The impact of COVID-19 on patient safety attendant use.

ABSTRACT: Patient safety attendants (PSAs) provide constant direct observation to patients who have cognitive impairments or thoughts. Some estimates report that an acute care hospital in the United States may spend more than $1 million annually on PSAs, an expenditure often not reimbursed. With no national defined standards to regulate or monitor PSA use, this study sought to determine the impact of COVID-19 on a PSA reduction program in a large Midwestern healthcare system.

A Structured Approach to Detecting and Treating Depression in Primary Care: VitalSign6 Project.

PURPOSE: This report describes outcomes of an ongoing quality-improvement project (VitalSign6) in a large US metropolitan area to improve recognition, treatment, and outcomes of depressed patients in 16 primary care clinics (6 charity clinics, 6 federally qualified health care centers, 2 private clinics serving low-income populations, and 2 private clinics serving patients with either Medicare or private insurance). METHODS: Inclusion in this retrospective analysis was restricted to the first 25,000 patients (aged ≥12 years) screened with the 2-item Patient Health Questionnaire (PHQ-2) in the aforementioned quality-improvement project. Further evaluations with self-reports and clinician assessments were recorded for those with positive screen (PHQ-2 >2). Data collected from August 2014 though November 2016 were available at 3 levels: (1) initial PHQ-2 (n = 25,000), (2) positive screen (n = 4,325), and (3) clinician-diagnosed depressive disorder with 18 or more weeks of enrollment (n = 2,160). RESULTS: Overall, 17.3% (4,325/25,000) of patients screened positive for depression. Of positive screens, 56.1% (2,426/4,325) had clinician-diagnosed depressive disorder. Of those enrolled for 18 or more weeks, 64.8% were started on measurement-based pharmacotherapy and 8.9% referred externally. Of the 1,400 patients started on pharmacotherapy, 45.5%, 30.2%, 12.6%, and 11.6% had 0, 1, 2, and 3 or more follow-up visits, respectively. Remission rates were 20.3% (86/423), 31.6% (56/177), and 41.7% (68/163) for those with 1, 2, and 3 or more follow-up visits, respectively. Baseline characteristics associated with higher attrition were: non-white, positive drug-abuse screen, lower depression/anxiety symptom severity, and younger age. CONCLUSION: Although remission rates are high in those with 3 or more follow-up visits after routine screening and treatment of depression, attrition from care is a significant issue adversely affecting outcomes.

VitalSign6: A Primary Care First (PCP-First) Model for Universal Screening and Measurement-Based Care for Depression.

Major depressive disorder affects one in five adults in the United States. While practice guidelines recommend universal screening for depression in primary care settings, clinical outcomes suffer in the absence of optimal models to manage those who screen positive for depression. The current practice of employing additional mental health professionals perpetuates the assumption that primary care providers (PCP) cannot effectively manage depression, which is not feasible, due to the added costs and shortage of mental health professionals. We have extended our previous work, which demonstrated similar treatment outcomes for depression in primary care and psychiatric settings, using measurement-based care (MBC) by developing a model, called Primary Care First (PCP-First), that empowers PCPs to effectively manage depression in their patients. This model incorporates health information technology tools, through an electronic health records (EHR) integrated web-application and facilitates the following five components: (1) Screening (2) diagnosis (3) treatment selection (4) treatment implementation and (5) treatment revision. We have implemented this model as part of a quality improvement project, called VitalSign6, and will measure its success using the Reach, Efficacy, Adoption, Implementation, and Maintenance (RE-AIM) framework. In this report, we provide the background and rationale of the PCP-First model and the operationalization of VitalSign6 project.

UT Southwestern's Palliative Care Program: Measurable Patient Impact and Cost-savings.

The purpose of this analysis was to measure the impact of palliative care services on hospital charges in the 5 days prior to death-the most expensive time of a patient's life-and identify hospital service categories and patient financial classes yielding the highest savings from palliative care. The analysis population included UT Southwestern patients admitted to the hospital between October 1, 2013, and September 30, 2016. Palliative care patients were defined as any patient who received at least one completed palliative care order. In order to create an accurate comparison group, a propensity score match was generated to identify patients most likely to have qualified for a palliative care consult. Covariates included in the model were age, sex, race, financial class, and number of comorbidities. Comorbidities were identified using the Elixhauser Comorbidity Index, and all charges were pulled for the 5 days prior to death. Total hospital charges were also reported by hospital service and financial class. Statistical significance was then derived using a gamma distributed log-linked generalized linear model. The final population included in the analysis, post the propensity score match, was composed of mostly white, non-Hispanic males. The majority of the patients had five or fewer comorbidities, and the primary preexisting conditions seen among patients were cardiovascular diseases (36.0%) and cancer (23.4%). The hospital service categories yielding the highest mean savings were pharmacy (mean $2,765; P < .0001) and labs (mean $1,063; P < .0001). Financial classes with the greatest savings were Medicaid and charity/self-pay. Overall, there was a significant difference in charges between those that received a palliative care consult and those that did not. The fact that the highest savings were in pharmacy and laboratory services suggests that unnecessary labs and medications are discontinued in an effort to improve patient care and quality of life while reducing costs during end-of-life care. Palliative care services ease the cost burden of end-of-life services for low-income populations.