Tri-State Residency Program & Community Health Center Collaborative

A Major Depressive Disorder Quality Improvement Program for Primary Care

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NJAFP recently took over management of a large collaborative that has been successfully led by the Pennsylvania Academy of Family Physicians (PAFP) since 2010. The Collaborative currently includes 30 family medicine residency programs and community health centers from across Pennsylvania, New Jersey and Delaware.  This Collaborative provides a unique opportunity for residency clinics and community health centers to come together for education, quality improvement and healthcare data analysis.

Program Description

Participating practices will improve the diagnosis, management and outcomes of patients with major depressive disorder (MDD) through comprehensive screening, treatment to remission, and behavioral health integration and care coordination within the medical neighborhood.

The project will improve the knowledge, confidence and performance of family physicians and providers and their care teams in the diagnosis, management and twelve (12)-month outcomes of patients with MDD.

MDD PATIENT SUBSET: Each practice will select at least twenty-five (25) patients and follow them from project start to end. We have used a similar structure in the past and find that having practices follow a subset further refines their improvement interventions. This is particularly important to improve outcomes for patients with MDD, for whom diagnosis and treatment are nuanced.

Both control practices and intervention practices will receive stipends through this program.

Learning Objectives

  1. Diagnose and monitor MDD in patients using standard, effective measurement tools (e.g., PHQ‑2, PHQ‑9)
  2. Describe the physiological, neurobiological, and environmental factors which contribute to MDD and its clinical presentation
  3. Develop individualized treatment plans for MDD patients with remission as goal, taking into consideration both pharmacologic and non-pharmacologic options, such as psychotherapy and exercise
  4. Employ shared decision making and use of decision aids when creating a treatment plan for patients with MDD
  5. Engage the behavioral health and psychiatric medical neighborhood in support of patients with MDD

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