Chronic Conditions - Key Activity 15

Action steps and roles

Below is a sequence of steps that practices could use to implement screening for behavioral health conditions.

1. Understand current recommendations for regular behavioral health screening.

Suggested team member(s) responsible: QI lead and frontline staff.

Guidance from “the USPSTF recommends that adults be screened for depression, alcohol abuse, and drug abuse, and that primary care physicians ensure there is appropriate diagnostic follow-up available from behavioral health clinicians.”^[1]

Please see the USPSTF website for more information:

• USPSTF’s recommendations for depression and suicidality in adults.
• USPSTF’s recommendations for anxiety screening for adults.
• USPSTF’s recommendations for unhealthy alcohol use in adolescents and adults.
  • Guidelines are currently proposed for this documentation. Practices should check back periodically to ensure that the most up-to-date recommendations are being utilized.
• USPSTF’s recommendations for unhealthy drug use.

2. Create a care gap report.

Suggested team member(s) responsible: QI lead and frontline staff.

Establish a baseline by assessing the percentage of patients for, or visits at, which behavioral health screening occurred.

See Key Activity 3: Use Care Gap Reports or Registries to Identify All Patients Eligible and Due for Care for more information.

3. Practices should flag all eligible patients for behavioral health screening and administer screening.

Suggested team member(s) responsible: Pre-visit planning staff.

There are many validated tools available. Practices should use tools that are:

• Validated or accepted for use in adults.
• Routinely used.
• Free.
• Easy to administer and score.
• Available in numerous languages.

This should be programmed as an alert in the EHR so staff are aware. These tools can also be used for discussion and planning for the day, such as during morning huddles or during the pre-visit planning process.

To screen for depression, consider:

• Patient Health Questionnaire-2 (PHQ-2)/Patient Health Questionnaire-9 (PHQ-9) (PHQ-2 in Spanish/PHQ-9 in Spanish).

To screen for anxiety, consider:

• Generalized Anxiety Disorder 7-Item Scale, which has seven questions.

To screen for post-traumatic stress disorder (PTSD), consider:

• Primary Care PTSD Screen for DSM-5 (PC-PTSD-5).

To screen for bipolar disorder, consider:

• Mood Disorder Questionnaire, which has 17 questions.

4. Create a protocol to screen for behavioral health conditions.

Suggested team member(s) responsible: Behavioral health clinicians, medical care clinicians, nursing staff.

Ensure standardized clinical workflows are in place for routine screening for adults. In many practices, MAs or other clinical support staff administer the mental health screenings in advance of the clinician visit. Clinic support staff alerts the clinician to a positive screen, who then reviews the results and, if appropriate, offers relevant treatments or referrals.

To maximize completion of behavioral health screenings, the workflow should be executed at any visit where the patient is new, has not been into the clinic in over a year, or requires regular follow-up. Practices should establish reoccurrence thresholds to ensure that patients are screened routinely as appropriate.

5. Develop workflows for integrating behavioral health during regular patient care, including provision of pharmacotherapy when indicated.

Suggested team member(s) responsible: Behavioral health clinicians, medical care clinicians, nursing staff.

• Identify mental health screening tools to be integrated universally in every clinical setting where patients may present.
• Establish an evidence-based, person-centered response protocol based on what is feasible for each area of practice and local mental health resources. Ideally, responses are tailored to condition severity and are strength based, culturally relevant and responsive to patients’ values and needs.
• Ensure staff can activate an immediate suicide risk assessment and response protocol as needed for patients with identified suicidal ideation, significant risk of harm to self and/or others, or psychosis.

6. Educate clinicians, frontline staff, administrative staff, patients and patients’ designated support networks on optimal care for patients, including detection, assessment, treatment, monitoring and follow-up best practices.

Suggested team member(s) responsible: Behavioral health clinicians, medical care clinicians, quality improvement staff.

• Facilitate trauma-informed training and education to address healthcare team member biases and stigma related to mental health conditions, including anti-racism considerations.
• Incorporate mental health into multidisciplinary rounding to establish a nonjudgmental culture of safety.
• Provide staff and provider training on common modalities to treat depression.

7. Develop and maintain a set of referral resources and communication pathways between the patient’s providers, community-based organizations, and state and public health agencies to address patient needs, including social drivers of mental and physical health.

Suggested team member(s) responsible: Care coordinators, behavioral health staff, quality improvement staff, clinic administration.

Establish care pathways that facilitate coordination and follow-up among multiple providers.

• Identity local resources for mental health conditions that necessitate immediate treatment (i.e., psychosis, suicidality).

Ensure a clear protocol for communication between primary care providers and the patient’s behavioral health providers.

8. Screen and provide linkage to resources for structural and social drivers of health that may impact clinical recommendations for treatment plans.

Suggested team member(s) responsible: Behavioral health clinicians, medical care clinicians, nursing staff.

• Transportation, childcare and housing, among other factors, may impact a patient’s ability to adhere to their mental health treatment plan.