Implementing a Mental Health Screening and Referral Program in a Cardiology Clinic

Background: Depression and anxiety negatively impact cardiac patient outcomes. Identifying and treating depression and anxiety in cardiac patients improves patient outcomes by decreasing the number of hospital admissions and mortality rates. Cardiology clinics can use mental health screenings to identify patients who would benefit from mental health treatment. Despite this, few cardiology clinics screen for depression or anxiety. Local Problem: This quality improvement project aimed to integrate a mental health screening and referral program into a Utah cardiology clinic using validated tools, Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder Questionnaire (GAD-7), at each visit to determine which patients needed a mental health referral. Methods: Pre-and post-implementation surveys were given to the five participating medical assistants to assess their knowledge of and attitudes toward completing mental health screenings and referrals in cardiology clinics. Before implementation, the participants attended an educational presentation that addressed the mental health effects on cardiac health, how to perform mental health screenings using the PHQ-9 and GAD-7 questionnaires, and how to create mental health referrals using the scores from the questionnaires. During implementation the number of screenings and referrals completed were tracked using the electronic health record (EHR). After implementation the EHR was reviewed to identify the number of mental health screenings and referrals the participants completed. Interventions: The participating medical assistants administered the PHQ-9 and GAD-7 questionnaires to all patients seen during the two-month implementation period. Scores from the questionnaires were recorded in the EHR and used to determine if a patient should receive a mental health referral. Mental health referrals completed were also recorded in the EHR. Results: During implementation, the cardiology clinic screened 82% (n=398) of the 517 patients seen using the PHQ-9 and GAD-7 questionnaires. Of those patients, 35% (n=148) screened positive for needing a mental health referral. Despite this, no mental health referrals were created. Post-implementation surveys indicated lack of time and inability to create referrals to a psychiatric provider as deterrents to completing the referrals. Conclusion: The number of positive screenings validates the need for mental health screenings in this cardiology clinic. The lack of completed mental health referrals indicates the need for further investigation. It may warrant the inclusion of a psychiatric provider into the practice.