78 - Implementing a Change Package for Depression Screening and Appropriate Response for Children with Rheumatic Disease

Publication Number: 4076.78

Emily Vara, Medical University of South Carolina College of Medicine, Charleston, SC, United States; Mileka RICHELLE. Gilbert, Medical University of South Carolina, Charleston, SC, United States; Kelly Rouster-Stevens, Emory University School of Medicine, Atlanta, GA, United States; Talia Buitrago-Mogollon, Levine Children's Hospital, Charlotte, NC, United States; Sarah Mabus, Levine Children's Hospital, Charlotte, NC, United States; Catherine Peterson, Levine Children's Hospital, Charlotte, NC, United States; Justin B.. Moore, Wake Forest University School of Medicine, Winston-Salem, NC, United States; Sheetal Vora, Levine Children's Hospital, Charlotte, NC, United States

Background: Children with rheumatic diseases (RD) are at risk for developing mental health (MH) issues, which can impact disease outcomes. MH disorders are underrecognized in pediatric RD. The ACR and CARRA published MH screening guidelines in pediatric RD. The ABP's "The Roadmap Project" has a readiness checklist to prepare for MH screening, which was used to create a depression screening change package with appropriate response documented. An implementation science (IS) framework gauged the effectiveness of our change package.

Objective: Evaluate if the change package is adaptable across diverse pediatric rheumatology clinics.

Aims: 1. Assess IS outcomes of feasibility and acceptability to aid depression screening and response; 2. Determine impact on contextual factors, including relative advantage and adoptability.

Design/Methods: An interdisciplinary team-physicians, psychologists, social worker, parents/patients, and an IS scientist-designed the implementation strategy. Using the Health Equity Implementation Framework, 3 pediatric rheumatology clinics piloted the change package, for screening RD patients aged >8 years (PROMIS) or >12 years (PHQ-9). Each center customized quality improvement methods to address site-specific barriers. A health equity fishbone diagram identified root causes of screening gaps. IS outcomes and clinical quality measures, and effectiveness of each package component, are being evaluated through REDCap surveys completed by clinical teams and parents/patients at regular intervals.

Results: We are 9 months into the 12-month implementation strategy. Surveys are reviewed at local and multi-site team meetings, and modifications enacted as needed. At baseline, all 5 parent/patient participants supported screening and valued MH resource pamphlets. Table 1 presents staff survey results, showing agreement across all 3 sites on feasibility, acceptability, and helpfulness of package components. Weekly, then monthly, random sampling of eligible patients assessed clinical quality measures (Figure 1). Sample demographics: 77% female, 60% White, 29% Black, 16% Hispanic, 92% English-speaking, 43% privately insured, 50% Medicaid. The most common RD were JIA and SLE. Appropriate responses used package tools and clinic/community resources (Figure 2). No emergent care was required.

Conclusion(s): Using IS, 3 diverse sites found the change package feasible and acceptable, offering a systematic approach to improve MH screening in pediatric rheumatology. Partnering with patients and parents as equal stakeholders enhanced adaptability and sustainability of depression screening.

Table
Sociodemographic features of screened patients at the three centers.

Figure 1
A randomly selected sample of 10 patients per month at each site were assessed for depression screening for a total of 30 patients per month across all 3 sites. Compiled data on percent of patients screened for depression (Figure 1A), patients with positive depression screen (Figure 1B), distribution of severity of depression (Figure 1C), diseases with positive depression screens (Figure 1D), and percent of patients with appropriate response to depression screening according their respective site's process map (Figure 1E) are depicted in pie charts.


Figure 2
Distribution of Responses to Positive Depression Screening. Each site developed a process map for responding to mild, moderate, and severe depression based on screening. A randomly selected sample of 10 patients per month at each site were assessed for depression screening. 90% of sampled patients had a positive depression screen. 91% of patients with positive screens were addressed with at least one of the responses noted in the bar graph. Other responses included situational stressors reviewed with patient and to return to clinic if concerns arise (14 of 24), PCP arranging local therapy referral (1 of 24), and Corresponded in EMR with Behavioral/Mental Health provider (1 of 24).