This Survey of Clinic and Medical Group Leaders Is Very Important to Understanding The

Appendix Introduction

This survey of clinic and medical group leaders is very important to understanding the effects of the DIAMOND Initiative. Your completion of the following items should take no more than 10-15 minutes, and it will allow us to develop information for all participants in the Initiative that is needed for:

1. Documenting the changes in practice systems that occur as part of participation in the DIAMOND Initiative 2. Learning which of those system changes are most important for producing improved care

In your answers, please focus on either your clinic (for clinic leaders) or on the cluster of clinics that are participating in the DIAMOND Initiative (for medical group leaders). Each question requires a response in order to move to the next screen.

This survey, or survey excerpt, was developed and is owned by the National Committee for Quality Assurance (NCQA). Any party that wishes to use the survey or a portion of it must seek approval by NCQA. Access and Communication

1. Does your clinic(s) have the following standardized processes to support patient access and communication with the clinic(s)? Yes, Yes, needs works well improvement No Don’t Know Scheduling patients with a personal clinician whenever possible Scheduling same day appointments based on patients’ requests

Patient Tracking and Registry Functions

2. Does your clinic(s) use and electronic data system that enables identification of the status of age-appropriate preventive services for your clinic as a whole? (i.e. can your clinic easily report on the percentage of patients up-to-date for specific preventive services?) Yes, Yes, needs works well improvement No Don’t Know

3. What best describes the medical records and information systems at your practice site? (check one) Paper record only Paper record supplemented with some electronic ordering or data systems (e.g., lab, radiology, prescriptions) Electronic medical record with separate ordering data systems Electronic medical record that handles all functions Other (please describe)

4. Does your clinic(s) use the following electronic or paper-based charting tools to organize and document clinical information in the medical record? Yes, Yes, needs works well improvement No Don’t Know Problem list Flow sheet for depression care List of over-the-counter medications, supplements, and alternative therapies List of prescribed medications, including both chronic and short-term A place to record at least 3 age- appropriate risk factors A place to record age-appropriate preventive services

5. Does your clinic(s) have a system to identify and send reminders to patients who are due for the following services? Yes, Yes, needs works well improvement No Don’t Know A follow-up visit for depression Prescription renewal for antidepressants Preventive services (e.g. immunizations, mammograms) Management of Preventive and Chronic Care

The next two sections ask about the specific tools and processes your practice has in place for organizing care for patients with chronic conditions.

Each Question requires a response.

6. Have all the clinicians in your practice agreed to follow evidence-based treatment guidelines for the following conditions and preventive services? Yes No Don’t Know Depression Age-appropriate screening tests Age-appropriate immunizations (e.g. influenza) Age-appropriate risk assessments (e.g. smoking, alcohol) Counseling (e.g. smoking cessation)

7. For each of the following conditions or preventive services, does your clinic(s) use guideline-based reminders, flowsheets, checklists, or other templates to remind physicians about needed services at the point of seeing the patient? These can include alerts within an EMR or paper notes attached to the front of the chart. Yes, Yes, needs works well improvement No Don’t Know Depression Age-appropriate screening tests Age-appropriate immunizations (e.g. influenza) Age-appropriate risk assessments (e.g. smoking, alcohol) Counseling (e.g. smoking cessation) 8. Do the non-physician members of your staff share responsibility for managing care for patients with depression in the following ways? Yes, Yes, needs works well improvement No Don’t Know Reminding patients of appointments Executing standing orders (e.g., medication refills, test orders, and delivery of routine preventive services) Following patients being treated for depression to assure guideline care Educating patients about self-care for depression Coordinating depression care with external disease management or case management organizations.

9. What components of care management are routinely provided to your patients with depression?

Do members of your practice staff or others … Yes, Yes, needs works well improvement No Don’t Know Perform pre-visit planning to assure that all needed information is available at the time of the visit (e.g., consult reports, PHQ9 scores) Measure depression severity at least monthly for newly treated patients Evaluate each patient newly diagnosed with depression for alcohol misuse and chemical dependency Identify and review all prescribed and over-the-counter medications, supplements, and alternative therapies with patients at each visit Complete after-visit follow-up for depression care (e.g., by a nurse or care manager) at each visit Closely monitor patient response and adherence to the care plan for depression Follow up when patients with depression have not kept important appointments 10. Does your clinic(s) have a system in place to assure that patients with depression: Yes, Yes, needs works well improvement No Don’t Know Receive more specific diagnostic codes than 311 (e.g., 296.2, 296.3) Receive treatment intensification if they fail to improve Are routinely reviewed by a psychiatrist if they are complex or failing to improve

11. What components of care management are routinely provided to your patients with depression?

Do members of your practice staff or others … Yes, Yes, needs works well improvement No Don’t Know Review and individualize the care management plan with patients Help patients set individualized treatment goals Review patient’s history of targeted clinical measurements over time (e.g. PHQ9 scores) Assess barriers when patients have not met treatment goals Assess barriers when patients have not filled, refilled or taken prescribed medications Provide a personalized relapse prevention plan to patients finishing active treatment

12. For patients with depression, does your clinic(s) routinely use the following activities to encourage patient self-management? Yes, Yes, needs works well improvement No Don’t Know Provide or connect patients to self- management support programs Provide educational resources in the language or medium that the patient understands Assess patient preferences, readiness to change, and self-management abilities 13. Are the following care management services in place to proactively identify and assist patients who receive depression care in inpatient or emergency facilities? These can be performed by the clinic(s) or an external organization. Yes, Yes, needs works well improvement No Don’t Know Identification of patients who have received depression care elsewhere (including hospitals, skilled nursing facilities, or emergency rooms ) Follow-up calls to patients with depression after discharge from other Coordination of care with external disease management or case management organizations, as appropriate

14. Check the appropriate boxes if you have a nurse of comparable person who serves as a care manager (provides education, follow-up, etc.) for patients with each of the following conditions. Check all that apply.

Depression Diabetes Heart Disease Asthma None

Test and Referral Tracking

15. Does your clinic(s) have a system outside of the paper chart to track care for patients with depression? Yes, Yes, needs works well improvement No Don’t Know Registry of all patients being treated for depression to monitor progress and track follow-up needs Tracking of mental health referrals until the consult report returns Performance Monitoring and Quality Improvement

16. Does your clinic(s) measure or receive results on the following types of performance measures for depression care? Yes, Yes, needs works well improvement No Don’t Know Clinical process (e.g., % of depressed patients who continue on antidepressants for 3 or 6 months) Clinical outcomes (e.g., depression response or remission rates) Patient experience of care from surveys of patients

17. Do your quality improvement activities for depression care include: Yes, Yes, needs works well improvement No Don’t Know Setting goals based on measurement results Taking action to improve performance of individual physicians Taking action to improve performance of the clinic(s) as a whole

18. On a scale of 1-10, where 1 = not a priority and 10 = highest priority of all, please rate the following: Not a Highest priority Priority Considering all the priorities your clinic(s) have over the next year (e.g., EMR, financial goals, quality improvement of various conditions, MD 1 2 3 4 5 6 7 8 9 10 recruitment), what is the priority of your clinic(s) for improving depression care?

Overall Comments

19. Please share any additional comments or thoughts about your clinic(s) systems for depression care. The 62 PPC-RD items by CCM concept mapped to whether they are considered a DIAMOND item (N=21), Depression-Specific scale item (N=41), or CCM scale item (N=41). The 20 non-DIAMOND depression items can be identified by comparing columns 1 and 2, and the 21 non-depression CCM items can be identified by comparing columns 2 and 3.

DIAMOND Depression- CCM Specific Scale Scale

Health Systems Measures or receives results of performance measures for depression care clinical processes x x clinical outcomes x x patient care experience surveys x x Quality improvement for depression care includes setting goals based on results x x Improving physician performance x x Improving clinic performance x x

Delivery System Redesign Standardized processes for access and communication with the clinic Scheduling patients with personal clinician x same day appointments x Non-physician staff share responsibility for managing care for depression patients by Reminding patients of appointments x x executing standing orders x x Assuring guideline care x x Educating patients about self-care x x Coordinating external care x x Components of care management routinely provided to patients with depression Pre-visit planning x x measure depression severity monthly x x Evaluate for alcohol/chemical use x x Review all medications x x after-visit follow-up x x Monitor response and adherence x x follow-up on missed appointments x x Services to identify and assist patients who receive inpatient or emergency care Identify patients who received care x x Follow-up calls after discharge x x Coordinate external care x x Care manager for patients with depression x x diabetes x heart disease x asthma x

Clinical Information Systems chart tools: flow sheet for depression care x x problem list x list of OTC meds, supplements, therapies x list of Rx meds x list of age-appropriate risk factors x list of age-appropriate preventive services x Non-paper system for Registry of depression patients x x Tracking referrals x x electronic data system to identify age-appropriate preventive x services non-paper medical records and information systems x

Decision Support MDs agree to guidelines for The 62 PPC-RD items by CCM concept mapped to whether they are considered a DIAMOND item (N=21), Depression-Specific scale item (N=41), or CCM scale item (N=41). The 20 non-DIAMOND depression items can be identified by comparing columns 1 and 2, and the 21 non-depression CCM items can be identified by comparing columns 2 and 3.

DIAMOND Depression- CCM Specific Scale Scale depression x x screening x immunization x risk assessment x counseling x Templates remind MDs of needed services for depression x x screening x immunization x risk assessment x counseling x System in place to assure patients Receive specific diagnosis codes x x Receive treatment intensification x x Review by psychiatrist if fail to improve x x

Self-Management Support System to identify and remind patients for Follow-up visit for depression x x Rx renewal for anti-depressants x x preventive services x Components of care management routinely provided to patients with depression Individualized care management plan x x Individualized treatment goals x x Review targeted clinical measures x x Assess barriers if tx goals not met x x Assess barriers if Rx not filled/refilled x x Personalized relapse prevention plan x x Activities to encourage patient self-management Connect to self-management programs x x Provide resources in language or medium patient x x understands Assess preferences, readiness and self-management x x abilities