Alliance Health Conf
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Transcript of Alliance Health Conf
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8/9/2019 Alliance Health Conf
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Improved Screening andManagement of Depression in the
Skilled Nursing Facility andLong-Term Care Setting
Center for Medicare Medicaid Services!CMS" Special Study
#resented $y% &icki 'oyle( )N( 'SN( #ro*ect Manager
To the +lliance for ,ealth
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#resentation utline
#ro*ect $ackground #ro*ect o$*ectives
#ro*ect design
M#) interventions Data analysis and findings
.uestions and discussion
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#ro*ect 'ackground
ne of t/o CMS pro*ects a/arded to .ualityImprovement rgani0ations !.I" on thetopic of Depression in 1223
Michigan .I !M#)" is /orking in the nursinghome setting
Ne/ 4ork .I !I#)" is /orking in the cardiacreha$ setting
#ro*ects $egan 5uly 1223
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Incidence and Significance of
Depression in the 6lderly 789 million !3:;" of +mericans older than :eriatric Depression% Lack of
)ecognition 50% of depressed nursing homeresidents are not appropriately
diagnosed
Less than 25% of depressed elderlyreceive adequate treatment
?,4@
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)easons for Missed Diagnosis
Depression symptoms are attri$uted to age(other physical illness( $ereavement( ordementia
Stigma associated /ith mental illness Depression is masked $y somatic symptoms
#atients deny psychiatric symptoms
InadeAuate assessment of elderly in nursinghomes
Depressed patients often present nomanagement pro$lems
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ConseAuences of Missed Diagnosis
or InadeAuate TreatmentSuicide 3B; of suicides occur in patients :< and older
(allahan , 2&&&)
lder adults account for 31; of the S
population $ut 12; of the more than =2(222suicide deaths annually (allahan , 2&&&)
6lderly /hite men age 9< and older suiciderate is : times higher than the generalpopulation (/$yert et al, 1999)
B2; of suicides see their primary carephysician /ithin one month of suicide($n0ell 199")
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ConseAuences !continued"
>reater Mor$idity
Impaired a$ility to manage other illnesses
Decreased Auality of life
Strain on family and health care /orkers
Decreased compliance /ith medical treatment
Depression increases mor$idity and mortality
in patients /ith congestive heart failure !C,F" Depression /orsens mor$idity post-stroke
and myocardial infarction !heart attack"
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ConseAuences !continued"
Increased Mortality
Increased risk of death $y
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ConseAuences !continued"
CoEt
Increased use of medical services
Chronicity% 1 in 4 depressed patients will be ill for
> 2 years
)ecurrence% ore than 50% will have arecurrence
#remature placement in nursing facilities Increased risk of hip fracture due to falls
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#revalence of Depression as a#revalence of Depression as a
ConcomitantConcomitant Condition
&1
21
&1
Cancer Dia$etes #ost-
#artum
#ost-
Stroke
#ost MI
assie /$llan, 199' 4ustman et al, 199' 5$*ie 6al+er,
1992' $rris et al, 199&
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#ro*ect $*ectives
Long-term $*ective
Improvement in depressive symptoms for theresident /ith an increase in daily function
Improve systems for depression management
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M#) Interventions )eadiness assessment of the facilities to determine
characteristics and resources
6ducational sessions !C6s for nursesHassistantsJ CM6for physicians( familyHresident education"
#ro*ect toolkit
n-site visitsHtechnical assistance
C.I consultation and tools
Data collection and analysisHDevelop data collection tool
Data reports and discussion !May 1221 and Novem$er1221"
+ssist facilities to develop a systematic process fordepression screening( assessment( and treatment
Interdisciplinary approach
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Development of Indicators
sing eisting literature and practiceguidelines( M#) developed o$*ectives forthe pro*ect
These o$*ectives /ere then revie/ed /ith
the Technical 6pert #anel !T6#"J dataavaila$ility from the MDS /as investigated
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.uality Indicator 3a and )esults
Proportion of newly admitted residents who areassessed for depression using the Geriatric
Depression Scale (GDS) by day 7 of stay
DK +ll residents /ho fulfill the inclusion and eclusioncriteria K 939
NK Those in the denominator /ith assessment done $y dayB K B3
)ate K ;
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.uality Indicator 3$ and )esults
Proportion of newly admitted residents who
are assessed for depression using the GDS by
day 14 of stay
DK +ll residents /ho fulfill the inclusion and eclusioncriteria K 939
NK Those in the denominator /ith assessment done $yday 37 K 1
)ateK 33;
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.uality Indicator 1a and )esults
Proportion of depressed residents who
receive depression treatment by day 7 of stay
DK )esidents /ith symptoms andHor a diagnosis of
depression $y day B of stay K 1:
NK Those in the denominator /ho receive depressiontreatment $y day B of stay K 12=
)ate K B
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.uality Indicator 1$ and )esults
Proportion of depressed residents who receive
depression treatment by day 14 of stay
DK )esidents /ith symptoms andHor a diagnosis of
depression $y day 37 of stay K =3=
NK Those in the denominator /ho receive depressiontreatment $y day B of stay K 179
)ateK B;
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Criteria for .Is 1a and 1$
Depression diagnosisHsymptoms may $e foundin the chart or MDS
Depressed residents must ehi$it symptomsincluding sad mood and t/o or more of the
follo/ing% Negative statements
+gitation or /ithdra/al
?aking /ith an unpleasant mood or not $eing a/ake
for most of the day and not comatose
'eing suicidal or having recurrent thoughts of death
?eight loss
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Criteria for .Is 1a and 1$
Treatment includes !any of the follo/ing" +ntidepressant medication
#sychological therapy $y any licensed mentalhealth professional
>roup therapy
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#revalence of Depression andTreatment
5e7resse 7ri$r t$
amissi$n
31
n821$t e7resse
-
n8"9
e0 ly ia:n$se
13
n81&(
#; 7ri$r t$
amissi$n
(1n82&3
$ #; 7ri$r t$
amissi$n
19
n8"(
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.uality Indicator = and )esults
Proportion of residents assessed positivefor depression by the GDS by day 14 who are alsoassessed positive for depression by the DSassessment
DK )esidents /ho /ere positive for depression $y the >DS!score < or more" $y day 37 of stay K 71
NK Those in the denominator /ith symptoms andHor a diagnosisof depression noted in either the MDS < day or 37 dayassessment K 1:
)ateK :1;
Di th t + M ft i
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Diseases that +ppear More ften in)esidents /hose Symptoms
Did Not Improve
34%
27%
52%
38%
27%
15%
23%
8%
35%41%
18%
57%49%
36%
19%23%
7%
40%
0%
20%
40%
60%
80%
100%
Allergies Seizure disorder Osteoporosis Emphys!O"# A$emi Arthritis
Symptoms &mpro'ed Symptoms #id (ot &mpro'e Smple
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Diseases that +ppear More ften in)esidents /hose Symptoms Improved
46%
38%
85%
31% 31%
46%
16%
23%25%
66%
20%
27%
27%
13%16%
73%
30%
22%
0%
20%
40%
60%
80%
100%
#i)etes !*+ Stro,e *yperte$sio$ "eriph 's- dis *emiplgi
Symptoms &mpro'ed Symptoms #id (ot &mpro'e Smple
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?hat ,appens to )esidents
/ho are Treated@
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?hat ,appens to )esidents /hoare Treated@
TI 1 indicated that =1 out of =< people /ho aretreated and /hose condition /orsened /erereassessed $y day :2 of stay
Diagnosis confirmedHresponse evaluated K 3!
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Conclusions
.I 3% The >DS is not consistently used $y the37 participating facilities to screen fordepression
.I 1( TI% The ma*ority of the residents identified
/ith depression are receiving treatment
.I =% The MDS is not sufficient $y itself toidentify depression
.I 1( TI = 7% +ntidepressant medication is theprevalent method of treatment
TI = 7% The ma*ority of the residents receivingtreatment are not improving $y day :2
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Conclusions
The ma*ority of the =1 residents /ith :2-daystays /ere reassessed after treatment fordepression /as initiated( $ut in
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Interim )emeasurement )esults
9% 11%
75%79%
62%
47%
60%
69%76%
52%
0%
20%
40%
60%
80%
100%
nB=818 nI=586
Assessed by Day7
nB=818 nI=586
Assessed by Day14
nB=269 nI=159
DepressedResidents Treated
by Day 7
nB=313 nI=180
DepressedResidents Treated
by Day 14
nB=42 nI=77
Assessed Psiti!eby "D# a$s
Assessed Psiti!e
by D#
Base$ine
Interi&
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+lgorithm for Treatment of >eriatric
Depression
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+d*usting Treatment of Depression
if Initial )esponse is InadeAuate Increase dose of initial antidepressant
medication
Change to ne/ antidepressant medication
+dd psychosocial interventions
Implement augmentation strategy
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?hen to )efer to a #sychiatrist
)eferral definitely indicated% #sychotic depression
'ipolar disorder
Depression /ith suicidal ideation
)eferral usually indicated%
Depression /ith comor$id su$stance a$use
Depression /ith comor$id dementia
Depression that has not responded to anadeAuate trial of antidepressant medication
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ConclusionsH)ecommendations
It appears that treatment initiation hasimproved from pre-')+ 392s
The current issue may not $e the initiation oftreatment( $ut the algorithm for treatment
The algorithm for treatment should includestrategies to optimi0e treatment and manageresponses in the geriatric resident
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.uestions@
Thank you
Contact Information%
&icki 'oyle( )N( 'SN
B=7-7