NR 702A Week 2 Practice Gap Write-Up Example

Practice Gap Write-Up: Completed Behavioral Health Contact Within 30 Days After a Positive PHQ-9 at One Federally Qualified Health Center Site

Student Name

College of Nursing, Chamberlain University

NR 702A: DNP Project & Practicum I

Instructor Name

Month Day, Year

Practice Gap Write-Up: Completed Behavioral Health Contact Within 30 Days After a Positive PHQ-9 at One Federally Qualified Health Center Site

The Current Figure

In April to June 2026, 98 of 287 adults whose PHQ-9 reached 10 or higher at a primary care visit at the site completed a behavioral health contact within 30 days: 34%. Source: the health center's quarterly quality dashboard, which lists positive screens, matched by the quality analyst to the behavioral health referral log, which records completed contacts; the matched table was produced on 2 September 2026.

A completed contact means a visit with the behavioral health consultant or the psychologist, whether face to face, on video or over the phone, documented as a behavioral health encounter. A referral placed, a phone message left or an appointment booked but missed does not count.

The Standard

The health center's 2026 quality plan, approved by the board's quality committee in January 2026, sets an internal target: half of adults with a positive depression screen will complete a behavioral health contact within 30 days. It is the health center's own standard, not a payer requirement or a professional body's benchmark. The federal reporting measure the health center submits each year counts whether a follow-up plan is documented, not whether the patient is seen, and on that measure the site performed well, at 79%.

The Difference, Written Out

Target 50% minus current 34% equals a gap of 16 percentage points. In patients, half of 287 is about 144, so the site was about 46 completed contacts short of its own target in one quarter.

Where the Patients Went

The 189 patients who did not complete a contact within 30 days did not all fall out at the same point, and the status field shows where. Of the 189 who did not complete a contact within 30 days: 71 were never reached after three call attempts; 43 were reached and booked but did not attend; 38 declined behavioral health; 22 completed a contact after day 30; and 15 had no record of a call attempt. The breakdown comes from the referral log's status field.

What the Difference Costs Here

For patients, untreated depression affects their other conditions: many of the 287 also have diabetes or hypertension managed at the site. For clinicians, a patient who screened positive and was not seen returns three months later with the same score, and the visit starts over. For the health center, the quality committee has named behavioral health integration as a priority, and the gap undercuts the integrated model it is funded to provide. Collaborative care, in which behavioral health is part of primary care, improved depression outcomes in a large trial (Unützer et al., 2002) and in a systematic review (Archer et al., 2012); the model's benefit depends on patients reaching the behavioral health clinician.

Why the Gap Exists Here

The referral is placed in the record and the consultant's assistant calls patients back, usually two to five days later. By then many patients do not answer unfamiliar numbers, and some have changed their minds. The consultant has few open slots on the same day as the primary care visit. The handoff happens after the patient has left the building.

How the Figure Was Produced

The analyst exported every adult primary care visit in the quarter where the PHQ-9 total reached 10, about 290 rows, and matched each to the referral log by record number and date, then to behavioral health encounters in the record within 30 days. Where a patient screened positive twice in the quarter, only the first visit counted. The analyst checked twenty matches by hand and found one error, a behavioral health encounter recorded under the wrong date, which was corrected. The method is written down so that the same figure can be produced each month from January without relying on memory, and so that anyone questioning the baseline can see exactly how it was built.

What These Figures Cannot Show

Whether patients who were not seen got help elsewhere, such as from a community clinic or an employee assistance program. Whether the 38 who declined made an informed choice. Whether the 22 seen after day 30 did as well as those seen sooner. And whether the April to June quarter is typical; the analyst is producing the January to March figure for comparison.

The matched table also depends on the PHQ-9 being entered in a structured field. Screens recorded only in a note are missed. The analyst estimates this affects a small number of visits, and has agreed to check a sample of notes each quarter so that the effect of notes-only screens on the figure is known rather than assumed.

Who Is Most Often Lost

The referral log's status field allows a rough picture of which patients the handoff loses. The referral log shows that the patients most often never reached were those referred late in the day or on Saturdays, when no behavioral health clinician was in the building and the callback came two or more days later. Patients who preferred Spanish were reached as often as others, which suggests language is not the main barrier, though the analyst cautions that the numbers in each group are small. Younger adults declined more often than older adults.

What Has Already Been Tried

In 2025 the behavioral health team added a second call attempt on the same day as the referral, when the assistant had time. The analyst's figures show no change in the quarter after; the assistant estimated that the same-day call happened for fewer than a quarter of referrals, because afternoons were busiest. The attempt is useful evidence: a change that depends on spare time at the busiest hour is unlikely to hold.

Why the Health Center's Own Target Is the Right Standard

A national benchmark for completed behavioral health contact after a positive screen does not exist in the form this measure uses, and borrowing one from a study set in a different system would compare unlike things. The health center's target was set by its own quality committee for its own patients, which makes it the standard the site will be judged against and the one any change will need to meet. Measurement-based approaches to behavioral health depend on a site setting and tracking its own targets (Fortney et al., 2017).

Measurement Consistency

The PHQ-9 is a validated measure of depression severity, with 10 commonly used as the threshold for at least moderate symptoms (Kroenke et al., 2001). The site uses that threshold for referral, so the population in the figure matches the clinical rule.

References

Archer, J., Bower, P., Gilbody, S., Lovell, K., Richards, D., Gask, L., Dickens, C., & Coventry, P. (2012). Collaborative care for depression and anxiety problems. Cochrane Database of Systematic Reviews, 2012(10), CD006525. https://doi.org/10.1002/14651858.CD006525.pub2

Fortney, J. C., Unützer, J., Wrenn, G., Pyne, J. M., Smith, G. R., Schoenbaum, M., & Harbin, H. T. (2017). A tipping point for measurement-based care. Psychiatric Services, 68(2), 179-188. https://doi.org/10.1176/appi.ps.201500439

Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606-613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x

Unützer, J., Katon, W., Callahan, C. M., Williams, J. W., Jr., Hunkeler, E., Harpole, L., Hoffing, M., Della Penna, R. D., Noël, P. H., Lin, E. H. B., Areán, P. A., Hegel, M. T., Tang, L., Belin, T. R., Oishi, S., & Langston, C. (2002). Collaborative care management of late-life depression in the primary care setting: A randomized controlled trial. JAMA, 288(22), 2836-2845. https://doi.org/10.1001/jama.288.22.2836