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Question Answered step-by-step Please read ONE De Los Santos, M. (2021). Pressure injury prevention in long-term care. American Nurse Journal, 16of the two scholarly writing articles. Select either: After reading them, please critically evaluate one or both them. Provide details and references if possible.  (7): 6-10.THE Centers for Medicare and Medicaid Services report that pressure injuries (PIs) affect millions of patients each year, with incidence rates ranging from 2.2% to 23.9% in long-term care organizations. PIs occur as a result of intense or prolonged pressure in combination with shear and are affected by excessive heat and moisture, poor nutrition and blood circulation, chronic illness, and soft-tissue conditions (for example, an abrasion or sprain). For 3 years, PI prevalence increased at a Texas long-term continuing care retirement community that provides independent living, assisted living, memory care, and skilled nursing. The organization faced several challenges, including the lack of a nurse educator and inconsistent continuing education for nursing staff. To address these challenges, a PI quality improvement team, consisting of the director of nurses, an assistant director of nurses, an RN, a licensed practical nurse (LPN) and a certified nurse assistant (CNA), was created to develop an evidence-based practice (EBP) project of educational interventions and strategies for consistent PI prevention. The project was part of the author's doctor of nursing practice (DNP) program. First steps The QI team started the project by using the PICOT (Patient, population, problem; Intervention; Comparison, control; Outcome, objective; Timeframe) mnemonic to develop this question: P: In LPNs caring for older adult residents in nursing homes, I: how will the implementation of a formal PI prevention program Pressure injury prevention in long-term care Follow the evidence to improve outcomes. By Melissa De Los Santos, DNP, RN LEARNING OBJECTIVES 1. Describe strategies for preventing pressure injuries (PIs) in long-term care (LTC). 2. Discuss how to implement a project designed to prevent PIs in LTC. The author and planners of this CNE activity have disclosed no relevant financial relationships with any commercial companies pertaining to this activity. See the last page of the article to learn how to earn CNE credit. Expiration: 7/1/24 CNE 1.6 contact hours MyAmericanNurse.com July 2021 American Nurse Journal 7 C: compared to no formal program O: affect PI incidence T: over a 5-month period? A systematic literature search was then completed across three databases (PubMed, CINAHL, and Cochrane Library). The search initially yielded more than 65,000 articles, but applying subject headings when possible and reviewing journal titles and abstracts narrowed the results to 51 articles. The inclusion criteria for those articles consisted of participants 18 years of age and older, articles published within 10 years, and those written or translated in English. Exclusion criteria included treatment options such as redistribution devices, wound care products, non-English items, and articles published before 2008. Applying these criteria and removing duplicate articles reduced the number to 20 studies: four Level I studies, four Level IV studies, two Level V studies, seven Level VI studies, and three Level VII studies from around the world. (See Hierarchy of evidence.) On the basis of a study analysis, the team found a body of evidence indicating that formal PI programs with consistent PI prevention education, interdisciplinary techniques, standardized PI risk assessments, increased communication, consistent documentation, and ongoing monitoring can help decrease PI incidence. Building the project Building the formal PI program required determining the stakeholders and establishing a timeline. Stakeholders Project stakeholders were the facility residents and their families, CNAs, staff RNs and LPNs, nursing administrators, and the organization's leaders. The EBP project included all residents who were at risk for PIs, and all received prevention strategies. Timeline Preliminary discussions began in the fall of 2018 and concluded in the spring of 2019, when the project received approval by the university, the DNP program, and the long-term care organization (the project didn't require institutional review board approval). By the end of 2019, QI team meetings were planned and support and resources were finalized. A timeline with evidence-based interventions and outcomes organized, captured, and documented three project implementation phases: educational intervention, implementation, and sustainment and dissemination. Health information collected as part of the project was deidentified. I used a logic model as the framework for my project. (See Logic model in action.) Launching the project The EBP project launched on July 1, 2019, with self-paced online PI education, risk assessments (weekly and Braden Scale assessments), interdisciplinary teamwork strategies, PI prevention strategy communication, and documentation using PI identification communication tools and repositioning charts to increase reporting and encourage ongoing monitoring. I led four staff development sessions on all shifts to introduce the EBP project to nursing staff. Participants completed a pretest (to gauge current PI knowledge) before the online education program and a post-test after. Phase 1: Educational intervention Phase one consisted of implementing three online, self-paced PI education modules from an outside vendor and developing the quality improvement team. The team's responsibilities included increasing PI prevention communication, promoting an effective multidisciplinary team, discussing goals in staff meetings, monitoring progress, assisting with accurate documentation of PI prevention strategies, and promoting sustainability. The 20-week nursing staff educational program focused on consistent use of PI risk assessment methods, effective interdisciplinary strategies, increased communication, and accurate documentation of PI prevention strategies. Integrated checklists served as reminders to consisHierarchy of evidence Different types of studies provide different levels of evidence. • Level I—Systematic review or meta-analysis of all relevant randomized controlled trials (RCTs) • Level II—Well-designed RCTs • Level III—Well-designed controlled trials without randomization • Level IV—Well-designed case control and cohort studies • Level V—Systematic reviews of descriptive and qualitative studies • Level VI—Single descriptive or qualitative study • Level VII—Opinions of authorities, reports of expert committees Source Mazurek Melnyk B, Fineout-Overholt E. Evidence-based Practice in Nursing & Healthcare: A Guide to Best Practice. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2018. 8 American Nurse Journal Volume 16, Number 7 MyAmericanNurse.com tently implement the change based on current protocols. For example, RNs completed monthly comprehensive skin assessments; LPNs completed quarterly and as-needed Braden Scale assessments; RNs and LPNs completed weekly skin assessments; and CNAs, restorative aids, and medication aids completed daily skin assessments during routine care. Flyers posted in the breakroom, next to the time clock, and behind both nurses' stations outlined the importance of implementing and documenting PI prevention. (See Promoting PI prevention.) Phase 2: Implementation Phase two focused on PI prevention strategies, consistent use of the Braden Scale, and weekly skin assessments. Two project implementation forms (a PI identification communication tool and a repositioning chart) previously used within the organization were resurrected for this project. Daily skin checks were documented on the PI identification communication tool, and PI prevention strategies, such as turning residents on a schedule, were documented on repositioning charts. Phase 3: Sustainment Phase three consisted of sustaining the prevention strategies, conducting team meetings, developing a skin algorithm, and incorporating project implementation forms into the electronic health record. Analyzing outcomes Outcome analysis included educational interLogic model in action A logic model is a graphic tool for planning, describing, managing, communicating, and evaluating a program or intervention. It consists of two main sections: process (inputs, activities, and outputs) and outcomes (short-, medium-, and long-term goals). Frequently, assumptions and contextual or external factors also are included. The author used the body of evidence and recommendations in the literature to create the model for the project described in the article. The process section helped guide implementation, and project outcomes were planned, outlined, and appraised throughout. External factors included the time it would take to complete training, and underlying assumptions included awareness of prevention strategies that will decrease PI risk. CNAs = certified nursing assistants, ID = identification, LPNs = licensed practical nurse, MAs = medication aids, PI = pressure injury, PIP = pressure injury prevention, RAs = restorative aids Learn more about logic models at cdc.gov/dhdsp/docs/logic_model.pdf. • Staff members (RNs, LPNs, CNAs, MAs, RAs) • PIP online education on Braden Scale, PI ID Communication Tool, and Repositioning Chart • Access to resident electronic charts and meeting rooms Inputs • By month 5, there will be a reduction of PI rates and costs associated with treatment in residents Outcomes • Conduct training sessions for accurate implementation and documentation of Braden Scale Activities • Inservices or workshops for staff leading to better documentation and increased reporting of skin alterations and PIs will occur • PIP education will be completed during the first month of implementation and available online for reinforcement for future use Outputs • By the first month after training, there will be an increase of knowledge of PI risk factors as evidenced by consistent use of Braden Scale, PI ID Communication Tool, and Repositioning Chart • By month 3, there will be an increased proportion of staff implementing strategies to decrease the risk of PIs as evidenced by consistent use of Braden Scale, PI ID Communication Tool, and Repositioning Chart and decreased incidence of PIs in residents Short-term goal Medium-term goal Long-term goal • Time to complete training • Paid or unpaid training • Other protocols currently being implemented External factors • Improve health outcomes by eliminating PIs Impact • Awareness of PIP strategies will decrease risk of PIs. • Consistent and accurate use of PIP risk assessments will decrease risk of PIs. • Increased understanding of PIP will decrease costs and improve health outcomes. • Empowering staff will influence behaviors to improve health outcomes. Assumptions MyAmericanNurse.com July 2021 American Nurse Journal 9 vention, PI prevention strategies, PI rates, and cost savings. Educational intervention The educational intervention yielded a 57% nursing staff completion rate. Knowledge change was calculated by analyzing staff pretest and post-test scores. In the pretest, 61.5% of nursing staff scored 80 on the PI assessments and 42% scored 100. In the post-test, 13% of staff scored 80 and 87% scored 100 (a more than 50% increase in 100 scores). PI prevention strategies In two-thirds of cases where CNAs had documented abnormal skin concerns on the PI identification communication tool, RNs and LPNs responded by completing multiple Braden Scale assessments, even though there was no formal protocol requiring them to do so. The results confirmed the value of the tool. Results also indicated the benefits of implementing multicomponent PI prevention initiatives, such as turning, repositioning, and mobilizing frequently, along with other interventions (such as completing the Braden Scale, skin assessments, special mattresses, topical products, heel protectors, pillows, nutritional assessments and interventions, hydration, PI reporting, and communication). Analysis of Braden Scale score averages and repositioning frequency percentages showed that patients with a high-risk Braden Scale score (between 10 and 12) had a 71% repositioning average; moderate risk (13 to 14) had a 59% repositioning average; at risk (15 to 18) had a 66% repositioning average. Inconsistent documentation affected the results, but repositioning averages were at or above 59% consistently. PI rates For 3 years, PI incidence rates at the organization had been rising steadly, from 0.67% in 2016 to 2.3% in 2017 and 5.3% in 2018. The national average was 7.2% to 7.3%. The EBP project achieved anticipated decreased PI rates. Between July and December 2019, four Stage II PIs were reported during the intervention (4% PI incidence rate in 2019), resulting in a 25% decrease in PI rates. Based on analysis, more consistent use of the PI identifiction communication tool with appropriate followup may have prevented more PIs. Cost savings According to the Agency for Healthcare Research and Quality, PIs in the United States cost between $9.1 and $11.6 billion per year. Costs associated with legal action resulting from facility-acquired PIs add to the economic burden. Based on the evidence, the EBP Promoting PI prevention As part of the quality improvement team's efforts to educate nursing staff about pressure injury (PI) prevention, they created a flyer to post throughout the organization. The flyer promoted staff empowerment through education and encouraged the use of a repositioning/skin inspection chart and a PI identification communication tool. At the end of each shift, completed charts and tools are submitted to the assistant director of nursing, who promptly reviews them to identify any new skin issues. Repositioning/skin inspection chart When developing the care plan, consider comorbid conditions, such as frailty and dementia. • Change the patient's position at least every 2 hours. • Reposition patients sitting in chairs every hour. • Inspect skin during activities of daily living. • Document the patient's position and skin inspection every shift. (View a repositioning chart at myamericannurse.com/?p=258423.) PI identification communication tool • Complete on all residents daily during routine care every shift. • If the skin inspection reveals an area of concern, note it on the tool below. PI identification communication tool Date: Check all that apply: Resident's name: n No skin problem noted Reporter's name: n Bruise n Skin tear n Reddened area Place an "X" on the area of the body where you see a concern. Reporter's signature ______________________________________________ Nurse's signature (if reporter is not a nurse) __________________________ 10 American Nurse Journal Volume 16, Number 7 MyAmericanNurse.com project was expected to reduce PI prevalence by at least 62%. This long-term care organization's financial policies prohibited the discovery of direct costs, but because PI prevalence decreased by 25% between July and December of 2019, it's safe to assume some savings occurred. In addition, it's reasonable to conclude that decreased PI prevalence rates are viewed as desirable by potential residents, which could increase revenue from patient recruitment. Sustaining the intervention To support sustainability and continued use of evidence for data-driven changes, the QI team developed a skin integrity algorithm. (See Skin integrity algorithm.) The team also recommended to nursing leadership that the organization continue to use Braden Scale and weekly skin assessments. The EBP project prompted a culture change within the organization, enhancing PI awareness and continued use of the implementation forms by nursing staff after the EBP project ended. Closing the gap This EBP project used evidence to close the gap between knowledge and action. Continued efforts include integrating implementation forms and the skin integrity algorithm into electronic formats for permanent use. Other recommendations are incorporating increased EBP into long-term care facilities for better outcomes and to increase the quality of care for all residents. AN Access references at myamericannurse.com/?p=258423. Melissa De Los Santos is a professor in the vocational nursing program at Austin Community College, Eastview Campus in Austin, Texas. Skin integrity algorithm To ensure the pressure injury (PI) prevention evidence-based practice was sustained, the quality improvement team developed a skin integrity algorithm. Weekly skin assessment No abnormal finding Abnormal finding Continue Braden Scale assessments per protocol Nurse follow-up assessment and complete a Braden Scale assessment Braden Scale risk scores* Mild-risk scores (15 to 18) Encourage mobilization, turning, and repositioning; document on repositioning chart every shift. Assist with peri-care and ADLs as needed. Maintain hydration and nutrition. Assist with mobilization, turning, and repositioning; document on repositioning chart every shift. Assist with peri-care and ADLs every shift. Implement consultations with physician, wound team, and dietician as needed. Assist with mobilization, turning, and repositioning; document on repositioning chart every shift. Assist with peri-care and ADLs every shift. Consult with physician, wound team, and dietician for additional interventions. Inspect, report, and document skin concerns on PI identification communication tool every shift. Inspect, report, and document skin concerns on PI identification communication tool every shift. Assist with hydration and nutrition every shift. Inspect, report, and document skin concerns on PI identification communication tool every shift. Assist with hydration, nutrition, and offer supplements every shift. Moderate-risk scores (13 to 14) High-risk scores (12 or below) ADLs = activities of daily living, PI = pressure injury *For this project, the Braden Scale Score for very high risk (9 or below) was incorporated into the high-risk score. MyAmericanNurse.com July 2021 American Nurse Journa  ORSchaeffer, A.M. & Jolles, D. (2019). Not missing the opportunity: Improving depression screening and follow-up in a multicultural community. The Joint Commission Journal on Quality and Patient Safety, 45: 31-39. Not Missing the Opportunity: Improving Depression Screening and Follow-Up in a Multicultural Community Ann M. Schaeffer, DNP, CNM; Diana Jolles, PhD, CNM Background: Screening for depression and documenting follow-up is a National Quality Forum-endorsed measure. Yet only seven states report depression screening and follow-up, making it the fourth-least-reported measure on the Medicaid Adult Core Set. In 2016 a multicultural health center found that only 9.1% of clients were screened and followed up for depression. This quality improvement project was conducted to increase the efficacy of Screening, Brief Intervention, and Referral to Treatment (SBIRT) for depression to 75% for screen-positive clients. Methods: Four Plan-Do-Study-Act (PDSA) cycles in a 90-day period focused on depression screening, patient engagement, population health management, and team building were used. The package of interventions—use of written standardized Patient Health Questionnaire (PHQ) screening tools in six languages, the Option GridTM for clients with positive PHQ screens, a "right care" tracking log for those clients, and team meetings and in-services to support capacity building—were operationalized using a point-of-care notebook that created a physical reminder and trigger for the use of the intervention tools. Surveys, charts, and registry data were analyzed to evaluate the population health impact of the interventions. Results: Provision ofevidence-based careincreased to 71.4%, and adherenceto follow-up increased from 33.3% to 60.0%. Screening in the client's preferred language increased the rate to 85.2%, identifying a positive PHQ incidence of 45.5%. Conclusion: Rapid-cycle improvement with a population health focus demonstrated improved depression screening and follow-up within a multicultural community health center. Outcomes were attributed to team engagement and the use of standardized tools. These processes can be applied to other primary care settings. The economic burden of depression in the United States is estimated at $210 billion annually,1 and worldwide, depression is the leading cause of disability.2 However, depression often goes unaddressed, particularly for minorities, immigrants, and refugees.3,4 The incidence of depression is also higher in those with comorbidities such as diabetes.5 Evidence-based guidelines recommend screening for depression when systems exist for adequate diagnosis, treatment, and follow-up.6 Increasing the efficacy of depression screening in primary care is a Healthy People 20207 and a National Quality Forum-endorsed measure found in the Centers for Medicare & Medicaid Services Adult Core measurement set.8 The measure has been demonstrated to have population health impact and is reliable, valid, relevant, and feasible. However, in the latest report of core adult quality metrics, only seven states reported screening for clinical depression and follow-up plan, making it the fourth-leastreported measure on the Medicaid Adult Core Set.8 The following project seeks to demonstrate how rapid-cycle improvement methodology can lead to improvements in depression screening and follow up. Harrisonburg Community Health Center (HCHC) is a Federally Qualified Health Center (FQHC) in rural 1553-7250/$-see front matter © 2018 The Joint Commission. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jcjq.2018.06.002 central Virginia that provides primary care to more than 12,000 patients, 47.5% of whom do not speak English as a first language.9 Audits from 2016 indicated that only 9.1% of HCHC clients were screened and followed up appropriately for depression, yet a community stakeholder survey identified depression as a major health concern.9,10 A gap analysis indicated many processes in need of improvement to achieve "right care" for depression at HCHC (Table 1). Research suggests that screening for depression is not enough; only when diagnosis, treatment, and follow-up occur, preferably in a team-based setting, do patients demonstrate significant improvement over time.11 Available Knowledge Cultural contexts can complicate treating depression in clients with minority, immigrant, or refugee status.4,12 The quality of therelationship with the provider may affect willingness to accept treatment, and the concept of a "warm handoff" may be confusing.3,13 Among various cultural groups, patients may downplay symptoms of depression, which can go unrecognized without careful screening.4,14 While language barriers can affect screening, depression screening tools are often valid when translated into other languages.15-17 Provider knowledge of right care for depression is a gap in best practice. Research suggests that providers who rely 32 Ann M. Schaeffer, DNP, CNM; Diana Jolles, PhD, CNM Not Missing the Opportunity Table 1. HCHC Practice Gap Analysis Best Practice∗ Best Practice Strategies How HCHC Differs from Best Practice Members of the care team understand the importance of depression screening. • All clinic staff receive training on depression screening and care. • A team-based approach to depression screening is more likely to be successful. • No routine training/education on depression. Evidence of team approach lacking. • PHQ-2 not a routine part of rooming the client. No standard of care for follow-up. All care team members who give the PHQ are able to score and interpret the results. • Follow prompts to administer PHQ-9 when PHQ-2 is positive. • Interpret results accurately using a rubric. • Report results to provider; initiate warm handoff to behavioral health. • Sometimes PHQ-9 is given even when PHQ-2 negative. • PHQ-9 score and assigned diagnosis may not be in agreement. • Only providers initiate warm handoffs. Cultural barriers/lack of understanding may exist about warm handoff process. Clients are screened at new visits, on an annual basis, or when clinically indicated. • New clients are screened at the first visit. • Clients are screened annually, or when indicated. • Previous PHQs are readily found in the EHR. • Not all new clients are screened. • Not all clients are screened. Varies by provider and service line (adult health vs. peds). • Previous PHQ scores can be difficult to locate quickly. For +PHQ, a correct diagnosis, client education, and a plan are documented. • Severity of depression assessed and diagnosis assigned. • Educate client, incorporate shared decision making. • Plan is documented in the chart. • Diagnoses vary, may not correlate with PHQ-9 score. • Depression education varies by provider. Care plan for +PHQ client varies, and no standard tools or resources are used. • Documentation of plan varies. When the PHQ-9 is positive, the client is appropriately offered resources for referral. • For practices with integrated BH, a warm handoff is offered and facilitated. • Options for community counselors and psychiatry are available for clients interested in that option. • Clients are followed for depression until improvement/remission. • LCSW is available for warm handoffs most days. Cultural confusion may exist about the warm handoff purpose. • Lists of community counselors are available. Psychiatry is available in the community; waiting time for new appointments can be lengthy. • PHQ rarely repeated in the same year to track changes in score over time. Clients receive appropriate follow-up after a positive depression screen. • Clients receive phone calls and/or follow-up appointments per guideline or toolkit. • Clients are followed for depression until they achieve improvement of symptoms. • Clients scheduled for return visits at irregular intervals (range: 2 weeks-6 months). No option for phone calls. • High no-show rate for follow-ups. PHQ rarely repeated within the same year to track changes in scores over time. Collaborative depression care is performed in a primary care setting to improve outcomes. • Plan of care is clearly documented. • Primary care setting includes BH services. • A care manager or team member coordinates care and follow-up. • Plan of care is inconsistently documented in the chart. • HCHC has behavioral health services available. • Depression screening, treatment, and follow-up are not being managed by care coordinator or team member. Whenever possible, depression screening and treatment are culturally appropriate and offered in the client's first language. • Written PHQ-2/PHQ-9 is available in multiple languages, as is SDM tool. • All written resources/materials are available in client's primary language. • Warm handoff/BH interventions are conducted in the client's language. • PHQ is done verbally, with use of interpreter when needed. No SDM tool used. • Few written resources exist; lists of counselors, community health resources, are available only in English. • Usually yes, if interpreters are available. Language line is available. ∗ Best practices per the US Preventive Services Task Force Recommendation Statement on Screening for Depression in Adults.6 HCHC, Harrisonburg Community Health Center; PHQ, Patient Health Questionnaire; EHR, electronic health record; peds, pediatrics; BH, behavioral health; LCSW, licensed clinical social worker; SDM, shared decision making. on clinical judgment, instead of a screening tool, underdiagnose depression significantly.4,18,19 Resources such as the Community Care of North Carolina (CCNC) Adult Depression Toolkit for Primary Care (2015)20 provide evidence-based algorithms to guide screening, treatment, and follow-up. In addition, the US Preventive Services Task Force (USPSTF) recommendation statement emphasizes that appropriate care for depression involves a multidisciplinary care team that collaborates effectively.6 Such resources emphasize common themes: appropriate screening, shared decision making, and timely, evidence-based treatment.6 Volume 45, No. 1, January 2019 33 Table 2. PDSA Cycles: Interventions/Tests of Change Intervention PDSA cycle 1: 7/10/2017-7/23/2017 PDSA cycle 2: 7/24/2017-8/6/2017 PDSA cycle 3: 8/7/2017-8/20/2017 PDSA cycle 4: 8/21/2017-9/3/2017 Teamwork meetings • Inservice team • Provide care plan "cheat sheets" • Share project progress • Coach correct documentation • Stakeholder meeting • "Hallway" project breakfast • Team meeting • Continue sharing project progress • Reinforce screening process, SDM • Warm handoff checklist added to SDM tool • Screening contest • Continue sharing progress, patient stories PHQ Depression Screening • Written PHQs • Blue Books—screening resource/trigger • Spread to second provider • Double # of Blue Books • Previsit planning • Smiles Cards— screening trigger • Continue written PHQs, Blue Books • Sustain the gains: written PHQs, Blue Books, previsit planning, Smiles Cards trigger Patient Engagement/ Brief Intervention—Option Grid • Option Grid (SDM tool) for +PHQ patients. • Spread to second provider • +PHQ template development • Continue Option Grid • Use +PHQ template • Chart audits • Continue Option Grid • Warm handoff education added to Option Grid • Continue Option Grid, +PHQ template Right Care Tracking Log • Begin tracking log for +PHQ patients • Spread to second provider • Revised log template • CCNC phone call form to team • Start follow-up phone calls • Continue using log; add follow-up visits, calls • Sustain the gains: use log, track follow-ups, continue phone calls PDSA, Plan-Do-Study-Act; SDM, shared decision making; PHQ, Patient Health Questionnaire; CCNC, Community Care of North Carolina. Rationale Studies have shown that screening alone yields weak benefits for depression, but when followed by evidence-based treatment protocols the benefits are much more significant.11,21 Screening, Brief Intervention, and Referral to Treatment (SBIRT) was developed as an evidence-based approach to identify and treat disorders related to substance abuse.22 In recent years, SBIRT has been applied to other chronic health conditions with success and was chosen as a model for this project based on an analysis of the practice gaps (Table 1). Studies that include SBIRT processes for depression such as shared decision making and timely follow-up demonstrate improved outcomes for depression.11,23 Interventions that respect cultural variations and engage stakeholders are more likely to result in positive responses to the SBIRT process.24 After careful review of the local system, the recent literature, and baseline data, the aim of this project was to increase the efficacy of depression screening and follow-up through SBIRT to 75% of screen-positive clinic clients in 90 days. METHODS HCHC is a rapidly growing FQHC in central Virginia, with three clinic sites. While the clinic is located in a midsized city that serves as a major refugee resettlement area, the surrounding county is rural, with a growing population of more than 200,000.10 Providers are both APRNs and MDs/DOs, and a multilingual team of clinic staff and interpreters areemployed. This project took placefrom lateJune to early September 2017 at the main clinic, which serves the most multicultural clientele, and was implemented with two provider teams (one certified nurse midwife and one physician). In this initiative, the nurse midwife was the project leader and served as a coach and resource, aided by a multidisciplinary team of committed clinic staff. The project was identified as a priority by leadership and therefore had support at the administrative level. The participating physician was the clinic medical director. Interventions Four core interventions were used throughout the quality improvement (QI) project: use of written standardized Patient Health Questionnaire (PHQ) screening tools in six languages, the Option GridTM for clients who screen positive for depression, a "right care" tracking log for screenpositive clients, and team meetings to support capacity building (Table 2). The package of interventions was operationalized using a point-of-care notebook called the "Blue Book." The book created a physical reminder and trigger for the team to remember to use the intervention tools. The project used the Model for Improvement, rapid-cycle improvement methods, and iterative change to conduct small tests of change prior to spreading across provider teams. The PHQ was used to screen for depression as a brief screening tool. All clients scoring anything other than zero were considered positive and qualified for the brief intervention and follow-up planning. Degrees of clinical depression (mild, moderate, severe) did not influence whether a person 34 Ann M. Schaeffer, DNP, CNM; Diana Jolles, PhD, CNM Not Missing the Opportunity Table 3. Depression Screening and Follow-Up Measures∗ Intervention Operational Definition Baseline (%) Result (%) PHQ Screening Process Measure # PHQ screens complete / # clients seen 32.5 85.2 Outcome Measure # PHQ screen+ (> 0) / # clients screened 12.5 45.5 Option Grid Process Measure # Option Grids completed / # +PHQ clients — 87.5 Outcome Measure Screen+ clients with choice of care plan documented in EHR / # screen+ clients 35.0 85.7 Right Care Treatment Log Process Measure # screen+ clients in log / # screen+ clients — 100.0 Outcome Measure 1. # clients with correctly documented follow-up/ 30.0 75.0 # clients in log 2. # clients completing scheduled visits /# clients in log 33.3 60.0 Team Engagement Meetings Process Measure # staff participating in meetings / # staff 0 94.1 Outcome Measure Average score on teamwork evaluation tool 14.0 16.0 Composite Aim Measure† # PHQ screen+ clients with completed Option Grid, choice of care documented in chart, and completed follow-up visit / PHQ screen+ clients — 71.4 ∗ Balancing measure is quality improvement project lead volunteer time in hours = 241 hours. † Project aim: Increase depression screening and follow-up to 75% in 90 days. PHQ, Patient Health Questionnaire; EHR, electronic health record. was considered positive or not. In addition, all clients were screened during the intervention, and we did not exclude anyone with a previous or current diagnosis of depression. The PHQ has demonstrated a sensitivity of 88% and a specificity of 88% for identification of major depression.25 The tool has demonstrated reliability across racial and ethnic groups.17 For HCHC, the PHQ was used in English, Spanish, Arabic, Russian, Kurdish, Swahili, and Tigrinya, increasing the likelihood of the clients using the tool in the language of their choice. When a client screened positive on the tool—defined as having any score other than zero— the Option Grid shared decision-making tool26 was used to standardize the conversation regarding follow-up options. Interpreters translated the Option Grid into the three primary languages spoken at HCHC (Spanish and Arabic, in addition to English), as research indicated that thetool used with an interpreter is not effective at promoting client engagement.27 Option Grids are standardized tools that help clients share what matters most to them, are easy to read, are simple to use, and meet policy requirements for shared decision making. Elements in the tracking log were chosen based on right care algorithms in the CCNC toolkit and included weekly follow-up phone calls, completed behavioral health appointments, and warm handoff visits to licensed clinical social workers within the primary care setting. All clients who had any degree of positivity were eligible for the follow-up log. Team meetings were conducted every two weeks to provide education, training, capacity building, and a communication mechanism to report feedback regarding the process improvements. Motivational strategies, including ongoing opportunity to provide process improvement feedback, consensus decision making, and a contest to build team performance, were employed. Study of Interventions The use of PHQ screening tools was tracked every three days through a tally of completed paper forms and chart audits. Patient engagement, screening, tracking log, and referral data were collected via chart audits performed every three days, throughout the project. For team engagement, a running tally of staff participating in capacity building was maintained. An evaluation tool was also completed at the end of each clinic day by the team, which tracked teamwork, previsit planning for depression screening, and satisfaction with that day's processes. Additional qualitative data on satisfaction with process changes were collected through conversation with staff and in written comments on the teamwork evaluation tool. Data were entered into a spreadsheet, and results were documented in run charts to monitor progress toward the goals (Table 3). Interpretation of run charts helped guide subsequent tests of change (Table 2). It was particularly important to note emerging trends in the data and potential development of actual shifts over time.28 Measures A total of 10 measures were tracked throughout the 90- day implementation: 4 process measures, 4 outcome measures, 1 composite aim measure, and 1 balancing measure. Measures and operational definitions are detailed in Table 3. Measures were derived from the standardized tools Volume 45, No. 1, January 2019 35 (PHQ and Option Grid), chart audits, team surveys, and follow-up log. The teamwork evaluation tool was adapted from resources at the Agency for Healthcare Research and Quality (AHRQ), as was the huddle tool introduced in the third Plan-Do-Study-Act (PDSA) cycle.14 Analysis Data for all operationalized measures were collected and plotted on run charts, which allowed data to be represented in a time-ordered sequence.28 In addition to reviewing the run charts for emerging shifts and trends, analysis of patterns related to common cause variation and special cause variation were considered.28 Qualitative feedback from the team was documented, and common themes were identified. Starting latein PDSA cycle 3, descriptivestatistics were calculated from the tracking log to gain insight into the frequency and severity of PHQ scores, patients who declined follow-up, and percentage of those experiencing remission of depression symptoms. Finally, this project was excused from review by the Institutional Review Board (IRB) of Frontier Nursing University (FNU) because it met federal requirements for QI and did not qualify as human subjects research. In 2016 FNU implemented a tool to distinguish QI from research and created a faculty work group comprised of IRB members and clinical faculty. This project met the criteria for QI using this established process.29 This project did not benefit from any sources of funding. RESULTS A total of 237 unduplicated clients were served during this project. Over 90 days, the efficacy of depression screening and follow-up at HCHC was improved through SBIRT, largely meeting or exceeding the goals (Table 3). The aim for this project achieved a mean of 71.4%, with an interquartile range of 23.9 and a demonstrated shift realized. Standardized use of PHQ screening, the use of the Option Grid during brief intervention, and a tracking log to manage population health over time were made possible through improvements in team capacity, use of standardized tools, and use of rapid-cycle QI methods. Screening HCHC's previous process of administering the PHQ verbally was unreliable, cumbersome, and often culturally inappropriate for clients, as noted by interpreters on the project team. With the use of paper PHQs in the client's preferred language, plus screening triggers for the team, the rate of screening increased from a baseline of 32.5% to 85.2% from late June to early September 2017, with a total of 123 PHQs administered. The baseline data represent the number of PHQs scoring more than zero detected in HCHC with old processes. This is not the rate of clinical depression; it is the rate of any degree of positive screening, which would then alert the clinic team to investigate the client's depressive symptoms further. With new processes implemented over this project, the rate of positive PHQs was found to be much higher than prior to use of the standardized tool. One result is that more clients were identified for further assessment of their depressive symptoms in a timely manner. As a result, the timely identification of depression increased to a mean of 45.5% and achieved a demonstrated shift (Figure 1).30,31 This rate was not surprising, given the high number of clients with risk factors identified in the literature.4,5 It was outside the scope of this project to report on individual PHQ scores and their subsequent clinical outcomes; however, similar to studies in the literature, we found that relatively low PHQ-2 scores were sometimes associated with suicidality.30,31 This supported the plan to screen everyone and address all screen-positive results with the full PHQ-9 tool. Patient Engagement Improved patient engagement resulted in both process and outcome goals being exceeded (Table 3). The largest barrier to client engagement was successful documentation of shared decision making and the client's voice in his or her own plan of care. Development of a positive PHQ template for theelectronic health record (EHR) during PDSA cycle 2 was instrumental in cuing both shared decision making and its documentation by the provider. Chart audits of patient engagement were also important for tracking and sharing progress back to the team. The Option Grid was well received by clients, but questions frequently arose about the purpose of behavioral health warm handoffs as a treatment option. Adding educational elements to the Option Grid in the client's preferred language helped achieve use of the Option Grid and documentation of the client's choice of care plan more than 80% of the time, exceeding outcome and process goals for client engagement. Follow-Up Previously, HCHC did not have standard guidelines for depression treatment and follow-up; treatment varied by provider. There was no population health management system for clients screening positive for depression. Use of resources in the CCNC toolkit and frequent feedback using data in the tracking log resulted in right care being offered and received 75.0% of the time, demonstrating a trend (Table 3). Starting in the second PDSA cycle, in midJuly, an outcome measure related to successful follow-up was added (Table 3). Data collected from thetracking log in PDSA cycles 2-4 revealed that, of clients declining followup, 45.8% had PHQ scores at or less than 5, comprising a low-risk group. Of the highest-risk patients declining services (PHQ > 16), 100% were already receiving mental health services in the community. 36 Ann M. Schaeffer, DNP, CNM; Diana Jolles, PhD, CNM Not Missing the Opportunity PHQ Positive Screens over Time: Baseline and Implementation Figure 1: Baseline percentage of screen-positive patients prior to the project was 12.5% without a standardized tool being used universally. Written PHQs in English, Spanish, Russian, Arabic, Tigrinya, Swahili, and Kurdish were administered over four PDSA cycles, with provision of screening cues to the team. Only 5% of clients were unable to complete a written PHQ; those were given verbally. Identified PHQ positive (>0) with new processes was 45.5% of all clients seen during the study time period. Loss of care coordinator resulted in a special cause variation in the data late in PDSA cycle 2. PHQ, Patient Health Questionnaire; PDSA, Plan-Do-Study-Act. Adherence to Evidence-Based Follow-Up: Pre- and Post-Project Changes Figure 2: Follow-up included completed phone calls, kept appointments with behavioral health or the provider, and warm handoffs. The last three data points were post-project, and therefore represent long-term follow-up. While compliance declined from the peak, the median remained above the baseline four weeks after the project's conclusion. Data suggest that patient engagement with compliance is higher with shorter, evidence-based intervals for follow-up. PDSA, Plan-DoStudy-Act. With more timely identification of depression and improved patient engagement, compliance with follow-up increased significantly throughout the four PDSA cycles (Figure 2). In addition, in just three PDSA cycles, 15.5% of clients achieved complete remission of their depression symptoms by complying with evidence-based, appropriate care. Although it was outside the scope of this project to measure the effectiveness of depression treatment, this represents an encouraging trend and positively reinforces the value of standardized screening and follow-up as precursors of effective treatment. Volume 45, No. 1, January 2019 37 Percentage of PHQ Positive Clients Who Were Appropriately Screened, Received Education with a Shared Decision-Making Tool, and Evidence-Based Follow-Up Figure 3: Composite measure: To meet the project aim, a client was appropriately screened as positive on the PHQ, engaged with shared decision making using the Option Grid, and choice of care plan, and evidence-based plan of care was correctly documented in the EHR. Inconsistent documentation of Option Grid use and patient's choice of care plan in the EHR led to introduction of the +PHQ template in the second PDSA cycle. Increasing and sustaining team engagement in PDSA cycles 2-4 resulted in higher rates of screening. Team engagement was reinforced with a variety of strategies, including addition of team huddles and sharing de-identified client stories. As a result, by PDSA cycle 4, team members were consistently taking the initiative to screen clients on their own. PHQ, Patient Health Questionnaire; EHR, electronic health record; PDSA, Plan-Do-Study-Act. Team Engagement Team capacity building was an essential part of the process improvements. Education was delivered to 94.1% of the team via project updates every two weeks, de-identified patient stories, and in-services. Teamwork evaluation scores improved, but the goal of a 20% increase was not achieved (Table 3). Contextual elements affecting teamwork included fluctuations in staffing and resignation of the care coordinator in mid-July, which resulted in a loss of previsit planning services, an item on theteamwork evaluation tool. Decisions madeto address these challenges included adding back previsit planning by the project leader, increasing team engagement through a screening contest and provision of regular project updates, and making resources and real-time coaching available during clinic hours. Factors affecting success were the positive PHQ template for the EHR and the team's commitment to screening. The provision of screening triggers to staff and increased real-time coaching for teams were factors believed to drive change. Balancing measures were APRN time, which totaled 241 hours for project planning and implementation. Teamwork evaluation tool scores also provided some insight into unintended project consequences. Scores decreased with loss of the care coordinator but were recovering and improving as the project came to a close. Future projects should continue to expand the evidence for best practices in team-based care for depression. DISCUSSION The project demonstrates how a community health system can incorporate the endorsed quality measure of depression screening and follow-up. The aim of this project reached an overall mean of 71.4%, with a fourth quartile mean of 77.5%, representing improved follow-up care for many of HCHC's clients (Figure 3). Initial goals for standardized screening, patient engagement, follow-up and team engagement were all met. Adherence to follow-up, while not achieving the goal, still increased from a baseline of 33.3% to 60.0% during the project (Figure 2). Strengths of this project included a robust process for team engagement, which supported and drovethescreening process. For a multicultural community, stakeholder input influenced process changes to make screening and follow-up care for depression appropriate. This project can serve as a model for care coordination and for other practices interested in improving right care for depression. 38 Ann M. Schaeffer, DNP, CNM; Diana Jolles, PhD, CNM Not Missing the Opportunity Interpretation Through standardized screening using the written PHQ tool, timely identification of depression increased at HCHC to a mean of 45.5% (Figure 1). Findings of this project are consistent with literature on the use of shared decision making, SBIRT, and right care for depression.11 The rate of any degree of positive, rather than responding only to moderate or severe depression scores, allowed the clinical team to investigate the client's depressive symptoms further and provide client-centered follow-up care. When the systems were in place for brief intervention and followup, they had the capacity to manage all positives regardless of severity. The prevalence of screen-positive clients was not surprising, given the high number of clients with risk factors identified in the literature and the impact of standardized screening on timely identification.4,5 Clients who were at risk for clinical depression were identified, and systems were put in place to reliably respond and track the population over time. Simple physical triggers were used at the point of care to remind the team to use the process tools. It was decided early in the project that resources such as the PHQs, Option Grid, and treatment algorithms needed to be available at the point of care, in clinic rooms. The creation of "Blue Books" containing all needed resources (and so named to avoid potential stigma to clients needing the resources) were placed in exam rooms. Extra Blue Books were created after PDSA cycle 1, and additional resources were included in later PDSA cycles as well. Ongoing feedback to the team after each PDSA cycle about screening rate, client outcomes, and prevalence of positive screenings helped reinforce commitment to the screening process. The Blue Books are believed to have been a trigger that drove process improvement and success across all interventions. The use of the positive PHQ template for the EHR was pivotal for reaching goals for cuing and documenting shared decision making, although it was acknowledged that actual practice may have occasionally varied from documented practice. Studies suggest that shared decision making for depression is most effective when stakeholder input and cultural contexts are considered.24,27 Qualitative data revealed that clients appreciated the Option Grid, particularly in Spanish and Arabic. Follow-up phone contacts in the client's own language were also extremely well received and may have enhanced compliance with follow-up. Overall teamwork evaluation scores were challenged by staff fluctuations but were improved with tools and processes to support and engage the team. Following right care guidelines for depression was a new practice for HCHC, and use of the tracking log was instrumental for providing feedback and to verify compliance with treatment. The literature suggests that team-based, coordinated care is associated with improvement in PHQ scores, an effect that may be sustained over time.21,23 Limitations HCHC serves a uniquely diverse community. Therefore, process changes related to multicultural clientele should be cautiously generalized to less diverse settings. One of the two providers in this project also saw clients younger than age 12, which were excluded from data collection to be in compliance with the USPSTF recommendation.6 Future projects should be preceded by robust processes thatexplore practice gaps and stakeholder priorities and be adapted for thosespecific sites. It was outsidethescope of this project to track and report individual PHQ-2 and PHQ-9 scores and responseto treatment over time. Understanding the value of PHQ-2 and PHQ-9 scores across clinical populations and tracking effectiveness to treatment is an important area of future study. CONCLUSION After four PDSA cycles, the efficacy of depression screening and follow-up careexceeded 70% for two careteams at a multicultural health center, a significant improvement from the baseline of 9.1%. The project demonstrated thefeasibility of using rapid-cycleimprovement to improve depression screening and follow-up within a multicultural community health center. This project shed light on the high incidence of depression in a diverse community with a high percentage of immigrants and refugees. This project also brought attention to a chronic condition with long-standing implications for individual and community health that too often goes unidentified and therefore unaddressed. The processes that led to these outcomes are now ready to be adopted by other careteams at HCHCand can serve as a model in other primary care settings. Conflicts of Interest. All authors report no conflicts of interest. Ann M. Schaeffer, DNP, CNM, is Certified Nurse Midwife, Harrisonburg Community Health Center. Harrisonburg, Virginia. Diana Jolles, PhD, CNM, is Instructor, Frontier Nursing University, Hyden, Kentucky, and a Certified Nurse Midwife, El Rio Community Health Center, Tucson, Arizona. 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