Depression in US adults is fairly common, with a reported 7.1% prevalence. The prevalence is reportedly higher within the population actively associated with a health care system (as much as 15%). Depression is a highly prevalent risk factor for cardiovascular disease, hypertension and diabetes, and is associated with higher morbidity and mortality. Individuals with depression often have sub-optimal control of chronic diseases, related to a number of healthcare behaviours (poor medication adherence). Depression, with or without accompanying chronic conditions, has been linked to greater use of healthcare services, including higher emergency room utilization and pharmacologic cost. Many patients with depression often go undiagnosed. Barriers to diagnosis include patient factors, such as reluctance to discuss behavioural health issues and a lack of knowledge of the relationship of depression to overall health. Physician barriers include limited time spent with the patient, and a bias that depression is always clearly evident.
Within our population health unit (Cleveland Clinic Community Care), we organized our workforce into interdisciplinary teams (IPU), enabled by a common electronic medical record (EMR) that curates relevant patient information into actionable lists and registries, which the teams address in structured panel management meetings during their workday. Presently, each physician is supported by a care team of: advanced practice provider, medical assistant, team nurse, care coordinator, social worker, pharmacist, behavioural health worker and patient navigator. While most of the information which the IPU’s use to make care decisions and deploy resources are based on clinical criteria, we have begun incorporating patient-reported data into their patient lists and registries in recognition of this dimension that has significant impact in patient engagement and health-seeking behaviours. Since 2017, every patient age 12 and older is asked to answer the depression screening questionnaire PHQ annually, prior to or during their appointment with their primary care physician (PCP). More recently, we deployed PROMIS and SDH (Social Determinants of Health) questionnaires, to capture self-reported functioning and barriers to care. In our latest EMR update, patient-reported data is now a visual “social wheel” that is incorporated in each patient’s “Storyboard”, again highlighting for every health caregiver the importance of this domain.
In reviewing our experience to date of 135,000 screened individuals, patients with depression or poor self-reported functioning are twice as likely to seek care in an emergency room setting, compared to similar patients who are not depressed. There is also a larger proportion of patients identifying as depressed who were hospitalized compared to those who did not report depression symptoms. After intervention by the primary care team, the rate of ED utilization decreased by half for patients whose PHQ-2 or PROMIS scores improve, representing a system savings in unnecessary cost of care of $1.3M.
While promising, the impact of these screenings and primary care intervention is not universal across our system. This initiative aims to scale this model across our 60+ primary care outpatient locations, caring for over 700,000 patients, in the State of Ohio.