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Purpose: This scholarly project developed a depression follow-up protocol for use by depression care managers in a military primary care clinic. Additionally, this project evaluated the impact of the protocol on HEDIS antidepressant medication measurements (AMM). Background: Depression occurs in as many as 60% of primary care patients. Significant evidence suggests (a) the prescribing and follow-up management of antidepressant drugs in primary care might not conform to evidence-based clinical guidelines, (b) patients are noncompliant with prescribed medication, and (c) treatment relapse is a major concern. Research indicates that an organized approach to patient follow-up by systematically contacting patients to provide specific interventions, facilitating treatment adherence, and/or monitoring symptoms or adverse effects improves tracking of side effects, increases adherence, and enhances the level of depression care. Practice Change: Mental health nurses utilized a standardized depression follow-up management protocol through a structured, secure e-mail follow-up for medication teaching and support. The primary care clinic HEDIS antidepressant medication management scores for both the acute and continuation phase were audited prior to implementation of follow-up and again at 3 months and 6 months to measure improvement in HEDIS scores. Outcomes: Postprogram evaluations HEDIS scores increased by 3% (Acute phase) and 10% (Continuation phase). Conclusion: Secure e-mail follow-up monitoring and feedback was associated with improvement in patient HEDIS scores in the primary care clinic. BACKGROUND AND EVIDENCE OF THE PROBLEM Depression is a prevalent condition affecting more than 20 million adults ages 18 and older in the United States and is associated with significant levels of disability, morbidity, and mortality. The World Health Organization (WHO, 2016) underscores the important public Running head: ENHANCING DEPRESSION CARE OUTCOMES IN PRIMARY CARE 3 health concerns and costs of depression among U.S. adults. The disorder is associated with excess resource utilization; an estimated $8,000 per year per patient. Murray and Lopez (1997) and WHO (2016) also predict that depression will increase from fourth to second place in contributing to the overall global burden of disease by 2020. Antidepressant medication and widespread combination psychotherapy has dramatically changed the disease trajectory and well-being of people living with depression. Antidepressant use for the treatment of depression has grown dramatically over the past 15 years; however, the quality of antidepressant treatment has failed to improve, particularly in primary care (Heise & van Servellen, 2013; Katon, 2010). Comparatively, McManus, Meltzer, Brugha, Bebbington, and Jenkins (2009) reported that the rates of antidepressant medication adherence were particularly low in primary care, where 90% 95% of depression cases are managed. Over the past 10 years, randomized controlled trials have identified types of depression treatment changes that should be implemented. These changes have been consistent with recommendations from the National Committee of Quality Assurance (NCQA), U.S. Preventative Task Force, and the Future of Family Medicine report (Future of Family Medicine Project Leadership Committee, 2004). The most underscored essential change was the implementation of a collaborative care model as a method to improve the quality of depression treatment. Within the collaborative model, one key component was the implementation of a depression care manager to provide patient self-management support and proactive follow-up care that was closely integrated with the primary physician. Eghaneyan, Sanchez, and Mitsche (2014) described collaborative care for depression as a system level intervention with four key characteristics: Running head: ENHANCING DEPRESSION CARE OUTCOMES IN PRIMARY CARE 4 1. A professional approach to patient care: This approach required either a general practitioner (GP) or family physician along with at least one other health professional (e.g., nurse, psychologist, psychiatrist, pharmacist) involved with patient care. 2. A structured management plan in the form of guidelines or protocols: Interventions included patient screening and/or patient/provider education. 3. Scheduled patient follow-up: An organized approach to patient follow-up by systematically contacting patients, providing specific interventions, facilitating treatment adherence, or monitoring symptoms and adverse effects. 4. Enhanced inter-professional communication: Introducing mechanisms to facilitate communication between professionals caring for the depressed person. This could include written or verbal feedback among providers. Despite consensus on the value of a collaborative model, this approach has not been the norm (Simon et al., 2011; Solberg, Trangle, & Wineman, 2005). Relapse has been common and the risk of developing more chronic forms of depression has increased. Considering the prevalence, complication, and cost to the healthcare system, the implementation of a collaborative-care approach to depression management with emphasis on proactive treatment and follow-up in primary care could improve treatment adherence as well as prevent relapses and serious complications. One of the most widely used sets of healthcare data-performance measured in the United States is the Healthcare Effectiveness Data and Information Set (HEDIS). HEDIS measures have been useful in promoting population health for wide-ranging chronic disorders. Conversely, other measures, such as those for Antidepressant Medication Management (AMM), have been less successful. Current HEDIS data suggests considerable opportunities for Running head: ENHANCING DEPRESSION CARE OUTCOMES IN PRIMARY CARE 5 improvement in the quality of mental health services (National Committee Quality Assurance Managed Behavioral Healthcare Organization Accreditation, 2014).

Enhancing Depression Care Outcomes in Primary Care Patients through Secure E-mail Structured Follow-Up Monitoring by Mental Health Nurse Practitioner