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The Substantial Impact of the PHQ-9

Nearly two years into the COVID-19 public health emergency (PHE), nursing home staff continue to see its impact on all residents, not just those who have recovered from COVID-19. According to the CMS memorandum QSO-20-39-NH, CMS’s focus has been on “protecting nursing home residents from COVID-19,” but CMS also recognizes “that physical separation from family and other loved ones has taken a physical and emotional toll on residents. Residents may feel socially isolated, leading to increased risk for depression, anxiety, and other expressions of distress.” A resident’s signs and symptoms of depression are measured using a standardized test, the PHQ-9 (Patient Health Questionnaire). It is vital for nursing home staff to monitor for changes in symptoms of depression both upon completion of the MDS assessment and between assessment periods. When a resident begins to display or report more signs and symptoms of depression, this can have a substantial impact on care areas, the care plan, Quality Measures, and, in some cases, reimbursement.

PHQ-9 impact on care areas and care planning

The RAI User’s Manual, page D-1, clarifies that “the presence of indicators in Section D [Mood] does not automatically mean that the resident has a diagnosis of depression or other mood disorder. Assessors do not make or assign a diagnosis in Section D; they simply record the presence or absence of specific clinical mood indicators. Facility staff should recognize these indicators and consider them when developing the resident’s individualized care plan.”

Signs and symptoms of depression can indicate mood distress, which, according to the RAI User’s Manual, is “a serious condition that is underdiagnosed and undertreated in the nursing home and is associated with significant morbidity.” Often, the direct care staff at the nursing home are best positioned to recognize small changes in mood. Early identification of these symptoms is key for early treatment and preventing negative outcomes.

If changes in the resident’s mood have not been identified between assessments, then the completion of a comprehensive assessment may help to identify worsening in mood. The Mood State care area will trigger if the total severity score on an annual or significant change in status assessment has worsened from the prior assessment. This comparison information is coded at V0100 on these comprehensive assessments. However, since this item is not coded on other assessments, it is a best practice when completing Quarterly assessments to look back at the prior severity score on the prior assessment for a manual comparison.

A resident will also trigger for the Mood Status care area if the severity score for the PHQ-9 score (or PHQ-9-OV (observation version)) is equal to or greater than 10, regardless of the prior assessment score.

The RAI User’s Manual, page 4-28, further directs that the “information gleaned from the assessment should be used as a starting point to assess further in order to confirm a mood disorder and get enough detail of the situation to consider whether treatment is warranted. If a mood disorder is confirmed, the individualized care plan should, in part, focus on identifying and addressing underlying causes, to the extent possible.”

PHQ-9 impact on Quality Measures

The mood severity score can also impact Quality Measures. The Percentage of Residents Who Have Depression Symptoms, an MDS 3.0 long-stay measure, uses two of the PHQ-9 questions and the total severity score (PHQ-9 or PHQ-9-OV) to trigger this measure. The MDS 3.0 Quality Measure User’s Manual clarifies that if either of the following questions have a frequency of seven or more days (coded as a 2 or 3) and a severity score of 10 or greater on the target assessment, the measure will be triggered:

  • Little interest or pleasure in doing things half or more of the days over the last two weeks
  • Feeling down, depressed, or hopeless half or more of the days over the last two weeks

In addition, if both the resident interview (PHQ-9) and the staff assessment (PHQ-9-OV) are incomplete, skipped, or dashed, then the resident is excluded from the measure. This means that the resident will neither trigger nor be used in the denominator of this measure. To ensure the accuracy of the Quality Measure, the PHQ-9 assessment must be completed following all guidance and coding instructions from the RAI User’s Manual.

Using PHQ-9 scores to determine if a Significant Change in Status Assessment is indicated

All residents in the nursing home must be monitored for a significant change in status and timely completion of the Significant Change in Status Assessment (SCSA) when warranted. Failure to maintain compliance may result in negative resident outcomes and citations during a survey. There are specific criteria for when a SCSA is required.

The RAI User’s Manual defines a significant change on page 2-22:

A “significant change” is a major decline or improvement in a resident’s status that:

  1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered “self-limiting”;
  2. Impacts more than one area of the resident’s health status; and
  3. Requires interdisciplinary review and/or revision of the care plan.

In addition, on page 2-25, the RAI User’s Manual also provides the following example. One consideration, which constitutes one of the two areas of decline that suggests a change is significant, is:

Presence of a resident mood item not previously reported by the resident or staff and/or an increase in the symptom frequency (PHQ-9©), e.g., increase in the number of areas where behavioral symptoms are coded as being present and/or the frequency of a symptom increases for items in Section E (Behavior).

This guidance clarifies that while a change in the mood severity score alone would not meet all of the criteria for a SCSA, if the resident had new mood symptoms in addition to other changes, such as weight loss or decline in function, it would meet the criteria and require the completion of an SCSA.

Using PHQ-9 scores in Interim Payment Assessment discussions

The Interim Payment Assessment (IPA) is an optional assessment used in the Patient-Driven Payment Model (PDPM) for Medicare Part A reimbursement. This optional assessment is the only assessment that will impact payment during the Medicare stay after the completion of the 5-Day PPS assessment. Since this is an optional assessment, when and whether this assessment will be completed for a resident is up to the facility staff. While there are many different clinical items that may be a part of the discussion when determining if an IPA will be completed, any changes in the PHQ-9 score should be at the top of that list.

The PHQ-9 (or PHQ-9 observation version) has a substantial impact on the nursing component reimbursement for residents who achieved the Special Care High, Special Care Low, or Clinically Complex clinical groups. If a resident has a total severity score of 10 or greater, this will qualify for the depression end-split. While this may seem insignificant, the difference between qualifying for the depression end-split and not is $30 per day, on average, for the FY 2022 rates.

When determining whether or not an IPA will be completed, there should be a comprehensive review of all items impacting each of the PDPM components. However, this must include a projection of all items, including the PHQ-9 severity score.

Final thoughts on the PHQ-9

The nurse assessment coordinator (NAC) is often responsible for monitoring for significant changes and voicing when an IPA may be indicated. However, monitoring for changes in depression symptoms is not as easy, since the PHQ-9 interview is only completed with the MDS assessment and preferably the day before or the day of the ARD. This can make it difficult to use the PHQ-9 results in deciding whether or not an SCSA or IPA would be indicated. However, strong communication and interaction with direct care staff, who may notice subtle changes in the resident’s mood, may provide clues to help with a projection of the PHQ-9 score. But it is also important to keep in mind that the PHQ-9 is a scripted interview—so the resident’s answers on the assessment are used regardless of the observations that were also made during the look-back period. The RAI User’s Manual clarifies that the PHQ-9 interview must be attempted with all residents, unless they are “rarely/never understood or cannot respond verbally, in writing, or using another method, or an interpreter is needed but not available” (p. D-2). In addition, the RAI User’s Manual states, “do not complete the Staff Assessment of Resident Mood items (D0500) if the resident interview should have been conducted, but was not done” (p. D-3). Follow the RAI User’s Manual instructions and coding guidance, as well as other resources (such as appendix D in the RAI User’s Manual or the VIVE videos from CMS) to ensure the interview is conducted appropriately and accurately. This will result in an accurate reimbursement, accurate Quality Measurements, and care planning that reflects the results of the assessment.  However, if observations differ from interview results, this information should be used in the care planning process to best meet the resident needs.

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