Lloyd F. Moss Free Clinic Mental Health Program

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Lloyd F. Moss Free Clinic Mental Health
Program Presented by Donna M. Bowser, DNP,
CFNP Marsha Green, NP, CNS
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Objectives

• Present baseline measurements for implementation
  evaluation of a mental health program in a free
  clinic setting
• Discuss initial implementation of integrated
  primary care model in a free clinic setting
• Provide initial preliminary outcomes of before
  after 3 months of mental health treatment

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Background

• Diabetes
• 7 of U.S. population (20.8 million) (CDC, 2007)
• Cost 132 billion in 2002 (CDC, 2007)
• Depression
• 6.7 of U.S. population (14.8 million)
• Cost 70 billion of direct indirect costs
  (National Institute of Mental Health, 2008)
• Poverty
• 36.5 million (lt 100 FPL) in 2006
• 49.7 million (lt 125 FPL) (U.S. Census Bureau,
  2007)
• Uninsured
• 15.8 of U.S. population (47 million) in 2006
  (U.S. Census Bureau, 2007)
• 1,718 Free clinics in U.S. serving 2.5 million in
  2003 (Isaacs Grant, 2007)

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Prevalence Rate of Diabetes Depression
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Cost of Diabetes Depression

• Depression interferes with the ability to
  perform healthy self care behaviors and hence
  greatly increase the medical costs (Ciechanowski,
  Katon, Russo, 2000 Lin et al, 2004 Olfson
  Gameroff, 2007)
• Costs is 4 ½ time more to care for individuals
  with diabetes who are depressed verses those
  without depression (Egede, Zheng, Simpson,
  2002)
• 70 increase in health care costs for individuals
  with diabetes who the diagnosis of major
  depression verses those without major depression
  (N4398)(Simon et al., 2005)

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Methods to Obtain Baseline Measurements

• Administer computerized (via ACASI) and paper
  questionnaires to 183 adults
• Patient Health Questionnaire 9 (PHQ-9)
• RAND 36 Health Survey (RAND-36)
• Diabetes Empowerment Scale (DES-SF)
• Audit of Diabetes Dependent Quality of Life
  (ADDQoL)
• Measured Missed Appointments Length of Medical
  Treatment in a Free Clinic Setting

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WHAT IS ACASI?

• Audio Computer Assisted Self Interviewing
• Touch Screen
• Headphones
• English Spanish
• Can be programmed for any questions
• Automatically scored and recorded (SPSS Excel)
• Ability of report to be printed off for medical
  chart
• Requires very limited staff time

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Patient Health Questionnaire 9A Measurement of
Depression
Pfizer. (2005) Patient Health Questionnaire-9.
Retrieved March 22, 2008 from http//www.phqscreen
ers.com/.
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RAND 36-Item Health SurveyA Measurement of
Quality of Health
Rand Health. (2007). Medical Outcomes Study 36
Item Short Form Survey. Retrieved March 22, 2008
from http//www.rand.org/health/surveys_tools/mos/
mos_core_36item.html.
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The Audit of Diabetes Dependent Quality of Life
(ADDQoL)
Bradley, C., Gorton, T., Symonds, E., Martin, A.,
Plowright, R. (1999). The development of an
individualized questionnaire measure of perceived
impact of diabetes on quality of life The
ADDQoL. Quality of Life Research, 8, 79-91.
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Diabetes Empowerment Scale (DES-SF) A Measurement
of Self-Efficacy
Anderson, R., Funnell, M., Fitzgerald, J.,
Marrero, D. (2000). The diabetes empowerment
scale. Diabetes Care, 23(6), 739-743.
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Length of Medical Treatment in the Free Clinic
Setting
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Missed Appointments Presence of Depression
PHQ-9 Patient Health Questionnaire - 9
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Conclusions

• 30.1 Prevalence rate of depression in a
  low-income, uninsured, racially-mixed, adult
  population with diabetes
• RAND-36 DES-SF vary significantly among those
  with depression those without depression in
  this population
• Implementation evaluation of mental health
  programs are needed to treat this population

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Getting Started

• Comparable to Outpatient Practice
• Intakes
• 1 Hour
• Follow-Up
• 30 Minutes
• Will eventually incorporate 15 minute slots

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Assessment Findings

• Diagnostically
• MDD
• GAD
• Panic Disorder
• PTSD
• Substance Dependence
• Bipolar Disorders, Type I and II

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Assessment Findings

• Behaviorally
• LACK OF SKILLS
• Coping Skills
• Unresolved Grief
• Unresolved Trauma Issues
• Communication Techniques
• Anger Management/Emotional Regulation
• Boundaries

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Networking in the Community

• Know the Mental Health Services in your community
• 12 step meetings
• Counseling for this population
• Senior Services
• Severe Substance Abuse Issues
• Sexual Trauma Support

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GROUPS

• Initial Ideas
• Dialectical Behavioral Therapy (DBT)
• The Dont Diet Live-It Workbook (for weight loss)
• General group therapy
• In Actuality
• General Group Therapy
• Facilitator

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Experiential Groups

• Equine Therapy
• Drumming

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Collaborative Care

• Working together as a team
• Clinical treatment team meetings
• Pharmacy Teamwork
• Brief Introductions/Consultations
• Joint Appointments

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Barriers to Treatment

• Patient misconception of Psychiatric care
• they might lock me up, they think Im crazy
• Transportation
• No vehicle
• Unable to afford fuel (coordinating appointments
  on same day)

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Patient Feedback

• Now feeling heard..Validation
• Most responsive to active listening and that I am
  reliable
• If previously prescribed meds, mass confusion
  secondary to broken treatment

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Clients Served So Far1st Five Months

• 146 Unduplicated Patients
• 538 Individual Patients
• 8 Group Sessions
• 12 Unduplicated Group Patients
• 28 Patient Visits for Groups
• Preliminary no show rate of 25 (groups gt
  individual appointments)

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OUTCOMES MEASUREMENTS

• Depression level (PHQ-9)
• Quality of Health (RAND-36)
• Diabetes Quality of Life (ADDQOL)
• Diabetes Self-Efficacy (DES-SF)
• Level of diabetes control (HgA1c)
• Hypertension control (Systolic Diastolic BP)
• Weight (BMI)
• Frequency of ER hospital visits (funding?)
• Number of missed days of work in past 7 days
  (funding?)

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Patient Health Questionnaire -9 Preliminary
OutcomesInitial After 3 Months of Treatment
(N44)
(Paired samples t-test p .000)
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RAND 36 Preliminary OutcomesInitial After 3
Months of Treatment (N44)
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Diabetes Empowerment Scale Preliminary
OutcomesInitial After 3 Months of Treatment
(n25)
Paired Sample t-test (initial at 3 months)
reached level of significance p .045
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• ACASI Demonstration
• Thank you for your attention.
• Are there any questions?
• For references further information
• Bowser, D., Utz, S., Glick, D., Harmon, R.,
  Rovnyak, V. (2009). The relationship between
  diabetes mellitus, depression, and missed
  appointments in a low-income uninsured
  population. Diabetes Educator, 35(6), 966-977.

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Study Question 1

• What is the prevalence of depression as measured
  by the Patient Health Questionnaire-9 in which a
  score of greater or equal to 10 identifies the
  presence of depression (PHQ-9 gt 10)?

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Study Question 2 Part A

• Is there a difference in quality of health as
  measured by the RAND 36 Health Survey (RAND 36)
  between patients with the presence of depression
  (PHQ-9 gt 10) and patients without the presence of
  depression (PHQ-9 lt 10)?

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Study Question 2 Part B

• Is there a difference in quality of life as
  measured by the Audit of Diabetes Dependent
  Quality of Life (ADDQoL) between patients with
  the presence of depression (PHQ-9 gt 10) and
  patients without the presence of depression
  (PHQ-9 lt 10)?

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Study Question 3

• Is there a difference in self-efficacy as
  measured by the Diabetes Empowerment Scale
  (DES-SF) between patients with the presence of
  depression (PHQ-9 gt 10) and patients without the
  presence of depression (PHQ-9 lt 10)?

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Study Question 4

• Is the length of time receiving health services
  at a mid-Atlantic Free Clinic related to the
  results of the PHQ-9, a measure of depression?

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Study Question 5

• Is there an increase in missed appointments by
  patients with the presence of depression (PHQ-9 gt
  10) in comparison to patients without the
  presence of depression (PHQ-9 lt 10?