This week we will be discussing an article that’s a little bit different from our usual content. This week, we will review and discuss a Quality Improvement Success Story published in August 2020 by the American Diabetes Association in collaboration with the American College of Physicians and the National Diabetes Education Program. In this article, authors Roberts, Barry, Yi-Frazier, Rutman, Pihoker, and Malik describe their efforts to improve mental health screening of patients at a pediatric diabetes clinic. 


Why did they do it?

The presence of comorbid mental health problems and chronic illness, such as diabetes, has been clearly linked to a variety of poor physical and psychosocial outcomes. Accordingly, as highlighted by the authors, the American Diabetes Association recommends routine psychosocial screening for individuals in outpatient settings (e.g. diabetes clinics). However, recent findings suggest that less than 45% of pediatric diabetes clinics screen patients for mental health concerns. Within the world of chronic illness, this lack of screening leads to issues related to both misdiagnosis, as well as missed diagnosis.

With regard to the current study, the authors note that within their clinic, fewer than 2% of patients were receiving mental health screenings on a yearly basis. Given these percentages, the authors set forth to improve screening for depression and diabetes and provided valuable insight as to how they accomplished this goal and what their results demonstrated. 


How did they do it?

Beginning in March of 2018, staff at the author’s clinic implemented workflow process changes, which included adding the following assessments into their testing regimen: the Patient Health Questionnaire (PHQ-9) and the Problem Areas in Diabetes Teen version (PAID-T).  Staff and division team members were also trained on the importance of mental health screening, how to assess suicidality, and how to document crisis planning. To facilitate timely evaluation of the highest risk patients and ensure that self-harm indications were not overlooked, the electronic tool automatically sent an email alert to the patient’s provider and social work team. Team members met monthly to discuss the screening process and to identify any areas of improvement. 


What did they find?

Throughout the entirety of this initiative, mental health screening rates for patients at this particular clinic with diabetes increased from 2% to 80%. Over the 16-month period, 480 individuals were screened. Of those individuals, 18% endorsed significant depressive symptoms, 11% reported concerns related to self-harm, and 22% endorsed elevated diabetes distress. 

The authors note that implementing a mental health quality improvement initiative can present unique challenges. Several considerations, such as developing processes to ensure appropriate and timely responses to high severity screenings, were reported to be critically important. We highly encourage you to read through this brief article on your own to learn the details about the great study that these authors carried out!


What does it all mean (our take)?

This article touches on a highly meaningful, yet often overlooked aspect of healthcare - evaluating comorbidity between mental health and chronic physical illness. Several factors associated with comorbidity, including rising costs and poorer outcomes, highlight the importance of this topic. Accordingly, we applaud the authors in taking the steps to increase rates of mental health screening in their clinic and also providing a framework by which other like-minded clinics can roll out a similar plan.

Whether misdiagnosed or simply not evaluated, mental health comorbidity among individuals with chronic illnesses is an important issue that must continue to be thoroughly researched. Developing plans to integrate comprehensive mental health screenings into workflows within such clinics, extending beyond simply evaluating for depressive concerns, is likely to assist in providing a more representative view as to the mental health concerns a patient with chronic illness may be experiencing. This very point was one of the driving factors behind the development of our system; to assist healthcare providers in more efficiently and accurately evaluating the mental health of their patients without impeding on their workflows and/or existing processes. We are looking forward to continuing to support the healthcare community and we feel strongly that the integration of a streamlined mental health assessment system will lead to the ultimate goal of improved patient outcomes.

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