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SMART-D: Screening, Measurement and Assessment of Response to Treatment for Depression

UT Southwestern Medical Center

SMART-D: Screening, Measurement and Assessment of Response to Treatment for Depression Logo

Program Website
Year:
2019
State:
Texas
Winner Status:
Finalist
Program Type:
Access to Care
Target Population:
Providers and Caregivers
Setting:
Clinic

Nature of the Problem

Major Depressive Disorder (MDD) is a chronic, often recurrent, and disabling condition that affects 5-10% of adults in the United States every year. In primary care, MDD is estimated to affect 10-14% of patients, yet rates of detection are low. For cases that are diagnosed, treatment is often delayed, and of those treated with antidepressants, only one out of five receive adequate treatment, contributing to poor outcomes in primary care settings. Estimates suggest only 6% of MDD patients achieve remission with acute-phase treatment. While universal screening can improve the detection of depressive disorders, clinical outcomes in primary care settings continue to suffer in the absence of high-quality evidence-based care. Primary care clinics serve as the initial access points for much of the general population, and encounters in these settings provide optimal opportunities to address depression and reduce stigma and barriers surrounding mental health. However, barriers related to diagnosis, treatment, and establishment of adequate follow-up for depression, including time constraints during patient visits and inadequate provider training, have kept current rates of screening and identification at approximately 4.2% and 47% respectively. A streamlined approach to increase detection and treatment of depression within primary care settings is greatly needed.

Program Description

Dr. Trivedi and colleagues at the Center for Depression Research and Clinical Care (CDRC), a cornerstone of the Peter O’Donnell Jr. Brain Institute at UT Southwestern Medical Center, have worked for decades to improve methodology and tools for earlier identification and treatment of depression in the primary care setting. The SMART-D model – Screening, Measurement and Assessment of Response to Treatment for Depression – utilizes VS6, a point-of-care, web-based application to screen, monitor depressive symptoms alongside treatment adherence and side effects, and support treatment planning with measurement-based care (MBC) and electronic clinical decision support. The use of patient-centered self-report assessments delivered in an electronic format via health-IT with EHR-integration helps to minimize cost, reduce provider burden, provide education and self-efficacy in patients through better recognition of symptoms and change, as well as enhance patient and provider engagement in treatment. SMART-D is also being leveraged as a platform through which the CDRC recruits participants for its two longitudinal research studies which comprehensively examine the biological underpinnings of depression and resilience. Research findings can be translated back into community-based settings through more personalized medicine including predictive models for the diagnosis and treatment of depression as well as innovative resiliency-building preventive strategies.

Disruption

The SMART-D model is uniquely designed to overcome inadequate depression treatment in primary care. First, by conceptualizing and approaching depression as a chronic medical illness and equipping providers with the necessary tools and training, the PCP takes primary responsibility for depression care, leveraging the already established provider-patient relationship and provider expertise in evidence-based care for chronic disorders. The SMART-D team provides a comprehensive training program to clinic providers and staff and works collaboratively with the clinic to build a tailored workflow to seamlessly integrate the application into the clinic’s existing operations. Second, the VS6 application currently offers several health-IT solutions: 1) Electronic clinical decision support facilitates personalized care delivery; 2) Remote Patient Assessment provides patients with the flexibility to complete assessments via their own electronic devices prior to office visits; and 3) The VS6 application is optimized for integration and interoperability with the EPIC EHR.

Leadership

Addressing the lack of universal depression screening and access to evidence-based treatment for depression in Texas and beyond is going to require both resolve and major collaboration among public and private sector partners. We have existing partnerships with policy experts and leaders within other clinical systems, along with additional local, state, and national stakeholders. For example, Dr. Trivedi is the chair of the institution’s Behavioral Health Subcommittee, which aims to improve the quality of behavioral healthcare within the Southwestern Health Resources clinical network. Another example is our partnership with the Meadows Mental Health Policy Institute working on the End Depression Initiative, in which we plan to launch multi-faceted community-wide programming that addresses depression in the workplace, schools, and settings serving underserved residents. SMART-D is a sustainable model that can be continued within our current healthcare systems and community-based settings, as well as expanded to other cities, states, and ultimately nationwide.

Scalability

The SMART-D model was initially launched in 2014 as a quality improvement project, called VitalSign6, through a Medicaid 1115 Waiver aimed to improve access for Texas’ medically underserved community via the Delivery System Reform Incentive Payment (DSRIP) pool. This initial funding allowed us to implement this model within 18 clinics serving a Medicaid/low income/uninsured adult population in Dallas and Denton Counties. Since then, we have secured additional funding that has allowed us to increase the number of our clinic partners, expanding into additional counties, fee-for-service clinics, and pediatric populations, with current operation in 25 clinics. Our achievement of integration with the EPIC EHR has allowed us to take the first step towards expansion of SMART-D throughout the Southwestern Health Resources system, consisting of over 4,000 providers, and we are currently piloting and testing implementation within our first two family medicine practices.

Results/Outcomes

Dr. Trivedi’s work has been at the forefront of transforming the quality of depression treatment. The STAR*D study established that systematic assessment of symptoms, treatment side effects and adherence at defined intervals using research-validated self-report instruments is not only associated with two times higher rates of remission, but also that high quality treatment can be achieved in primary care settings with outcomes equal to those of specialty care settings. Expansion of this early work into the VitalSign6 project and beyond has demonstrated that SMART-D can be successfully implemented within real-world community settings. Since August 2014, over 50,000 total patients have been screened for depression within our community partners, of which ~20% have screened positive. 87% of patients with a confirmed depressive diagnosis have been entered into MBC treatment, with 25% of patients currently in full remission of their depression symptoms – a significant increase from the 6% national average.