AMH Implementation Program

AMH Implementation Program

Overriding Goals

•To improve the comfort and confidence of family physicians in diagnosing and treating their mental health patients as measured by surveys.

•To improve the quality of patient care available in non-specialized general practice for adults with mild to moderate depression and anxiety either as a primary diagnosis or comorbid with other mental health problems and chronic diseases. This will be accomplished by the use of tools that engage the patient in shared partnership andthat lead to correct diagnosis and the use of CBT skills not only pills. This will be measured by qualitative surveys and symptom and function changes as measured by the PHQ9 and GAD 7 scales.

•To decrease healthcare provider stigma by improving the comfort and confidence of family physicians in treating their mental health patients.

Learning Outcomes

By the end of the implementation, participants will be able to…

1.Utilize the AMH hyperlinked algorithm to access all tools on your computer or EMR

2.Apply screening tools such as the PHQ9, GAD 7, SAQs to identify adults who may have depression and anxiety or unhealthy styles, and where appropriate, use the DAI to screen for all mental disorders looking for the presence of comorbid complicating disorders. Screening results to be confirmed by the DSM 5.

3.Use non pharmacological CBT interventions, CBIS, Bounce Back and ASW as first line therapy for mild to moderate depression and anxiety

4.Understand that listening and hearing IS treatment

5.Engage, partner and share responsibility, in the use of all tools and development of a care plan (CBIS Problem List Action Plan and Mental Health Plan) that utilizes AMH tools and resources including medications.

6. Integrate AMH tools and resources into an effective sustainablework flow.

7.Become familiar with the CBIS Indigenous approach

8.Report increased comfort and confidence in dealing with depression and anxiety and all patients with mental health concerns.

9.Use appropriate tools to assess and plan a management strategy and treat X (TBD) adult patient with mild to moderate depression and anxiety.

Key Messages in this program include…

1.AMH issues are typically under-identified.

2.The vast percentage (~80%) of mild to moderate AMH issues can be effectively managed in primary care.

3.Take your time in the assessment so that you don’t miss something important or misidentify a condition. Short term pain, long term gain. Accurate assessment = less chance of being stuck.

4.Listening and hearing IS treatment. This is your greatest tool along with CBT skills to help you if “stuff comes out”. Even if you have specialist access, there is typically a long wait until that happens or between sessions. Other than PHQ9, GAD 7, SAQs no other assessment tools are to be used at home.

5.It’s not all up to you. MH problems are chronic and cannot be “fixed” but can be managed more easily with shared responsibility, patient engagement and negotiation.

6.Non-pharmacological management is the foundation upon which effective treatment is based (skills not just pills).

7.Increased comfort and confidence fights healthcare provider stigma

Instructional Plan for AMH

Outcome

How to assess?

How to teach?

Resources needed?

1. Utilize the AMH hyperlinked algorithm to access all tools on your computer or EMR

• Demonstrate to peer

• Pre LS1 place on computer
• Case based scavenger hunt
• Small group activities

• Office computer
• Lap top for LSessions
• Case studies, tool practice
• CBIS Indigenous approach on algorithm

1. Apply screening tools such as the PHQ9, GAD 7, SAQ to identify adults who may have depression and anxiety or unhealthy styles, and where appropriate, the DAI to screen for all mental disorders looking for the presence of comorbid complicating disorders. Screening results to be confirmed by the DSM 5.

• PHQ9, GAD7, SAQs, Demonstrate self administration to peer

• DAI: Demonstrate to peer
• Post action plan case study report
• Report from coach
• Sharing experiences at next learning session

• Demonstrate depression confirmation in DSM5

• Lecture
• Paired activity

• Patient advocate

• Lecture/video
• Paired activity
• Case study with hidden info that requires elicitation

• Lecture

• Jo’s sheet of all tools
• Copies of PHQ9, GAD7, SAQs
• Patient advocate

• Internet access
• DAI pad
• Hidden info answers

• Laminated DSM5 Major depression

1. Use non pharmacological CBT interventions, CBIS, Bounce Back and ASW as first line therapy for mild to moderate depression and anxiety

• Post action plan case study report
• Report from coach
• Patient feedback
• Sharing experiences at next learning session

• CBIS: manual review,demo/video paired activity with top 5 skills
• BB: lecture
• ASW: lecture

• Jo’s sheet of all tools
• Internet access to all tools including CBIS Indigenous Approach

1. Know that listening and hearing IS treatment

• Sharing experience at next learning session
• Coach report

• Patient advocate
• Lecture,examples

• Patient advocate

1. Engage, partner and share responsibility, in the development of a care plan (CBIS Problem List Action Plan and Mental Health Plan) that utilizes AMH tools and resources including medications.

• RL, PL,PLAP

• demonstrate with peer
• Report from coach

• Patient feedback
• Sharing experiences at next learning session

• Demonstration PLAP

• Activity debrief
• Mental Health plan demo

• RL, PL, PLAP handouts
• Case studies
• Flip charts
• Mental Health Plan laminated handout

1. Integrate AMH tools and resources into an effective work flow.

• MOA report
• Report from coach
• Sharing experiences at next learning session

• MOA coach discussion, questions, provision of Jo’s organizing tools
• Coach visits and problem solving sharing ideas during action periods

• Jo’s tools

1. Report increased comfort and confidence in dealing with depression and anxiety and all their mental health patients.

• Sharing experiences at next learning sessions
• Pre/post surveys

• Paired and group activities during LSs, and real practice during action periods
• Coach visits and problem solving and sharing ideas during action periods
• Coach reports describing findings, solutions during action periods in next learning sessions

• Frank’s video of his flow

1. Use appropriate tools to assess and plan a management strategy and treat X (TBD) adult patient with mild to moderate depression and anxiety.

• Sharing experiences at next learning sessions
• Report from coach
• Pre/post surveys

• Action period planning with local groups
• Group discussion
• Fee discussion

• Esther’s BAP and Action period forms
• Fee case studies

Pre-visit

1. 6 question survey of barriers desires encountered by family docs, 2. Orientation to Algorithm demonstrating location of tools on algorithm 3. Review of use of mental health log sheet, and 4. confirmation of use of EMR

• Utilize the AMH hyperlinked algorithm to access all tools on your computer or EMR

• Apply screening tools to identify adults who may have depression and anxiety or unhealthy styles. Screening results to be confirmed by the DSM5
• Use non pharmacological CBT interventions, CBIS, Bounce Back, and ASW as first line therapy for mild to moderate depression and anxiety
• Engage, partner and share responsibility in the use of all tools and development of a care plan that utilizes AMH tools and resources including medications
• Integrate AMH tools and resources into an effective work flow
• Report increased comfort and confidence in dealing with depression and anxiety and all their mental health patients

• Utilize the AMH hyperlinked algorithm to access all tools on your computer or EMR
• Apply screening tools such as the PHQ9, GAD 7, to identify adults who may have depression and anxiety or unhealthy styles. Screening results to be confirmed by the DSM5
• Use of non pharmacological CBT interventions, CBIS, BB and ASW as first line therapy for mild to moderate depression and anxiety
• Know that listening and hearing IS treatment.
• Engage, partner and share responsibility in the use of all tools and in the development of a care plan that utilizes AMH tools and resources including medications.
• Integrate AMH tools and resources into an effective work flow
• Report increased comfort and confidence in dealing with depression and anxiety and all their mental health patients

• Utilize the AMH hyperlinked algorithm to access all tools on your computer or EMR
• Apply screening tools such as the DAI where appropriate to screen for all mental disorders looking for the presence of comorbid complicating disorders. Screening results to be confirmed by the DSM5
• Use non pharmacological CBT interventions, CBIS, BB and the ASW as first line therapy for mild to moderate depression and anxiety
• Know that listening and hearing IS treatment.
• Engage, partner and share responsibility, in the use of all tools and the development of a care plan that utilizes AMH tools and resources including medications
• Integrate AMH tools and resources into an effective work flow
• Report increased comfort and confidence in dealing with depression and anxiety and all their mental health patients.
• Use appropriate tools to assess and plan a management strategy and treat 6 adult patients with mild to moderate depression and/or anxiety

• Utilize the AMH hyperlinked algorithm to access all tools on your computer or EMR
• Apply screening tools to identify adults who may have depression and anxiety or unhealthy styles and where appropriate the DAI to screen for all mental disorders looking for the presence of comorbid complicating disorders. Screening results to be confirmed by the DSM5
• Use non pharmacological CBT interventions, CBIS, BB and the ASW as first line therapy for mild to moderate depression and anxiety
• Know that listening and hearing IS treatment
• Engage, partner and share responsibility in the use of all tools and development of a care plan that utilizes AMH tools and resources including medications.
• Integrate AMH tools and resources into an effective work flow.
• Report increased comfort and confidence in dealing with depression and anxiety and all their mental health patients. Use appropriate tools to assess and plan a management strategy and treat 6 adult patients with mild to moderate depression and anxiety.

• Apply screening tools to identify adults who may have depression and anxiety or unhealthy styles (SAQ)
• Use non pharmacological CBT interventions (CBIS) as a first line therapy for mild to moderate anxiety
• Know that listening and hearing IS treatment
• Engage, partner and share responsibility in the use of all tools
• Integrate AMH tools and resources into an effective work flow
• Report increased comfort and confidence in dealingwith depression and anxiety and all their mental health patients.

1. Confirm patient population
2. Confirm MOA role
3. Ensure algorithm is on computer and use tools from algorithm
4. If possible embed scales into EMR
5. Use screening tools (PHQ9, GAD 7)
6. Use self management tools, CBIS, ASW, BB
7. Billing questions/tech assistance

1. Share experiences
2. Patient feedback
3. Coach report
4. Algorithm tricks
5. DAI
6. Patient advocate
7. DAI practice
8. Break
9. Use of tools, CBIS, ASW

1. Brief action planning
2. Evaluations, AP review

1. Review log sheet progress
2. Use of DAI
3. Use of other resources
4. Discuss optimal office flow (include MOA)

1. Sharing experiences
2. Report from coach
3. More on CBIS skills (including SAQs)
4. Cultural Modification of CBIS
5. Physician and Advocate Perspective
6. Break
7. Sustainability and improvement tips
8. Community Resource Café
9. Sustainability plan
10. Wrap up, evaluations

• Utilize the AMH hyperlinked algorithm to access all tools on your computer or EMR
• Apply screening tools to identify adults who may have depression and anxiety or unhealthy styles. Screening results to be confirmed by the DSM5
• Use non pharmacological CBT interventions, CBIS, BB, and ASW as first line therapy for mild to moderate depression and anxiety
• Engage, partner and share responsibility in the use of all tools and development of a care plan that utilizes AMH tools and resources including medications
• Integrate AMH tools and resources into an effective work flow
• Report increased comfort and confidence in dealing with depression and anxiety and all their mental health problems.

1. Welcome, roles

1. Survey feedback

1. Funding, CME credits

1. What are we trying to accomplish

1. Physician, patient advocate testimonial

1. Break

1. Algorithm scavenger hunt

1. Tools intro, tips, PL, RL, PLAP

1. BB

1. Billing

1. Action planning, Evaluations

• Lecture/intro
• Graphed feedback and validation

• Lecture

• Lecture

• Story telling

• Small group activities, activity debrief

• Motivational presentation

• Lecture
• Lecture

• Facilitated discussion

• Activity debrief, how many docs selected appropriate tools on the algorithm
• Exit survey re impact of physician and patient advocate stories

1. Utilize the AMH hyperlinked algorithm to access all tools on your computer or EMR
2. Apply screening tools to identify adults who may have depression and anxiety or unhealthy styles. Screening results to be confirmed by the DSM5
3. Use non pharmacological CBT interventions, CBIS, BB, and ASW as first line therapy for mild to moderate depression and anxiety
4. Know that listening and hearing IS treatment
5. Engage, partner and share responsibility in the use of all tools and development of a care plan that utilizes AMH tools and resources including medications
6. Integrate AMH tools and resources into an effective work flow
7. Report increased comfort and confidence in dealing with depression and anxiety and all their mental health problems.

1. Share experiences/patient feedback

1. Coach report

1. Algorithm tricks

1. DAI

1. Patient advocate

1. Anxiety tips

1. ASW

1. Brief action planning

1. Evaluations, AP review

• Facilitated discussion

• Lecture

• Lecture

• Lecture
• Paired activity

• Storytelling

• Lecture

• Lecture

• Facilitated discussion

• Facilitated discussion

• Responses during experience sharing (how many participants demonstrated more comfort, confidence, demonstrated reflection on his her use of the tools, algorithm
• Results of docs MOAs experience reflected in coach report

1. Sharing experiences

1. Report from coach

1. More on CBIS skills (including SAQs)

1. Cultural Modifications of CBIS

1. Physician and Advocate perspective

1. Sustainability and improvement tips

1. Community Resource Café

1. Sustainability plan

1. Wrap up, evaluations

• Facilitated discussion

• Lecture

• Lecture, paired activity

• Lecture

• testimonials

• Lecture

• Group activity

• Group activity

• Group activity

• Responses during sharing experiences showing increasing use of tools and increasing comfort and confidence
• Reports of patient experience/feedback
• Results of coach report
• Exit survey of stage of readiness to continue to use tools

Bibilography

1.Patten, SB; Wang, JL; Williams, JVA et al. Descriptive Epidemiology of Major Depression in Canada. Canadian Journal of Psychiatry; Feb 2006; 51, 2; 84.

2.Kessler, R; Petukhova, M; Sampson, N; Zalavsky, AM; Wittchen, H-U. Twelve-month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the US. Int J Methods Psychiatr Res. 2012 Sep:21(3) 169-184.

3.Kennedy SH; Lam RW; Prikh SV; Patten SB; Ravindran AV. CANMAT Clinical Guidelines for the management of major depressive disorder in adults: J of Affective Disorders 117 (2009) S1-S2.

4.Otto, MW; Smits, JAJ; Reese, HE. Cognitive-Behavioral Therapy for the treatment of Anxiety Disorder J Clin Psychiatry 2004;65 (suppl 5).