(052) Barriers to Entry into Collaborative Care for Depression: Understanding Disparities in Depression Screening and Referral

‎Background/Significance: The Collaborative Care Model (CoCM) for depression within primary care improves ‎mental health treatment access and outcomes for patients, including racial/ethnic minority populations (Interian, 2013; ‎Hu, 2020). Sustaining this evidence-based intervention with equitable delivery necessitates understanding of factors ‎that may pose barriers to engagement (Shelton, 2020). The purpose of this study was to assess sociodemographic ‎differences in depression screening and CoCM referral rates within an implementation research trial.‎

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Methods: The Collaborative Behavioral Health Program (CBHP) is a CoCM program implemented using a ‎randomized roll-out trial across 11 primary care clinics in an academic-based health system (Smith et al., 2021). After ‎two years of follow-up in each clinic (10/29/2018 to 1/28/2023), there were 319,733 eligible primary care encounters ‎‎(representing 125,140 unique patients). Electronic health record (EHR) data included gender, age, race/ethnicity, ‎insurance status, Patient Health Questionnaire (PHQ-2; PHQ-9) depression scores, and CBHP referral codes. We ‎assessed the proportion of primary care encounters/patients who were screened for depression (PHQ-2, PHQ-9) and ‎referred to CBHP. Full analyses, to be completed prior to poster submission, will test differences in screening and ‎referral by sociodemographic and insurance status.‎

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Results: Preliminary results showed that 82,130 out of 319,733 encounters (25.7%) had a PHQ-2 and 4358 ‎‎(1.4%) had a PHQ-9 documented in the EHR. Among those screened with the PHQ-9, 2,249 (52%) had an elevated ‎score (≥10), of whom 361 (16.1%) had a CBHP referral code. In total, 778 CBHP referrals were placed (including 417 ‎without a documented PHQ-9 score ≥10). Sociodemographic and insurance status differences in screening and referral ‎will be reported.‎

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Discussion: Primary care patients were only screened for depression at 26% of encounters, and 16% of ‎encounters with elevated PHQ-9 scores also had a CBHP referral code. We will discuss sociodemographic and insurance ‎status differences along the CoCM engagement cascade: differences between encounters with vs without a PHQ-2 or ‎‎-9 recorded, and between encounters with elevated PHQs that were vs were not referred to CBHP.‎

‎Conclusion/Implications: Screening and referral rates during the first two years of CBHP implementation were ‎low. Findings from this study will identify disparities in depression screening and CoCM referral processes in an ‎implementation trial across an urban academic health network. This knowledge will provide insights into the screening ‎and referral process to inform sustainability and equity in CoCM programs.‎

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References: ‎
‎1. Interian A, Lewis-Fernández R, Dixon LB. Improving treatment engagement of underserved U.S. racial-ethnic ‎groups: a review of recent interventions. Psychiatr Serv. 2013;64(3):212-222.‎
‎2. Hu J, Wu T, Damodaran S, Tabb KM, Bauer A, Huang H. The Effectiveness of Collaborative Care on Depression ‎Outcomes for Racial/Ethnic Minority Populations in Primary Care: A Systematic Review. Psychosomatics. ‎‎2020;61(6):632-644.‎
‎3. Shelton RC, Chambers DA, Glasgow RE. An Extension of RE-AIM to Enhance Sustainability: Addressing Dynamic ‎Context and Promoting Health Equity Over Time. Front Public Health. 2020; 8:134.‎
‎4. Smith JD, Fu E, Rado J, et al. Collaborative care for depression management in primary care: A randomized roll-out ‎trial using a type 2 hybrid effectiveness-implementation design. Contemp Clin Trials Commun. 2021; 23:100823.‎