Research for Evidence Based Practice

Seattle University Seattle University

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Doctor of Nursing Practice Projects College of Nursing

2020

Evaluating the Impact of a Depression Care Management Evaluating the Impact of a Depression Care Management

Program Program

Natalie Dreyfoos Seattle University

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Running head: EVALUATING THE IMPACT OF A DEPRESSION CARE 1

Evaluating the Impact of a Depression Care Management Program

Natalie Dreyfoos, BSN, RN

A DNP project submitted in partial fulfillment of the

requirements for the degree of

Doctor of Nursing Practice

Seattle University

2020 Approved by: _______________________________ Date: April 22, 2020 DNP Mentor: Janiece DeSocio, PhD, RN, PMHNP-BC, FAAN

EVALUATING THE IMPACT OF A DEPRESSION CARE 2

Abstract

Depression is a common mental health disorder that causes significant individual and societal burden. Depression care management programs use a collaborative approach to lessen these effects. Evaluating patient satisfaction and experience are essential to obtain a comprehensive view of program benefits. This program evaluation project evaluated the experiences of patients in a depression care management program provided by a healthcare system in Washington state. A mixed methods approach using opened ended question surveys, telephone interviews and PHQ-9 scores provided a deeper understanding of individual experiences. The analysis showed patients were highly satisfied with the program. Collectively, depression severity scores decreased however co-morbid conditions frequently impacted a patient’s progression. This project demonstrates the value of a depression care management program from a patient’s perspective. Program recommendations were designed to mitigate limitations and enhance depression care. Patient feedback is essential to assess the effects of a program and should be incorporated in future evaluations.

Keywords: Depression Care Management program, quality improvement, patient

experience, patient satisfaction, co-morbid conditions.

EVALUATING THE IMPACT OF A DEPRESSION CARE 3

Table of Contents

Introduction ..................................................................................................................................... 4

Background ..................................................................................................................................... 4

Project Purpose ............................................................................................................................... 7

Methods........................................................................................................................................... 8

Project Design ............................................................................................................................. 8

Sampling Plan ............................................................................................................................. 8

Data Collection ........................................................................................................................... 9

Data Analysis ............................................................................................................................ 11

Ethical Considerations .............................................................................................................. 16

Results ........................................................................................................................................... 17

Discussion ..................................................................................................................................... 24

Limitations ................................................................................................................................ 27

Recommendations ..................................................................................................................... 28

Conclusion .................................................................................................................................... 29

References ..................................................................................................................................... 30

Appendix A ................................................................................................................................... 36

Appendix B ................................................................................................................................... 37

Appendix C ................................................................................................................................... 38

EVALUATING THE IMPACT OF A DEPRESSION CARE 4

Evaluating the Impact of a Depression Care Management Program

Depression is a pervasive mental health disorder and the leading cause of disability

worldwide adding to the global economic burden of $1 trillion in lost productivity each year

(National Alliance on Mental Illness website, n.d., para. 11). In primary care, depression is one

of the most common chronic health conditions and requires a comprehensive treatment approach

(Unutzer & Park, 2012). Multifaceted challenges exist in this setting that prevent many patients

from receiving adequate depression care (Unutzer & Park, 2012). Collaborative care for

depression has been shown to improve clinical care outcomes and effectively address patient

needs, successfully combating these challenges (Simon et al., 2011; Unutzer & Park, 2012). As

the delivery of mental health in primary care continues to evolve with the adoption of new

healthcare technology, active involvement of patient feedback is essential to maintain high

quality, patient centered care (Roberge et al., 2016; Simon, 2019). The need to assess patient

feedback led to this doctoral project that is aimed at conducting an evaluation of a healthcare

system’s Depression Care Management (DCM) program.

Background

Prevalence

In the United States one person dies of suicide every 12.3 minutes and in Washington

state suicide is the 2nd leading cause of death for 10 to 24-year-olds (Harborview Injury

Prevention & Research Center website, n.d.). A common underlying condition affecting more

than 67% of suicide victims is depression (Archer et al., 2012). In 2017, an estimated 17.3

million adults in the United States experienced at least one major depressive episode (National

Alliance on Mental Illness website, n.d., para. 2). The prevalence of depression in primary care is

EVALUATING THE IMPACT OF A DEPRESSION CARE 5

estimated between 8% and 14% with 45% of individuals who died by suicide having contact

with a primary care provider within one month of suicide (Akincigil & Matthews, 2017, p. 660).

Evidenced based treatment for moderate to severe depression includes but is not limited

to antidepressant medication (American Psychiatric Association [APA], 2010). However,

approximately 50% of patients prematurely discontinue their antidepressant medication (Sansone

& Sansone, 2012; Simon et al., 2011). Inadequate treatment of depression leads to high

utilization of medical services. For example, the financial strain of depression in the United

States increased 22%, or $210.5 billion, between 2005 and 2010. This increase was due to direct

medical costs accrued in this population (Chow, Doane, Sheehan, Alphs, & Le, 2019, para. 1).

Primary Mental Health Care

The primary care setting is an ideal location for timely depression diagnosis and

management (Akincigil & Matthews, 2017). Almost 30 million Americans receive

antidepressant prescriptions each year, most often prescribed by their primary care provider

(Unutzer & Park, 2012, p. 4). Antidepressant therapy has been shown to significantly improve

quality of life and lead to depression improvement and remission (American Psychiatric

Association, 2010; Garrison, Angstman, O’Connor, Williams, & Lineberry, 2016).

Unfortunately, as little as 20-40% of patients receiving depression treatment in primary care

show substantial clinical improvement (Unutzer & Park, 2012, p. 4). Furthermore, rates of

medication adherence and follow-up care remain disturbingly low in this setting (Simon et al.,

2011). Challenges to effective treatment in primary care include time constraints, conflicting

demands, limited provider training and patient fear of stigma (Unutzer & Park, 2012). Reasons

for patient nonadherence to medication vary and include concerns about side effects, fear of

EVALUATING THE IMPACT OF A DEPRESSION CARE 6

addiction, forgetting to take medications, lack of sufficient patient education and poor patient

follow up (Sansone & Sansone, 2012).

Collaborative Care

Collaborative care programs are based on principles from the chronic illness care model

(Unutzer, Harbin, Schoenbaum, & Druss, 2013). These programs track patient progress using

validated clinical rating scales and adjust treatment if the patient isn’t improving (Unutzer et al.,

2013). Patient outreach and monitoring is delivered using telehealth technology, like telephone

encounters and online messaging (Simon et al., 2011; Simon, 2019). Consistent evidence

indicates that DCM programs are effective at reducing healthcare utilization and improving

medication adherence, follow up care, patient satisfaction and depression clinical outcomes

(Archer et al., 2012; Bjorkelund et al., 2018; Ludman et al., 2016; Meunier et al., 2014; & Simon

et al., 2011).

Patient-Centered Care

The Institute of Medicine’s (IOM) report Crossing the Quality Chasm: A new health

system for the 21st century identified ‘patient-centeredness’ as one of the six aims for healthcare

improvement (Institute of Medicine [IOM], 2001). In this seminal report, patient-centered care is

defined as providing care that is respectful and responsive to individual patient preferences,

needs, and values, ensuring that patient values guide all clinical decisions (Institute of Medicine

[IOM], 2001, p. 3). Furthermore, the Institute for Healthcare Improvement identified patient

experience (including quality and satisfaction) as one dimension of the “Quadruple Aim”

(Martin, Nelson, Lloyd, & Nolan, 2007). Patient centeredness and satisfaction are fundamental

elements in health care and have been linked to higher quality care and better clinical outcomes

(Crosier, Scott, & Steinfeld, 2011; Luxford, 2012). Perceptions of poor communication is

EVALUATING THE IMPACT OF A DEPRESSION CARE 7

associated with elevated adverse events (Luxford, 2012). Therefore, healthcare organizations

must promote active participation of patients during program implementation to guide changes

and provide patient-focused care (Luxford, 2012; Roberge et al., 2016).

Depression Care Management Program

The healthcare system’s DCM program was designed to improve the depression health of

patients who are prescribed antidepressant medication. Patients advance through specific clinical

pathways as they receive care management services from a registered nurse (RN). A clinically

validated behavioral health questionnaire containing the Patient Health Questionnaire-9 (PHQ-9)

is used to monitor and advance these patients through each pathway. During the course of the

program the RN provides a multitude of services including care coordination, provider

consultation, emotional support, education and treatment plan adjustments to optimize

antidepressant therapy. Telehealth, including phone outreach and online secure messaging, is

utilized to provide these care management services. Once a patient is stabilized on antidepressant

medication and their depression severity is reduced, as evidenced by PHQ-9 score reduction,

they are discharged from the program.

Project Purpose

The healthcare system had yet to conduct an evaluation of patients’ experiences in the

DCM program. Therefore, the aim of this project was to identify the program’s strengths and

limitations by systematically describing and analyzing patients’ experiences. These experiences

were defined as patients’ impressions of the DCM program; their subjective assessment of

depression symptom severity; and their reactions to program engagement methods. Investigating

these specific patient experiences will provide insight into the factors that hindered program

engagement and patient progression. The project’s main objective is to provide recommendations

EVALUATING THE IMPACT OF A DEPRESSION CARE 8

to mitigate the program’s limitations in an effort to optimize patient centered care in depression

management. This project will answer the following questions:

1. What are patients’ impressions of the DCM program?

2. What were patients’ assessments of their depression symptom severity as they

progressed through the DCM program?

3. What factors impacted patients’ progression through the DCM program?

4. What prevented patients from responding to the initial invitation email sent by the

DCM program?

Methods

Project Design

This program evaluation used mixed methods. Combining data sets can produce a

meaningful interpretation of a phenomenon and can strengthen the validity of project findings

(Creswell & Plano Clark, 2011). This project was designed to improve depression care

management by evaluating patient experiences using both quantitative and qualitative

information. Depression symptomology (i.e. feelings of pessimism, amotivation) could have

distorted a patient’s assessment of care therefore a single data collection method would’ve been

ineffective (Martino et al., 2011). Merging quantitative and qualitative data provided a better

understanding of a patient’s experience and helped identify key characteristics that facilitated or

hindered a patient’s progression through the DCM program.

Sampling Plan

A convenience sampling method was used to recruit individuals > 18 years of age who

met enrollment criteria for the DCM program. Potential participants were identified from a report

generated by the healthcare system’s electronic medical record (EMR). Eligible patients were

EVALUATING THE IMPACT OF A DEPRESSION CARE 9

then separated into two groups and for the purpose of this project will be called group one and

group two. Specific criteria were used to filter patients into each group (See Table 1). Failure to

meet inclusion criteria or patient declination would constitute exclusion from the project.

Table 1: Group Specific Criteria

Program participation Email invitation received between

Access to contact method

Group 1

Currently enrolled, completed or dropped out May 2018 – October 2019

Enrolled in patient health portal to

receive SM

Group 2

Opened initial email invitation but never responded; never

participated in program May 2018 – November 2018 Phone number

listed in EMR

Note. SM (secure messaging); EMR (electronic medical record)

Data Collection

Concurrent quantitative and qualitative data collection took place over a three-month

period, from December 2019 - February 2020. Qualitative data consisted of a questionnaire for

group one and phone interviews for group two. Open-ended questions were used to provide rich

subjective information regarding patient experiences. A literature review and consultation with

experts from the DCM program guided the development of questions. Quantitative data

consisted of patients’ PHQ-9 scores during the course of the program. These scores were

frequently collected during the program and provided a good measurement for patient’s

depression symptom severity. PHQ-9 scores and demographic information, including age and

gender, were only collected from group one participants. The project alignment table (See

Appendix A) outlines the rationale and relationship between the project’s objectives, data

collection plan and outcome measures.

Group one qualitative data collection. Qualitative data collection for group one took

place over the entire three-month period. An open-ended questionnaire was the major data

EVALUATING THE IMPACT OF A DEPRESSION CARE 10

source. Other sources included care management chart notes. Patients were sent a secure

message (SM) containing an explanation of project objectives and instructions regarding

participation. The open-ended questionnaire was copied into the SM and patients were asked to

reply to the message with their responses. The SM was sent to patients twice during the data

collection period, once in December 2019 and once in January 2020. Patient responses were

collected until February 2020; seven responses were received. Chart notes continued to be

reviewed through March 2020.

An open-ended questionnaire containing four questions was developed for this project

(See Appendix B-1). The questions were designed to explore patients’ personal experiences

while enrolled in the DCM program. At the end of the survey, patients were given an opportunity

to provide additional comments. An extra question was included for a patient who dropped out of

the program. All patient responses were used to understand the DCM program’s strengths and

limitations from a patient’s perspective.

Group one quantitative data collection. Over a two-month time period, February -

March 2020, a retrospective chart review was used to collect quantitative data from group one

participants only. PHQ-9 scores were the major data source. Data collection was contingent on

the patient agreeing to participate in the project by responding to the open-ended questionnaire.

Once all responses were received (N = 7), PHQ-9 scores were collected from each patient’s chart

during the time they were actively participating in the DCM program.

The PHQ-9 is a self-report tool used to screen, diagnose, monitor and measure the

severity of depression (PHQ-9, 1999). It consists of nine questions that ask a patient to select the

frequency they’ve experienced depressive symptoms in the past two weeks (See Appendix C).

EVALUATING THE IMPACT OF A DEPRESSION CARE 11

This tool has sound psychometric properties and is effective at detecting changes in depression

over time (American Psychological Association, n.d.; Lowe, Kroenke, Herzog, & Grafe, 2004).

Group two qualitative data collection. Qualitative data collection for group two took

place in January 2020 over three days. A telephone interview was the major data source. Due to

previous unsuccessful attempts through secure messaging, group two participants were contacted

by phone and provided a verbal explanation of project objectives and instructions regarding

participation. Patients were either contacted in the morning on day one, in the afternoon on day

two and/or in the evening on day three. Handwritten notes were taken to record responses.

Patients were excluded from the project if they were contacted twice with no response or

contacted once on day three with no response.

A telephone interview script with a single open-ended question was developed for this

project (See Appendix B-2). The question was designed to elicit a patient’s reason for not

clicking on the hyperlinked questionnaire. All patient responses were used to understand and

improve the DCM program’s engagement methods.

Data Analysis

Qualitative and quantitative data were organized into a Microsoft Excel sheet. Responses

to questionnaires and telephone interviews were analyzed to understand patients’ impression of

the DCM program (questionnaire) and their reaction to the program’s engagement methods

(telephone interview). MAXQDA2018 software was then used to further organize, link and

analyze patient responses. PHQ-9 scores were analyzed to understand the patients’ assessment of

their depression symptom severity as they progressed through the program. Descriptive statistics

were then employed to describe changes in PHQ-9 scores overtime. After independent analysis

EVALUATING THE IMPACT OF A DEPRESSION CARE 12

was completed, data triangulation of qualitative and quantitative information was used to reveal

the final project findings.

Qualitative analysis. Content analysis served as the method for qualitative inquiry. This

method is used for identifying, analyzing, organizing, describing and reporting themes found in a

data set (Nowell, Norris, White, & Moules, 2017). Inductive reasoning was used for a

conventional approach to content analysis. This approach is used when a project’s aim is to

describe a phenomenon, in this case the impressions and reactions of patients (Hsieh & Shannon,

2005). Coding categories emerged directly from the raw data during analysis. To ensure

trustworthiness in content analysis of group one and two’s data, the qualitative process was

guided by five phases: (1) Familiarization, (2) coding, (3) generating themes, (4) reviewing and

naming themes, and (5) defining themes (Lincoln & Guba, 1985; Nowell et al., 2017, table 1).

The application of each phase is presented in tables 2-6.

Phase 1 familiarization. Patient responses were recorded verbatim into an excel

spreadsheet representing the initial familiarization with the data. Responses were then uploaded

into MAXQDA and cross checked with raw data. Both platforms were used to review responses

several times in order to obtain a comprehensive view of the information. Notes were taken to

document potential codes for each survey and interview question.

Table 2: Familiarization: Group One & Two

Phase 1: Familiarization Group One

SURVEY QUESTIONS 1 2 3 4

POTENTIAL CODES

Patient specific, compassionate, collaborative,

consistent promotes self-

Medication options,

supportive, guided discovery,

enhances

Flexible, Adaptive to

patient needs, explanation

Ignored, medication ineffective

EVALUATING THE IMPACT OF A DEPRESSION CARE 13

awareness, adaptive

knowledge, comprehensive

Group Two INTERVIEW QUESTION 1

POTENTIAL CODE

Email timing, # of emails, forgot, uninterested, link problem, computer problem, Insurance, loves giving input, insurance change

Phase 2 coding. MAXQDA’s automated coding function was used to develop

preliminary codes for each survey and interview question. Automated codes and potential codes

from phase 1 were compared and refined (i.e. codes mentioned once were discarded). These

question specific codes were blended together into one large group.

Table 3: Coding: Group One & Two

Phase 2: Coding Group One

SURVEY QUESTION 1 2 3 4

MAXQDA AUTO CODES

Nurse, frequent, communication

Medication, options, helped,

alternatives

Directed, flexible, contact

Annoyed, health,

antidepressant BLENDED

PHASE 1 CODES & MAXQDA

CODES

Empathic, active listening, communication, trusting relationship, coordinated, consistent, shared decision making, supports self-

management, collaborative, options, explanation

Group Two INTERVIEW QUESTION 1

MAXQDA AUTO CODES Emails, forgot, computer

BLENDED PHASE 1 CODES

& MAXQDA CODES

Emails, forgot, disinterest, insurance, technology, computer, link, timing

EVALUATING THE IMPACT OF A DEPRESSION CARE 14

Phase 3 generating themes. A final set of blended codes were selected and grouped

together based on similar attributes. To ensure accuracy, patient responses were reviewed again

and compared to selected attributes. During this process, preliminary themes started to emerge.

Table 4: Generating Themes: Group One & Two

Phase 3: Generating Themes Group One

FINAL BLENDED CODE SET

Empathic, active listening, patient specific, consistent, shared decision making, supports, self-management, trust, ignored, influence, effective

interactions, care transitions, coordination

GROUPED ATTRIBUTES

Empathic, active listening, patient specific,

consistent

Shared decision making, supports self-management,

trust

Ignored, influence, effective

interactions

Care transitions, coordination

PRELIMINARY THEMES Communication

Decision Support; Collaborative

Care Overlooked Access to Care

Group Two FINAL

BLENDED CODE SET

Emails, communication, disinterest, forgot, technology problems

GROUPED ATTRIBUTES Emails, communication Disinterest, forgot Technology problems,

insurance change PRELIMINARY

THEMES Virtual Communication

& Timing Disinterest Technology Problems

Phase 4 reviewing and naming themes. To establish referential adequacy, preliminary

themes and their corresponding attributes were compared to the raw data. Attributes were

renamed and finalized. Themes were renamed using succinct phrases that represented their

specific attributes.

Table 5: Reviewing and naming theme - Group One & Two

Phase 4: Reviewing and Naming Themes Group One

FINAL THEMES Care Partnership Holistic

Communication Comorbidity Importance

EVALUATING THE IMPACT OF A DEPRESSION CARE 15

FINAL ATTRIBUTES

Shared decision making, Self-

management, Support and Trusting relationships

Empathic, Active listening, Personalized,

Responsiveness and Inclusive

Passive listening; knowledge deficit

Group Two FINAL

THEMES Invitation Challenges

FINAL ATTRIBUTES

Overlooked virtual communication, Absent initiation and Lack of appeal Telecommunication problem

Phase 5 defining themes. A definition for each theme was formulated to fully understand

the data. The final set of themes were separated into two categories: program strengths and

limitations.

Table 6: Defining themes - Group One & Two

Phase 5: Defining Themes Group One

THEME DEFINITION

Care Partnership (Strength)

A supportive alliance between a provider and patient that includes trust, guidance, self-discovery and shared decision making that

directs depression care.

Holistic Communication

(Strength)

Empathic interactions between patient and provider that is inclusive, responsive and attentive to patient needs providing a foundation for

reflection and growth.

Lost in translation (Limitation)

Ineffective communication that leads to patients feeling ignored and unaware of program benefits. It risks a reduction in high quality

patient-centered care.

Group Two THEME DEFINITION

Invitation Challenges (Limitation) Challenges encountered by patients that prevented them from

responding to the initial invitation email.

EVALUATING THE IMPACT OF A DEPRESSION CARE 16

Quantitative analysis. Descriptive statistics were used to analyze all data using

Microsoft Excel. PHQ-9 scores from group one participants were organized according to date.

Scores were filtered into specific timeframes: intake, 1-2 months, 3-4 months, and 5-6 months.

Figure 1 depicts these scores plotted on a line graph (Figure 1). Group mean scores were then

calculated for each timeframe and also plotted on a line graph (Figure 2). The set of scores from

patient G were excluded from the mean analysis because there were only two data points: intake

and 1-2 months.

Mixed methods analysis. The mixed method analysis consisted of comparing qualitative

and quantitative data from group one participants. After independent analysis was completed, the

findings were further examined to determine how they would be combined. Data triangulation

was used to discover mutually supported findings. Triangulation refers to using multiple data

collection methods or multiple sources of data to obtain a comprehensive understanding of the

phenomenon of interest (Heale & Forbes, 2013). Qualitative data sources consisted of findings

from individual questionnaire responses and chart notes. The quantitative data consisted of

findings from PHQ-9 scores. Each patient’s scores were graphed separately and matched to their

questionnaire responses and chart notes (Table 9). Merging independent findings provided a

deeper understanding of patients’ experiences.

Ethical Considerations

The protocols and conduct of this project were submitted to the healthcare system’s

Institutional Review Board (IRB) and Seattle University’s IRB. The project was designed to

improve the healthcare system’s processes with the goal of improving patient care therefore it

was approved as exempt per federal regulations 45 CFR 46 (Protection of Human Subjects,

2018). Despite exemption status, steps were taken to notify patients of pertinent project

EVALUATING THE IMPACT OF A DEPRESSION CARE 17

information (Office of Human Research Protections [HHS], n.d.). All participants were provided

with an explanation of the project’s purpose. No monetary and/or other incentives were

provided. The project investigator and professional mentors complied with all regulations to

maintain participant confidentiality.

Results

Qualitative and quantitative data were collected from multiple sources (See Table 7).

Content analysis, descriptive statistics and data triangulation offered a complete evaluation of the

DCM program from the patient’s point of view.

Table 7: Data Sources, Sample and Analysis

Data Sources Assessment Analysis Method Sample

Online survey DCM program impression Content Analysis N = 7

Individual PHQ-9 Depression severity Descriptive Statistics N = 7

Mean PHQ-9 Depression severity Descriptive Statistics N = 7

Chart notes, PHQ-9, survey Impact of DCM program Data Triangulation N = 7

Individual Interviews Barriers to program engagement Content Analysis N = 14

Group One

The majority of participants in group one were female. The sample consisted of five

women and two men with an average age of 49 years old and a range between 21-75 years of

age. DCM program enrollment time varied between 2-8 months. Patient A dropped out at 8

months and Patient B completed the program at 3 months.

Qualitative findings. Three major themes were found from the online questionnaire

responses: Care partnership, holistic communication and lost in translation. Relevant patient

EVALUATING THE IMPACT OF A DEPRESSION CARE 18

quotes are provided below. These findings were used to answer the following project question:

What are patients’ impressions of the DCM program?

Care partnership. Care partnership incorporated shared decision making, self-

management, support and trusting relationships.

“We were able to determine that I needed an increase in dosage of my medications.”

“The best part is being able to bounce ideas off each other about ways to help me.”

“[the nurse] helps me troubleshoot how I’m feeling and gives some options regarding

medication adjustments.”

“Feeling as though someone was looking out for me with the consistent check-ins.”

“the monthly contact (and more, as needed) is a good reminder to actively think about

your progress, where you want to be, etc. It keeps one from slipping through the cracks

and just accepting treatment as is…depression management is never as simple as

diagnosis/prescription/set it and forget it.”

Holistic communication. Holistic communication included empathy, active listening,

personalization, responsiveness and inclusion in care.

“[the nurse] gets back to me promptly and I don’t feel like a burden. She is helpful,

caring and listens with no judgement.”

“It’s helped me during my worst times…”

“The nurse was diligent and kept looking until a solution was found and followed up with

me regularly.”

“It’s helped me be more thoughtful and aware of my mental health.”

“I probably wouldn’t have reached out so the fact that I am contacted first makes care

easier.”

EVALUATING THE IMPACT OF A DEPRESSION CARE 19

Lost in translation. Information lost in translation included passive listening and

knowledge deficit.

“The original doctor I went to zeroed in on the depression screening and ignored my

actual health complaints, which have since continued and gotten worse. It made me

resentful and really annoyed that I’d been honest on the depression screening, because I

wasn’t getting help with my health which has led to not being able to work out at all,

being sick constantly and therefore more depressed.”

“Not doing well. I had high hopes that my antidepressant would work and just sort of

gave up when it didn’t.”

“I had no idea I was in [the program].”

Quantitative findings. Individual PHQ-9 scores from six participants are graphed in

Figure 1. Scores from patients A, B, C, D and F decreased by at least two points in 6 months.

Patient E’s scores increased by three points at 6 months. The group’s mean PHQ-9 scores is

graphed in Figure 2. At six months, there was a net score decrease of 23% indicating that the

majority of patients’ depression symptoms were improving. These findings were used to answer

the following project question: What were patients’ assessments of their depression symptom

severity as they progressed through the DCM program?

EVALUATING THE IMPACT OF A DEPRESSION CARE 20

Figure 1. Individual Scores

Figure 2. Group Mean Scores

Mixed method findings. Questionnaire responses and graphed PHQ-9 scores were the

primary data source. Chart notes were investigated to further understand factors that facilitated or

hindered patient progression. The main finding that emerged during analysis was the importance

0

5

10

15

20

25

Intake 1-2mo 3-4mo 5-6mo

PH Q

-9 S

co re

s

Time

A B C D E F

13

10.7 9.3 10

0 2 4 6 8

10 12 14

Intake 1-2mo 3-4mo 5-6mo

PH Q

-9 S

co re

Time

EVALUATING THE IMPACT OF A DEPRESSION CARE 21

of comorbidities. The findings are detailed in table 3 and were used to answer the following

project question: What factors impacted patients’ progression through the DCM program?

Table 9: Mixed Method Findings

Pt Chart Note Themes: Quotes PHQ-9 Graph

A

Dropped out at 8 months

Medication adjustment Co-morbid condition

Lost in translation “Not doing well. I had high

hopes that my antidepressant would work and just sort of

gave up when it didn’t.”

B Completed

at 3 months

Care Partnership "We were able to determine that I needed an increase in dosage of my medications."

C None

Holistic Communication "It's helped me be more

thoughtful and aware of my mental health."

16 13

10 9

0

5

10

15

20

25

Intake 1-2mo 3-4mo 5-6mo

PH Q

-9 S

co re

s

9 6 6 6

0

5

10

15

20

25

Intake 1-2mo 3-4mo 5-6mo

PH Q

-9 S

co re

s

13 11

9 7

0

5

10

15

20

25

Intake 1-2mo 3-4mo 5-6mo

PH Q

-9 S

co re

s

EVALUATING THE IMPACT OF A DEPRESSION CARE 22

D

Medication adjustment

Situational

change

Co-morbid condition

Care Partnership "The best part is being able bounce ideas off each other about ways to help me. [The nurse] helps me troubleshoot how I am feeling and gives

some options regarding medication adjustments."

Holistic Communication

"[The nurse] gets back to me promptly and I don't feel like a burden. She is helpful, caring

and listens with no judgement."

E

Medication adjustment

Co-morbid condition

Care Partnership "The monthly contact (and more as needed) is a good reminder to actively think

about your progress, where you want to be, etc. It keeps

one from slipping through the cracks and just accepting

treatment as is…depression management is never as

simple as diagnosis/prescription/set it

and forget it."

F Co-morbid condition

Care Partnership "Feeling as though someone is

looking out for me with the consistent check ins."

Holistic Communication

"I probably wouldn't have reached out so the fact that I am contacted first makes care

easier."

19 20

12

17

0

5

10

15

20

25

Intake 1-2mo 3-4mo 5-6mo

PH Q

-9 S

co re

s

17

8

14 14

0

5

10

15

20

25

Intake 1-2mo 3-4mo 5-6mo

PH Q

-9 S

co re

s

4 6 5

7 0

5

10

15

20

25

Intake 1-2mo 3-4mo 5-6mo

PH Q

-9 S

co re

s

EVALUATING THE IMPACT OF A DEPRESSION CARE 23

G

Medication adjustment

Co-morbid condition

Care Partnership "A medication was found

that doesn't exacerbate my symptoms from another

disorder I have."

Holistic Communication "The nurse was diligent and kept looking until a solution was found and followed up

with me regularly."

Lost in Translation “The original doctor zeroed in

on the depression screening and ignored my actual health complaint which have since

continued and gotten worse. It made me resentful and really annoyed that I’d been honest on the depression screening, because I wasn’t getting help

with my health…” “I had no idea I was in [the

program]”.

Group Two

The majority of participants in group two were female. The sample consisted of nine

women and five men with an average age of 40 years old and a range of 21-73 years of age.

Qualitative findings. Individual interviews highlighted several rationales for not clicking

on the hyperlink to complete the questionnaire. These reasons were grouped together into a

category called invitation challenges. Relevant patient quotes are provided below. These findings

were used to answer the following project question: What prevented patients from responding to

the initial invitation email sent by the DCM program?

Invitation challenges. Invitation challenges included overlooked virtual communication,

environmental factors and telecommunication problems.

9

14

0

5

10

15

20

25

Intake 1-2mo 3-4mo 5-6mo

PH Q

-9 S

co re

s

EVALUATING THE IMPACT OF A DEPRESSION CARE 24

“I probably saw it and forgot to fill it out.”

“…I probably saw it, opened it and totally spaced filling it out.”

“I was dealing with a lot and I felt like I was just kind of not in a place to do it.”

“I’ve been putting myself on the back burner.”

“…due to family member illness I have not been able to pay attention to my emails.”

“…I had seen that as a follow up to a previous medical plan that I’m no longer on.”

“My depression is very light and so I don’t need a lot of follow up.”

“I clicked on the link and tried to submit it but had problems.” The patient was unable to

recall exact problem with submission.

“I didn’t see the link.” The initial email was missing the questionnaire link.

“I’m not computer savvy. I prefer printed or mailed information.”

Discussion

This mixed methods program evaluation aimed to explore patients’ experiences in the

DCM program. The findings for this project were drawn from the analysis of quantitative and

qualitative data. Content analysis and data triangulation produced a deeper understanding of the

program’s strengths and limitations. This section summarizes project findings and details

recommendations to mitigate program limitations.

Two major program strengths emerged from the collection of patient quotes: Care

partnership and holistic communication. The DCM program contains attributes that align with

features from patient-centered care as defined by the IOM (2001) including respect and

responsiveness. Holistic communication was a prevalent theme in questionnaire responses.

Patients felt the nurse was attentive to their specific needs which guided their overall treatment

plan. This is critical in depression care as patient preferences strongly influence acceptance and

EVALUATING THE IMPACT OF A DEPRESSION CARE 25

adherence to treatment (Rossom et al., 2016). Patients valued the consistent check-ins and

treatment guidance they received during the program. These features encouraged active

participation in care and these patients are more likely to receive guideline-concordant care

(Martino et al., 2011). The majority of patients felt supported and empowered through a care

partnership that was developed with the nurse. This relationship provided them with a sense of

security and was rooted in trust which is apparent in the following remarks: “It keeps one from

slipping through the cracks…”; “Feeling as though someone was looking out for me…”; “It has

helped during my worst times…”; and “I probably wouldn’t have reached out so the fact that I

am contacted first makes care easier.”. The DCM program provides a safety net for patients who

are reluctant to discuss their emotional distress with a primary care provider due to time

constraints, conflicting demands and/or fear of stigma (Unutzer & Park, 2012).

The program had a positive effect on the majority of patients’ depression severity scores

consistent with the evidence that collaborative care programs improve depression clinical

outcomes (Archer et al., 2012; Bjorkelund et al., 2018; Ludman et al., 2016; Meunier et al.,

2014; & Simon et al., 2011). Some individuals experienced increasing severity and spikes in

symptoms due to medication adjustments, situational factors and/or symptoms related to co-

morbid conditions. Despite these small setback’s these patients were continually satisfied with

care and felt the program was helpful. Patient satisfaction is linked to quality care, better clinical

outcomes and is a key element in the Quadruple Aim (Crosier, Scott, & Steinfeld, 2011;

Luxford, 2012; Martin, Nelson, Lloyd, & Nolan, 2007). Solely relying on the clinical assessment

of symptoms may not be indicative of whether the patient is improving or feeling better.

The primary program barrier impacting patient progression was the presence of comorbid

conditions. The co-occurrence of depression and other disorders is common and negatively

EVALUATING THE IMPACT OF A DEPRESSION CARE 26

impacts quality of life, causes functional impairments and increases mortality (Kang et al.,

2015). More than half the patients in group one had a chronic physical or mental health disorder

co-occurring with their depression. Symptom severity scores frequently increased during an

exacerbation of symptoms caused by another disorder. Two patients who experienced spikes in

depression severity suffered from other mental health conditions that may have required a higher

a level of care or adjunctive treatment (i.e. psychotherapy).

Increasing PHQ-9 scores prompt a change in antidepressant treatment (i.e. increase

dosage, switching medication) which is challenging in co-occurring disorders as medication side

effects may further exacerbate symptoms from the secondary condition. Furthermore, this

alteration may not have an effect and may actually worsen a patient’s depression symptoms

because their other disorder was not adequately treated. This was apparent from the following

patient quote:

“The original doctor I went to zeroed in on the depression screening and ignored my

actual health complaints, which have since continued and gotten worse. It made me

resentful and really annoyed that I’d been honest on the depression screening, because I

wasn’t getting help with my health which has led to not being able to work out at all,

being sick constantly and therefore more depressed.”

Ineffective communication led to the patient feeling that her other health concerns were

disregarded because she told the truth about her emotional distress. Perception of poor

communication can lead to adverse events (Luxford, 2012) and in this case the patient’s physical

symptoms got worse and her depression increased. Another patient, who also suffered from a

chronic comorbid condition, prematurely dropped out of the program because she was

discouraged when her antidepressant medication was ineffective. During the program, her PHQ-

EVALUATING THE IMPACT OF A DEPRESSION CARE 27

9 scores indicated her depression was improving even though she continued to struggle with

symptoms from another disorder. Post program participation, she was experiencing

exacerbations of both her disorders suggesting that the addition of the DCM program helped her

depression despite the comorbid condition. Before she dropped out of the program her PHQ-9

score indicated her depression severity was low however the patient felt her antidepressant was

ineffective. Considering symptoms from both her conditions when trying to understand what was

contributing to her impression that the medication was ineffective, may have aided in treatment

modification and possibly reduced the risk of her dropping out of the program. Patients enrolled

in the DCM program who suffer from co-occurring conditions may not experience or maintain a

reduction in depression severity despite antidepressant treatment. They can experience spikes in

depression symptoms due to an exacerbation of another disorder. These patients require

increased attention to both disorders and/or possible referral to a higher level of care.

Prominent themes emerged during the evaluation of patient rationales for not clicking on

the program’s invitation hyperlink. Most patients forgot to respond to the initial outreach but

stated they would have been interested in participating in the program. In addition, patients felt

that environmental factors (i.e. family illness, life transition and personal need) prevented them

from responding. Two individuals had telecommunication problems including submitting the

link and seeing the attached link. The timing of this project’s follow-up was two years past the

date of the initial invitation therefore patients may not have remembered the specific reasons

they chose not to engage.

Limitations

Depression is a self-limiting disorder due to the vegetative symptoms possibly preventing

patients from participating in this program evaluation. The sample size was small therefore it

EVALUATING THE IMPACT OF A DEPRESSION CARE 28

may not represent information that is generalizable to all DCM program participants. Self-

reported data has inherent limitations as participants may have responded in a socially desirable

manner on the phone and through secure messaging. Furthermore, longitudinal effects due to this

project’s timeframe prevented the collection of data from patients during different time intervals

(i.e. pre and post evaluation).

Recommendations

Improving screening for comorbid physical and mental health conditions during

enrollment is essential to provide high quality patient centered care in the DCM program.

Improved screening may consist of looking for “red flags” (i.e. chronic pain, unexplained

somatic symptoms and PTSD) during program engagement by conducting a patient chart review;

adding extra screening tools specific to common co-occurring disorders in the behavioral health

questionnaire; or developing a care management EMR alert that is triggered when an eligible

patient has a history of a comorbid condition. Documenting these “red flags” or alerts in the care

management notes can prompt the care team to evaluate and consider contributing comorbid

factors when assessing individual patient progress.

Expanding care management programs for other mental health disorders (i.e. PTSD) or

disorder classifications (i.e. Anxiety disorders to include generalized anxiety, PTSD, OCD, etc.)

would be highly beneficial. All patients despite their diagnosis would benefit from the support

provided by the DCM program however each diagnosis requires treatment that may differ from

depression. By implementing separate care management programs, the healthcare system can

increase access to mental health care that is comprehensive, and patient centered.

Patient feedback is essential to fully understand how a patient is responding to treatment.

PHQ-9 scores provide an accurate clinical analysis of depression symptom severity however

EVALUATING THE IMPACT OF A DEPRESSION CARE 29

these scores do not provide a full assessment of patient progress. Gathering intermittent patient

feedback about the program provides important information to the care team and offers an

opportunity for patients to reflect on their progress. An example of program feedback is a

questionnaire that is sent out every two months to assess features that have helped the patient and

things they would like to improve.

To improve program engagement, individualized outreach methods and educational

materials are necessary as each patient has a specific learning style and communication

preference. Customizing outreach will increase patients’ awareness of program features allowing

them to fully benefit from the program. An example of tailoring to specific patient needs is

providing a pamphlet to eligible patients in the primary care office that summarizes the DCM

program. Then in the invitation email or phone call the healthcare professional can assess how

the patient would like to receive educational information (i.e. written or video) and how they

would like to interact with the care team (i.e. secure messaging or phone call). Furthermore,

interpreters or bilingual team members are needed to help patients who speak different languages

navigate the DCM program.

Conclusion

In summary, the project findings demonstrate that patients’ value the care provided by the

healthcare system’s DCM program. Telehealth allows the patient to feel supported and

connected during depression treatment. Future projects should take place to evaluate patients’

experiences at different time intervals (i.e. pre-, active and post enrollment) as new iterations of

the DCM program are implemented to further understand the patients’ journey and maintenance

factors. Patient feedback must be incorporated to continually improve the program’s patient

centeredness.

EVALUATING THE IMPACT OF A DEPRESSION CARE 30

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EVALUATING THE IMPACT OF A DEPRESSION CARE 36

Appendix A

EVALUATING THE IMPACT OF A DEPRESSION CARE 37

Appendix B

(1) Group One Questionnaire

Question 1: (program strength): What is (or was) the best part of the depression care management program? Question 2: (program strength) In what ways has (or did) the depression care management program helped you? Question 3: (program weakness) What changes would improve the depression care management program? Question 4: Do you have any additional comments? Question 5 only asked patient who dropped out: (program weakness) Select all that apply - Why did you stop participating in the depression care management program?

a. I stopped taking my medication. b. I never planned on taking medication. c. I was more interested in therapy rather than medication. d. I had a bad experience with medication. e. I was unsure about the purpose of the depression care management program. f. My depression got better, and I didn’t need it? g. My insurance changed. h. I prefer to manage my medication with my provider. i. It wasn’t helping me. j. It’s another reason. Please specify .

(2) Group Two Interview Script

Intro: “Hello, my name is Natalie. I’m a registered nurse and doctoral student calling from (medical institution’s name). I’m reaching out to patients who were invited to participate in the antidepressant medication follow up program. I’m working with this program to improve their online communication. Would you be willing to answer one question that will take less than 5 minutes of your time?” (If yes, ask): “Is this a good time for you to talk?” (If yes, continue to question), (If not a good time, ask): “Could I call at a better time for you? What time?” Question: You were sent an email through (medical institution’s name)’s website. You were asked to click on a link and fill out a questionnaire about your antidepressant prescription and symptoms. (Medical Institution’s name) did not receive a response from you to this questionnaire. We are interested in know if there were issues with (medical institution’s name) communication or the link, or if there were other reasons you didn’t click on the link to complete the questionnaire.”

EVALUATING THE IMPACT OF A DEPRESSION CARE 38

Appendix C

Spitzer, R. L., Williams, J. B., & Kroenke, K. (n.d.). Patient Health Questionniare-9 (PHQ-9) [Measurement tool]. Unpublished instrument. Retrieved from https://www.phqscreeners.com/images/sites/g/files/g10060481/f/201412/PHQ-9_English.pdf