrals (O) over six months (T)?”    

The population consists of adults (18 years and older) who participate in routine care in primary care clinics across Miami-Dade County. This population is heterogeneous, with people from a variety of racial, ethnic, cultural, and socioeconomic backgrounds who experience recognized and/or unrecognized signs and symptoms of depression.

The intervention involves; 1, Screening of patients using the standardized PHQ-9 in routine primary care visits; - An intervention level 2 – The development of a structured nurse practitioner-led PHQ-9 screen referral and follow-up program. Nurse practitioners will follow up with patients to verify treatment initiation, administer/review PHQ-9 scores, establish behavioral health connections and treatments, and coordinate behavioral health treatments and follow-up assessments to ensure continuity of care. The comparison group involves what is generally done currently, which is mixed: screening for depression is not consistent and is reliant on the provider's judgment and not on standard guidelines.

Expected Results include better patient identification of depression, improved behavioral health referral, earlier initiation of treatment, improved care coordination, and improved patient engagement. The six-month assessment period provides adequate length of time to measure results for improving screening compliance, referral completion, and integration of behavioral health services in primary care practice.

Vulnerable populations and settings.

The proposed project will reach adults aged 18+ receiving primary care in primary care clinics throughout Miami-Dade County, FL. This group of people is at risk due to their social, economic, and health disadvantages, which make them more susceptible to undiagnosed and untreated depression. Miami-Dade is one of the most culturally diverse counties in the United States and is home to large, diverse Hispanic, Black, and Caribbean communities and an immigrant population. While this diversity adds to the richness of the community, it also presents problems of access to health services, differences in language, beliefs about mental illness, and literacy.

Chronic diseases such as depression occur at high rates among people with other chronic medical conditions, such as heart and blood vessel disease, diabetes, hypertension, obesity, and pain (Vadakkiniath, 2023). Adverse medication compliance, poor health management, and increased healthcare use related to depression are associated with decreased adherence to medication, healthy lifestyle, and follow-up appointments. So, a chance exists to embed depression screening in the primary care environment to help identify mental health issues early before they arise, in the context of routine health care delivery.

Evidence-Based Proposal

The proposed intervention is for a national standardized Patient Health Questionnaire-9 (PHQ-9) depression screening to be implemented for all adult attendees to participating primary-care clinics. The PHQ-9 is a brief, reliable, and evidence-based screening tool that has been validated and is highly sensitive and specific for the diagnosis of a depressive disorder in a variety of patient populations, and requires a few minutes to arrive at a diagnosis.

The proposed program will involve having each adult patient fill out the PHQ-9 in their routine primary care contacts. Depending on how severe a patient's symptoms are, the nurse practitioner will triage the score and follow through with a plan of action. Patients who are mildly depressed will receive information on depression and motivational strategies and will be seen again at subsequent visits.

Several resources are needed to successfully implement this, including educational opportunities for the staff on how to administer a PHQ-9, having the screening tool integrated into an EHR system, creating standardized pathways for referrals, other behavioral health providers' involvement, education materials for patients, and administrative support. The initial cost of implementing the PHQ-9 is relatively low due to the low cost of the screening, and given the fact that the screening is currently being used in health care settings, operational costs need not be a factor for consideration (Brooks, 2023).

The proposed project will have an implementation period of six months. Staff training, workflow design, and changes in the electronic health record will be finished after the first month. Effort will be placed on universal screening from months 2-5, coordinating referrals and follow-up for patients, and continued monitoring of implementation outcomes. To verify the effect of the project, the rates of screening, identification for depression, referrals completed, and program efficacy will be measured at the 6-month mark.

Theoretical Framework

The Chronic Care Model (CCM) would be an appropriate theory to utilize for this capstone given its emphasis on proactive, coordinated care of chronic conditions delivered by an inter-professional team in the context of evidence-based clinical decision making and patient-centeredness. A single-episode treatment is not always the best treatment for depression since often this is a chronic condition that should be evaluated, given a treatment, and monitored over time.

The Chronic Care Model is linked to better outcomes via patient-client engagement and an empowered clinical team. The model can enable systematic depression screening, standardized depression treatment, coordinated referrals to behavioral health, self-management education, and follow-up care. However, the nurse practitioner plays a key role in ensuring the various professionals of the health care team collaborate, follow patients' progress, and educate on how to manage depression, as well as coordinating care.

The model also includes support from the healthcare system, resources from the community, clinical information systems, and supporting evidence-based decisions. When implemented as clinical tools and made mandatory by integrating the PHQ-9 into routine clinical practice, these provisions are in line with these principles by facilitating standardized assessment, better documentation, and better clinical decision-making between different providers (Brooks, 2023). The Chronic Care Model helps make this project work by expanding mental health services into primary care instead of providing separate health support for depression, which helps to embed treatment for depression into the care cycles of patients.

Current State of the Problem

Depression is one of the most prevalent conditions treated by primary care, and a leading cause of disability worldwide. Depression is frequently not recognized in routine clinical assessments and is not adequately treated, which results in late diagnosis and treatment of the disorder, despite having available validated screening tools and evidence-based treatments for depression. People with physical complaints who are being cared for by a Primary Health Care provider may not manifest psychological signs and symptoms, and standardized screening is important to identify those needing further evaluation. The proposed change in practice consists of rolling out a Patient Health Questionnaire-9 (PHQ-9) depression screening protocol, a nurse practitioner (NP) referral and follow-up protocol for adults who are treated in primary care clinics across Miami-Dade County, Florida. The goal is to enhance the identification of depression and the number of behavioral health referrals completed within six months compared to the current system of inconsistent screening and provider discretion.

Evidence Supporting Standardized Depression Screening

Existing literature remains robust in that the standardization of depression screening promotes the detection of symptoms of depression in primary care. Garcia et al. (2022) determined that universal screening for depression led to greater parity in depression detection across various adult patients. These results demonstrate that standardized screening helps to minimize the effects of provider judgment and will help to decrease disparities among racial and ethnic groups and by socioeconomic status. The results of these findings are significant for Miami-Dade County, Florida, due to its diverse population of Japanese-speaking residents as well as its being a culturally and linguistically diverse county. When administered in a universally standardized manner, the PHQ-9 is an evidence-based assessment for every eligible patient, rather than allowing for diagnoses to fall through the cracks. But, as also pointed out by Garcia et al., screening alone would not be helpful if positive results are not promptly assessed, referred, and treated, and as such, there is a need for structured follow-up of the proposed intervention.

Integrated Mental Health Care and Quality Improvement

There are several studies that further support the integration of mental health services in Primary care. Isaacs & Mitchell (2024) found that elements of integrated care models include collaborative effort among members of the medical care and behavioral health team, clinical pathways, leadership support, and communication between primary care and behavioral health providers. Through their review, they found that integrated care (IC) provides better access to mental health care and less fragmentation of care. Knight et al. (2022) reported similar results when they looked at quality improvement collaboratives in general practice. They discovered that organizational commitment, ongoing monitoring, provider education, and leadership are needed to achieve sustainable improvement of clinical outcomes.

There are a number of consistent findings that integrated approaches to care are effective in managing depression, but divergent findings on how these approaches are implemented. Although both studies highlighted the critical importance of organizational readiness and different approaches to ensuring quality, Isaacs and Mitchell (2024) went further in emphasizing the importance of integrating other disciplines into the team and ensuring organizational readiness. Knight et al. (2022) focused mainly on methods for quality improvement, which included collaborative learning, quality audit and feedback, and monitoring performance. Both reviews, however, found that leadership of standardized processes and the tracking of outcomes are effective in supporting the success of evidence-based interventions over time.

Evidence Supporting Nurse Practitioner-Led Care

NPCs are also well-positioned to facilitate better patient engagement and health care coordination, backed by evidence. Baglini et al. (2024) tested a nurse practitioner-led telemedicine referral bridge for enhancing attendance at a psychiatric first visit. Issues about transport, poor scheduling, referral protocol, financial constraints, or fear and confusion are all factors related to patients missing behavioral health appointments. Appropriate follow-up by a nurse helped to increase the completion rate in the study, which gave next-patient education, cared for patients, and maintained regular communication.

Leadership is more important for nurse practitioners than behavioral health coordination. A nurse practitioner (NP) collaborative CHM was assessed in a randomized controlled trial with heart failure (HF) patients by Chen et al. (2025). While the group was not identical to adult patients with depression, the results of this study showed that collaborative care led by a nurse had significant positive outcomes for patients regarding medical costs, functional status, nurse lectures regarding self-management, and fewer rehospitalizations. The implications of these findings are that when patient education, patient monitoring, trans-disciplinary team collaboration, and continuity of care are realized, chronic disease management is enhanced through coordinated NP leadership. Improved long-term disease management is appropriate for depression care; this is because depression is often accompanied by chronic diseases like cardiovascular disease, diabetes, and hypertension.

Application of Evidence to the Proposed Practice Change

There is further evidence supporting nurse-led depression interventions from a systematic review and meta-analysis conducted by Cranstoun et al. (2024), which explored nurse-led psychological intervention for adult cancer patients who are depressed. Interventions delivered by nurses were found to significantly alleviate depressive symptoms and enhance emotional well-being and patient engagement. Results presented in this study, although undertaken with oncology samples, support the role of an evidence-based nurse to effectively provide mental health interventions in addition to ongoing clinical care. Likewise, Babu et al. (2025) found that nurse depression management in primary care promotes depression symptom tracking, adherence to depression treatment, patient education, and continuity of care. They noted that nurses have a unique opportunity to offer continuous assessment, remind patients of treatment plans, facilitate multidisciplinary management, and assess patients for other services that address behavioral and mental health. These studies, combined, indicate that NP's can be expanded beyond screening for depression, and should manage the depression as a whole.

The evidence also illustrates the value of quality improvement work being undertaken in a structured way when working towards change in practice. According to Knight et al. (2022), quality improvement collaboratives are effective in increasing implementation success when they set measurable targets and give providers frequent feedback about their performance and encourage a team-based approach to implementation. Implications to the proposed project: If the proposed project is to be implemented, it is important to monitor screening compliance, completion of the PHQ-9, behavioral health referrals, and attendance of the intervention throughout the 6-month intervention period.

Strengths, Limitations, and Controversies in the Evidence

Despite the overwhelming evidence for depression screening and collaborative care, there are also a few concerns and challenges to standardized screening. One question that has come up is whether or not to try screening everyone for depression if resources for behavioral health are not available. Increased screening may lead to a higher volume of patients needing treatment and thereby strain already limited BH services, albeit this may not happen, as the past couple of years have demonstrated and Garcia et al. (2022) recognized. Likewise, Isaacs and Mitchell (2024) found workforce deficiencies and lack of communication amongst others as insurmountable challenges in the delivery of integrated mental healthcare. These findings show that screening is not enough and underscore the importance of coordinated care, referral systems and administrative support. Another restriction is with regard to the population studied. Cranstoun et al. (2024) directed their attention towards adults with cancer, for instance, and Chen et al. (2025), towards heart failure patients. While these populations vary from the suggested evidence-based adult primary care population, the value of nurse-led collaborative care links to depression management, further supporting the justification for nurse-led approaches with this other population.

Currently, the evidence is supportive for requiring standardized depression screening of patients, nurse practitioner-led depression referral and/or follow-up, as both are a response to multiple gaps in the current evidence. Although screening for depression began to gain ground in primary care, its use remained inconsistent, screening was poorly integrated into behavioral health, and the processes for depression screening, diagnosis, and referral were not well connected. Standardized screening enables a consistent approach to identifying patients for extra screening, and using a nurse-led follow-up service increases referral completion, engagement with patients and continuity of care. The intervention is also consistent with evidence-based practices for delivery of integrated healthcare and quality improvement practices that promote long-term sustainability.

Justification for the Proposed Practice Change

This practice change is expected to yield greater depression identification, higher rate of behavioral health referrals completed, earlier initiation of treatment, better integration of primary care and mental health, and better patient outcomes. Other clinical benefits may include decreased use of the emergency department, better control of associated chronic conditions, decreased health service costs, and better quality of life. Staff education, a change to electronic health records, standardization of a referral pathway and administrative support are required for implementation.

Summary of the Evidence

In sum, the literature is supportive of the effectiveness of standardized depression screening via nurse practitioner-led collaborative care. The studies examined confirmed the following common findings: improved depression identification is related to standardized screening tools; screening along with coordinated follow-up has a higher level of success; improved implementation is associated with leadership, quality improvement strategies, and interdisciplinary collaboration. There are some differences of opinion on the methods used to implement the practices and the populations studied, but the overall studies strongly suggest that a practice change is warranted for adult primary care patients in Miami-Dade County.

Implementation and Conclusion

Implementation of the Practice Change

The proposed practice change will incorporate a new Patient Health Questionnaire-9 (PHQ-9) depression screening tool and a nurse practitioner (NP) referral and follow-up procedure for adults in all clinics in Miami-Dade County, FL that participate in this practice change. The change will address issues of inconsistent depression screening as well as a lack of continuity regarding the process of depression identification, referral, depression onset of treatment, and treatment follow-up. The project will focus on key components of the Chronic Care Model, including: proactive care, team-working across disciplines, clinical information systems, engagement and involving patients, and planning for follow-up. The proposed intervention has evidence of effectiveness for screening for depression identification and nurse-led coordination for facilitating continuity and engagement in depression care. The implementation process would be in selected primary care clinics for adults 18 years and older. The PHQ-9 is administered as part of the clinical routine, during routine primary care visits, to eligible patients (Hawkins, 2023). The NP will follow up on the results and decide on the best possible course of action for that patient depending on their score and the story they reported. A standardized behavioral evaluation referral will be given to patients who need further behavioral evaluation, and patients in need of follow-up will be followed through by the NP or designated nursing staff. No experiments will be conducted with human subjects, and no experimental treatment will be provided as part of the intervention. Instead, it talks about implementing an evidence-based clinical process into routine practice and assessing the aggregate practice outcomes before and after the process is implemented.

Implementation Timeline and Setting

Implementation Period	Major Activities	Responsible Personnel
Month 1	Staff education, EHR workflow preparation, referral pathway development, baseline data collection, and stakeholder orientation	Project NP, nurse manager, EHR specialist, behavioral health team
Months 2–3	Begin standardized PHQ-9 screening and NP-led referral and follow-up; monitor screening completion	NPs, registered nurses, primary care providers
Months 4–5	Continue screening, referral coordination, patient follow-up, audit, and feedback	NP project leader, nurses, behavioral health providers, quality team
Month 6	Compare baseline and post-implementation outcomes, obtain stakeholder feedback, and develop sustainability recommendations	NP project leader, nurse manager, quality-improvement team

Participants, Barriers, and Influencing Factors

Those involved in the practice change process will comprise EHR workers and administrators, adult primary care providers, behavioral health professionals, registered nurses, and primary care patients. Participation from patients will come via routine clinical screening, not research, and is not required or requested. Nurses will facilitate or screen with the PHQ-9 and share pertinent information. NPs will see results, follow up, and ensure continuity of care for referrals. Referrals will be received by behavioral health professionals and be adequately evaluated and treated. The EHR team will facilitate the incorporation of the PHQ-9 into the EHR and implement documentation/reporting.

There are multiple factors that could influence implementation, both internal and external, that must be taken into account. Facility or staff barriers can include resistance to change, other competing clinical priorities, lack of training, lack of consistency in documentation, lack of behavioral health capacity, and disruption to workflow (Bhosekar et al., 2025). External factors encompass physical (e.g., transportation) and financial (e.g., costs) barriers, language barriers, stigma, behavioral health provider shortages, and more. In Part II, the workforce barriers and communication complications were deemed significant barriers to mental healthcare integration of the current community services. These barriers will be tackled using education, regular communication, audit and feedback, standardization of workflows, and interdisciplinary working. Evidence regarding quality improvement suggests that measurable targets, provider feedback, collaboration among professionals, and an organization’s commitment to implementation can enhance successful implementation.

Evaluation of the Practice Change

Assessment of effectiveness of the practice change will be done through comparison of baseline and implementation outcomes at the end of the 6-month period. The key process measure to be tracked is the percentage of eligible adult patients with primary care who are screened for PHQ-9. Other key indicators will include the percentage of positive screens that are referred to a behavioral health provider, the percentage of behavioral health referrals completed, behavioral health referral delay (time to referral), and the percentage receiving documented NP follow-up.

Due to the brevity, evidence-based validation of the PHQ-9, and its usefulness in everyday primary care practice, it will be the primary standardized clinical assessment tool used (Waheed et al., 2024). Monthly review of aggregate data will take place to look for screening compliance and referral completion changes. Results from baseline to the end of the six months will be compared to see if the practice changes have led to increased identification and co-ordination of care for depression. This evaluation will not gather identifiable data for research purposes; rather, it will focus on data that assists with improving the quality of the aggregate.

Leadership and Management

This will be facilitated through the NP project leader's transformational collaborative, and evidence-based leadership. Collective leadership behavior through partaking in "Transformational Leadership" modelling will be carried out through the communication of vision, motivation, acknowledgment, and support for participation in a practice shift. Coordinating among primary care, nursing, behavioral health, information technology, and administrative personnel will be essential to the successful management of depression, so collaborative leadership will be important. The NP will also employ change-management techniques to uncover resistance, help convey expectations, offer education, and offer a response to the issues that may arise in the implementation.

The nurse manager will provide assistance with staffing, integration of workflow, accountability, and nurse staff development. The NP will be the clinical champion who will ensure adherence to the PHQ-9 protocol and coordination of interdisciplinary care. Regular audit and feedback will enable the team to suggest any improvement/refinement in the performance if identified throughout the process of implementation. This strategy is based on research that leadership, education, monitoring, and commitment are crucial to maintaining integrated mental health services.

Stakeholder Engagement, Presentation, and Budget

Other stakeholders will be the CNO or nursing administrator, nurse manager, primary care NP, registered nurses, physicians, behavioral health providers, quality-improvement staff, EHR experts, clinic administrators, and influential patient representatives (Dresser et al., 20225). Executive Support provided by the CNO; alignment of efforts with organization priorities. The nurse manager will make sure to coordinate staffing and workflow. NPs and registered nurses will carry out screening and follow-up. Referrals will be taken care of by the behavioral health providers. The quality-improvement team will help with the process of measuring data, and EHR specialists will assist with embedding the PHQ-9 within the clinical process.

The proposal will be given at a stakeholder meeting, and the presentation will be brief and consist of an explanation of the stakeholder problem, the evidence, the proposed workflow, an increase in expected outcomes, the timeframe to incorporation, and the plan for incorporation evaluation. The presentation will highlight that the cost of implementation of the PHQ-9 is fairly modest and the high costs lie in staffing education and EHR configuration, in arranging referrals, and in monitoring. A preliminary six-month budget is estimated to cost $1,500 for staff training and education, $2,500 to help configure the EHR and understand how to report on it, $2,000 to educate patients about the EHR and communicate with them, and $3,000 for coordinating the project and quality-improvement efforts, for a total of $9,000. Wherever feasible, existing clinic staff and facilities would be utilized to reduce any extra expenditure.

Conclusion

Depression is a serious public health problem often missed in primary care environments that have a significant effect on patient health, quality of life, and health care costs. Living with depression in adults can be related to any number of social determinants of health, and patients in Miami-Dade County may be more vulnerable to undiagnosed depression and delayed treatment. A consistent depression screening tool (PHQ-9), along with a nurse practitioner-led referral and follow-up program, is an evidence-informed approach towards better identification, higher behavioral health referrals, and better continuity of care. This project aims to implement aspects of the Chronic Care Model, including interdisciplinary care, patient-centeredness, and systematic follow-up to optimize mental and physical health outcomes. When implemented effectively within the proposed six-month timeframe, this intervention could lead to better depression identification, prompt action when identified, decreased health disparities, and better primary care for depression for adults in Miami-Dade County.

The review will be changed in the following ways – for 6 months: Standardize the way adults in Miami-Dade County who visit the health office for primary care are checked for depression using the PHQ-9, and introduce a standardized referral and follow-up process. The change directly addresses the inconsistent screening and the lack of integrated follow-up, as identified in Part I and II. The evidence is in favor of increased standardization of screening, nurse-led co-ordination, interdisciplinary working, and ongoing quality monitoring. Ongoing positive outcomes will be required to have robust NP leadership, staff learning and development, utilization of stakeholders, adequate facilities/equipment supporting EHRs, and a robust behavioral health referral program.

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