IM PLEM EN TA TION OF DEPRESSION SCREENING PROTOCOL

AND TOOLS TO IM PROVE SCREENING FOR DEPRESSION

IN PATIENTS W ITH DIABETES

IN THE PRIM ARY CARE SETTING

BY

PRIYA BAJRACHARYA

A dissertation subm itted to the Graduate School

in partial fulfillm ent o f the requirements

for the degree

D octor o f N ursing Practice

New M exico State University

Las Cruces, New M exico

M ay 2016
 ProQuest Number: 10142151

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“ Implementation o f Depression Screening Protocol and Tools to Improve Screening

for Depression in Patients with Diabetes in the Primary Care Setting,” a dissertation

prepared by Priya Bajracharya, in partial fulfillm ent o f the requirem ents for the

degree, Doctor o f N ursing Practice, has been approved and accepted by the following:

Dr. Loui Reyes » J

Dean o f the Graduate School

Dr. Linda Summers

Chair o f the Exam ining Committee

3 y /y
Date

Comm ittee in charge:

Dr. Linda Summers, Chair

Dr. Conni DeBlieck

Dr. Anita Reinhardt

D ean’s Representative:

Dr. Daubney Harper

 DEDICATION

Thank - you Lord Ganesh for prayers answered. I w ould also like to dedicate

this project to my family.

I would like to thank my m other for her continuous support and guidance

throughout my life. W ithout her love and support I would not be the person I am.

Thank you to my husband Dr. Anup Amatya for all his support, love and

understanding. His b elief in me has been a great reason for m y success.

 ACKNOW LEDGEM ENTS

This project would not have been possible w ithout the support o f many

people. M any thanks to my adviser, Dr. Summers, who read m y num erous revisions

and provided constructive feedback. Also, thanks to my com m ittee m em bers, Dr.

DeBlieck, Dr. Reinhardt and Dr. Daubney, who offered guidance and support. Thanks

to the New M exico State University and the faculties for helping me to successfully

achieve my doctorate degree.

I would like to thank Dr. M urali for giving m e perm ission to conduct the

quality im provement project at his privately owned prim ary care clinic.

And finally, thanks to my husband, parents, and num erous friends who

endured this long process with me, always offering support and love.

iv
 VITA

N ovem ber 20, 1980 B om in Kathm andu, Nepal

March 1997- M arch 1999 Little Flow er High School, Indore, India

January 1999- M ay 2002 Tribhuvan University, K athm andu, Nepal

January 2004- M ay 2005 State U niversity o f New York, Plattsburgh, N Y

January 2006- M ay 2008 C linton Com m unity College, Plattsburgh, N Y

August 2009- M ay 2011 Upstate M edical University, Syracuse, NY

January 201- Current New M exico State University, Las Cruces, NM

P R O F E S S IO N A L

2011-2013 Prim ary Care Provider as FNP in Rural Health,

M alone, NY

2013-2015 Prim ary Care Provider as FNP in Family

Practice, Las Cruces, NM

2015- Current Prim ary Care Provider as FNP in M ountain

V iew U rgent Care, Las Cruces, NM

C E R T IF IC A T IO N S

M ember o f American A cadem y o f N urse Practitioner

H O N O R S , R E C O G N IT IO N AND A W A R D S

2004- 2005 D ean’s List, State U niversity o f New York,

Plattsburgh, N Y

F IE L D O F STU D Y

M ajor Field N ursing

 ABSTRACT

IM PLEM EN TA TION OF D EPRESSION SCREEN IN G PROTOCOL

A ND TOOLS TO IM PROVE SCREENING FOR DEPRESSION

IN PATIENTS W ITH DIABETES

IN THE PRIM ARY CA RE SETTING

BY

PRIYA BA JRACH A RYA

D octor o f N ursing Practice

N ew M exico State University

Las Cruces, New M exico, 2016

Dr. Linda Summers, Chair

Purpose: This quality im provem ent project incorporated depression screening

questionnaires/tools and screening protocol into prim ary care practice. The project

also evaluated the effectiveness o f the intervention in establishing depression

screening practice in the clinic.

 Data Sources: B rief and validated depression screening questionnaires were

selected and incorporated w ithin patients’ electronic health record (EHR). Well

trained certified medical assistants (M A) adm inistered patient health questionnaires

(PHQ) PHQ-2 and PHQ-9 to all adult patients seen for prim ary care at the project

site. A fter thirty days o f the implem entation, data were generated from the patients’

EHR. The data on total num ber o f adult patients screened using the questionnaires,

num ber o f type 2 diabetic patients screened using PHQ-2 and PHQ-9, num ber o f

referrals made, and num ber o f patients that received m edical treatm ent were

collected.

Conclusion: The im plem entation o f the depression screening questionnaires in

patients’ EHR along with the depression screening protocol resulted in increased

screening o f adult patients. It was proven by 82.5% depression screening rates at the

project clinic. This active screening increased the detection o f depression risk in the

adult patients with chronic medical conditions such as type 2 diabetes in prim ary care

setting.

Implication for practice: The PHQ-2 and PHQ-9 questionnaires used on intake

can assist prim ary care providers in screening, diagnosing and m onitoring depression.

The project findings indicated that integration o f the intake screening questionnaires

into an electronic health record m ade the screening process easier and m ore efficient.

K eyw ords: depression and type 2 diabetes, depression screening tools, depression

screening guidelines, depression screening in prim ary care and electronic m edical

record, diffusion o f innovation theory.

 TABLE OF CONTENTS

LIST OF ACRONYM S ............................................................................................ xii

Chapter

1. Introduction .................................................................................................... 1

Problem Statement ........................................................................................ 1

Background ............................................................................................... 1

Diabetes and Depression ........................................................................ 1

Significance o f the Problem .................................................................. 3

Consequences o f the Problem .............................................................. 4

Theory Overview ..................................................................................... 6

Practice Knowledge Gap ........................................................................ 6

Proposed Solution ......................................................................................... 7

Research Question ................................................................................... 8

Population .................................................................................................. 8

N eeds A ssessm ent ......................................................................................... 9

Organizational A ssessm ent ................................................................... 11

Values ......................................................................................................... 11

A ssessm ent o f Resources ...................................................................... 12

SW OT Analysis ............................................................................................ 12

Strengths .................................................................................................... 12

Lim itations.................................................................................................... 13

O pportunities ............................................................................................ 13

viii
 Threats ........................................................................................................ 14

Project Overview .......................................................................................... 14

Goals and Objectives .............................................................................. 14

Scope o f Project ........................................................................................ 15

O rganizational M ission and Values .................................................... 16

Key Stakeholders ..................................................................................... 16

Project team ......................................................................................... 17

Institutional leadership ...................................................................... 17

Cham pions for change ...................................................................... 17

Fiscal Analysis and Resources Needed .................................................... 18

Budget ........................................................................................................ 18

Process and Outcome Objectives .............................................................. 18

2. SYNTHESIS OF SUPPORTING EV ID ENCE/LITERA TU RE AND

PRO JECT FRAM EW ORK ....................................................................................... 20

Systematic Review ........................................................................................ 20

Diabetes and Depression ............................................................................. 23

Depressing Screening in a Primary Care Setting ................................... 24

G uidelines and Recom mendations ............................................................ 25

Depression Screening Tools .................................................................. 25

Barriers to Depression Screening Guidelines .................................... 26

Relevant Theory and Concepts ............................................................. 30

Process o f Systematic Review .............................................................. 33

3. W O R K PL A N ................................................................................................ 35

ix
 Project Schedule ............................................................................................. 35

M ilestones ....................................................................................................... 36

Implementation M ethods ............................................................................. 37

M easures ......................................................................................................... 38

Data Sources ................................................................................................... 38

M ethods o f Data Collection ........................................................................ 39

Data Analysis ................................................................................................. 39

4. RESULTS AND INTERPRETATION ..................................................... 41

Outcome Evaluation ...................................................................................... 41

5. LEADERSHIP AND M AN A GEM ENT .................................................... 45

Organizational Culture ................................................................................. 45

Change Strategy ............................................................................................. 45

Leadership Style ............................................................................................. 46

Inter-professional Collaboration ................................................................ 47

Conflict M anagem ent .................................................................................... 48

Ethical Considerations ................................................................................. 49

6. DISCUSSION .................................................................................................. 52

A ssessm ent o f Project Impact and Sustainability .................................. 52

Contributing Factors to Success or Lack o f Success .............................. 53

Information Added to the Body o f Knowledge ..................................... 54

7. CONCLUSION ................................................................................................ 56

Impact on Health Outcom es beyond

Project Implementation Site ........................................................................ 56

x
 Sum m ary o f Local, National, and International
Health Policy Im plications .......................................................................... 57

A ppendices ........................................................................................................... 59

A. R O G ER S’ D IFFUSION O F INNOVATION TH EO RY .................... 60

B. D EPRESSION SCREEN IN G PRO TO CO L .......................................... 62

C. PATIEN T H EA LTH Q UESTION N AIRES 2 & 9 .................................. 64

D. PATIEN T PA RTICIPA TIO N CO N SEN T FORM .............................. 66

E. PO ST-PRO JECT IM PLEM EN TA TION SURVEY ............................ 69

F. TA BLE 1: PATIEN T CH A RA CTERISTICS ..................................... 71

G. TA BLE 2: CH A RA CTERISTICS OF PATIENTS

SCREEN ED USIN G PHQ-2 ...................................................................... 73

H. TA BLE 3: CH A RA CTERISTICS OF PATIENTS

ID EN TIFIED AS D EPRESSED USIN G P H Q -9 ..................................... 75

I. A PPRO V A L LETTER FROM IN STITU TION A L

REVIEW B O A R D ........................................................................................... 77

J. SRIREN GA M M U RA LID H ASA N, M .D. LETTER

OF EN D O R SEM EN T...................................................................................... 79

REFERENCES ........................................................................................................... 81

xi
 LIST OF ACRONYM S

A AFP A m erican A cadem y o f Fam ily Physicians

ACA A ffordable Care Act

ACPM American College o f Preventive M edicine

ADA American Diabetes A ssociation

AHRQ A gency o f Healthcare Research and Quality

APN A dvanced Practice Nurses

BDI Beck D epression Inventory

BRFSSS Behavioral Risk Factor Surveillance System Survey

CAH Critical Access Hospitals

CDC Center for Disease Control

CDS Clinical Decision Support

CES-D Centers for Epidem iologic Studies Depression Index

CINAHL C um ulative Index to N ursing and A llied Health Literature

CQM Clinical Quality M easures

CM M S Centers for M edicare and M edicaid Services

DNP D octor o f N ursing Practice

EHR Electronic Health Record

GDS G eriatric Depression Scale

HART H arvest 9 0 A dventist Research Task Force

HDS H am ilton Depression Scale

HIPPA Health Insurance Portability and A ccountability Act

IDF International Diabetes Federation

IOM Institute o f M edicine

IRB Institutional Review Board

IT Information Technology

MA M edical Assistant

N DSR National Diabetes Statistics Reports

NGC National G uidelines Clearinghouse

NIM H N ational Institute o f Mental Health

NM SU New M exico State University

PCP Primary Care Provider

PHQ Patient Health Questionnaire

PRIM E-M D Prim ary Care Evaluation o f M ental Disorders

SPSS Statistical Package for the Social Sciences

SW OT Strength, W eakness, Opportunity, & Threat

USB Universal Serial Bus

USPSTF U.S. Preventive Services Task Force

W HO W orld Health O rganization

 CHAPTER 1

INTRODUCTION

P ro b lem S tatem en t

Background

A ccording to the Centers for Disease Control (CDC, 2014a), both depression

and diabetes are highly prevalent in the U.S. O ver 6.5% o f the U.S. adult population

has been diagnosed with diabetes. In 2014, the prevalence o f depression was found to

vary across populations o f diabetic adults, but was estimated to be between 18-31%.

Despite the severity o f the problem, m ajor depression goes unrecognized and

untreated, and m ay result in tragic consequences such as suicide and im paired

interpersonal relationships at work and at home.

The link between diabetes and depression is a significant issue. Individuals

with depression experience reduced functioning and decreased quality o f life

(M arkowitz, Gonzalez, W ilkinson & Safren, 2011). Depression is associated with

poor adherence to medical regim ens and treatm ent in patients with co-m orbid medical

conditions such as diabetes (Coventry et al., 2011). This may result in higher rates o f

mortality, cardiac events, hospitalizations, diabetes-related com plications, functional

im pairm ent, health care costs, and a decreased quality o f life (Bassett, Adelm an,

Gabbay & Anel-Tiangco, 2012).

Diabetes and Depression

According to the 2014 National Diabetes Statistics Reports (NDSR), 29.1

m illion people (or 9.3%) o f the U.S. population have diabetes, 21.1 m illion people are

diagnosed with diabetes, and 27.8% with diabetes go undiagnosed. Diabetes was the

1
seventh leading cause o f death in the U.S. in 2010, based on the 69,071 death

certificates in which diabetes was listed as the underlying cause o f death. The N DSR

report also supported that people with diabetes m ay have or develop other

com plications or conditions such as depression.

The aforem entioned report suggested that recognizing and treating depression

in patients with diabetes may also help to avoid com plications related to diabetes.

Hence, screening and addressing depression should be an essential part o f diabetes

care, which can be accom plished in a coordinated m anner in prim ary care settings.

There are several validated depression screening tools available that can be easily

adm inistered at a prim ary care setting to assist providers w ith the screening process

(Fann et al., 2009). Although some tools cannot be used to diagnose depression, high

scores can indicate a higher severity o f symptoms o f depression during a specific time

period. The higher score can prom pt prim ary care providers (PCPs) to seek further

screening and to provide timely treatm ent or referral for their patients.

Routine screening o f all patients for depression is supported by professional

organizations, and is covered as a part o f the Affordable Care A ct (A CA) (USPSTF,

2009). The American Diabetes A ssociation (ADA) (2008) recom m ended regular

screening o f depression in diabetic patients throughout diabetes m anagem ent,

including at diagnosis, routine m anagem ent visits, and hospitalizations. PCPs can

thus use routine depression screening to improve health outcom es o f patient with

diabetes.

2
Significance of the Problem

Diabetes is a m ajor global health concern that affects over 387 million

individuals (W orld Health O rganization [W HO], 2015; International Diabetes

Federation [IDF], 2014). In 2014, the W HO estim ated the global prevalence o f

diabetes am ong adults to be 9%, and w orldw ide deaths linked to diabetes were over

1.5 million in 2012 (WHO). In the U.S. for 2013, it was estim ated that 29.1 million,

or 9.3% o f the population, had diabetes (CDC, 2014a). In 2010, diabetes was the

seventh leading cause o f death in the U.S. (CDC, 2014b). In 2012, the estim ated total

direct and indirect cost o f diabetes in the U.S. was $245 billion (CDC, 2014b). In the

state o f New M exico, 8 % o f the total population were diagnosed with diabetes in

2010, which increased by 40% from 1995 figures (CDC, 2012). The Behavioral Risk

Factor Surveillance System Survey (BRFSSS) report also supported a high

prevalence o f depression among individuals with chronic medical conditions in New

M exico (CDC, 2005). The report showed that 3.8% o f adults in New M exico had

current symptom s o f depression. In addition, they were more at greater risk to have

certain health conditions — such as diabetes and other m edical conditions — than

persons w ithout depression.

According to W HO (2012), depression is also a m ajor global health problem

that affected over 350 million individuals o f all ages and was a leading cause o f

disability. In the U.S., approxim ately 6.7% o f adults experience m ajor depression;

further, women are 70% more likely than m en to experience depression throughout

their lifetimes (National Institute o f M ental Health [NIMH], n.d.). Lifetime

prevalence rates o f depression range from 10-15% (Lepine & Briley, 2011).

3
 The burden o f depression includes an increased m ortality risk encom passing

suicide, cardiac death, and cognitive/social im pairm ents (Lepine & Briley, 2011).

Depression in em ployees has also been linked to functional im pairm ents, including

absenteeism and decreased productivity in w ork settings. Individuals who are

consistently identified as high-risk include: (a) women; (b) people with other

psychiatric disorders, including substance abuse; (c) people with a fam ily history o f

depression; (d) people with a chronic m edical disease such as diabetes; and (e) people

who are unem ployed or with low er socioeconom ic status (Riley, M cEntee, Gerson, &

Dennision, 2009).

Consequences of the Problem

The com pelling body o f research supports an existing relationship between

depression and diabetes (Roy & Lloyd, 2012). Studies have shown that the risk o f

depression is higher in individuals w ith diabetes than those w ithout diabetes. In a

2012 study by Roy and Lloyd, at least one-third o f diabetic patients were found to

have a depressive disorder. Individuals with com orbid depression and diabetes are

found to be more likely to exhibit uncontrolled diabetes, increased medical

com plications, and increased health costs, according to de Groot, Anderson,

Freedland, Clouse, and Lustm an (2001).

A m eta-analysis conducted by G onzalez et al. (2008) and Anderson,

Freedland, Clouse, and Lustm an (2001) showed a significant association betw een

depression and treatm ent non-adherence in patients with diabetes. N on-adherence to

m edical treatm ent is well know n to increase risk o f micro- and m acro-vascular

com plications related to diabetes. These com plications can im pact patients’ overall

4
health outcom es and quality o f life. Furtherm ore, a cross-sectional study finding

dem onstrated a strong relationship between depression, poor self-diabetic care, and

m edication adherence (Lee, Lennie, Heo & M oser, 2012). N on-adherence can

increase overall healthcare costs for patients with comorbidity. Additionally, a

diagnosis o f diabetes increases the risk o f incidents o f depression and can contribute

to a m ore severe course o f depression (Bassett et al., 2012). So, there is a concurrent

relationship between diabetes and depression. The high prevalence o f co-m orbid

depression and diabetes has also been supported by study findings which show that

depression m ight arise from the psychosocial burden and bio-chem ical changes

related to diabetes and its treatm ent (Riley et al., 2009).

B esides decreased physical functioning and health outcom es, diabetic patients

with com orbid depression experience increased health care costs (Simons et al.,

2005). The Agency o f Healthcare Research and Q uality (AHRQ) recognized diabetes

and depression am ong the top ten m ost expensive health conditions. Therefore, both

diabetes and depression are significant health concerns that produce an overw helm ing

burden to the individual and society.

5
Theory Overview

R ogers’ " Diffusion o f Innovations” theory (2003) was used to guide this

project’s im plem entation and evaluation. The theory is addressed in detail in chapters

2 and 4, and is depicted in Appendix A.

Practice Knowledge Gap

A t an outpatient prim ary care clinic in southern New M exico, PCPs —a

physician, two nurse practitioners, and three certified medical assistants (M A) —were

seeing several patients with diabetes who were potentially at risk o f depression. The

providers serving this select population o f diabetic patients was proficient in treating

and m anaging psychological conditions such as depression and anxiety. D espite their

know ledge and proficiency in m anagem ent o f the psychological conditions, patients

were not routinely screened for the depression. This was evidenced by a lack o f

screening docum entation in the patient electronic health records (EHR). The clinic’s

EHR provider, eClinicalW orks, offered an option for users to activate depression

screening questionnaires using a clinical decision support (CDS) tool. According to

Gill et al. (2012), these EHR-based clinical decision support tools have been

extensively used and w ere perceived as helpful for screening and assessm ent o f

patient sym ptom s in different clinical settings. Despite the known benefits, the project

site was not utilizing these tools. The clinic also lacked a formal process and written

protocol for identifying patients at risk for depression.

M ost o f the providers at the project clinic identified lack o f protocol, lack o f

time, and lack o f screening tools within the EHR to be the main barriers for

screening. Researchers Osborn, Kozak, and W agner (2010) identified additional

6
barriers to depression m anagem ent in prim ary care practice, such as com peting

medical demands that require providers to prioritize services and defer som e services

to other specialists and the reim bursem ent structures. Despite the obstacles created by

everyday practice, evidence suggested that evidence-based screening and treatm ent

for depression can be cost efficient.

Proposed Solution

Primary care settings provide a unique opportunity for developm ent and

im plem entation o f an evidence-based change program for screening and treatm ent for

diabetic patients at risk o f depression (Osborn et al., 2010). Evidence-based clinical

practice guidelines for screening and treating depression in prim ary care settings have

been available for over a decade. These guidelines ensure that health services are

provided in a consistent, high quality, and cost-effective manner. Therefore, the

application o f formal clinical protocol can improve detection and treatm ent o f

depression in prim ary care settings.

The aim o f this project was to remove depression screening and m anagem ent

gap from the intervention site. This author developed a clearly stated depression

screening protocol (Appendix B), and incorporated valid and b rief depression

screening tools in the patients’ EHRs. In so doing, the project aimed to identify

patients who were at risk for depression and thus decrease the incidence and severity

o f com plications related to co-morbidities. Gill et al. (2012) showed that severity

questionnaires such as the Patient Health Questionnaires (PHQ-2; PHQ-9, A ppendix

C) could assist busy PCPs in screening, diagnosing, and m onitoring depression. In

7
addition, when the questionnaires were em bedded into patient EHRs, they w ere easy

to use and led to improvements in quality o f care.

Utilization o f depression screening tools and referrals w ithin patient EHRs has

also shown to positively im pact use o f clinical quality m easures (CQM ). CQ M s are

tools that help measure and track the quality o f health care services provided by

eligible professionals, eligible hospitals, and critical access hospitals (CA Hs) within

the health care system (CDC, 2014). These m easures use data associated with

providers’ ability to deliver high-quality care or relate to long-term goals for quality

health care. CQM s measure m any aspects o f patient care, including adherence to the

guidelines.

Research Question

The project question that was used to guide the data collection, analysis, and

interpretation o f this project was: “Does im plem entation o f evidence-based

depression screening protocol and tools increase depression screening rates in a

prim ary care practice in southern New M exico?”

The author hypothesized that, after 30 days im plem entation o f the screening

protocol and tools, at least 25% o f all patients w ith type 2 diabetes could be screened

for depression.

Population

O ver 56.8 % o f the populations o f Las Cruces, New M exico (where the

project took place) are o f Hispanic origin (U nited States Census Bureau, 2010). Two

relevant studies found that Hispanics are disproportionately affected by type 2

diabetes. Prevalence o f diabetes in this m inority group was found to be tw o times

8
higher than with Caucasian groups (M ier et al., 2008). Hispanics were also found to

be at risk for com plications or co-m orbidities related to type 2 diabetes. An

exploratory cross-sectional study conducted by M ier et al. (2008) showed that the

overall rate o f clinical depressive symptom s in Hispanic adult patients o f M exican

origin with type 2 diabetes (residing on both sides o f the Texas-M exico border) were

sim ilar —39% and 40.5% , respectively. The generalization o f the findings was

limited due to convenience sampling; however, the findings suggested that diabetes

and depression m ust be addressed in diabetes initiatives at the U .S.-M exico border

region.

Needs Assessment

Depression and diabetes are m ulti-faceted problem s that often require

extensive intervention at the prim ary, secondary, and tertiary levels (Scogin & Shah,

2006). Proper screening may lead to accurate identification o f individuals at risk.

Once identified, appropriate treatm ent or referral for treatm ent o f the individual with

depression can be made. Interventions such as screening for depression and referrals

to the mental health specialists are identified as two vital measures to reduce adverse

health consequences and health care costs.

The prim ary care clinic is a unique place w here a wide range o f individuals o f

all ages seek m edical and preventive services. A ccording to the American College o f

Preventive M edicine (ACPM ), PCPs are the principal contacts for more than 50% o f

patients with mental illnesses, approxim ately 35% o f patients seen in prim ary care

meet criteria for some form o f depression, and 10% suffer from m ajor depression.

A ccording to Riley et al. (2009), approxim ately 25% to 50% o f diabetic patients with
depression are identified in prim ary care settings. These studies support that prim ary

care practices are ideal places for conducting com prehensive depression screening

and m anaging diabetes and depression. Active screening in these practices may help

to improve patient physical and m ental health outcomes. Therefore, routine structured

screening for depression in prim ary care settings needs to be realized in order to

im prove the depression diagnosis rate. Additionally, an established, ongoing intake

screening practice would assist in prom pt diagnosis, thereby im proving overall

patient outcomes.

An observation study conducted by Parchman, Romero, and Pugh in 2006

identified provider related barriers to screening in prim ary care practice. Competing

medical dem ands often require PCPs to prioritize services and defer some services to

subsequent visits. Schmitt, M iller, Harrison, and Touchet (2010) identified other

barriers to depression screening in prim ary care practice, including (a) visit duration,

(b) reim bursem ent structures, (c) lack o f incentives, and (d) availability o f affordable

mental health services.

To resolve the issue o f postponed or deferred services, studies have been

investigated the use o f different screening technologies, including a com puter-based

approach or patient sign-in forms which allow for faster screening. Farrell et al (2009)

perform ed initial depression screening in a rural prim ary care setting, using the PHQ-

9 questionnaire (A ppendix C). The researchers incorporated the questionnaires in

com puter systems to facilitate depression screening. They found that participants and

medical providers w ere accepting o f the electronic screening program as long as it

worked into the clinic visit flow. The researchers reported that the average time

10
required for a patient to com plete the electronic depression screening was less than

three minutes. This finding supported incorporating the screening questionnaire into

the patient’s EHR to help overcom e time-related barriers existing at the southern New

M exico project site.

Organizational Assessment

Health care system s are com plex. They m ust be adaptive in order to develop

resilience and survive in the fluid and dynam ic health care market (Swanson et al.,

2012). Problem s and problem solving in a com plex health care system are linked to

the health care environm ent (Zaccagnini & W hite, 2011). Therefore, assessing the

key com ponents o f the health care environm ent becomes a crucial elem ent within

problem solving. Some key com ponents o f the health care environm ent include the

values, m ission, and culture. These com ponents represent m acro-environm ental

forces that influence and shape the environm ent o f an organization (Ledlow &

Coppola, 2011).

This project was im plem ented in a busy outpatient prim ary care clinic which

provides com prehensive care to southern New M exico patients. The clinic is

independently ow ned and operated. Organizational assessm ent o f the clinic was

necessary to determ ine suitability and readiness to support the intervention.

V alues

The proposed project goals aligned with the mission and values o f the targeted

organization. Clearly, recognition o f depression in patients with chronic medical

conditions such as diabetes could im prove overall patient outcome, which was the

organization’s prim ary goal. Hence, identifying the presence o f com orbid condition

11
such as depression is am ong the first step toward developing a com prehensive

m anagem ent strategy.

Assessment of Resources

Some im portant resources supporting change include financial, personnel, and

material resources (M oran et al., 2014). In accordance with this inform ation, the site

resources were assessed prior to im plem entation o f the project.

The providers at the project site included one board-certified physician and

two board-certified family nurse practitioners; all were well-trained and proficient in

depression m anagem ent and treatment. In addition to the board-certified providers,

the clinic also had three certified MAs who were skilled in collecting patient medical

histories and vital signs. The clinic implemented the current EHR system in 2009.

The system used selected questionnaires to generate dashboard reports showing total

num ber o f patients screened for depression; these reports were later in the data

analysis for this quality im provem ent project.

SWOT Analysis

A strength, weakness, opportunity, and threat analysis (SW OT) exam ines

internal and external attributes and threats to the project (M ind Tools, 2014). A

SW OT analysis o f this project site was conducted to ensure successful

implem entation. The analysis showed the following:

Strengths

Strengths o f the organization can promote im plem entation o f the quality

im provem ent project (M oran et al., 2014). A prim ary strength o f this project site was

the recognition w ithin the com m unity o f its long history o f providing com prehensive

12
medical care. O ther strengths included high patient satisfaction rate, fiscal soundness,

and com petent em ployee pool. M oreover, the clinic em ployed board-certified PCPs

who were proficient in providing mental health services. A ccording to Riley et al.

(2009), PCPs are in the best position to conduct com prehensive depression screening,

manage diabetes and depression, and improve physical and mental health outcom es

for the patients. It was confirm ed that the clinic had successfully im plem ented the

user friendly EHR, eClinicalW orks, which provided the option to incorporate

depression screening questionnaires.

Limitations

Conversely, some lim itations were identified w ithin the clinic that could

create barriers to implementation o f this project. The clinic did not em ploy well-

trained office m anager or a nurse leader to guide the evidence-based practice. Based

on my personal knowledge the intervention site was also lacking the standard policy

and protocol needed to guide the clinical practice. Hence, the w ell-trained PCPs were

not routinely screening for depression in adult patients with diabetes. One PCP who

showed resistance to the change indicated that he/she was unlikely to change his/her

way o f providing care.

Opportunities

As project leader, I assessed and leveraged the opportunities that could

support project im plem entation and potential dissemination. A majority o f providers

at the clinic supported the notion that clinical protocol and depression screening

practice could increase their clinical outcomes and revenue. A ccording to the Centers

for M edicare and M edicaid Services (CM M S, 2014), M edicare plans such as Plan B

13
reim bursed depression screening in adults once a year under Fee-for-Service

M edicare, and there is no coinsurance and no patient deductible. D epression

screening and depression care support has been found to im prove clinical outcom es in

adults and is recom m ended by the U.S. Preventive Services Task Force (U SPSTF)

(2009).

Threats

Busy clinic schedules and limited staffing are potential threats to

im plem entation o f any new project. This project aim ed at im plem enting a b rief

depression screening questionnaire w ithin patient EHRs to overcom e the tim e-related

barrier. The screening w ould be com pleted by available personnel w ho had received

the proper training.

Project Overview

Goals and Objectives

Project goals are defined as a description o f the outcom es that the project

intends to deliver (M oran et al., 2014). The project goal was to determ ine the

effectiveness o f an evidence-based depression screening protocol and screening tools

in achieving a m inim um 25% depression screening rate. The project objectives were

to (a) develop and im plem ent evidence-based depression screening protocol

(Appendix B); (b) incorporate validated depression screening tools PHQ-2 and PHQ-

9 in patient EFIRs; and (c) initiate appropriate treatm ent for patients identified to have

moderate to severe depression.

14
Scope of Project

The validated depression screening questionnaires PHQ-2 and PHQ-9

(Appendix C) were incorporated into patient EHRs. The two certified M As were

trained to adm inister depression screening questionnaires on intake in all adult (ages

18-10) patients w ho w ere scheduled for prim ary care services at the clinic. The

assistants were required to com plete Institutional Review Board (1RB) training. Upon

com pletion o f the training, they w ere rew arded with twenty dollar gift cards.

W ritten patient participation consent forms (Appendix D) were created.

Signed consent forms w ere obtained from the patients before adm inistration o f the

questionnaires. The patients were provided with w ritten laminated copies o f both

questionnaires (PHQ-2 & PHQ-9, A ppendix C), and were allowed to read them

before responding to the questionnaires. The questionnaires were available in both

English and Spanish. The PHQ-2 questionnaire was used as an initial screening tool.

If patients replied “yes” to any o f the questions in the PHQ-2, the EH R system

autom atically directed the M As to ask questions in PHQ-9. The severity o f depressive

sym ptom s and provision o f relevant interventions were based on PHQ -9 scores. A

depression severity score o f “5 or m ore” reflected evidence o f depression and

warranted intervention by the providers.

Demographic inform ation such as age, gender, and ethnicity o f the screened

patients were collected and em bedded in the patients’ EHRs. A fter 30 days o f project

implem entation, the principal investigator collected data on the total num ber o f adult

patients who were screened using PHQ-2 and PHQ -9 questionnaires. All required

data were collected w ithout patient identifiers.

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Organizational Mission and Values

As discussed previously, this project’s goals and objectives were aligned with

the m ission o f the organization. According to the medical director o f the clinic, the

mission o f the clinic is to provide effective, com prehensive, timely, and cost-effective

care to the patients and the community.

A ccording to the clinic proprietor, the guiding principles included provision o f

high quality, cost effective, and individualized patient-centered care. In order to

provide quality care, providers were w illing to adapt changes that could be beneficial

to patient outcomes. This project aim ed to establish a depression screening practice at

the intervention site w hich would improve overall clinical outcomes. Depression

screening and depression care support had been found to improve clinical outcom es

in adults and older adults and was recom m ended by the U SPSTF (2009). Treating

adults and older adults diagnosed with depression through screening in prim ary care

settings with m edication treatm ent or referral (or both) was found to result in

im proved clinical outcom es and overall enhanced m orbidity (USPSTF, 2009). The

proposed project exem plified the values and m ission o f the prim ary care site in

southern New Mexico.

Key Stakeholders

Key stakeholders are individuals who can influence the project and have an

interest in the project outcom e (M oran et al., 2014). M arketing and obtaining buy-in

for any practice change are crucial for project sustainability (Keele, 2011). The

purposes o f this quality im provem ent project w ere to determine the effectiveness o f

16
an evidence-based depression screening protocol, and to incorporate screening tools

in patient EHRs in order to increase depression screening rates.

The key stakeholders in this project included two board certified PCPs, two

certified M As, inform ation technology (IT) personnel, adult patients ages 18-100, and

the investigator who led this quality im provem ent project. The PCPs followed the

screening protocol, reviewed the depression screening scores, and initiated the

m edical treatm ent or referral based on the depression severity level. The IT personnel

helped to integrate depression-screening tools/questionnaires within the

eClinicalW orks. The two certified M As adm inistered screening tools in adult patients

during their intake initial encounters. All stakeholders who agreed to be a part o f this

project understood the importance o f the project outcom es as they related to potential

perform ance im provements.

P ro ject team . The project team included the two PCPs, two certified M As, Dr. Linda

Summers (project Chairperson), Drs. Conni DeBlieck and Anita Reinhardt

(com m ittee members), Dr. Amatya, biostatistician at New M exico State U niversity

(NM SU), and the investigator.

Institutional leadership. Institutional leaders included the clinic’s medical director

who was an independent ow ner o f the clinic. The clinical director gave perm ission to

im plem ent this project at his clinic. He was fully aware o f the foreseeable benefits o f

this project.

Champions for change. The prim ary cham pion for change in this project was the

investigator/D octor o f N ursing Practice (DNP) student. The investigator collected and

presented evidence to the other team members. As a change agent and cham pion o f

17
this quality im provem ent project, the investigator applied transform ational leadership

principles throughout the project. Additionally, an individual from the IT Departm ent

was identified as a champion for change. This IT individual was proficient in

installing new features (such as depression screening questionnaires) within the

patients’ EHRs.

Fiscal A nalysis an d R esources N eeded

As previously discussed, this project did not pose any additional cost to the

intervention site. The only cost to the clinic was printing o f patient consent forms

(Appendix D). Any additional resources were provided by the investigator. Some o f

these included depression screening training and coaching to the certified M As, two

gift cards for the M As for their participation, and cost to develop three lam inated

depression screening questionnaires (PHQ-2 & PHQ-9, A ppendix C)

B udget. The project budget is an estimate o f the cost o f im plem enting the project; it

includes indirect and direct costs (M oran et al., 2014). The direct costs included

equipm ent and supplies. Indirect costs involved day-to-day organizational operating

costs.

Equipm ent and supplies included the depression screening training, papers,

printing, lamination, and two gift certificates. As this project was im plem ented w ithin

the investigator’s workplace, there was access to office space, internet, and paper and

printing services.

P rocess an d O u tco m e O bjectives.

A ccording to M oran et al. (2014), process measures assist in identification o f

possible barriers and facilitators to the project. According to these researchers, the

18
process measures help to determine if the proposed project is im plem ented according

to plan. A post-project im plem entation survey (Appendix E) was developed and

distributed to the certified MAs. Additionally, time to choose, m odify, and add a

com puterized version o f the depression screening tool to the EH R progress notes was

recorded; number o f revisions was also reported.

Outcomes measures provided inform ation about depression screening rate and

utilization o f PHQ-2 and PHQ-9 questionnaires. The project goal was to screen at

least 25% o f adult patients with diabetes by end o f project im plem entation (30 days).

The hypothesis for the project included that at least 18% o f screened patients would

be positive for depression, and at least 30% o f patients who scored positive in PHQ-2

would be further screened using PHQ-9.

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 CH A PTER 2

SYNTHESIS OF SUPPORTING EV IDENCE

AND PRO JECT FRA M EW ORK

Systematic Review

Critical literature review was conducted to gather evidence on diabetes and

depression, risk o f depression in patients with diabetes, health burden o f the co­

m orbidities, and the best m ethod for screening and treating depression in patients

with diabetes.

Screening and referrals for depression treatm ent have been identified as two

vital measures in reducing adverse health consequences, decreasing costs, and

improving quality o f life related to chronic medical conditions (Scogin & Shah,

2006). A ccording to the American College o f Preventive M edicine (A C PM ) (2011),

PCPs are the principal contacts for m ore than 50% o f patients with mental illnesses;

approxim ately 35% o f patients seen in prim ary care meet criteria for some form o f

depression; and 10% o f patients suffer from m ajor depression. A pproxim ately 25-

50% o f diabetic patients with depression are identified in prim ary care settings

(ACPM , 2011). These findings support the notion that prim ary care practices are ideal

for conducting com prehensive depression screening, and for m anaging diabetes and

depression to improve patient physical and m ental health outcom es (Riley et al.,

2008).

The review o f the literatures revealed several available guidelines and

recom mendations; however, providers m ust analyze the guideline quality as well as

the organization providing the recom m endations. The U SPSTF (2009) recom m ended

20
screening all adults for depression — irrespective o f their underlying m edical problem

— as long as supports are in place to assure accurate diagnosis, effective treatment,

and follow-up. A dditionally, A DA (2008) also recom m ended regular screening o f

depression in diabetic patients throughout their course o f diabetes m anagem ent,

including at diagnosis, routine m anagem ent visits, and hospitalizations. M oreover, the

CM M S (2014) also concluded that the evidence is adequate to support screening for

depression in adults. D epression screening is determ ined to be reasonable and

necessary for the prevention or early detection o f illness or disability, and appropriate

for individuals entitled to benefits under Part A or enrolled under Part B (CM M S).

Therefore, CM M S covers annual depression screening for M edicare beneficiaries in

prim ary care settings that have staff-assisted depression care supports in place to

assure accurate diagnosis, effective treatm ent, and follow-up.

Identifying depression in the diabetes cohort in prim ary care practice can be a

challenge for the provider. Choosing a valid and reliable depression screening

instrum ent to screen for adult patients with chronic m edical conditions such as

diabetes can also be a challenging task (A nderson et al., 2002). And, not all o f the

tools are found to be appropriate for busy prim ary care practices, as they are lengthy

and require accuracy on the part o f the interviewer. However, there are depression

screening instrum ents that have been studied and found to be valid and reliable in

m any patient populations.

The PHQ-2 and PHQ-9 (Appendix C) have been reported to be effective

screening tools for evaluation and m anagem ent o f depression in busy clinical settings.

PHQ was developed by Spitzer, Kroenke & W illiam s in m id-1990s as an alternate

21
screening instrum ent to the Primary Care Evaluation o f M ental Disorders (PRIM E-

M D) w ith an educational grant from Pfizer. The PHQ-2 consists o f only two

questions: “O ver the past two weeks, have you often been bothered by little interest

or pleasure in doing things?” and, “O ver the past two weeks, have you been feeling

down, depressed, or hopeless?” The PHQ-2 has a sensitivity o f 83% and specificity

o f 92% (R iley et al., 2009). The PHQ-2 questionnaire can be used as an initial

screening tool. If any o f the answers in the PHQ-2 questionnaire are positive, the

PHQ-9 can be adm inistered (additional seven questions). The PHQ- 9 was found to

have a sensitivity o f 70% and specificity o f 92% when cutoff is greater than 10

(H am m ash et al., 2013). The PHQ-9 has been found to be acceptable in a num ber o f

different patient groups, including patients w ith/w ithout diabetes. This may be

because o f its relative brevity, ease o f interpretation, and concurrence with the

diagnostic criteria o f m ajor depression. The H arvest 9 0 A dventist Research Task

Force (HART) study also suggested that the PHQ-2 m ight be the m ost useful

instrum ent, as it contains only two questions which can be adm inistered into routine

patient encounters (Pederson et al., 2009).

A research study by Lee et al. (2009) has also verified that the PHQ-9 can be

used in patients with chronic m edical conditions without worry o f overestim ating

depressive sym ptom s and outcomes. Based on the validity, reliability, and ease o f

use, the PHQ-2 and PHQ-9 w ere considered applicable for the diabetes population.

22
 Diabetes and Depression

As stated before, according to N DSR (2014), 29.1 m illion people (or 9.3% o f

the U.S. population) had diabetes, 21.1 million adults were diagnosed with diabetes,

and 27.8% o f people with diabetes were undiagnosed. Diabetes was the seventh

leading cause o f death in the U.S. in 2010, based on the 69,071 death certificates in

which diabetes was listed as the underlying cause o f death. Additionally, the NDRS

report also supported that people with diabetes may have or may develop other

com plications or conditions, such as depression.

As stated earlier, BRFSSS data suggests the higher prevalence o f depression

am ong patients w ith diabetes. Li et al. (2008) analyzed the BRFSSS data to estimate

the prevalence o f depression am ong adults with diabetes. The study results showed

that the age-adjusted prevalence rate o f m ajor depression was 8.3% among U.S.

adults w ith diabetes in 2006. Furtherm ore, the study results also suggested that the

PHQ-9 could be potentially useful as a brief and cost-effective, self-adm inistered

diagnostic instrum ent to identify people with m ajor depression in population-based

surveys as well as in clinical practice (Li et al., 2008).

The Cochrane database was utilized to search for the relevant investigations.

A search o f the database, using the search term “type 2 diabetes and depression,”

yielded five articles. One o f these included a systematic review on diabetes self­

m anagem ent intervention for adults with type 2 diabetes. No random ized controlled

trial could be found on this subject.

A correlational study conducted by Basset et al. (2012) exam ined relationship

between depression, diabetes treatment satisfaction, and health outcomes; 545

23
participants were recruited. Patients eligible for the study were identified from billing

data, searching the Pennsylvania State Diabetes Registry, chart reviews from nine

Penn State Hershey M edical center prim ary care offices, and three hospitals affiliated

prim ary cares that predom inantly served a Hispanic population. The study findings

showed a clear relationship between depression and treatment satisfaction. The

prevalence o f depression among poorly controlled diabetes (H b alc= 8.4) was 35.6%.

Depression severity was measured using the Centers for Epidemiologic Studies

Depression Index (CES-D) score. The diabetic non-com pliant patients scored CES-D

greater than 12. This supported the perception that depression in diabetic patients can

lead to poor health outcomes.

Depression Screening in a Primary Care Setting

Primary care is a logical environm ent for depression recognition in older

adults. However, much has been learned about the diagnosis and treatm ent o f

depression, a serious and com m only overlooked psychiatric illness often seen initially

by PCPs. In preparation for planning o f this project, a com prehensive evaluation o f

the literature for current depression screening recom m endations and practice

guidelines, as well as problems with providers’ lack o f understanding o f and

adherence to such guidelines, was performed, utilizing the databases such as

Cochrane, PubM ed o f the National Library o f M edicine, and the Cum ulative Index to

N ursing and Allied Health Literature (CINAHL).

The search term “depression screening and prim ary care” yielded three

results, two o f which were systematic reviews. One o f the system atic review s looked

at determ ining the clinical and cost effectiveness o f screening instrum ents in

24
improving the recognition, management, and outcom e o f depression screening cases.

Findings o f the study suggested that the screening instrum ents had borderline but

effective impact on the overall recognition o f depression by clinicians (Gilbody,

House & Sheldon, 2005). Therefore, the evidence supported increased identification

o f patient risk o f depression with screening in prim ary care.

Guidelines and Recommendations

The use o f guidelines and recom m endations aids PCPs and other providers in

providing the most up-to-date care to their patients (Ani et al., 2008). Further

database searches were conducted, searching for the guidelines and recom m endations

for depression screening in prim ary care practice and in diabetic patients. M edlines

and CINAHL were searched, using the search term “depression screening guidelines

and recom m endation.” The search produced extensive evidence on these subjects.

Depression Screening Tools

The systematic literature review, using the same aforem entioned databases,

showed that there are different validated tools or instrum ents available that have been

shown effective in screening for depression in a clinical setting. Some o f the

instrum ents or tools included the Beck D epression Inventory (BDI), the G eriatric

Depression Scale (GDS), the CES-D, the H am ilton D epression Scale (H DS), PHQ-9,

and PHQ-2.

Instituting routine annual screening for patients with diabetes using these tools

can help identify diabetic patients at risk for depression. Hence, this project focused

on identifying barriers to guideline adoption and initiating appropriate intervention.

Interventions such as installing a depression screening tool in the patient EH R system

25
can serve as a rem inder for the provider to screen for depression, consequently

improving PCP adherence to depression screening guidelines and, consequently,

improving overall patient outcomes.

Barriers to Depression Screening Guidelines

Further database searches were conducted to search for studies on barriers to

screening and types o f interventions to im prove screening by health care providers

and referral for treatm ent or supportive resources. M edline, CINAHL, and PubM ed

were searched, using the search term s “barriers to screening for depression in diabetic

patients” and “im proving screening for depression by PCPs.” The searches yielded

extensive evidence on these subjects and several relevant studies were utilized.

Burman, M cCabe, and Pepper (2005) conducted a study to investigate barriers

to screening and treatm ent related to depression and anxiety and the diagnostic and

treatm ent practices o f prim ary care advanced practice nurses (APNs) in the state o f

Wyoming. The researchers mailed questionnaires to evaluate providers’ perceptions

about treatm ent barriers, screening and treatm ent practice, and attitudes tow ard

depression and anxiety. The survey results showed that the APNs felt positive and

confident about treating patients with depression and anxiety; however, they agreed

that rates o f screening for m ental disorders were relatively low at their practices. They

identified several barriers to screening and treatm ent o f depression in their practices.

The m ost com mon barriers (identified by 44% o f the A PNs) included (a) lim ited time

in encounters; (b) lack o f useful screening instrum ents; (c) cum bersom e and

unfam iliar psychiatric diagnostic systems; (d) patient resistance to seeking help,

diagnosis, m edication and non-m edication treatments; (e) patient concerns about the

26
stigm a o f m ental illness; and (f) inadequate mental health providers for referral

(Burman et al., 2005).

It was clear from this study finding that m ost APNs in prim ary care are well

trained to identify, evaluate, and treat patients with depression. However, there are

some organizational barriers that could limit APNs from utilizing their skills. The

m ost com m on barrier identified from this study was a lack o f standardized

approaches to screening, assessing, referring, and treating these patients in prim ary

care settings.

Parchm an et al. (2006) conducted an observation study to identify the most

com mon barriers to depression screening in prim ary care. The researchers concluded

that com peting medical dem ands required PCPs to prioritize services and defer some

services to subsequent visits. They identified visit duration, reim bursem ent structures,

lack o f incentives, and the availability o f affordable mental health services as barriers

to depression screening in prim ary care practice. The m ost com m on m odifiable

barriers identified by both studies included tim e-related barriers and visit duration.

As regards the tim e-related barrier, studies have been conducted to examine

different technologies for screening, such as a com puter-based approach or patient

sign-in form to allow for faster screening. Farrell et al. (2009) perform ed initial

depression screening in a rural, prim ary care setting using the PHQ-9 questionnaire.

The researchers incorporated the questionnaires in com puter systems to facilitate

depression screening. They found that the participants and medical providers were

accepting o f the electronic screening program , as long as it w orked into the flow o f

the clinic visit. A dditionally, the researchers reported that the average time required

27
for a patient to com plete the electronic depression screening was less than three

minutes. This evidence supported incorporation o f the screening questionnaire or tool

in patient EHRs as an aid to overcome any tim e-related barrier.

The aforem entioned literature review focused on the many barriers to

im plem enting a depression screening program. However, all studies recom mended

specific designs for the im plem entation o f a depression screening program. The

critical review o f evidences surrounding problem s related to current depression

screening practices largely showed that, while clinical practice guidelines and

recom m endations for depression screening were well written, revised, and supported

by research, they w ere often not being used routinely by PCPs. Varied adherence to

published guidelines was likely due to limited awareness, familiarity, agreement, self-

efficacy or outcome expectancy, and time constraints.

D espite the prevailing consensus concerning the value o f depression

screening, the screening recom m endation had not been followed by PCPs in this

prim ary care clinic. M oreover, studies suggested that the use o f com puterized clinical

decision support systems has a positive effect on aligning practices with the evidence-

based guidelines.

Hence, the project sought to develop and im plem ent a new clinical protocol

and to incorporate depression-screening tools in patient EHRs to im prove depression

screening rates. Studies docum enting significance o f the problem, coupled with

several guidelines to screen depression in prim ary care settings, provided useful

inform ation as to the necessity to establish depression screening protocol in the

prim ary care setting. The evidence clearly supported that PCPs were responsible for

28
screening, diagnosing, and treating the m ajority o f people with type 2 diabetes

m ellitus and co-morbid depression in the community. As a result o f the im pact o f co-

morbid depression on patient self-care and treatm ent outcomes, screening for

depression in the context o f a structured approach to case m anagem ent and patient

follow-up is recom mended in people with diabetes and cardiovascular disease.

This literature review sum m arized the need for improved recognition and

treatm ent o f depression in diabetes and integrating screening tools and therapies into

a busy family or general medical practice setting. Hepner et al. (2007) perform ed an

observational analysis o f data collected from 1996-1998 in three random ized clinical

trials to exam ine the effect o f adherence to practice guidelines on depression. Their

results showed that greater adherence to practice guidelines significantly predicted

few er depressive symptom s on continuous measures(P=0.001 for 12 m onths, P=

0.01 for 18months, and P= 0.001 for 24 months) and dichotom ous measures (P=

0.05 for 18 and 24 m onths). Guideline-concordant depressions care was shown to be

linked to im proved outcomes in prim ary care patients with depression.

Additionally, in regard to barriers related to lim ited visit time, this project

integrated a com puter-based depression screening approach to allow for faster

screening. Fann et al. (2009) utilized electronic registration to screen patients for

depression; the m ethod was found to be efficient and allowed for faster screening.

The average reported time to complete the com puter-based PHQ-9 was found to be

two m inutes (Fann et al., 2009). The evidence supported im plem entation o f

com puter-based screening tools as an effective intervention to rem ind and assist

providers to screen for depression in a tim ely manner.

29
Relevant Theory and Concepts

The healthcare system in the U.S. is com plex and dynam ic; therefore, change

is inevitable and constant. A theoretical framework can help nurse leaders to facilitate

change within an organization. These theories can help to identify standards o f care,

direct patient care, evaluate patient care, predict outcom es o f care, and assist nurses in

understanding the care provided. Therefore, the theoretical fram eworks and models

guide the nursing through the research to the clinical practice. A ppropriate selection

and utilization o f a theoretical framework provides the foundation for designing and

planning effective strategies for behavior change interventions and ensures that the

im plem entation o f evidence-based findings into practice has a better probability o f

success (Sales, Smith, Curran & Kochevar, 2006).

This project utilized R oger’s “Diffusion o f Innovations” as a theoretical

framework to guide the change process, im plem entation, and evaluation o f the project

(Appendix A). According to Rogers (2003), diffusion is the process in w hich an

innovation is com m unicated through certain channels over time am ong the m em bers

o f a social system. Innovation refers to an idea, practice, or object that is perceived as

new by an individual or other unit o f adoption. “N ew ness” in an innovation does not

just involve new knowledge, but m ay also be expressed in terms o f persuasion or a

decision to adopt (Rogers, 2003). There is evidence to support screening for

depression in diabetic patients using validated screening tools in a prim ary care

setting; therefore, the importance o f screening for depression is not a new knowledge.

However, the attitudes toward decisions to adopt screening protocol into practice on a

consistent basis define it as an innovation. The im plem entation o f the depression-

30
screening protocol as a m eans to identify the patients at risk for depression is a new

idea or innovation for the prim ary care setting.

R oger’s “Diffusion o f Innovation” involves five stages: knowledge,

persuasion, decision, im plem entation, and confirm ation (Appendix A) (Rogers,

2003). Knowledge involves awareness o f whowill be im pacted by the practice

change, w hatdoes the practice change project entail, whenwill it occur, wherewill it
take place, and howwill it take place.

The persuasion stage occurs w hen the individual develops a positive or

negative attitude about the innovation based on the inform ation received (Rogers,

2003). The decision stage occurs w hen the individual w ho participates in the change

process chooses to adopt or reject the change. The im plem entation stage occurs when

the innovation is im plem ented into practice. The final confirm ation stage occurs when

the individual evaluates the outcomes and chooses to adopt or reject the innovation

(Rogers, 2003).

This theory guided the im plem entation o f the project. Initially, a b rief staff

meeting was held to discuss project specifics with the project team, which included

the two M As, two PCPs, and the medical director. The providers agreed that a need

existed for the screening protocol and depression screening tools at their practice site.

Details o f the proposed project were presented to the team as to who, w hat, w hen, and

where the project would be implemented.

The initial staff meetings included the certified M As. D iscussion focused

prim arily on increasing their knowledge regarding the im portance o f screening for

depression in adult patients, depression screening tools/questionnaires, and proper

31
adm inistration and docum entation o f the tools. The project leader presented evidence

to support the need for this project. The team m em bers were then able to make

inform ed decisions to adopt or reject the proposed project, based on the clarity and

com pleteness o f the relevant inform ation and perceived usefulness o f the proposed

project. All questions and concerns w ere addressed clearly and concisely to remove

any confusion.

A fter the team made a decision to accept the proposed project, the depression

screening questionnaires PHQ-2 and PHQ-9 (Appendices C) were incorporated in the

patients’ EHRs, and the screening protocol was distributed to the providers. A b rief

training session was organized to instruct the MAs on proper adm inistration and

docum entation o f the screening questionnaires within the patient EHRs. The training

program was organized during a lunch break. The individual team m em bers evaluated

project im plem entation and accepted project adherence based on (a) individual

perception o f the benefit, (b) com patibility with the prim ary care clinic, and (c)

overall com plexity o f the project (Keele, 2011; Rogers, 2003).

A ccording to Rogers (2003), individuals and groups do not all adopt an

innovation at the sam e time. A doption by individuals and groups typically follows a

distribution pattern which Rogers described w ith five adopter categories: innovators,

early adopters, early majority, late m ajority, and laggards based on degree to which

they adopt new ideas (Rogers, 2003). It was im portant that the project leader

recognized that the assem bled team was com posed o f an array o f individuals who

w ould probably differ in their progression and patterns o f innovation adoption.

32
Process of Systematic Review

The relevant data and evidences were collected using electronic databases

such as CINAHL, Pub Med, Ovid, and Cochrane. The databases were searched using

the following search terms: depression, diabetes, depression screening, depression

and diabetes, depression screening tools/instrum ents, depression screening

recom m endation, and depression screening in prim ary care practice. The inclusion

criteria for articles included: published w ithin the last 10 years, English language, and

full text. Studies included were random ized control trials, systematic reviews, cross-

sectional studies, and expert opinions and recom mendations.

The Cochrane database was utilized to search for the relevant evidence. A

search o f the database, using the search term “type 2 depression and diabetes,”

yielded five articles, one o f which included system atic review on diabetes self­

m anagem ent intervention for adult with type 2 diabetes. N o random ized controlled

trial could be found on this subject.

The CIN A H L database was utilized to extract full-text, peer-review ed articles

on “type 2 diabetes and depression,” w hich resulted in 30 articles. O f the 30 articles,3

were system atic reviews published between 2005 and 2015. One o f the reviews

focused on effects o f depression on self-efficacy and adherence in patients with type

2 diabetes. A CIN AH L search using the term “depression screening in type 2 diabetic

patients” with search criteria “2010-2015,” “ full text,” and “peer-review ed” yielded

3,400 articles. The database search using the term “educating PCPs on depression

screening in diabetic patients” generated 548 articles from 2010-2015.

33
 Data on the incidence o f depression and diabetes were obtained from various

sources, including the N DSR 2014, Diabetes Report Card 2012, and the BRFSSS.

The search term “depression screening in prim ary care” yielded three results,

two o f which were systematic reviews. One o f the systematic reviews looked at

determ ining the clinical and cost effectiveness o f screening instruments in improving

the recognition, management, and outcome o f depression screening cases. Farrell et

al. (2009) suggested that the screening instrum ents had borderline but effective

im pact on overall recognition o f depression by clinicians. Therefore, the evidence

supported increased identification o f patients at risk o f depression with screening in

prim ary care.

Further database searches were conducted to search for quality evidence on

barriers to screening, types o f interventions to improve screening by health care

providers, and referral for treatm ent or supportive resources. M edline, CINAHL, and

PubM ed were searched using the search terms “barriers to screening for depression in

diabetic patients,” and “improving screening for depression by PCPs.” The searches

yielded extensive evidence on these subjects and several relevant studies were

utilized.

For the purpose o f this quality im provement project, information on

depression screening recom m endations and guidelines for diabetic patients were also

obtained directly from the various national level, evidence-based sources and

databases. The sources included National Guidelines Clearinghouse (NGC), the

USPSTF, and the ADA.

34
 CHAPTER 3

W ORK PLAN

Project Schedule

The com plete timeline for the implementation and analysis o f the proposed

project was 30 days. During that period, the project leader coordinated and com pleted

the work needed for this project, including the following:

1. scheduled the initial m eeting with the providers and M As to discuss

the need for this quality im provement project;

2. developed a depression screening protocol (Appendix B) for the clinic

based on depression screening recom m endation and guidelines;

3. presented a brief training program for the certified M As on proper

adm inistration and docum entation o f PHQ-2 and PHQ-9 questionnaires (Appendix C)

within the patient EHRs;

4. developed a depression screening training attendance log; and

5. launched live depression screening for adult patients at the

intervention site.

After 30 days o f project im plem entation, data was collected on:

1. total adult patients screened for depression;

2. total num ber o f adult diabetic patients screened positive using PHQ-2

and PHQ-9 questionnaires; and

3. total num ber o f patients who received medical treatm ent and referrals.

Additional data, including patient ethnicity and age o f adult patients screened positive

using either questionnaire, were collected.

35
 The post-project im plem entation survey (Appendix E) was distributed to the

MAs to assess their com fort level when adm inistering the questionnaires and their

perceptions on the importance o f the screening process. A fter collaboration with the

NMSU biostatistician, the data analysis was completed.

Milestones

The project milestones included essential key deliverables to be com pleted

during the project’s course to ensure progress to com pletion (M oran et al., 2014). The

m ilestones for this project included:

1. evaluation o f depression screening recom m endations and guidelines;

2. selection o f evidence-based depression screening tools or

questionnaires;

3. assessm ent o f the clinic’s current protocol and policy;

4. developm ent o f a depression screening protocol (Appendix B);

5. organization o f a training program for the M As on proper

adm inistration and docum entation o f the selected depression screening

questionnaires;

6. doctoral com mittee approval;

7. IRB approval; and

8. outcomes data analysis.

After the m ilestones were met, the data w ere interpreted, the im pact and significance

o f the project outcome on the prim ary care clinic was assessed, and the contribution

to healthcare knowledge was evaluated.

36
 Implementation Methods

A ccording to M oran et al. (2014), the im plem entation methods define the

procedures for im plem enting the proposed project. At the beginning, a b rief

presentation on the goal and objectives o f the proposed project was presented to the

project team. This presentation included (a) evidence-based inform ation to support

com orbidity o f depression in diabetic patients; (b) im portance o f screening for

depression in prim ary care setting; and (c) supportive inform ation on depression

screening tools, including their validity and reliability. Furtherm ore, the potential

issues and barriers to the screening procedures were identified during the meeting.

A ccording to M oran et al., identification o f issues that im pact project im plem entation

should also be part o f the m onitoring process.

The depression screening protocol (A ppendix B) was created to guide the

PCPs and MAs through the screening process. The protocol outlined the criteria for

screening adult patients for depression using the PHQ-2 and PHQ- 9 questionnaires

(Appendix C).

As m entioned in chapter 2, R ogers’ “ Diffusion o f Innovations T heory”

provided a fram ework for identifying or addressing problem s that arose (cited in

Keele, 2011) (Appendix A). The first stage involved clear com m unication about

problem specifics to increase awareness and know ledge o f the problem . This was

achieved during the initial staff m eeting and presentation. The second stage identified

potential problem solutions and persuaded the team m em bers to gain buy-in for

potential resolutions. Intense research began to collect evidence on the potential

solution; to facilitate project im plem entation; this was presented to the team during

37
the staff meeting. The third stage involved the team decision to adopt or reject the

alternative proposed resolution. The final stage involved application o f the solution to

the project. This last stage included confirm ation that the solution was or was not an

effective solution. This evaluation was based on data generated from EHRs after

project im plem entation.

Measures

The m easures used to assess usefulness o f the depression screening protocol

(Appendix B) and screening tools included a post-project im plem entation survey

(A ppendix E) as discussed in chapter 1 (see Project Overview, Deliverables). The

post-project im plem entation survey assessed participant know ledge and com fort level

in using depression screening tools in the EHR. This survey also helped the project

leader to assess project sustainability by assessing the participants’ w illingness to

continue with the screening process in the future. Furtherm ore, the survey results

assisted the assessm ent for the need for further education and protocol revision.

Data Sources

The data sources included: (a) the certified MAs who adm inistered depression

screening questionnaires; (b) the adult patients w ho agreed to participate in the study;

(c) the PCPs w ho initiated m edical treatm ent and initiated appropriate referral to the

m ental health counseling; and (d) the patient EHRs (eClinicalW orks, 2015).

Additionally, process measures were collected using the survey m ethod to assess

know ledge and com fort levels o f the MAs when adm inistrating the questionnaires.

The survey took no longer than two m inutes to complete.

38
 Methods of Data Collection

The patient EHRs were used to track or generate data on:

1. utilization o f the depression screening questionnaires (PHQ-2 and

PHQ-9) (Appendices C);

2. num ber o f adult type 2 diabetic patients screened using the tools and

their scores;

3. types o f treatm ent plans initiated by the providers; and

4. num ber o f referral made by them.

The EHRs were also used to identify the patients’ demographic

characteristics. A b rief w ritten survey was distributed to the MAs after 30 days o f

project im plem entation. The survey exam ined the M A s’ com fort level when

adm inistering depression screening questionnaires and their perceptions o f how these

tools im proved quality o f care. Each survey response was m anually entered the data

into a secured passw ord-protected com puter system. Statistical Package for the Social

Sciences (SPSS) statistical software was used to analyze the data.

Data Analysis

The next step was to analyze the quantitative data using SPSS software. The

prim ary outcom es o f this project were the total num ber o f adult patients and diabetic

patients screened using PHQ-2 and PHQ-9 (Appendix C). Descriptive statistics,

including proportions and confidence intervals, were used to analyze the prim ary

outcomes. The same statistical methods were used to analyze dem ographic

characteristics and provider treatm ent plans for the patients with PHQ-9 positive

result. Furtherm ore independent samples /-tests and chi-square tests were used to

39
analyze (a) differences in various dem ographic characteristics between PHQ-2

“screened” and “not screened” patients; (b) severity o f depression by various

dem ographic variables and diabetes status; and (c) provider’s treatment plan to

m anage depression.

Survey m ethod was used to collect feedback from the MAs on the “ease o f

use” o f the depression screening tools and also on the M A s’ perceptions o f clinical

usefulness o f the screening questionnaires. The survey questionnaires contained five

statements; the M A s’ levels o f agreement with those statements were recorded in the

Likert scale {stronglyagree, agree, stronglydisagreeanddisagree). The following

statements were included in the survey:

1. “The depression screening protocol helped me to screen adult patients

for depression.”

2. “PHQ-2 and PHQ-9 questionnaires were easy to follow.”

3. “PHQ-2 and PHQ-9 questionnaires took less than five m inutes to

adm inister.”

4. “I am now com fortable in adm inistering the questionnaires.”

5. “I am m ore likely to use depression screening tools in care o f m y next

adult patients.”

It was anticipated that the com fort level o f the MAs in adm inistering the screening

tools w ould increase overtime. As a result, the clinical outcomes o f the patients with

chronic m edical conditions such as depression would with time.

40
 C H APTER 4

RESULTS AND INTERPRETATION

Process measures help determine w hether a proposal is im plem ented

according to plan (M oran et al., 2014). The post-im plem entation survey was

distributed to the MAs who administered depression screening questionnaires during

initial patient encounters. Both MAs participating in this project reported that the

depression questionnaires were easy to adm inister and took less than five m inutes to

complete. They also reported that their com fort level when adm inistering the

screening tools increased overtime. These positive results assured project

sustainability.

The time to create the depression screening protocol (Appendix B ) was

recorded. The protocol was based on preexisting depression screening guidelines and

recom mendations; hence, protocol creation took less than an hour. The protocol was

m odified based on feedback from the com mittee members. The team found the

protocol or algorithm easy to follow, and it did not require any modification.

The overall survey results showed that the questionnaires w ere easy to locate,

administer, and took less than five m inutes to complete. Therefore, the findings

supported that incorporation o f a b rief electronic version o f questionnaires could

solve the time related barrier to the depression screening in the busy prim ary care

clinic.

Outcomes Evaluation

Outcom es measures provided inform ation on (a) current use o f depression

screening tools;(b) likeliness to screen for depression in type 2 diabetic patients; (c)

41
likeliness to initiate and refer identified patients for treatment; and (d) barriers to

change.

Two PCPs and the two M As encountered a total o f 378 patients during the

project period. The patients w ere com prised o f 148 (39.2% ) m ales and 230 (60.8% )

females; 276 (73%) Hispanics (H); 95 (25.1% ) Caucasians (C); and 7 (1.9% ) Asians

(A). The average age o f the patients was 44 years (S D -1 8.5). O f the patients, 18.8%

(71 patients) were identified with type 2 diabetes (see A ppendix F) for a breakdow n

o f dem ographic characteristics).

O f the total adult patients who visited the clinic, 82% (±4% ) w ere screened for

depression using the PHQ-2 questionnaire (A ppendix C); and approxim ately 85% o f

adult diabetic patients were screened for depression using the PHQ-2 questionnaire.

This screening rate was significantly higher than the 25% that was targeted for this

project (p<0.001). PHQ-2 screening was not perform ed on 15.8% o f C aucasian and

18.5% o f Hispanic patients (see A ppendix G) for characteristics o f patients w ho were

screened using PHQ-2). O f those 312 PHQ-2 screened patients, a total o f 78 (25.6% )

were found to be positive for depression. PHQ-2 was positive (+) for 46 (23.4% )

female (F) and 32 (27.8% ) m ale (M) patients; 29 (36.2% ) Caucasian and 49 (21.8% )

Hispanic patients; and 32 (52.5% ) diabetic and 46 (18.3% ) non-diabetic patients. On

average, PHQ-2(+) patients w ere som ew hat older (M ean=46.51, SD=16.03 years)

than PHQ-2(-) patients (M ean=42.6, SD= 18.09 years).

All the patients with positive PHQ-2 results were further evaluated with PHQ-

9 questionnaires (see Appendix H). This second level o f evaluation found that 44.7%

o f PHQ-2(+) patients were severely depressed, 31.6% were m oderately depressed,

42
and 21.1% were m ildly depressed. H igher proportion o f males with depression was

found to have m oderate to severe levels o f depression com pared to the females (M:

80.6% vs. F: 73.3%). Furtherm ore, 41% o f the PHQ-2(+) patients were also type 2

diabetic, com pared to only 12% o f PHQ-2(-) patients.

Providers initiated m edication and/or referred the depressed patients to a

specialist, depending on the severity o f their condition. N either medication nor

referral was initiated for patients with m inim al and m ild levels o f depression, whereas

m edication was initiated at the clinic for all patients with severe depression. These

patients were also referred to a specialist. In contrast, providers w ere m ore subjective

and individualized in the treatm ent o f patients with moderate levels o f depression.

Providers initiated m edication treatment at the clinic for 75% o f these patients; 12.5%

o f the patients did not receive the m edication treatm ent; and the rem aining 12.5% o f

the patients refused the treatment. Overall, a higher proportion o f female patients

refused to initiate the m edication (F = 9.1% vs. M = 4.0%). The rate o f refusal was

approxim ately the same for Caucasian and Hispanic patients (12.5%). N onetheless,

rate o f m edication initiation differed by patient ethnicity. M edication was initiated at

a higher rate am ong Caucasian patients with a moderate level o f depression than

Hispanic patients (C = 87.5% vs. H = 6 8 .8 %). M oreover, 6.2% and 30.8% o f

Hispanic patients with moderate and M SD levels o f depression, respectively, also

refused referral to a specialist. In contrast, none o f the Caucasian patients w ith a

moderate level o f depression refused to be referred to a specialist. The m ajority (75%)

o f patients -- both Caucasian and Hispanic — with a moderate level o f depression,

however, were not referred to a specialist. Decision to refer a patient with a moderate

43
level o f depression depended on other conditions, such as diabetic status and the

actual score on PHQ-9. It is also notew orthy that a higher proportion o f depressed

diabetic patients had moderate to severe levels o f depression (T2DM = 90% vs. non-

T2DM = 6 6 %).

44
 C H APTER 5

LEADERSHIP AND M ANAGEM ENT

Organizational Culture

Ledlow and Coppola (2011) defined organizational culture as the norms,

values, and basic assumptions o f an organization. The project site for this study was

owned and m anaged by a sole proprietor who believed in providing quality

com prehensive care to the individuals in the community. Patient satisfaction was

identified as a m ain goal and value o f the organization. The clinic was free from any

external influences that could impact its practice. The clinic also had a consistent

organizational culture and an open com m unication channel between the medical

director (owner) and the staff members. Such m utual alignm ent within the

organization prom otes greater trust and integrity among the staffs, heightens staff

morale, and im proves jo b satisfaction (Ledlow & Coppola, 2011). These supportive

organizational cultures created a favorable environm ent for this quality im provem ent

project. The stakeholders took part in the proposed project with a com m on goal o f

im proving their patients’ outcomes.

Change Strategy

R oger’s Diffusion o f Innovation theory was used as a guide to change and to

im plem ent this project. Researchers Ledlow and Coppola (2011) believed that, in

order to m ove an organization towards change, the health leader should model

behavior, com m unicate expectations, train team members, be consistent, and m onitor

and revise the process to improve efficiency. The project leader m odeled behavior

and consistently com m unicated the expectations o f the proposed project with the

45
team. Role modeling, teaching, and coaching should be continuous throughout the

course o f the project (Ledlow & Coppola, 2011). The team members w ere educated

and well inform ed about the project process before its im plem entation to ensure

adherence. The MAs w ere provided opportunities for ongoing com m unication

through emails and phone calls.

In addition to consistent com munication and teaching, ongoing m onitoring

and evaluation o f the project process is crucial in ensuring its successful im plantation.

Unique to this project, the project leader conducted ongoing evaluation m easurem ents

o f the project through periodic review o f patient EHRs and by helping M As during

the screening process. The project leader was available at the project site every w eek

to m onitor the progress o f the project and to address any issues or incidents related to

the project. Ongoing com munication with the PCPs provided a means for early and

prom pt identification o f issues related to the project.

The goal o f proposed project was aligned with the m ission o f the organization

or the project site. It was clear that the recognizing depression am ong patients with

chronic m edical conditions such as diabetes could improve overall patients’ outcome,

which was the goal o f the organization.

Leadership Style

Transformational leadership principles were applied throughout the project.

According to Zaccagnini & W hite (2011), transformational leadership develops

transformational cultures in which follower maturity is fostered and developed.

Transformational leadership is m ost often used as a guide to determ ine the am ount o f

direction, support, and delegation needed from the leader. The principles o f

46
transformational leadership guided this project. This leadership style helped builds

com m itm ent to objectives, while empowering followers to accom plish those

objectives. This is accomplished through im parting to others a sense o f their value

and potential (Zaccagnini & W hite, 2011). The project leader learned

transformational leadership skills and principles through hands-on practice and

experience, advanced education in evidence-based inquiry, and actual research

utilization. The project leader was also com m itted to im proving the quality o f

healthcare by providing the highest possible level o f quality evidence-based practice

care.

Inter-professional Collaboration

The importance o f inter-professional team w ork in im proving health care is

well recognized and docum ented by several professional organizations and literatures.

In 2003, the Institute o f M edicine (IOM ) called for changes to im prove health care

through inter-professional teamwork. Zaccagini and W hite stressed effective

com munication as crucial to ensuring effective inter-professional collaboration

(2011). These researchers identified several measures which im prove com m unication,

including, in part:

1. speaking concisely and clearly;

2. being aware o f gestures such as posture and facial expression;

3. avoiding defensiveness; and

4. using questions to clarify.

The project leader engaged in ongoing open com m unication with the team throughout

the project. The MAs were encouraged to send em ails and call the project leader to

47
clarify any issues related to the project. The project leader provided tim ely responses

to the correspondents to increase team com m itm ent.

In addition to the project team, the project leader collaborated with

com m unity behavior health specialists to stream line patient care. Referral form s were

incorporated in patient EHRs to initiate tim ely referrals and care to the patients

identified with depression.

Conflict Management

Conflict is inevitable in all forms o f organization. M ost people view conflicts

as negative episodes; however, there are positive aspects to conflict (Ledlow &

Coppola, 2011). A n effective leader accepts conflict as a natural growth process that

can positively influence the organizational culture. C onflict can be a distinct asset to

the small organization if it is handled properly (Ledlow & Coppola, 2011). In

particular, it can help the organization to learn from its mistakes and identify areas o f

needed im provement.

A transformational leader focuses on deep-rooted causes rather than

superficial effects when assessing conflicts (Ledlow & Coppola, 2011). The project

leader encountered conflict during the project im plem entation phase. The initial goal

was to involve all three PCPs at the clinic; how ever, one provider consistently

resisted to change his practice. O ther project m em bers viewed his conflicting view as

a threat to the project’s ultim ate success. U pon further investigation, the project

leader found that the particular provider sees m ajority o f patients for urgent care.

Ultimately, the team decided the study should include only those two providers who

saw the majority o f the prim ary care patients. To avoid other potential conflicts, the

48
project leader also perform ed a thorough assessm ent to verify that the clinic’s m ission

was aligned with the goal o f this proposed project.

Ethical Consideration

To protect the human subjects who were included in this project, the project

proposal was subm itted to the IRB at NM SU after DNP com m ittee approval. The

NM SU IRB approved the project proposal on 22 Septem ber 2015.

The subjects for this proposed project included adult patients 18-100 years

old. Subjects also included two PCPs and the MAs (who were not considered

vulnerable subjects). All ethnicities and genders w ere included.

W ritten consent forms (A ppendix D) were w ritten for the patients, and the

forms were presented to the com m ittee members for their suggestions and subsequent

approval. All steps o f the study w ere clearly explained within the consent forms.

Certified M As were trained to get signed consent forms from the patients before

adm inistrating the depression screening questionnaires (Appendix C, PHQ-2 & PHQ-

9). The M As inform ed the patients that participation in this study was voluntary and

that they had the right to refuse to participate or to leave the study at any time. The

patients were allow ed to refuse to participate in the study without any penalty or loss

o f benefits. They were inform ed that refusal to participate in the study w ould not

harm their relationship with the PCPs at the clinic. All adults who registered to be

seen at the clinic were approached and asked if they w ished to participate in the

study. Those who agreed were requested to sign the consent form before com pleting

the PHQs.

49
 Data used for this project did not contain any identifiable patient information.

All the security m easures offered by the EH R system was applied to the information

collected for this study. To com ply with the Health Insurance Portability and

A ccountability Act (HIPPA), only m edical personnel involved directly with patient

care w ere allowed to access the screening results. The de-identified data generated

from the EHR was stored in the SPSS form at in a password-protected universal serial

bus (USB) device.

Some o f the possible risks o f this project were identified, and helpful

interventions to alleviate those risks were identified by the project leader and the

PCPs. It was recognized that the questions in the PHQ-2 and PHQ-9 m ight cause

individuals to feel anxious and em barrassed, especially those questions regarding

depression symptoms. It was also acknow ledged that there m ight be other

unpredictable em otional and psychological risks. The patients who developed

em otional distress during the screening process or in com pleting the PHQ

questionnaires had access to PCPs. The clinic was well equipped with these providers

who were trained to provide mental health counseling and treatment. If participants

were in need o f a higher level o f treatm ent, they would be prom ptly referred to mental

health specialists in the community.

During this project im plem entation, one adult patient with diabetes was

identified with suicidal ideation. He/she was im m ediately admitted to the M esilla

V alley Hospital for closer observation, evaluation, and treatment. W ithout this

project, the patient w ould have gone unrecognized as an at-risk suicide, and the

situation could have led to negative consequences. Therefore, this project was found

50
to be effective in identifying adults who were at risk for depression and health risk

behavior. A recognition system for depression in prim ary care is particularly needed,

as the prevalence o f depression in adult prim ary care patients has been found to range

from 7-36% (Conwell, 2011). Additionally, depressed patients with chronic

conditions such as diabetes are commonly noncom pliant to standard treatm ent plans

(Conwell, 2011).

51
 CHAPTER 6

DISCUSSION

Assessment of Project Impact and Sustainability

Screening for depression followed by effective treatm ent in prim ary care

setting was found to be an im portant part in depression m anagem ent in adult patients

(Fann et al., 2009). Availability and know ledge o f validated depression screening

tools and w illingness on the part o f adults to be screened create a potent com posite

for improved depression care in prim ary care practice. The findings from this project

suggested that projects such as this have the potential for positively im pacting patient

outcomes.

To date, research studies that have investigated the im pact o f depression

screening in patients with diabetes are surprisingly limited; however, enough

evidence exists to suggest that depression is the m ost com m on comorbidity. The

PCPs in this study perceived that identification and m anagem ent o f depression in

these patients m ight improve their clinical outcomes. Despite the im portance o f

depression screening and guidelines, the providers were not screening their adult

patients for depression. One o f the most com m on barriers identified by the clin ic’s

PCPs was a lack o f time, and they recognized the need for a b rief but efficient

screening tool. The barriers to depression screening in busy prim ary care clinics could

be eased by incorporating a b rief screening questionnaire such as the PHQ-2 and

PHQ-9 in patient EHRs.

Based on the project findings, the project leader concluded that incorporation

o f a b rief and validated depression screening tool in patient EH Rs significantly

52
im proved depression screening rate at the project site. The providers and the M As

became increasingly com fortable with the screening questionnaires. Because the

questionnaires were easy to adm inister and required a minimal am ount o f time, the

medical team was w illing to continue screening ongoing patients. Hence, the

sustainability was proven favorable. The screening rate will continue to be evaluated

at three-, six-, and twelve-m onth intervals.

The main lim itation for this project was timing. A sense o f urgency existed

from the start. O ther limitations included the small num ber o f PCPs and M As at the

clinic, and the geographical location - the southw est region o f the U.S. W hile this

project showed im provem ent in depression screening practice, it did not exam ine

outcomes o f care for diabetic patients or other patients with depression.

Despite these limitations, this project has significant im plications for

improving quality o f depression care in prim ary care settings. The project findings

suggest that EHR-based screening tools can be useful in im proving providers’

practice with respect to the key recom m endations o f national guidelines.

Contributing Factors to Success (or Lack of Success)

There were several factors that contributed to the success o f this project. This

project focused on improving the outcomes for adult patients with diabetes in the

prim ary care setting. The project leader com pleted com prehensive planning for

success o f the project from the start. All stakeholders were invited to be on board

during the planning process and were well inform ed about the goals and objectives.

Good planning helped to keep the project team focused and on track, and kept all

stakeholders aware o f project progress. Open com m unication am ong project team

53
members contributed greatly to the project’s success. The project leader was available

at the clinic to clarify any questions or confusion during im plem entation o f the

intervention.

In addition to the project leader’s contribution, other factors contributed to the

success o f this project. The project site was an independently owned private

organization. Decisions were made prom ptly w ithout a need for lengthy approvals

from m ultiple organizational levels. The clin ic’s m edical director, w ho was also an

independent owner, was receptive to the change from the start. The project team

members w ere well trained and dedicated to offering quality care to their patients.

They w ere also proficient in using EHRs in their routine practice. A ccording to

M oran et al. (2014), w ithout the right team in place, any strategy and plan has the

potential o f com pletely falling apart. Hence, all involved must be com m itted to the

group, share sim ilar visions for the projects, and strive for overall success. Other

contributing factors included the overall cost to im plem ent the project; happily, this

project was com pleted w ith alm ost no added cost to the organization.

Information Added to the Body of Knowledge

This project added to the grow ing body o f literature that shows that

im plem enting a b rief validated depression screening tool is feasible and effective in a

busy prim ary care practice. The scores obtained from b rief depression screening tools

such as PHQ-2 and PHQ-9 can result in a diagnosis o f depression disorder during a

routine prim ary care visits. This m ay ensure prom pt identification and tim ely

initiation o f treatm ent for potentially vulnerable adults. M edication treatm ent for

depression m ay be prom ptly offered by w ell-trained PCPs; alternately, the patient

54
may be referred for behavior counseling and/or for medication treatm ent by a mental

health specialist. In addition, other researchers may benefit from the findings o f this

study. The data gathered for this project showed that there is a need to screen every

adult who is seen in prim ary care practice for depression, particularly for those with

chronic m edical conditions such as diabetes.

55
 CHAPTER 7

CONCLUSION

Impact on Health Outcomes

Beyond Project Implementation Site

A ccording to the CDC, diabetes and depression are m ajor public health

problem s (CDC, 2014 (a)). The AHRQ recognized diabetes and depression among

the top 10 m ost expensive health conditions (as cited in CDC, 2014). Individuals with

diabetes and co-m orbid m ajor depression w ere found to have higher odds o f

functional disability and medical com plications than individuals with either diabetes

or m ajor depression alone (Glied, H erzog & Frank, 2010). Screening adults for

depression is supported by international and national organizations such as the WHO,

the USPTF, and the Am erican A cadem y o f Family Physicians. These organizations

also recom m end screening for depression in prim ary care clinics with the capability

to treat depression (USPSTF, 2009). Furthermore, the ADA (2008) recom m ended

screening diabetic patients for psychosocial problem s such as depression and

diabetes-related distress as an ongoing part o f the medical m anagem ent o f diabetes.

PCPs are well positioned to identify the diabetic patients who are at risk o f such

com orbid conditions.

Despite the aforem entioned screening recom m endations and guidelines, the

individuals at risk for depression are not routinely screened for depression in many

prim ary care settings (A nderson et al., 2002). M any barriers to routine screening were

identified during the literature review for this project. Common barriers included lack

o f know ledge about depression screening guidelines, lack o f time, and lack o f clinical

56
incentives. The main focus o f this project was to eliminate a tim e-related barrier by

utilizing brief and validated electronic depression screening tools. This project’s goal

was to determ ine effectiveness o f a brief and validated depression screening protocol

to achieve a minimum 25% depression screening rate in adult patients w ith diabetes

at a prim ary care practice in southern New Mexico. These project findings supported

the im portance o f depression screening protocol (Appendix B) and validated the use

o f the PHQ questionnaires in primary care. Implementing these interventions into

patient EHRs enabled efficient screening for depression in adults with diabetes at this

clinic and could likewise benefit any other busy prim ary care practice.

Summary of Local, National, and International

Health Policy Im plications

Local and national policy called for patient-centered care in 2010 under the

A ffordable Care A ct (cited in CM M S, 2014). The results o f this project offer

prelim inary inform ation that the use o f depression screening tools by prim ary care

practices m ay help in early identification and treatm ent o f depression in adults at risk.

A fter prom pt identification o f the condition, PCPs can encourage their patients to take

part in their own healthcare. This aligns with the principle o f patient-centered care

where patients are collaborative partners in their own health care.

Healthcare reform acts such as the ACA also give nurses new opportunities to

deliver care and play integral roles in leading change (M oran et al., 2014). A PN s have

been identified by the National Council as im portant innovators who help shape

quality and safety o f the nation’s healthcare delivery system. N ursing research helps

build the scientific foundation for clinical practice, prevention, and im proved patient

57
outcomes (M oran et al., 2014). D evelopm ent and im plem entation o f this quality

im provem ent project provided a unique opportunity for this author/project leader. An

opportunity was seized to utilize evidence-based skills and know ledge to improve

safety and quality o f life o f patients who were at risk for depression. This project

dem onstrated the successful integration o f depression screening tools for screening

and m anagem ent o f depression in prim ary care settings. This project has also

transformed the current practice at a prim ary care clinic in southern N ew M exico. The

site is now consistently utilizing depression screening tools for adult patients during

their routine encounters.

58
A PPENDICES

59
 APPEND IX A

R O G E R S’ DIFFU SION OF IN NOVATION TH EO RY

60
 APPENDIX A

R O G ER S’ DIFFUSION OF INNOVATION THEORY

H igher a d o p tio n

H ig h er Level o f d iffu sio n .......................

Knowledge Decision im p le m e n ta tio n ] Confirmation

i > A doption
Need for
further
education
Diabetes and Present and
>Rejection “ ; -> L ater Adoption \
depression evidence training.
C ontinued Rej& tion
comorbidity. based
effectiveness
Importance o f o f systematic
screening for approaches to
depression in depression
diabetes. screening and
m anagement.
Knowledge
about the Emphasize on To implement Implementation o f Team m em bers are
screening tools. sim plicity and screening depression adm inistrating
briefness o f protocol and to screening protocol PHQ-2 and PHQ-9
the selected adm inister and PHQ-2 and in patients with
depression- screening tool in PHQ-9 in patients’ diabetes during their
screening tool diabetic patients. EHR. routine visits.
incorporated
in the EHR.

F igurel: R ogers’ Diffusion o f Innovation theory (2003)

61
 APPEND IX B

D EPRESSION SCREEN IN G PRO TOC OL

62
 A PPEND IX B

DEPRESSION SCREEN IN G PROTOCOL

If a patient> 18 years old, ask PHQ-2 in EHR.

Administer PHQ-2 by certified MAs.

PHQ - “No” (-) PHQ = “Yes” (+)

No action. Screen during Ask remaining 7 questions

routine follow up. of PHQ-9 by MA

___________ 4______
PHQ<10 PHQ9 >10

i__
Providers Providers
Discuss the score with the patient. Discuss the score. Assess
Assess suicidal ideation suicidal ideation.
Evaluate the previous treatment. Find if out on any current Rx?
Initiate the treatment if not on prior If not initiate treatment and
treatment. refer patients for counseling
Recommend follow up in two to three Recommend follow up in two
weeks. weeks.

Interpretation o f PHO-9 score

Total score Depression severity

1-4 None
5-9 M ild depression
10-14 M oderate depression
15-19 M oderately severe depression
20-27 Severe depression

Figure 2: D epression Screening Protocol

63
 A PPEND IX C

PATIEN T HEA LTH Q U ESTIO N N A IR E 9

64
 A PPEND IX C

PATIEN T HEALTH Q U E ST I0N N A IR E9

D C hange to K essler 10

G PH Q -9: Patient Health Q uestionnaire for D ep ression

Over the la st tw o w e e k s how often have you b een bothered by any of the following problem s?
For each question, se lec t the option that b e st d escrib es the am ount of time you felt ttiat way.
More than half Nearly
In la s t 2 weeks... Not at all Several days
the days ever* da
0 1 2 3

1. Little interest or p leasure in doing things O O O O

2. Feeling down, d e p r e sse d , or h o p e le ss 0 0 0 0

3. Trouble falling or staying a sle e p , or sle ep in g too
much
O 0 0 O

4. Feeling tired or having little energy 0 0 0 O

5. Poor appetite or overeating 0 0 0 0

6. Feeling bad about yourself - or that you are a failure
or have let yourself or your family down
0 0 0 O

7. Trouble concentrating on things, su ch a s reading the

new spap er or watching television
0 0 0 0
8. Moving or speaking s o slowly that other p eople could
have noticed.
0 0 0 0
Or the opposite - being s o fidgety or r e s tle s s that you
have b een moving around a lot m ore than usual.
9. Thoughts that you would be better off dead, or of
hurting yourself in s o m e way
0 0 0 0
0 PHQ-9 S c o r e [ I P revious S c o re s nfa nfa

Aaac-sea from th« PRIME-MO P a tie n t Screening S o * stisn n « i'«

1999. Pftzw Inc

PHQ'9 ; K1° I EggggmgRHJ

Figure 3: Patient H ealth Questionnaire

Spitzer, K roenke & W illiam s ( 1 9 9 9 )

65
 A PPEN D IX D

PATIEN T PA R TICIPA TIO N CO N SEN T FORM

66
 APPENDIX D

PATIENT PARTICIPATION CONSENT FORM

You are invited to participate in a research study conducted by Priya Bajracharya,

FNP-C, a principal investigator. This research study will screen all adult patients for
depression using the Patient Health Questionnaires PHQ-2 and PHQ-9 during their
clinic visit. The decision to join, or not to join, is entirely up to you. In this research
study, we are evaluating the effectiveness o f im plem entation o f depression screening
protocol and incorporation o f a depression screening questionnaire to increase
depression screening in adult patients.

W H A T IS IN V O L V E D IN T H E STU D Y ? If you decide to participate, you will be

asked to answer first two questions o f PHQ-9 questionnaire. D epending on your
response, you will then be asked to answ er the rem aining seven questions on the
questionnaire. The am ount o f time required for you to participate will be about two
minutes. You have right to stop participating in this study at anytime.

R IS K S : This study involves the following risks: Some individuals m ay feel

depressed, anxious, or em barrassed when answ ering questions about depression
symptoms. There m ay also be other risks that we cannot predict.

You will have access to a certified family nurse practitioner and a physician at the
prim ary care clinic if you feel overwhelm ed by any disclosure. The prim ary care
providers can assist you to process emotional problem s if they arise. The providers
are trained to provide medical treatment if needed. If you are in need o f higher
treatment or counseling, you will be referred to persons with a higher level o f
training.

W H A T A R E T H E B E N E F IT S T O T A K IN G P A R T IN T H E STU D Y ? It is
reasonable to expect the following benefits from this study: From the results o f the
screening tools, a diagnosis o f a depression disorder m ay result. Treatm ent for
depression may then be offered by your prim ary care provider, or you m ay be
referred for counseling and/or medication treatm ent by a mental health specialist.
However, we cannot guarantee that you will personally experience benefits from
participating in this study. Others may benefit in the future from the inform ation we
find in this study. The data gathered will be analyzed to determine if there is a need to
screen every adult for depression who is seen in prim ary care practice.

C O N F ID E N T IA L IT Y : All questionnaires will be em bedded in the electronic

medical record. All the security measures afforded by the system will also apply to all
the inform ation collected for this study. The principal investigator will collect all
statistical data needed; data will contain no patient identifiers. Only m edical
personnel involved directly with your care and the research investigator will have
access to the screening results. The N ew M exico State U niversity College o f N ursing

67
and the clinic will have access to the data after it is collected and sorted by the
principal investigator, Priya Bajracharya, FNP-C. The de-identified data generated
from the EM R for the purposes o f data analysis will be stored in a passw ord-protected
USB device.

WHAT ARE YOUR RIGHTS AS A RESEARCH PARTICIPANT? Participation

in this study is voluntary. You have the right to refuse to participate or to leave the
study at any time. Deciding not to participate or choosing to leave the study will not
result in any penalty or loss o f benefits to which you are entitled, and will not harm
your relationship with the prim ary care providers at the clinic.

WHO CAN YOU CONTACT FOR QUESTIONS OR PROBLEMS? You can

call Priya Bajracharya, FNP-C/DNP student, at X X X -X XX -XX X X or em ail at
X XX X XXXXXXXX if you have any questions about the study, any problem s,
unexpected psychological discomfort, or think that som ething unusual or unexpected
is happening. If you have any questions pertaining to your rights as a research subject,
you may contact the Office o f the Vice President for Research at (575) 646-7177 or at
ovpr@ nm su.edu.

SIGNATURE: I have read each section o f this paper (or it was read to me). I know
that being in this study is voluntary and I choose to be in this study. I know I can stop
being in this study without penalty. I f I wish, I can request a copy o f this consent
form. I can also receive inform ation regarding the study results if I wish.

Participant Name (printed) ____________________________________________________

Participant S ignature________________________________________D a te _____________

W itnessed b y ______________________________________________ D a te ______________

68
 APPEND IX E

POST-PROJECT IM PLEM ENTATION SU R V E Y

69
 APPENDIX: E

POST- PRO JECT IM PLEM ENTATION SURVEY

1. The depression screening protocol helped me to screen adult patients for

depression.
a) Agree
b) Strongly agree
c ) Disagree
d) Strongly disagree
e) D on’t know

2. PHQ-2 and PHQ-9 questionnaires were easy to follow.

a) Agree
b) Strongly agree
c) D isagree
d) Strongly disagree
e) D on’t know

3. PHQ-2 and PHQ-9 questionnaires took less than five minutes to

administer.
a) A gree
b) Strongly agree
c ) D isagree
d) Strongly disagree
e) D on’t know

4. I am now comfortable in administering the questionnaires.

a) Agree
b) Strongly agree
c) D isagree
d) Strongly disagree
e) D on’t know

5. I am now more likely to use depression screening tools in care of my next

adult patients?
a) A gree
b) Strongly agree
c ) Disagree
d) Strongly disagree
e) D on’t know

70
 APPEND IX F

PATIEN T CH ARA CTERISTICS

71
 APPENDIX F

TABLE 1: PATIENT CH ARACTERISTICS

PHQ2
Not
Screened P
screened
Overall N (%) 66(17.5% ) 312(82.5% ) < 0 .0 0 0 1
A ge(± S D ) 45.44±22.18 43.58±17.68 0.532
Gender 0.053
Female 33 (14.3%) 197 (85.7%)
Male 33(22.3% ) 115 (77.7% )
Race 0.420
Asian 0 ( 0 .0 %) 7(100.0% )
Caucasian 15(15.8%) 80 (84.2%)
Hispanic 51(18.5% ) 225 (81.5% )
T2DM 0.260
No 56(18.2% ) 251 (81.8% )
Yes 10(14.1% ) 61 (85.9%)

72
 APPEND IX G

TA BLE 2: CH A RA CTERISTICS OF PATIENTS

SCREEN ED USING PHQ-2

73
 A PPENDIX G

TABLE 2: CHARACTERISTICS OF PATIENTS SCREENED

USING PHQ-2

PHQ2
N egative Positive P
Overall N (%) 234 (75%) 78 (25%) < 0 .0 0 0 1
A ge(± S D ) 42.60±18.09 46.5 l=tl 6.03 0.073
Gender 0.227
Female 151 (76.6% ) 46 (23.4%)
Male 83 (72.2% ) 32 (27.8%)
Race 0.013
Asian 7 (100% ) 0
Caucasian 51 (63.8% ) 29 (36.2% )
Hispanic 176 (78.2% ) 49 (21.8% )
T2DM < 0 .0 0 0 1
No 205 (81.7% ) 46 (1 8 .3 % )
Yes 29 (47.5% ) 32 (52.5% )
Severity < 0 .0 0 0 1
M inim al to mild NA 18(23.7% )
M oderate to severe NA 58 (76.3% )

74
 APPEND IX H

TA BLE 3: CH ARA CTERISTICS O F PATIENTS

ID EN TIFIED AS D EPRESSED USIN G PHQ-9

75
 APPEND IX H

TA BLE 3: CH ARA CTERISTICS OF PATIENTS

IDENTIFIED AS D EPRESSED USING PHQ-9

Severity
M inim al to M oderate to
P
M ild severe
Overall N (%) 18(23.7% ) 58 (76.3%) < .0 0 0 1
Age (±SD) 40±13.52 47.93±16.31 0.047
G ender 0.325
Female 12 (26.7%) 33 (73.3%)
M ale 6 (1 9 .4 % ) 25 (80.6%)
Race 0.786
Caucasian 6 (2 1 .4 % ) 22 (78.6% )
Hispanic 12 (25.0% ) 36 (75.0%)
T2DM 0.027
No 15 (33.3% ) 30 (66.7% )
Yes 3 (9.7%) 28 (90.3% )
M edication < .0 0 0 1
Initiated
No 18 ( 1 0 0 %) 3 (5.2%)
Yes 0 51 (87.9%)
Refused NA 4 (6.9%)
Referral <0001

No 18(100% ) 29 (50.0%)
Yes 0 23 (39.7%)
Refused NA 6(10.3% )

76
 A PPEN D IX I

A PPRO V A L LETTER FOR IN STITU TIO N A L REV IEW BO ARD

77
 A PPEND IX I

A PPRO V A L LETTER FROM IN STITU TION A L REVIEW BOARD

Office of the Vice President for Research

NM
STATE ;
INSTITUTIONAL REVIEW BOARD (IRB)
Dr. Rolston St. Hilaire, Chair
MSC 3 RES
UNIVERSITY | New Mexico State University
i P.O. Box 3001
Las Cruces, NM 88003-8001
Phone: 575-646-7177 Fax: 575-646-2480
Email: ovpr@nmsu.edu
DATE S e p te m b e r 22, 2015

FROM T he Office of R e s e a rc h C om pliance

TO Priya B ajracharya
Departm ent Head Pam Schultz
Faculty Advisor Linda Summers
Faculty Advisor Conm DeBlieck

SU B JE C T D e c is io n M e m o f o r A p p lic a t io n 1 2 3 6 9

Project Title : 12369-A i implementation of Depression Screening Protocol to improve Screening for Depression ir,
Application Type Expedited
Review ty p e Expedited
Approval Penod Septem ber 22 2C15 - Septem ber 22 2 0 16
Category 7

The NMSU Institutional Review Board Chair. Dr Rolston St Hilaire, has reviewed and approved the above application for the
conduct of research involving human subjects

The application was reviewed in accordance with the review process outlined in 45 CFR 46 110(b)(2) - Category 7

The research must be conducted according to the proposal/protocol that was approved by the IRB Any changes in the
research, instruments, or the consent docum ent(s) must be submitted to the IRB prior to implementation Additionally, any
unexpected hazards or adverse events involving nsk to the subjects or others must be reported immediately to the IRB. using
the appropriate form, within the time frame specified In the NMSU Principles and Procedures for the Conduct of Research
Involving Human Subjects

Please note that the IRB approval is valid for only one ( l ) year Pursuant to federal regulations, the IRB must review and
approve all research protocols involving human subjects at intervals appropnate to the degree of nsk, but no less than once
per year Therefore, in order to continue your project after the above approved penod, you must submit a request for
continuation 45 days prior to the above referenced expiration date

Note Data collected during a period of lapsed approval is unapjxoved research and can never be reported or published as
research data

If you should have any questions, please do not hesitate to contact the Office of R esearch Compliance at 646-7177 or via
e-mail at ovpr@nmsu edu

78
 A PPEND IX J

SRIREN GA M M URA LID H ASA N, M .D. LETTER OF EN D O RSEM EN T

79
 A PPEND IX J

SRIREN GA M M U RA LID H ASA N, M .D. LETTER OF EN D O RSEM EN T

SRIRENGAM MURALIDHASAN, MJD.

BOARD C ERTIFIED I f f FAM ILY PRACTICE

1605 EL PASEO ROAD

LAS CRUCES, NM 88001
PHONE (575) 523-5400
FAX (575) 523-5401

August 2 3 .2 0 1 5

To: New M exico State University internal Review Board.

Priya Bajracharya, FNP-C. DNP student at NM SU has our permission and support to do her

research project at our facility. The project will com prise o f gathering data related to depression

disorder and implementation o f an electronic PHQ-2 and PHQ-9 questionnaire. Relevant

information w ill be obtained from w illing adults patients, upon sign- in to be seen by their

primary c a a providers.

R e sp ec tfu lly .

D r S rirc n g a m M u ra lid h a sa n . M D

80
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81
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