Standardized Depression Screening in Primary Care

Standardized Depression Screening in Primary Care ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON Standardized Depression Screening in Primary Care Please follow instructions below: As a DNP student you will be required to complete a scholarly project. Chamberlain DNP 805 Standardized Depression Screening in Primary Care. Standardized Depression Screening in Primary Care A. Identify a problem or a topic of interest in nursing that you would like to propose for the DNP scholarly project. The following are the (three) topics that need to be developed. First topic: Initiation of Standardized Depression Screening in Primary Care: A Quality Improvement Project-please write a summary of what the project will be and where. Include in text citations a references. Location where it will be implemented. I have attached a sample of an entire project. This should be 250 words a summary. Improving Utilization of PHQ Tools for Screening Depression in a Primary Care Practice-please write a summary of what the project will be and where. Include in text citations a references. Location where it will be implemented. I have attached a sample of an entire project. This should be 250 words. Adolescent Depression Screening: A Care Guideline Approach in Primary Care -please write a summary of what the project will be and where. Include in text citations a references. Location where it will be implemented. I have attached a sample of an entire project. This should be 250 words. This essay will be evaluated based on the applicant’s ability to follow the essay instructions, using a logical/organized thought process, while demonstrating command of the English language and compliance with APA formatting and style guidelines. Ideas should be clear. Applicants are highly encouraged to provide current evidence support ideas. Standardized Depression Screening in Primary Care Please make sure that paper meets these guidelines, its written in clear, concise language and it has references. Chamberlain DNP 805 Standardized Depression Screening in Primary Care initiation_of_standardized_depression_screening_in_college_health.pdf dnp_project_example_2.pdf dnp_project_example.pdf Standardized Depression Screening in Primary Care. Messiah University Mosaic HNES Educator Scholarship Health, Nutrition, and Exercise Science 2018 Initiation of Standardized Depression Screening in College Health: A Quality Improvement Project Kristen Slabaugh Messiah College, [email protected] Shannon Harris Sam Wilcock Messiah College, [email protected] Follow this and additional works at: https://mosaic.messiah.edu/hnes_ed Part of the Nursing Commons Permanent URL: https://mosaic.messiah.edu/hnes_ed/2 Recommended Citation Slabaugh, Kristen; Harris, Shannon; and Wilcock, Sam, “Initiation of Standardized Depression Screening in College Health: A Quality Improvement Project” (2018). HNES Educator Scholarship. 2. https://mosaic.messiah.edu/hnes_ed/2 Sharpening Intellect | Deepening Christian Faith | Inspiring Action Messiah University is a Christian university of the liberal and applied arts and sciences. Our mission is to educate men and women toward maturity of intellect, character and Christian faith in preparation for lives of service, leadership and reconciliation in church and society. www.Messiah.edu One University Ave. | Mechanicsburg PA 17055 Running head: INITIATION OF STANDARDIZED SCREENING 1 2 3 4 5 Initiation of Standardized Depression Screening in College Health: 6 A Quality Improvement Project 7 Kristen Slabaugh, DNP, CRNP, CNE 8 Shannon Harris DNP, FNP, CCRN 9 Samuel Wilcock, PhD 10 11 1 INITIATION OF STANDARDIZED SCREENING 12 2 Abstract 13 Background: Depression is a leading health concern in college health. An on-campus health 14 clinic was identified as conducting complaint-based screening. U.S. Preventative Services Task 15 Force recommends standardized screening in all primary care settings. Objective: To implement 16 a quality improvement project for standardized screening and referral of depressive symptoms 17 and identify factors related to mentoring program interest in a college health clinic. Methods: 18 Demographic survey and Patient Health Questionnaire-2 were distributed to students who met 19 inclusion criteria. Positive screens received further intervention with Patient Health 20 Questionnaire-9 and immediate evaluation, encouragement of follow-up, or educational handout. 21 Results: Of students receiving primary care services at a college health center, 221 completed 22 demographic surveys, 165 completed the PHQ-2, and 8 students received interventions for 23 positive screens. Furthermore, 74.6% of students expressed interest in a mentoring program. 24 Conclusions: The project demonstrates ease of standardized screening in the college health 25 setting without excessive burden to staff or budget. This is a critical preventative care measure 26 for improving early detection and management of depression at college health centers. 27 Implications: Initiation of standardized screening on college campuses is a worthwhile 28 investment and should be implemented by registered nurses (RNs) and advanced practice nurses. 29 Support program initiation should be considered to help students with unmanaged symptoms. 30 31 Keywords: depression; standardized screening; suicide prevention; college health INITIATION OF STANDARDIZED SCREENING 32 Initiation of Standardized Depression Screening in College Health: 33 A Quality Improvement Project 34 3 Depression is an ongoing and worsening issue in the college-aged population. Ninety 35 five percent of college counseling centers agree that the number of students on campus with 36 significant psychological problems is a growing concern, and depression is the second most 37 commonly presenting condition (36.4%) (American Psychological Association [APA], 2013). 38 Additionally, suicide is a leading cause of death among college students in the United States. Chamberlain DNP 805 Standardized Depression Screening in Primary Care Standardized Depression Screening in Primary Care. As 39 many as 8% of college students have seriously considered suicide in the past 12 months (Suicide 40 Prevention Resource Center, 2014). A change in practice from complaint-based to standardized 41 screening can promote earlier identification of symptomatic students and reduce long-term 42 sequelae. Untreated depression can lead to physical and emotional problems such as: (a) pain 43 and physical illness, (b) substance abuse, (c) relational difficulties, (d) social isolation, (e) self- 44 mutilation, (f) increased hospitalizations, (g) premature death, (h) academic difficulties, and (i) 45 suicidal/homicidal ideations (Mayo Clinic, 2017). Early identification, referral, and treatment 46 reduces risk of complications, improves coping skills, and decreases costs (Mayo Clinic, 2017). 47 48 Background & Significance/Problem Statement An identified college health center (HC) utilized a complaint-based screening approach 49 where students were screened for depression only if they presented with depression-related 50 complaints (suicidality, sadness, extreme fatigue, anhedonia, etc.). This is inconsistent with the 51 U.S. Preventative Services Task Force (USPSTF) recommendation to screen all patients, 52 regardless of reason for the visit (Sui & USPSTF, 2016). The nature of depression-related 53 symptoms (DRS) prevents patients from seeking care for their symptoms, making it important to INITIATION OF STANDARDIZED SCREENING 54 conduct standardized rather than complaint-based screening for optimal detection. In the past 55 four years, the number of mental health (MH) visits conducted by the HC rose nearly 300%. 4 56 According to the Association for University and College Counseling Center Directors 57 (AUCCCD) Annual Survey, 95% of college counseling center directors agree that significant 58 psychological issues are a growing concern on their campus (AUCCCD, 2013). Many students 59 take medical leave without returning to complete their program; a significant loss of revenue for 60 the college and financial loss for students who have debt, but no degree. Seventy seven percent 61 of medical leaves in last three years were related to MH issues, many of which were the result of 62 delayed diagnosis or treatment. Faculty note that students were struggling academically, despite 63 being more intellectually prepared. Many of the struggling students admitted to recognition of 64 DRS but refused to seek help due to the perceived stigma. Additionally, students who received 65 services for depression continued to express concerns related to symptom management. 66 The overall purpose of this project was to initiate a standardized screening and referral 67 process for depression in students at a college-based HC to reduce the incidence of untreated 68 depression on a college campus. A population intervention comparison outcome (PICO) question 69 was developed: In college-aged students receiving care at a student HC, will the initiation of a 70 valid and reliable depression screening tool, when used by the advanced practice nurse for 71 screening, referral, and follow-up, effectively increase the identification of students with 72 depression to initiate treatment which can reduce suicide attempts, improve academic 73 performance, and provide cost savings, when compared to the current practice of complaint- 74 based screening? A secondary aim of this project was to identify demographic factors to guide 75 future research regarding interest in campus-wide programming or mentoring to improve student 76 outcomes and wellbeing. INITIATION OF STANDARDIZED SCREENING 77 78 5 Literature Review A comprehensive review of literature and article reference lists was conducted using 79 CINAHL, PubMed, Medline, Cochrane Library, PsycINFO, and Google Scholar for articles from 80 2011-2017. Chamberlain DNP 805 Standardized Depression Screening in Primary Care Seventeen studies resulted, all of which demonstrated the need to increase screening 81 for emotional distress and improve awareness of the need for services to the college-aged 82 population. A gap between the current state (poor depression screening rates) and the desired 83 state (improved screening and depression detection rates) was consistently noted. 84 Several valid and reliable tools were used to screen for depression, which demonstrated 85 effectiveness in one or two tiered approaches (Beiter et al., 2015; Chung et al., 2011; Kanuri, 86 Taylor, Cohen, & Newman, 2015; Lyoo, Ju, Kim, Kim, & Lee, 2014). Mass or standardized 87 screening, rather than complaint-based screening, was preferred due to generally low detection 88 rates across campuses for standard practice (Khubchandani, Brey, Kotecki, Kleinfelder, & 89 Anderson, 2016; Mackenzie et al., 2011). Early initiation and treatment reduces deleterious 90 health effects and should be encouraged (Klainin-Yobas et al., 2014; Klein, Ciotoli, & Chung, 91 2011; Mahmoud, Staten, Hall, & Lennie, 2012). The use of in-office screening and education is 92 preferred over online tools (Eisenberg, Hunt, Speer, & Zivin, 2011; Youn et al., 2012), and 93 senior administrative support is critical to program success for screening and early intervention 94 (Chung et al., 2011). 95 The PHQ-2 and PHQ-9 surveys were selected to maintain consistency with the current 96 screening methodology of the clinic. Appropriate cut points were determined based on the 97 review of literature and desire to improve specificity over sensitivity (Kroenke, Spitzer, & 98 Williams, 2001; Kroenke, Spitzer, & Williams, 2003). Clinical practice guidelines and 99 professional organization recommendations were identified to guide the intervention and referral INITIATION OF STANDARDIZED SCREENING 6 100 process for positive screens (Sui & USPSTF, 2016; Trangle et al., 2016; UHC Community Plan, 101 2016). 102 103 Theoretical and Conceptual Framework The IOWA Model of Evidence Based Practice to Promote Quality Care was identified to 104 guide the incorporation of research evidence, clinical expertise, and patient values during the 105 translation of evidence into practice (Titler et al., 2001). This QI model combines problem and 106 knowledge focused triggers with organizational and collaborative efforts to seek improvement 107 based on research findings. It also clarifies necessary steps for the application of research into 108 practice with the goal of improved quality of care (Hall & Roussel, 2014). 109 Pender’s Health Promotion Model was used to guide and inform the scholarly project 110 with a focus on three areas: (a) individual experiences and characteristics, (b) behavior-specific 111 cognitions and affect, and (c) behavioral outcomes (Petiprin, 2016). This principle allowed 112 individuals to incorporate previous experiences or behaviors into interventions for positive 113 screening by choosing lifestyle modifications, consideration of pharmacotherapy, or counseling. 114 Intended interventions could be followed-up by campus or primary care provider (PCP) staff. 115 Holistic well-being was promoted by screening for MH related concerns during appointments for 116 physical health complaints, empowering students with the awareness of DRS and autonomy in 117 decision making, which improves self-efficacy and reduces perceived barriers associated with 118 initiation of care for depression. 119 120 121 122 Methods Sample All students with NP appointments at the HC were recruited for participation. Most students were traditional college-aged males and females (ages 18-22). Chamberlain DNP 805 Standardized Depression Screening in Primary Care Inclusion criteria were INITIATION OF STANDARDIZED SCREENING 7 123 students enrolled at Messiah College who presented for a non-MH related NP appointment and 124 were over 18 years of age, willing to participate, and able to read and understand English. 125 Exclusion criteria included age under 18 years and presentation for a RN, counseling center, or 126 MH-related appointment. Students who presented for non-provider appointments were excluded 127 due to lack of ability to follow-up on positive findings without an NP appointment. Students 128 with MH related complaints were already being screened with the PHQ-9, thus excluded from 129 this study. 130 Eligible patients were brought to a private exam room and the demographic questionnaire 131 and PHQ-2 survey were explained by the intake nurse after obtaining informed consent. The 132 demographic survey was completed (n=221) and students who were not currently receiving any 133 treatment for depression (counseling or medication, on or off campus) proceeded to the PHQ-2 134 (n=160). If the PHQ-2 score was positive (>3), the student completed the PHQ-9 (n=8). Scores 135 were calculated and referral and algorithm decisions were made by the NP. Students who were 136 already receiving depression-related treatment completed the demographic survey only; PHQ-9 137 scores were obtained as necessary to evaluate severity of symptoms, response to treatment, and 138 level of improvement but were not included in the analysis. 139 Setting 140 The setting was a student HC with medical and counseling services located on the 141 campus of a small, liberal arts, Christian college. The medical center was staffed by one 142 master’s prepared family NP and eight RNs. Three exam rooms were used and noise 143 contamination was an issue. Sound machines and radios were used in patient rooms and 144 common spaces to improve confidentiality. The waiting room was separate and screening was 145 conducted in exam rooms to facilitate explanation and ease of answering questions. INITIATION OF STANDARDIZED SCREENING 146 8 Tools 147 The PHQ-2 tool was used for initial screening and PHQ-9 tool for further evaluation. 148 Demographic data was collected to assess risk factors for depression across campus (level in 149 school [first year, sophomore, junior, senior, graduate], major, history of MH, current treatment 150 for depression, and mentoring program interest). The PHQ-2, an abbreviated version of the PHQ- 151 9 has demonstrated validity and reliability as a screening tool only, not diagnostic, at a variety of 152 cut points. A meta-analysis by Manea et al. (2016) demonstrated pooled sensitivity of 76%, 153 pooled specificity of 87%, pooled likelihood ratio of 6.02, pooled negative likelihood ratio of 154 0.27, and pooled diagnostic odds ratio of 22.20. Criterion validity was demonstrated in 155 concordance with MH professional interviews at a cut point of 3 or greater and was comparable 156 to the PHQ-9 for depression (kappa 0.48-0.62 versus 0.54-0.58). Construct validity was 157 established by strong association between PHQ-2 scores and disability days, functional status, 158 and symptom-related difficulties, making it an appropriate tool to use as a first step approach to 159 depression screening (Kroenke, Spitzer, & Williams, 2003). Reliability and validity of the PHQ- 160 9 has been widely established by multiple independent assessments. Diagnostic validity of the 161 PHQ-9 demonstrates a sensitivity of 88% and specificity of 88% for scores greater than ten. 162 Internal consistency is also high with Cronbach alphas of 0.86 and 0.89 (APA, 2018). 163 Screening and referral algorithms 164 Students with a negative score on the PHQ-2 (<4) or PHQ-9 (<10) received a printed 165 educational handout from the National Institute of Mental Health (2017). Chamberlain DNP 805 Standardized Depression Screening in Primary Care For PHQ-9 scores >10, 166 a follow-up visit was strongly encouraged (on or off campus, provider or counselor based) and 167 an educational handout was provided via the patient portal. For scores >20 on the PHQ-9 or >0 168 on the suicide question (#9), the provider evaluated DRS during the current appointment. INITIATION OF STANDARDIZED SCREENING 169 Data collection 170 Data was collected January-March 2017 (n=221) via paper survey. This included a de- 171 identified demographic survey, PHQ-2 scores, and PHQ-9 scores as indicated based on the 172 algorithm. PHQ-2 and PHQ-9 surveys were scanned into the student’s electronic health record 173 and numeric score recorded on the demographic survey. The principle investigator did not have 174 access to any patient health record. Involved staff received training on project implementation 175 regarding the administration, scoring, and follow-up of the survey, tool, and algorithm (Figure 176 1). 177 Institutional Review Board approval 178 All collected data were de-identified, hence IRB exemption was obtained through the 179 University of South Alabama and Messiah College, location of the student HC. All participants 180 were provided an information script and informed consent was obtained prior to data collection. 181 9 Results 182 Results were aggregated using the Statistical Package for Social Science (SPSS) IBM 183 Version 24.0 for MacOS. The analysis focused on the frequencies and relative frequencies of 184 various PHQ-2 and PHQ-9 scores and mentoring interest and preferences as a whole as well as 185 when compared across various demographic measures such as class level, major/school, and MH 186 history. PHQ-2 scores ranged from 0 to 6 and PHQ-9 scores ranged from 0 to 24 (Table 1). On 187 the PHQ-2, 3.7% of students screened positive (n=8), 68.5% screened negative (n=148), and 188 27.8% were already receiving an intervention for a MH condition (n=61). Furthermore, 2.3% of 189 students had a PHQ-2 of three (n=5), an alternate cut point for further evaluation. All students 190 with positive PHQ-9 scores received further interventions. The only statistically significant risk 191 factor for depression was a history of MH illness (p=<0.05) (Table 2 and 3). No statistically INITIATION OF STANDARDIZED SCREENING 192 significant relationships were identified between PHQ scores and level in school, major, or 193 timing in semester. Lack of statistically significant findings is likely due, in part, to the low 194 positive detection rate. 10 195 In general, 76.4% of students (n=169) expressed definite or possible interest in a 196 mentoring program to manage stress, anxiety, or depression. Of this group, 10.2% were 197 interested only if a program was major specific (n=23) and 25% noted possible interest (n=55). 198 Interest in a mentoring program varied by school. All participants from the School of the Arts 199 (departments of music, theater and dance, and visual arts) expressed definite or possible interest 200 in a program (n=19). Participants in the School of Science, Engineering, and Health were most 201 likely to be interested in a major-specific program (17.4% vs 4.1-6.3%) (Figure 2). More 202 specifically, nursing (22.7%) and engineering (13.6%) majors were most likely to be interested 203 in a major-specific program rather than a non-major specific program. 204 205 Discussion Eight students had positive PHQ-2 scores (>3) and were further screened with PHQ-9. 206 Seven had positive PHQ-9 scores (>10 of >0 on question #9) and received interventions 207 (immediate evaluation [n=5] or patient education hand-out and encouragement to schedule 208 follow-up [n=2]). Approximately 28% of participants were already receiving an intervention for 209 depression. With the national rate of depression in college students estimated around 30-36% 210 (APA, 2013), the HC is already identifying and/or treating most symptomatic students. 211 There were no major difficulties with program implementation. However, the survey plus 212 screening were costly of time (approximately 2 to 7 minutes). Process improvements could 213 significantly lessen staff time. The relatively low detection rate makes it difficult to assess fully 214 the requirements for provider time. A high number of positive PHQ-9 screenings could INITIATION OF STANDARDIZED SCREENING 215 significantly increase the burden for staff, especially if immediate evaluation and treatment 216 initiation was required. Elimination of the demographi … Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10