Lloyd F. Moss Free Clinic
Mental Health Program
Presented by:
Donna M. Bowser, DNP, CFNP
Marsha Green, NP, CNS
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
Donna M. Bowser, DNP, CFNP Lloyd F. Moss Free Clinic
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Background
• Diabetes:
– 7% of U.S. population (20.8 million)
– Cost $132 billion in 2002 (CDC, 2007)
(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 (< 100% FPL) in 2006
– 49.7 million (< 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)
Donna M. Bowser, DNP, CFNP Lloyd F. Moss Free Clinic
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Prevalence Rate of Diabetes & Depression
Source
Sample Size
Socio-Economic
Status
Sample %
with
Diabetes
Anderson et al., 2001
21,351
Unknown
All
31%
Ciechanowski et al.,
2001
367
Middle Class?
All
30.2%
Katon et al., 2004
4385
Middle Class?
All
12%
de Groot et al., 2006
221
Middle Class
All
25.3%
Anderson et al., 2007
739
Low-income
All
31.4%
Olvera et al., 2007
109
Low-income
All
32.3%
Mauksch et al., 2001
500
Low-Income
Unknown
51%
Mims, 2006
18,000
Low-income
Unknown
27%
Donna , DNP, CFNP Lloyd F. Moss Free Clinic
Sample % with
Depression
4
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
(N=4398)(Simon et al., 2005)
Donna M. Bowser, DNP, CFNP Lloyd F. Moss Free Clinic
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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
Donna M. Bowser, DNP, CFNP Lloyd F. Moss Free Clinic
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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
Donna M. Bowser, DNP, CFNP Lloyd F. Moss Free Clinic
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Percent of Participants
Patient Health Questionnaire – 9
A Measurement of Depression
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
45%
Mean Score of Sample = 6.72 (95% CI [5.85, 7.61])
Mean Score of those with Depression = 14.49 (95% CI [13.44, 15.54])
30.1 % with PHQ-9 > or = to 10 (95% CI [23.3%, 36.8%])
55.2% with PHQ-9 > or = to 5 (95% CI [47.9%, 62.5%])
25%
16%
9%
Less than 5 or 5 to 9 or mild
no depression depression
(N=82)
(N=46)
10 to 14 or
moderate
depression
(N=30)
Depression Level
15 to 19 or
moderately
severe
depression
(N=16)
Pfizer. (2005) Patient Health Questionnaire-9. Retrieved March 22, 2008 from http://www.phqscreeners.com/.
Donna M. Bowser, DNP, CFNP Lloyd F. Moss Free Clinic
5%
20 to 27 or
severe
depression
(N=9)
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RAND 36 Subject Area Score
RAND 36-Item Health Survey
A Measurement of Quality of Health
80
70
60
50
40
30
20
10
0
PHQ-9 < 10
PHQ-9 > or = to 10
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.
Donna M. Bowser, DNP, CFNP Lloyd F. Moss Free Clinic
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Mean Weight Impact Score
The Audit of Diabetes Dependent
Quality of Life (ADDQoL)
-4.00
-3.50
-3.00
-2.50
-2.00
-1.50
-1.00
-.50
.00
PHQ-9 < 10
PHQ-9 > or = to 10
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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Donna M. Bowser, DNP, CFNP Lloyd F. Moss Free Clinic
Diabetes Empowerment Scale (DES-SF)
A Measurement of Self-Efficacy
Mean Score
of
Each
Question
4.5
4.0
3.5
3.0
2.5
2.0
1.5
1.0
0.5
0.0
PHQ-9 <10
PHQ-9 > or
= to 10
Mean Score DES-SF = 3.8
(95% CI [3.76, 4.00])
Individual Questions of DES-SF
Anderson, R., Funnell, M., Fitzgerald, J., & Marrero, D. (2000). The diabetes empowerment scale.
Diabetes Care, 23(6), 739-743.
Donna M. Bowser, DNP, CFNP Lloyd F. Moss Free Clinic
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Length of Medical Treatment in the
Free Clinic Setting
Percentage of
Participants in
Each Treatment
Period
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
42%
31%
33%
31%
26%
27%
24%
22%
16%
16% 17%15%
Total
PHQ-9 < 10
PHQ-9 > or =
to 10
< 1 Year
1 to < 3
Years
3 to < 5
Years
> or = to
5 Years
Length of Medical Treatment in a Free Clinic Setting
Donna M. Bowser, DNP, CFNP Lloyd F. Moss Free Clinic
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Missed Appointments & Presence of
Depression
75.0%
80%
65.5%
70%
60%
Percentage of
Appointments
50%
34.5%
40%
25.0%
No Missed
Appointments
1 or More
Missed
Appointments
30%
20%
10%
0%
PHQ-9 < 10
PHQ-9 > or = 10
Presence or Absence of Depression
PHQ-9 = Patient Health Questionnaire - 9
Donna M. Bowser, DNP, CFNP Lloyd F. Moss Free Clinic
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Conclusions
• 30.1% Prevalence rate of depression in a lowincome, 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
Donna M. Bowser, DNP, CFNP Lloyd F. Moss Free Clinic
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Getting Started
Comparable to Outpatient Practice
• Intakes
– 1 Hour
• Follow-Up
– 30 Minutes
– Will eventually incorporate 15 minute slots
Marsha Green, NP, CNS Lloyd F. Moss Free Clinic
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Assessment Findings
• Diagnostically
–
–
–
–
–
–
MDD
GAD
Panic Disorder
PTSD
Substance Dependence
Bipolar Disorders, Type I and II
Marsha Green, NP, CNS Lloyd F. Moss Free Clinic
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Assessment Findings
• Behaviorally
– LACK OF SKILLS
•
•
•
•
•
•
Coping Skills
Unresolved Grief
Unresolved Trauma Issues
Communication Techniques
Anger Management/Emotional Regulation
Boundaries
Marsha Green, NP, CNS Lloyd F. Moss Free Clinic
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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
Marsha Green, NP, CNS Lloyd F. Moss Free Clinic
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GROUPS
• Initial Ideas
– Dialectical Behavioral Therapy (DBT)
– The Don’t Diet Live-It Workbook (for weight loss)
– General group therapy
• In Actuality
– General Group Therapy
• Facilitator
Marsha Green, NP, CNS Lloyd F. Moss Free Clinic
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Experiential Groups
• Equine Therapy
• Drumming
Marsha Green, NP, CNS Lloyd F. Moss Free Clinic
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Collaborative Care
• Working together as a team
–
–
–
–
Clinical treatment team meetings
Pharmacy Teamwork
Brief Introductions/Consultations
Joint Appointments
Marsha Green, NP, CNS Lloyd F. Moss Free Clinic
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Barriers to Treatment
• Patient misconception of Psychiatric care
– “they might lock me up”, “they think I’m crazy”
• Transportation
– No vehicle
– Unable to afford fuel (coordinating appointments on
same day)
Marsha Green, NP, CNS Lloyd F. Moss Free Clinic
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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
Marsha Green, NP, CNS Lloyd F. Moss Free Clinic
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Clients Served So Far
1st 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 >
individual appointments)
Marsha Green, NP, CNS Lloyd F. Moss Free Clinic
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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?)
Donna M. Bowser, DNP, CFNP
Lloyd F. Moss Free Clinic
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Patient Health Questionnaire -9
Preliminary Outcomes
Initial & After 3 Months of Treatment (N=44)
14.59
16
2.3%
P 14
H
12
Q
9 10
S
c
o
r
e
Improved
(n=35)
9.27
18.2%
8
Worsened
(n=8)
6
79.5%
4
No Change
(n=1)
2
0
Initial
3-Month
Change in Mean PHQ-9 Score
(Paired samples t-test p =.000)
Direction of Change
Donna M. Bowser, DNP, CFNP Lloyd F. Moss Free Clinic
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RAND – 36 Preliminary Outcomes
Initial & After 3 Months of Treatment (N=44)
70.0
60.0
50.0
40.0
30.0
Initial
20.0
3-Month
10.0
0.0
Energy & Fatigue, Social Well-being, and Social Functioning
before and after treatment reached level of significance of p < .05
Donna M. Bowser, DNP, CFNP Lloyd F. Moss Free Clinic
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Diabetes Empowerment Scale
Preliminary Outcomes
Initial & After 3 Months of Treatment (n=25)
D
E
S
S
c
o
r
e
4.13
4.2
4.1
4
3.75
3.9
3.8
3.7
3.6
3.5
Initial
3-Month
Length of Treatment
Paired Sample t-test (initial & at 3 months) reached level of
significance: p= .045
Donna M. Bowser, DNP, CFNP Lloyd F. Moss Free Clinic
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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.
Donna M. Bowser, DNP, CFNP Lloyd F. Moss Free Clinic
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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 > 10)?
Donna M. Bowser, DNP, CFNP Lloyd F. Moss Free Clinic
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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 > 10) and patients
without the presence of depression
(PHQ-9 < 10)?
Donna M. Bowser, DNP, CFNP Lloyd F. Moss Free Clinic
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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 > 10)
and patients without the presence of
depression (PHQ-9 < 10)?
Donna M. Bowser, DNP, CFNP Lloyd F. Moss Free Clinic
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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 > 10) and
patients without the presence of
depression (PHQ-9 < 10)?
Donna M. Bowser, DNP, CFNP Lloyd F. Moss Free Clinic
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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?
Donna M. Bowser, DNP, CFNP Lloyd F. Moss Free Clinic
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Study Question 5
Is there an increase in missed
appointments by patients with the
presence of depression (PHQ-9 > 10)
in comparison to patients without
the presence of depression (PHQ-9 <
10?
Donna M. Bowser, DNP, CFNP Lloyd F. Moss Free Clinic
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