Scholarship | Policy Analysis: Enhancing depression screening rates across the state of Massachusetts

Ahmad Al-Musa

 

Problem Statement


What actions can the Massachusetts Executive Office of Health and Human Services take to better improve screening rates of depression in underserved and underdeveloped communities in the state?

 

Background


Depression can be defined by the American Psychological Association as a chronic medical condition that impacts the way people perceive themselves as well as the world around them (Purushottam, 2018). Signs and symptoms of depression may include different severities of sadness, loss of interest, fluctuation in appetite, change in sleeping patterns, and in some cases homicide/suicide (Purushottam, 2018). 

That said, according to the latest reports, rates of depression have been on the rise throughout the United States of America, and even more so in the state of Massachusetts (Boca,2017). To further illustrate this, a statistical study had been conducted to identify the rates of depression from 2011 to 2015 between the USA and the state of Massachusetts(MA). The rates of the report illustrated the following -8.3% (MA) 8.7% (USA) in 2011/2012, 8.6% (MA) 9.9% (USA) in 2012/2013, 11.1% (MA) 11% (USA) in 2013/2014 and finally 12.4% (MA) 11.9% (USA) in 2014/2015 (Boca,2017). This data provided to show that the state of Massachusetts had identified at least a 4.1% increase in the annual average percentage of depression cases in 2015 than in 2011. Massachusetts also surpassed the annual average of the USA in 2015 by a total of .5%.

The Massachusetts Executive Office of Health and Human Services(EOHHS) is the largest state-run entity that helps lead the collective understanding of the importance of health care in Massachusetts. The organization generates laws and policies that helps align the state with evidence-based guidelines and encourages a culture of transformation towards better, easier and more cost-effective care. The Massachusetts Executive Office of Health and Human Services overlooks several sub-entities within the state the help promote and regulate such policies (EOHHS, 2016). These sub-entities include the Board of Registration in Medicine, Massachusetts Department of Children & Families, Department of Developmental services, Executive office of Elder Affairs, Massachusetts Department of Mental Health, Department of Public Health. Department of Transitional Assistance, Department of Veterans’ Services, Department of Youth Services, Massachusetts Commission for the Blind, Massachusetts Rehabilitation Commission, Massachusetts for the Deaf and Hard of Hearing, Mass Health, Office for Refugees and Immigrants, Soldiers Home in Chelsea and Soldiers Home in Holyoke (EOHHS, 2016).. Choosing the EOHHS to be an ally of this project would be considered a great idea due to its vast influence across the state

 

Past Efforts to solve problems


  1. There has been much effort made within the state of Massachusetts to help alleviate the exposure of depression to its population. In 2008, the state of Massachusetts became the only state in the country (to date) to mandate behavioral/mental health screenings (aka Rosie D screenings) in a primary care setting. The Rosie-d screenings consist of at least eight different types of screens that are adjusted and provided based off age (Hacker et al, 2014). One of these screens that are provided is the Public Health Questionnaire.  This screening tool has been used as early as 12 years of age to help identify and diagnose levels of depression in the general population. Every year, organizations that screen and collect such data are mandated to report to the Department of Public Health Department on the screening efforts. 

  2. Massachusetts was the only state to establish an accreditation for organizations that demonstrated co-location/co-sharing of medical home efforts between primary care and behavioral health services. This is accreditation is known as the National Committee of Quality Assurance Prime Certification (NCQA, 2011).  Healthcare organizations that deemed successful at achieving such accreditations were able to enhance their quality strategies on behavioral health integration & services, engaging “evidence-based guidelines on treatment”, help better detect behavioral health/mental health diagnoses via primary screenings and patient involvement, establish standardized health assessment tools and optimized referral processes and follow up procedures (NCQA, 2011).  

  3. Ever since Mass Health had agreed upon the quality measures to be used towards the ACO model within the state, one measure caught many health organizations by surprise. This measure was defined by the “Percentage of members 12 to 64 years of age with a diagnosis of depression or dysthymia who have a PHQ-9 administered at least one time in the four-month measurement period” (Chung,2013). Classic indications for depression screenings have usually been based and aligned with the patient’s yearly physical visit in primary care. It has been recently suggested that continuous screenings might be justified in patients that have been diagnosed with depression and/or mood disorders (Teddy, 2006). Its noted that these groups of patients may lack a normal cognitive response increasing their risks for suicidal or homicidal attempts, so management of such population requires a high index of suspicion. Screening at the time of initial presentation and performing a quarterly (every three or four months) monitoring system as opposed to once a year is now being considered the accepted standard for these patients in Massachusetts.

 

Stakeholders


  1. For us to take this initiative and establish widespread engagement, it is crucial for us to ally this ingenuity with the community health partners of Massachusetts. Currently Massachusetts has a league that allies with at least 52 community health centers (with over 300 access sites) within the state on quality metrics and performance improvement efforts (Mass League,2013). This league is called the Massachusetts league of Community Health Centers and its main roles and duties is to help “support health access, develop information technology, integrate clinical quality initiatives, develop human health care work force and analyze state/federal regulated policies” (Mass League,2013) 

  2. Funders: Grant money is a required necessity to help support the continuous sustainability of this quality improvement strategy. Aligning our efforts with the Blue Cross Blue Shield Grant Foundation will help expand our engagement collaboration. Blue Cross Blue Shield Grant Foundation has directed financial resources to behavioral health/mental health projects in the past (Sandstorm, 2013).  Such projects include patient outpatient access to behavioral health, fostering integration of behavioral health and primary care, understanding barriers to integration, Implementing Rosie-D early screening efforts for pediatric age groups and addiction/recovery services in the city of Boston-blue print for better care (Sandstorm, 2013). Due to the nature of previous grant opportunities, the stakeholders would be satisfied to see such a grant proposal

  3. Department of Public Health of Massachusetts is one of the main key stakeholders of this policy. The political authority would help enforce health care organizations to provide a better emphasis on establishing and monitoring metrics to better achieve performance results. In addition to the qualitative aspect of earlier screenings, such a move would help lower the overall costs of treatment for the patients as well as the organization that are delivering treatment. This would help save the state financial resources, time and energy to be better used towards other public health issues. 

  4. Since the Massachusetts Executive Office of Health and Human Services oversees the Massachusetts Department of Mental Health, this would help organize our efforts and transformation strategies via top-bottom approach. The department is part of the governmental vector of Massachusetts (Mass govt.) that provides and encourages mental/behavioral health screening and psych-social services to population of the state. The department has provided an emphasis on the coordination and co-location of primary care and behavioral health services within health care organizations to provide a person centered whole health team approach. This type of force would help support the concept of more primary care screenings, monitoring and follow up within the state   

  5. Finally, it would be very crucial to involve the members of the ACO programs within the state of Massachusetts. Currently, there are 3 distinct programs (A, B, C) that envision a different approach towards the same goal of enhancing care. All three programs utilize the same performance improvement measures/metrics to assist they’re their journey from switching from fee-for-service to pay-for-performance. All together there are 23 measures, with at least 2 measures consistent with depression screening and remission (Otrompke,2012). This move, by-default would allow such measures to become a priority for the organization and its performance strategies.

 

Policy Options


  1. Authorizing all health care organizations within the state of Massachusetts to become accredited/deemed as a Patient Centered Medical Home. This approach would not just help align the organization with evidence based practices but also create better access to primary care prevention centers. This move would embrace the idea of patients as partners, understanding and organizing relationship based care, optimizing care team approaches, understanding the barriers of empanelment and promoting a quality improvement environment that helps the outcomes of patients over time. This interface would help provide more screening opportunities to the general population, allowing for earlier diagnoses and earlier interventions 

  2. Place pressure on private sectors in the state of Massachusetts to release more funding opportunities towards health care program that prioritize primary care services. This move would help provide more resources to health care centers (especially community health centers) to engage in quality improvement initiatives. Such resources should be regulated to ensure that such financial support would be used to the intended service. There have been many grant opportunities in the past by various organizations, but due to the current political wave of events,  massive budget cuts have occurred, which has had a both direct and indirect effect on such health care organizations (House, 2018)

  3. Provide more hands-on training by the Department of Public towards the Mass league on how to better integrate behavioral health and primary care services. This has been a major issue for some organizations in Massachusetts. Some health care organizations lack the proper training, knowledge and even location on how to implement a co located/co- integrated system that allows behavioral health providers and primary care providers to work/interact in a common shared team(Godoy, 2017). This disjunction can be fixed by proper training and clinical on-site exercises. Demolishing such barriers, would allow the patient to see both the behavioral health provider and the primary care provider in the same day. This would help highlight the significance of such a co-located relationship and meaningful interaction. Data points such as depression screening, substance abuse screening and warm hand offs between providers can be used to identify gaps in clinical care 

  4. Allow the Massachusetts Executive Office of Health and Human Services to invest in a program that calculates patient’s acuity and risk score depending on severity and co-morbidities of the patient.  Elements such as social determinants of health, medical diagnoses and mental health diagnoses could be used to stratify patients based off a risk score. This technique would provide two advantages-1 Typically the higher the risk the  costlier the patient is, so extra attention to these patients may relieve the financial burden of both the patient as well as the health organization 2- Patients that are considered more complex need more care attention and supporting services, so linking them to the care they need might help out with their overall prognosis. Such a program would be very helpful to use, especially because many diseases/social determinants co-exists with depression. And by identifying and fixing the underlying cause, the signs and symptoms of depression could be alleviated 

 

Recommendations


The most effective policy option here would be to have state authorities enforce health care organizations within the state of Massachusetts align and achieve the Patient Centered Medical Home standards. The reason would be because achieving such an accreditation would by default provide the theoretical and practical infrastructure needed to engage in an integrated health care team. Once deemed, the chance of the organizations receiving grant opportunities form outside vendors would be a lot higher than those organizations that do not have the accreditation. Once the funding is received, it would be easier for them to generate training opportunities for their own staff as well as other health care partners. Once training has been completed, at that point, staff could start using high-risk patient rosters to further outreach to patients that are deemed “critical” and “complex”. 

In conclusion, such a shift towards better care would help health care institutions enhance their capabilities of screening and monitoring more clinical quality outcomes. This shift would also help eliminate the fee-for-service model, granting more cost savings overall. Finally, in a system where clinical care is more pro-active in its approach towards outreach and care deliveries, the outcome of such system would only conclude to a community with healthier minds and bodies  

 

Reference

Chung, H., Kim, A., Neighbors, C. J., Cummings, J., Ricketts, S., O’Grady, M. A., & Raum, D. (2013). Psychiatry and Primary Care: Early experience of a pilot intervention for patients with depression and chronic medical illness in an urban ACO. General Hospital Psychiatry, 35468-471. doi:10.1016/j.genhosppsych.2013.04.014

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Godoy, L., Long, M., Marschall, D., Hodgkinson, S., Bokor, B., Rhodes, H., & ... Beers, L. (2017). Behavioral Health Integration in Health Care Settings: Lessons Learned from a Pediatric Hospital Primary Care System. Journal Of Clinical Psychology In Medical Settings, (3-4), 245. doi:10.1007/s10880-017-9509-8

Hacker, K. A., Penfold, R., Arsenault, L., Zhang, F., Murphy, M., & Wissow, L. (2014). Screening for Behavioral Health Issues in Children Enrolled in Massachusetts Medicaid. Pediatrics133(1), 46–54. http://doi.org/10.1542/peds.2013-1180

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(2016). EOHHS ANNOUNCES $1.9 MILLION IN STATEWIDE GRANTS TO ADDRESS HOUSING INSTABILITY. States News Service.

(2013). MASSACHUSETTS LEAGUE NAMES GENTILE PRESIDENT/CEO. States News Service.

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