Primary Care Depression Initiative
Program Design
Leslie Born, Carolynne Darby, Nick Kates and Catherine McPherson-Doe
Phone: 905-667-4848 ext 116
Email Leslie Born, Enhanced Depression Care Initiative Coordinator.
Goal
To improve outcomes for patients with depression by assisting inter-professional primary care practice teams to deliver comprehensive depression care.
KEY COMPONENTS OF THE MODEL
Identification and Assessment of Depression
The 2-question screen and the PHQ-9 are two screening tools to assist with recognition and diagnosis. Formal assessment follows to confirm diagnosis.
Treatment (Acute and Maintenance)
Together, the clinician and patient select a depression management approach based on the determination of depression severity, in conjunction with the PHQ-9 defined diagnostic categories. Clearly delineated treatment recommendations follow, using available evidence-based guidelines. Treatment may include support, “watchful waiting”, antidepressant treatment and/or psychological counselling.
The PHQ-9 will be given to patients at identified intervals during treatment to review response to treatment and assist in treatment decisions. The goal of acute treatment is full remission of symptoms; the goal of maintenance treatment is the prevention of relapse and recurrence, with follow-up visits during the maintenance phase at pre-determined intervals, utilizing tools, including the PHQ-9.
Registry Development
The depression registry will assist practices to track the treatment and management of patients with major depression, as well as to identify those who are at high risk of developing a major depressive episode.
Self Management Support
In conjunction with the HFHT self management initiative, self management for depression will be designed as an approach that all health care providers can use during patient interactions to assist patients in being active managers of their own health.
Practice Involvement
Each family practice is unique from patient populations to the composition of the interprofessional teams. This will influence how depression care in each practice will be delivered and which team member/s will perform which component of depression care.
For many practices, this may involve changes to the way care is organized – for example actively monitoring an individual’s progress at regular intervals after they have completed a course of treatment.
HFHT Involvement
Starting in January 2008, the Depression Coordinator will work closely with pilot sites and their collaborative depression care teams. Our goal is to systematically disseminate this model across all Hamilton Family Health Team practice sites using
Plan/Do/Study/Act (PDSA) cycles. Ongoing support will be provided from the HFHT, especially from the Mental Health Program.
Community Partners
Collaborative meetings are being conducted to strengthen our community linkages and partnerships and to enhance our existing service system by improving communication and optimizing stepped care pathways and our coordination of care. As we strive for seamless patient pathways, our community relationships are integral.
Advisory Committee
A group of family physicians, mental health counsellors, consumers, psychiatrists and other interprofessional team members that will ensure that our recommendations reflect patient, professional, clinical and family practice needs.
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