Literature Collection

BACKGROUND: Depression adversely affects health outcomes in patients with childhood-onset systemic lupus erythematous (cSLE). By identifying patients with depressive symptoms, we can intervene early with referrals to mental health resources and improve outcomes. The aim of our quality improvement project was to increase and maintain rates of standardized depression screening for youth with cSLE seen within our pediatric rheumatology clinic. METHODS: Patients with cSLE 12 years of age or older seen for routine follow-up at our pediatric rheumatology clinic from September 16, 2019, through December 30, 2022, were offered the Patient Health Questionnaire-9 modified for adolescents (PHQ-A) to screen for depressive symptoms. A multidisciplinary team developed a key driver diagram to plan potential interventions to improve rates of screening. Plan‒Do‒Study‒Act (PDSA) cycles were used to prepare, implement, and evaluate interventions. Notable interventions focused on accurately identifying eligible patients, facilitating bidirectional communication between staff, and integrating and automating screening within the electronic health record (EHR). Statistical process control (SPC) methods were used for data analysis. RESULTS: The percentage of eligible patient encounters where depression screening was completed increased from 0 to 81% and was maintained for more than 6 months. This represents special cause variation, as evidenced by data shifts on our statistical process control chart. Among the 592 patients who completed depression screens, 114 (17%) were positive for moderate to severe symptoms, and 59 (9%) were positive for suicidal ideation (SI). CONCLUSIONS: A high rate of standardized depression screening for youth with cSLE was achieved and maintained via integration and automation within our EHR. Establishing a highly reliable screening system is a critical first step in improving mental health care for this vulnerable population of youth.

Mental health symptoms are common in the general population and are overrepresented in patients receiving palliative care and hospice services. This introduction to the special issue on Mental Health in Palliative Care and Hospice highlights the ongoing need for research and training to prepare our palliative care workforce to address the concerns of patients experiencing serious illness and mental health concerns. Multilevel approaches are needed to enhance understanding of mental health needs among people with serious illness. Public health outreach is needed within our communities, targeted support is needed for family caregivers, and structured training for palliative care and hospice clinicians is needed to enhance competent mental health in these settings.

Background: Having prescribers use clinical video teleconferencing (telemedicine) to prescribe buprenorphine to people with opioid use disorder (OUD) has shown promise but its implementation is challenging. We describe barriers, facilitators and lessons learned while implementing a system to remotely prescribe buprenorphine to Veterans in rural settings. Methods: We conducted a quality improvement project aimed at increasing the availability of medications for OUD (MOUD) to Veterans. This project focused on tele-prescribing buprenorphine to rural sites via a hub (centralized prescribers) and spoke (rural clinics) model. After soliciting a wide-range of inputs from site visits, qualitative interviews of key stakeholders at rural sites, and review of preliminary cases, a "how-to" toolkit was developed and iteratively refined to guide tele-prescribing of buprenorphine. After internal and external facilitation strategies were employed, Veterans with OUD at three clinics were transitioned to buprenorphine treatment via telemedicine. Results: Factors impacting adoption of the tele-prescribing intervention were mapped to the Consolidated Framework for Implementation Research (CFIR) constructs. Barriers to adoption included concerns about legality of tele-prescribing a controlled substance, conflicting interests between different stakeholders, and coordination with an existing buprenorphine program requiring more attendance and abstinence from Veterans than the tele-prescribing program required. Factors facilitating adoption included a sense of mission around combating the opioid epidemic, preexisting use of and comfort with tele-prescribing, and rural sites' control over Veterans referred to tele-prescribers. A total of 12 patients from rural areas were successfully transitioned onto buprenorphine, of whom 9 remained on buprenorphine 6 months after initiation of treatment. Conclusions: Implementing tele-prescribing was negotiated with stakeholders at the target clinics and operationalized in a toolkit to guide future efforts. Implementation issues can be addressed by activities that foster collaboration between hubs (centralized prescribers) and spokes (rural clinics) and by a toolkit that operationalizes tele-prescribing procedures.

OBJECTIVE: To develop effective pharmacy-based interventions to mitigate harm from opioid use disorders. Programs include responsible opioid prescribing, expanded access to medication-assisted treatment (MAT), naloxone, and community interventions. SETTING: Clinical pharmacists practicing at Indian Health Service (IHS) locations in the Southwest, Midwest, and Great Lakes regions. These pharmacists serve culturally diverse American Indian populations throughout the United States and interface with tribal and federal programs to impact the opioid epidemic in Indian Country. PRACTICE DESCRIPTION: Pharmacists have reduced barriers to care by expanding clinical practices to include novel approaches in pain management clinics and MAT programs. PRACTICE INNOVATION: As part of a multidisciplinary team, IHS pharmacists provide comprehensive patient care while focusing on the prevention of opioid dependence and opioid overdose death. EVALUATION: Pharmacists have also expanded professional competencies to include coprescribing naloxone and training first responders on naloxone use. RESULTS: Pharmacists within IHS have proactively completed advanced training on responsible opioid prescribing, augmented services to increase access to MAT for American Indians and Alaska Natives, and increased access to naloxone for opioid overdose reversal. Pharmacists have also developed a comprehensive training program and program measurement tools for law enforcement officers serving in tribal communities. These materials were used to train 350 officers in 6 districts and conduct a mass naloxone dispensing initiative across Indian Country. Pharmacists have consequently developed successful community coalitions that are focused on saving lives. CONCLUSIONS: Pharmacist involvement in key initiatives including responsible opioid prescribing, expanded access to MAT, and expanded access to naloxone for trained first responders, coupled with an emphasis on enhanced education, illustrates pharmacists' impact with the opioid epidemic.