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Homeless individuals encounter barriers such as lack of health insurance, increased cost of care and unavailability of resources. They have increased risk of comorbid physical disease and poor mental health. Depression is a prevalent mental health disorder in the US linked to increased risk of mortality. Literature suggests depression screening

Homeless individuals encounter barriers such as lack of health insurance, increased cost of care and unavailability of resources. They have increased risk of comorbid physical disease and poor mental health. Depression is a prevalent mental health disorder in the US linked to increased risk of mortality. Literature suggests depression screening can identify high-risk individuals with using the patient health questionnaire (PHQ-9).

The objective of this project is to determine if screening identifies depression in the homeless and how it impacts healthcare access. Setting is a local organization in Phoenix offering shelter to homeless individuals. An evidence-based project was implemented over two months in 2019 using convenience sampling. Intervention included depression screening using the PHQ-9, referring to primary care and tracking appointment times. IRB approval obtained from Arizona State University, privacy discussed, and consent obtained prior to data collection. Participants were assigned a random number to protect privacy.

A chart audit tool was used to obtain sociodemographics and insurance status. Descriptive statistics used and analyzed using Intellectus. Sample size was (n = 18), age (M = 35) most were White-non-Hispanic, 44% had a high school diploma and 78% were insured. Mean score was 7.72, three were previously diagnosed and not referred. Three were referred with a turnaround appointment time of one, two and seven days respectively. No significant correlation found between age and depression severity. A significant correlation found between previous diagnosis and depression severity. Attention to PHQ-9 varied among providers and not always addressed. Future projects should focus on improving collaboration between this facility and providers, increasing screening and ensuring adequate follow up and treatment.

ContributorsParamo, Cinthia Arredondo (Author) / Thrall, Charlotte (Thesis advisor)
Created2020-05-04
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Description
Declaration of Conflicts: This project has no conflicts of interest to declare.

Context: This project was completed at a federally qualified primary healthcare clinic in Phoenix, Arizona that served patients of all age groups, but primarily cared for the Hispanic population providing primary care, preventative services, family planning, two lab

Declaration of Conflicts: This project has no conflicts of interest to declare.

Context: This project was completed at a federally qualified primary healthcare clinic in Phoenix, Arizona that served patients of all age groups, but primarily cared for the Hispanic population providing primary care, preventative services, family planning, two lab technicians, one promoter, two medical assistant supervisors, five front desk staff, one chief administrative officer, one chief financial officer, two medical directoers who were also providers at the clinic.

Problem and Analysis Assessment: During my clinical rotations, I saw the burden a missed patient appointment had not only on the patients themselves, but also on the clinic, providers, and the staff. It caused delay in treatment for patients, and it did not allow other patients that wanted to be seen to be seen. It also increased unnecessary costs and wasted provider time. Thereafter, I met with some of the leadership team and one of the medical directors to determine a solution to reduce the number of missed appointments that were occurring. An educational session was kept to discuss the findings of this problem to the providers and the staff and when surveys were handed out to the patients, providers, and staff to assess their satisfaction with the old scheduling system versus the new scheduling system, they were also provided with a cover letter discussing the project.

Intervention: In order for improvements in care to occur, a system process change including the way patients are scheduled must occur. In this case, an open-access scheduling system (OAS) was implemented. OAS allows a patient to schedule an appointment on the 'same-day' or the 'next-day' to be seen. One provider at each of the clinics, each day of the week was available for 'same-day' appointments from 1300-1600. The providers were still available for scheduled appointments using the previous scheduling method. Walk-ins were still accepted, and were scheduled based on patient provider preference; however, if an appointment was not available for their preferred provider, they were typically seen with the provider that was the 'same-day' provider for that day.

Strategy for change: Since patients were only allowed to schedule appointments one month in advance, only one month was needed to implement this process change. A recommendation for the future would be to clearly identify the patient encounter type, and label it as a same-day appointment, as this would be helpful when gathering and extracting data for this type of patient group specifically.

Measurement of Improvement: Over a three-month period, a data collection plan was used to determine the number of Mas over a three-month period before and after implementation of this change. Satisfaction scores were measured using likert scales for patients, provider, and staff, and a dichotomous scale was used to determine the likelihood of emergency room or urgent care use. A comparison was done to measure revenue during the same time frame. During the three months, a clinically significant decrease in MAs was seen (<0.52%), with an increase in revenue by 41%. Additionally, a statistically significant increase in patient, provider and staff satisfaction was also noted when compared to the old scheduling system, as >68% of all patients, providers and staff reported feeling either very satisfied or extremely satisfied with the new scheduling system. Additionally, patients also reported that they were less likely to visit an emergency room(88%) or urgent care (90%) since they were able to be seen the same-day or the next-day by a provider.

Effects of changes: An incidental finding occurred during this study - where 877 more patients were seen in the three months during the implementation of this project, compared to the three months prior; which likely resulted in a 41% increase in revenue. Additionally this project, allowed patients that wanted to be seen on the same day, to be seen, and it decreased unnecessary costs associated with emergency room or urgent care visits. Some of the limitations involved included the current political environment, appointment slots that were previously 15 minutes in length (in 2016), increased to 20 minutes in length (in 2017), a language barrier was noted for the patient surveys since English was not the first language for many of the patients who completed the survey (although documents were translated), and the surveys used were not reliable instrument given that a reliable instrument in previous studies could not be found.

Lessons learnt: In order to have accuracy of the survey results, it is best for the author of the study to hand out and provide scripture for the survey so that complete data is received from the surveyors.

Messages for others: Begin by making a small process change where only one provider allows for the open-access scheduling so that the entire office is not affected by it, and if results begin to look promising then it can be expanded. Additionally, correct labeling of patients as 'same-day' is also important so that additional data can be gathered when needed regarding the 'same-day' patients.

Patient/Family/Guardian Involvement: Patients who benefited from the new scheduling system (open-access scheduling) were asked to fill out a survey that asked them to disclose some demographic data and asked them to determine their satisfaction with the new vs old scheduling system and their likelihood of visiting an emergency room or urgent care.

Ethics Approval: Arizona State University Institutional Review Board (IRB) Received: September 2017
ContributorsPatel, Dimple (Author) / Thrall, Charlotte (Thesis advisor) / Glover, Johannah-Uriri (Thesis advisor)
Created2018-05-02
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Background: The cost of substance use (SU) in the United States (U.S.) is estimated at $1.25 trillion annually. SU is a worldwide health concern, impacting physical and psychological health of those who use substances, their friends, family members, communities and nations. Screening, Brief Intervention (BI) and Referral to Treatment (SBIRT)

Background: The cost of substance use (SU) in the United States (U.S.) is estimated at $1.25 trillion annually. SU is a worldwide health concern, impacting physical and psychological health of those who use substances, their friends, family members, communities and nations. Screening, Brief Intervention (BI) and Referral to Treatment (SBIRT) provides an evidence-based (EB) framework to detect and treat SU. Evidence shows that mental health (MH) providers are not providing EB SU management. Federally grant-funded SBIRT demonstrated evidence of decreased SU and prevention of full disorders. Implementation outcomes in smaller-scale projects have included increased clinician knowledge, documentation and interdisciplinary teamwork.

Objective: To improve quality of care (QOC) for adolescents who use substances in the inpatient psychiatric setting by implementing EB SBIRT practices.

Methods: Research questions focused on whether the number of SBIRT notes documented (N=170 charts) increased and whether training of the interdisciplinary team (N=26 clinicians) increased SBIRT knowledge. Individualized interventions used existing processes, training and a new SBIRT Note template. An SBIRT knowledge survey was adapted from a similar study. A pre-and post-chart audit was conducted to show increase in SBIRT documentation. The rationale for the latter was not only for compliance, but also so that all team members can know the status of SBIRT services. Thus, increased interdisciplinary teamwork was an intentional, though indirect, outcome.

Results: A paired-samples t-test indicated clinician SBIRT knowledge significantly increased, with a large effect size. The results suggest that a short, 45-60-minute tailored education module can significantly increase clinician SBIRT knowledge. Auditing screening & BI notes both before and after the study period yielded important patient SU information and which types of SBIRT documentation increased post-implementation. The CRAFFT scores of the patients were quite high from a SU perspective, averaging over 3/6 both pre- and post-implementation, revealing over an 80% chance that the adolescent patient had a SU disorder. Most patients were positive for at least one substance (pre- = 47.1%; post- = 65.2%), with cannabis and alcohol being the most commonly used substances. Completed CRAFFT screenings increased from 62.5% to 72.7% of audited patients. Post-implementation, there were two types of BI notes: the preexisting Progress Note BI (PN BI) and the new Auto-Text BI (AT BI), part of the new SBIRT Note template introduced during implementation. The PN BIs not completed despite a positive screen increased from 79.6% to 83.7%. PN BIs increased 1%. The option for AT BI notes ameliorated this effect. Total BI notes completed for a patient positive for a substance increased from 20.4% to 32.6%, with 67.4% not receiving a documented BI. Total BIs completed for all patients was 21.2% post-implementation.

Conclusion: This project is scalable throughout the U.S. in MH settings and will provide crucial knowledge about positive and negative drivers in small-scale SBIRT implementations. The role of registered nurses (RNs), social workers and psychiatrists in providing SBIRT services as an interdisciplinary team will be enhanced. Likely conclusions are that short trainings can significantly increase clinician knowledge about SBIRT and compliance with standards. Consistent with prior evidence, significant management involvement, SBIRT champions, thought leaders and other consistent emphasis is necessary to continue improving SBIRT practice in the target setting.

Keywords: adolescents, teenagers, youth, alcohol, behavioral health, cannabis, crisis, documentation, drug use, epidemic, high-risk use, illicit drugs, implementation, mental health, opiates, opioid, pilot study, psychiatric inpatient hospital, quality improvement, SBIRT, Screening, Brief Intervention and Referral to Treatment, substance use, unhealthy alcohol use, use disorders

ContributorsMaixner, Roberta (Author) / Guthery, Ann (Thesis advisor) / Mensik, Jennifer (Thesis advisor) / Uriri-Glover, Johannah (Thesis advisor)
Created2019-05-02