Home Health Line article by Katherine Vanderhorst on OASIS-E changes

OASIS-E: Outcomes Careful response to signs of depression can help with other outcomes too

Now that agencies will be required to use a more extensive test for depression, put a plan in place for how to respond should patients exhibit signs and symptoms. This can go a long way in keeping patients safe and improving quality outcomes.

The Patient Health Questionnaire (PHQ-9) assessment tool is being added with OASIS-E and is used to assess the likelihood of depression and how severe it might be based on the presence and frequency of nine possible symptoms.

When patients receive a positive result, clinicians should notify the physician. Just calling the office and telling them the score is not sufficient.

The best thing to do is to fax over the results with a note. If a patient does not have a diagnosis and the doctor sees a positive result, the physician is more likely to act and evaluate the patient for depression. Categorize in your communication to the physician what level of depression the score indicates.

How to communicate PHQ-9 results

Scenario 1: The following scenario shows how to talk to your patient’s physician about positive PHQ-9 results. In this scenario the patient was assessed for depression using PHQ-2 to 9 version of the geriatric depression screening (GDS) — not on antidepressants.

Clinician: Doctor, thank you for the home care referral. When our nurse admitted Mrs./Mr. ______________to home care she/he completed the Medicare mandated depression screening tool, the PHQ-9. The patient’s score on this instrument was a 15 which is indicative of moderately severe depression.

Note: Be sure to tell the physician the exact numerical score and whether it shows moderate or severe depression. Also be sure to inform the physician whether or not the patient is suicidal.

Clinician: I asked the patient whether or not he/she was suicidal, and the patient said he thinks about suicide one to two times a month but has no active plan. This patient is not on any medication to treat depression. I was concerned that if left untreated, the depression will get in the way of the patient following his/her treatment plan for congestive heart failure.

Would you be willing to evaluate the patient further for depression and determine if the patient requires medication to address the patient’s depression?

We can reassess the patient’s level of depression in three to six weeks, at recert and discharge. At that point, I can let you know whether the depression is the same, improved or worse.

Scenario 2: Seeking orders for recertification. Clinician: Thank you for being so responsive to my requests regarding your patient _____________ (Patient name) whom our agency has been caring for since _____ (Date). This is her___ episode of care. She/he is currently on the following medication _______ (Drug and dose). The patient is being evaluated to be recertified for episode number 2. I have consistently re-evaluated her level of depression using the PHQ-9 test, which indicates that your patient is improving/not improving (Choose one) but is still scoring ____ on the PHQ-9 at a level to indicate the need for an additional episode.

Would you be willing to write the orders for an additional episode of care? Thank You!

Plan for suicide indicator

If a patient has answered positively to item I, “Thoughts that you would be better off dead or hurting yourself in some way,” on the PHQ-9, it’s imperative that a further suicide screen is completed and that the patient’s physician be notified immediately.

An agency should have a protocol in place as to how to respond when patients are having thoughts that they would be better off dead or hurting themselves in some way. (See story below.) It is crucial that the patient is assessed to determine if the patient has a plan and the means to commit suicide.

One recommended tool to screen for suicide risk is The Columbia-Suicide Severity Rating Scale (C-SSRS). It is a questionnaire used for suicide assessment. The tool was developed by Columbia University with Support of National Institute of Mental Health (NIMH). According to the Columbia Lighthouse project, whose mission is to end suicide, the C-SSRS is a tool that supports suicide risk assessment through a series of simple, plain-language questions that anyone can ask.

The Lighthouse Project website offers training and recorded webinars that clinicians can watch to learn how to use the tool and screen for suicide (https://cssrs.columbia. edu/training/training-options/)

Create a care plan addressing depression

Be ready with a plan for managing patients with depression after a diagnosis is confirmed by a physician. It’s helpful to have care paths/plans to address depression and other mental issues. The care plans should address an interdisciplinary approach to managing a patient’s depression.

Once you have a diagnosis and/or a confirmed treatment from the physician, you can do the following to assist in depression management:

1. Explain to patient that you have identified he/she has depressive symptoms and would like to work with patient and physician to decrease depressive symptoms.

2. Identify goals with patients and their families that are specific, measurable, achievable, relevant and timely.

3. Complete a comprehensive depression assessment that includes PHQ-9 and a suicide screen.

4. Facilitate adherence to antidepressant medication. Teach on medication, side effects and uses. Monitor effectiveness and compliance. Assist in setup.

5. Conduct psychoeducation. This is very important. Some of the areas to cover in teaching are the following. • What is depression? • Signs of depression relapse • Strategies to improve sleep, exercise and nutrition • Importance of journaling • Importance of exercise/ movement for the brain • Safety planning • Medication education • Importance of activities, socialization and routine

6. Assess efficacy of nursing interventions at initial evaluation, weeks four through six, recert, discharge and as clinically necessary. Collect information by/ through: • Administering appropriate screening tools (PHQ9, C-SSR) • Patient/family self-reports of symptom relief • Clinician observation

Editor’s note: The scenarios above are copyrighted and printed with permission from C&V Senior Care, from Taking Your Share in Behavioral Health Care.

About the author: This article was written by Katherine Vanderhorst, PMH-BC,BSN,CCM, president of C&V Senior Care Specialists Inc. in Williamsville, N.Y