Program Title: A Collaborative Care Model for Perinatal Depression Support Services (COMPASS)

A. Award Category: Innovative Programs in Care

B. Program Objectives & Overview of Innovation

Perinatal depression, affecting one in seven women, is one of the most common pregnancy-related complications. Perinatal depression develops either during pregnancy or after delivery and can persist for years if left untreated. It significantly impairs functioning of the new mother, and can lead to both short and long term problems in her child. Prompt recognition and intervention reduces these complications, however the majority of women with depression do not receive adequate treatment. Barriers to care are myriad: obstetricians often report inadequate training in directly delivering mental health care while patients perceive stigma as well as logistical barriers to separate psychiatric appointments. Ultimately, less than one out of every ten women with perinatal depression will receive adequate mental health treatment.

COMPASS is a perinatal collaborative care model that re-imagines prenatal care delivery. In COMPASS, mental health care is seamlessly integrated into the prenatal clinic setting, fostering an environment of collaboration and care delivery for the whole woman. COMPASS uses a three-pronged approach including (1) the development and implementation of a perinatal depression educational training program for Northwestern obstetric providers, (2) a clinical care program including a perinatal psychiatrist and therapist to enable collaborative mental health care within the Northwestern Obstetric practices, and (3) an evaluation of the health utilization implications of this collaborative care model described in more detail in Appendix A. COMPASS promises to optimize perinatal mental health care across Northwestern but also to serve as a model for successful and sustainable implementation of perinatal collaborative care across academic medical centers around the country.

C. Program Details, Key Personnel, Timeline

The following individuals are essential to the COMPASS program and their roles described below. The clinical care flow in COMPASS is described in Appendix B.

1. Program Director (Emily S Miller, MD MPH): As the PD of the COMPASS program, Dr. Miller is responsible for program development, administrative oversight, development of the obstetric educational program, and data collection/analysis.

2. Care Coordinator (Rebekah Jensen, LCSW): Ms. Jensen is the lynchpin of the COMPASS system, responsible for the clinical intake into the program as well as the ongoing symptom surveillance and patient tracking. She orchestrates the discussion of the COMPASS weekly case review and facilitates communication between mental health and obstetric providers regarding individualized care plans.

3. Clinical Liaison (Jaqueline Gollan, PhD): Dr. Gollan clinically supervises the psychiatric care in addition to coordinating with Dr. Miller on the administrative oversight of the program to ensure sustainability.

4. Perinatal Psychiatrist(s): COMPASS remains committed to not just immediate care delivery, but also to training mental health providers who will go on to positively impact the lives of women across the country with their developing expertise in perinatal psychiatry. To that end, the Women’s Mental Health Fellow(s) at Northwestern, supervised by faculty, perform the clinical consultations and management of women referred for COMPASS psychiatric care.

5. Therapist (Rachel Ostrov, LCSW): Ms. Ostrov, under the supervision of Dr. Gollan, provides evidenced based psychotherapy to patients referred to COMPASS.

COMPASS opened its doors January 2017 and has grown steadily since with over 1100 referrals to date (Figure 1). Educational materials have been developed to support obstetric providers with screening and management of mild to moderate perinatal depression. Women referred to the program are evaluated by the care coordinator within 72 hours of referral by the obstetrician and a plan of care is initiated. The collaborative care model allows timely access to specialist assessment for those at highest risk; consultations with a perinatal psychiatrist are made within one week if they are needed. Evidence-based stepped care plans are discussed during our weekly multidisciplinary meeting (including obstetrics, perinatal psychiatry, perinatal psychology, and social work) that inform adjustments in care with the goal of all women referred achieving remission of their depressive symptoms. Women are followed in a registry to enable close follow-up of all women referred. Thus COMPASS provides exemplary mental health care across the entire Northwestern Medicine faculty practices.

D. Source of Initial and Sustained Funding/Support

Start-up award from the Friends of Prentice Special Projects Program has funded the initial obstetrician education, implementation of clinical care programs, and development of a database to enable programmatic evaluation. The awarded budget was intended to fund initial three years of the program, but through modest revenue collection and good financial stewardship by the COMPASS team, these start-up funds have stretched for a projected 5-6 years of operation. In the meantime, we are actively working to become budget neutral through applying for additional innovation grants, the profit margin of billable psychotherapy, and exploration of new collaborative care billing codes (begun this calendar year in some of our state’s commercial insurance plans). COMPASS thus not only aims to improve perinatal depression clinical outcomes but also to provide a roadmap to implementation of perinatal collaborative care systems across the United States.

E. Length of Time in Operation and Sustainability Plans

A central goal of COMPASS is sustainability. We are developing the administrative capacity to facilitate sustained access to clinical mental health services for obstetric patients receiving prenatal care at Northwestern Medicine. Future plans include the revenue streams described above as well as continually establishing ourselves as an invaluable service to both the psychiatry and obstetric departments.

F. Summary of Results and Evidence of Impact

There are approximately 4500 women per year that receive prenatal care in obstetric offices served by COMPASS. Since our clinical launch January 23 2017, we have had 1140 women referred to the COMPASS program (Figure 1), 818 (72%) of whom have enrolled in the COMPASS program to initiate mental health treatment. Initial diagnoses included 453 (55%) depression, 445 (54%) generalized anxiety, 47 (6%) bipolar, and 250 (30%) other. For initial treatment, 76% received psychotherapy (including 400 distinct patients seeing our therapists), 53% received pharmacotherapy, 39% received both psychotherapy and medication, and 9% declined any formal psychiatric treatment but were enrolled in an electronic symptom monitoring program. (Outcomes being tracked are outlined in Appendix A.) Importantly, while approximately 10% of the OBGYN population served by COMPASS receives Medicaid supported prenatal care, over 20% of women enrolled in COMPASS have Medicaid insurance. Thus, we anticipate that COMPASS not only improves clinical outcomes for all women, but also reduces disparities in mental health care experienced by this most vulnerable population.

G. Discussion of the Likelihood Others Could Replicate Your Program

A key goal of COMPASS is to develop and implement a program that can be replicated. To date, we have mentored 8 other medical centers since our inception over 2 years ago. These centers are actively initiating similar programs, using our advice and/or clinical algorithms. We also have a forthcoming publication (“Implementation of Perinatal Collaborative Care”) written specifically to assist others in development and implementation of similar programs. We believe the screening and management algorithms created for COMPASS, the experience obtained to generate a collaborative care culture, and the administrative efforts developed to ensure the program can be financially sustainable are the essential components to enable replication of the COMPASS program across the United States.

H. Supporting Documents (optional)

a. Appendix A: Program Details

b. Appendix B: COMPASS Clinical Workflow

c. Appendix C: Obstetrician Educational Packet & Protocols

I. Contact Information

Emily S Miller, MD MPH, Program Director, emily-miller-1@northwestern.edu, (312) 695-6296 Appendix A

Program Details

COMPASS programming began in September 2016 with a clinical launch in January 2017. Details regarding each of the aims of COMPASS are described below:

1. Obstetrician education: Prior to embedding a perinatal psychiatrist and therapist within the Northwestern prenatal clinics, we rolled out focused obstetrician training on perinatal mental health disorders. These trainings included recommended screening protocols, initial clinical evaluations, differential diagnoses, and general treatment algorithms. In addition, with experts in obstetric pharmacology, a medication in pregnancy resource guide (including dosing, common side effects, and drug-drug interactions specific to obstetric practice) was developed (Appendix C). Trainings have occurred as a part of the Department of Obstetrics and Gynecology Grand Rounds, Resident and Fellow Didactics, and Clinical Division Meetings for the various obstetrics groups. Patient and provider centered educational handouts were developed and disseminated. Repeated provider educational programs will be performed quarterly throughout the year and comprehensively at the beginning of each academic year to ensure sustained awareness.

2. Clinical care program: A critical aspect of COMPASS is the development of a collaborative care model. A central tenet of collaborative care is population-cased care with measurement-based target to treatment. To that end, we have implemented a patient registry with protocolized depression symptom surveillance by our care manager. Women who are not clinically improving are discussed at our weekly multi-disciplinary (including representation from obstetrics, psychiatry, psychology, and social work) team meeting. Systematic case reviews dictate the next steps in care escalation. In addition to adherence to core collaborative care principles, we have integrated a perinatal psychiatrist and therapist (LCSW) within the prenatal clinics in order to facilitate on-site access to mental health consultation for both patients and obstetric providers. Patients are able to schedule appointments at the time of their prenatal visit, minimizing the perceived stigma and logistical barriers to separate psychiatric appointments that obstruct treatment participation in traditional care models. Appendix B illustrates the clinical work flow of the COMPASS program.

3. Evaluation of health services implications and sustainability: The third-prong of the COMPASS program includes a critical assessment of its patient care and health system impact. The former will be evaluated by comparing adherence to state and national perinatal depression screening guidelines (at the first prenatal visit, in the third trimester, and postpartum) before and after implementation of COMPASS. In addition, mental health care treatment initiation and retention in mental health care for women diagnosed with a psychiatric illness will be compared before and after the COMPASS model. In addition to patient-centered outcomes, health services utilization outcomes will be tracked. These will include obstetric health service utilization (inclusive of add-on obstetric visits outside of the standard prenatal visits, emergency room or triage evaluations, and missed prenatal care visits) as well as neonatal service utilization (inclusive of preterm births, small for gestational age births, NICU admissions and length of stay, neonatal treatment for maternal substance abuse, and initiation/continuation of breast feeding).