Health Center Screens and Treats Depression and Addictions on Cape Cod
In 2004, four community health centers on Cape Cod, Mass., began screening their patients for depression and addictions. Patients were originally referred elsewhere for treatment, but the centers later hired social workers and a psychiatrist and began mental health treatment themselves.
This project was part of the Robert Wood Johnson Foundation Local Funding Partnerships program. The program helps local organizations across the country offer a wide range of health services and interventions in collaboration with community foundations, corporate grantmakers and other local funders. For more information on the program, see Grant Results.
- The four health centers screened 16,161 patients for depression and addictions over the grant period.
- The number of patients who screened positive but failed to pursue treatment declined substantially after the centers began offering mental health treatment.
- The proportion of people who screened positive for depression declined over the course of the project.
The Robert Wood Johnson Foundation (RWJF) provided a $460,000 grant for the project from July 2004 through August 2008.
Cape Cod's reputation as a summer vacation spot for the affluent belies the status and needs of its year-round residents, who are poorer and less likely to be insured than other Massachusetts residents. According to the Barnstable County Department of Human Services, Cape Cod residents have:
- Addiction-related hospital admissions of 2,245 per 100,000 people compared to 1,900 per 100,000 people for the state of Massachusetts.
- Suicide rates of 9.8 deaths per 100,000 people on Cape Cod compared to 7.7 deaths per 100,000 people for the state of Massachusetts.
Mental health problems are most acute for low-income residents. A 2004 survey of residents by the department found that among the most needy Cape households:
- More than three-quarters reported "a lot" of depression, anxiety or stress.
- More than 40 percent reported adult substance abuse.
- Some 21 percent reported children or teenagers with behavior or emotional problems.
Further complicating matters, in these households, 64 percent reported not having enough money to pay for doctor visits or prescriptions, and 30 percent said they had difficulty paying for a mental health counselor.
In 1987, the RWJF Board of Trustees authorized $8 million to fund a two-year trial of a matching grants program to be called Local Initiative Funding Partners.
Many matching grants programs set up by national foundations seek to replicate ideas formulated by the national foundation itself. Renamed the Robert Wood Johnson Foundation Local Funding Partnerships in 2007, this program was to be different. The local community would identify a pressing need, design the strategy for addressing it and put together a funding package that would provide at least one dollar of outside support for every dollar of RWJF grant money. Each project would have one lead local funder, but additional supporters would be welcomed.
To be eligible, a project would have to fall within the general scope of RWJF's interest in addressing the needs of vulnerable populations, but a proposal would not have to meet the kind of specific criteria common to other RWJF programs. Instead of being top-down, Local Funding Partnerships would be bottom-up-with an emphasis on innovation. RWJF hoped this local "ownership" would ensure sufficient support to keep the projects going after the RWJF grant ended. This hope was realized, with 86 percent of the Local Funding Partnership projects funded from 1987 to 2001 continuing at least one year after RWJF funding ended, according to a study by Mathematica Policy Research.
In 2004, four community health centers on Cape Cod began to screen their patients for depression and addiction. The four health centers were:
- Community Health Center of Cape Cod (formerly the Cape Cod Free Clinic in Falmouth) in Mashpee, Falmouth and Bourne.
- Outer Cape Health Services in Provincetown and Wellfleet.
- Mid-Upper Cape Community Health Center in Hyannis.
- Duffy Health Center in Hyannis.
The clinics sought to integrate primary and behavioral health care by:
- Screening all patients for depression, addictions and suicide risk, using the PHQ-9 questionnaire originally developed by the Pfizer Corporation. After an initial screening, patients were rescreened at six-month intervals and at annual checkups.
The PHQ-9, a nine-item depression scale, is based directly on the diagnostic criteria for major depressive disorder in the Diagnostic and Statistical Manual, Fourth Edition (DSM-IV). There are two components of the PHQ-9: assessing symptoms and functional impairment to make a tentative depression diagnosis and deriving a severity score to help select and monitor treatment.
- Providing on-site counseling, care management and medication assistance for those diagnosed with depression. Each center hired a social worker to oversee screening and to develop care plans in consultation with the primary care staff.
- Coordinating clinical evaluations, substance abuse treatment and outside counseling for patients needing these services.
In the first two years of the project, the centers referred patients off-site for treatment. They discovered that many patients did not keep their referral appointments for a number of reasons, including:
- Lack of transportation
- Conflicts with work schedules
- Need for child care
- Inability to follow through because of their mental health problems.
Even when patients kept appointments, problems of communication between agencies resulted in discontinuity of care. In response, the centers hired a shared psychiatrist and sought state licenses to provide mental health care. By the end of the grant period, Community Health Care of Cape Cod and the Duffy Health Center had received licenses, and Outer Cape Health Services was pursuing one.
Other funding for the project came from:
- Cape Cod Healthcare Foundation ($160,500)
- Barnstable County ($150,000)
- The Cape Cod Foundation ($28,000)
- Edward Bangs Kelley and Eliza Kelley Foundation ($28,000)
- Cape and Islands United Way ($28,000)
- The Bilezikian Family Foundation ($28,000)
Working closely with Spitfire Strategies, a communications firm, the health centers drafted a concept paper to bring attention to the project and the prevalence of depression on Cape Cod. See the Bibliography for details.
The concept paper attracted the attention of local and state media, according to the project director. The Boston Globe ran a story on the project on June 11, 2008, and local newspapers and radio subsequently ran stories.
The project director reported the following results to RWJF:
- The four health centers screened 16,161 patients for depression and addictions over the grant period (July 2004 through August 2008). Of these:
- Some 6,929 (43 percent) indicated some level of depression. Of these, 3,159 (45.6 percent) were treated by the centers or referred to other facilities for care.
- Some 4,101 (25 percent) had active addictions. Of these, 1,754 (42.8 percent) were treated or referred elsewhere.
- The number of patients who screened positive but failed to pursue treatment declined substantially over the course of the project. In the first year, when all patients were referred off-site for treatment, 69.5 percent of patients did not pursue treatment. By the third year of the project, when the centers were offering treatment on-site, only 10.5 percent failed to pursue treatment.
- The proportion of people who screened positive for depression declined over the course of the project. In the first year, 51 percent of those screened indicated some level of depression. In the third year, only 39 percent screened positive. The health centers attributed this decline to their success in identifying patients with depression and offering them treatment.
- The integration of behavioral health care with primary health care provides better care for patients. Having medical staff and social workers working together on behalf of patients is key given the high correlation of depression, addictions and health conditions. To be able to treat patients for various issues "holistically" in one place makes a great deal of sense for community health center patients who often have multiple health issues and various obstacles to care. (Project Director)
AFTER THE GRANT
The four centers continue to screen and treat patients for depression and addiction. They also have received support to expand their efforts on mental health:
- The Tower Foundation provided a $300,000 grant to the Community Health Center of Cape Cod to open a Family Resource Center. The center will have a dedicated phone line for families in need and will offer assessments, family counseling, child psychiatry services, primary care and dental services for families.
The Massachusetts Department of Public Health awarded the Community Health Center of Cape Cod a $9,000 grant to support a suicide prevention, coalition-building project. The department also made a $300,000 grant to the center to develop a regional suicide prevention strategy.
GRANT DETAILS & CONTACT INFORMATION
Region-wide program to identify and coordinate care for low-income, uninsured and immigrant adults with depression and anxiety
Community Health Center of Cape Cod (Falmouth, MA)
Dates: July 2004 to August 2008
(508) 477-7090 ext. 127
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Concept Paper: Cape Cod Health Centers Pull Together to Help Stem the Rising Tide of Cape Cod Suicide, Depression and Addictions. Mashpee, MA: Community Health Center of Cape Cod, 2008.
Report prepared by: Barbara Matacera Barr
Reviewed by: Robert Narus
Reviewed by: Molly McKaughan
Program Officer: Jane Isaacs Lowe