NR 705A Week 2 Intervention Design Example

Intervention Design Paper: The Same-Day Behavioral Health Introduction Written as a Recipe, With Its Trigger, Actors, Dose, What It Displaces and Edge Conditions

Student Name

College of Nursing, Chamberlain University

NR 705A: DNP Project & Practicum II

Instructor Name

Month Day, Year

Intervention Design Paper: The Same-Day Behavioral Health Introduction Written as a Recipe, With Its Trigger, Actors, Dose, What It Displaces and Edge Conditions

The Trigger

A PHQ-9 total of 10 or more entered on the rooming tablet during an adult primary care visit at the site. The tablet already calculates the total and files it in a structured field in the record. The trigger is the score appearing, not anyone's memory: the medical assistant sees it on the tablet before leaving the room.

The Actors, in Order

Medical assistant. On seeing a score of 10 or more, sends a one-line secure message to the behavioral health consultant's group: room number, patient's preferred language, and "PHQ 10+, warm handoff request." Then tells the patient, in the patient's language: "Our behavioral health counselor may stop by today. Is that all right with you?" Records the patient's answer in the visit note template.

Primary care clinician. Reviews the score and the patient's answer before or at the start of the visit, asks about safety as usual, and, if the patient agrees, says before the end of the visit: "I'd like you to meet our counselor today, before you go." If the consultant has not arrived by the end of the visit, walks the patient to the consultant's office or the waiting area outside it.

Behavioral health consultant. On receiving the message, replies within five minutes with one of three answers: "coming now," "in 20 minutes" or "booked, use open slot at 10:00 or 14:00." Joins the visit or meets the patient after it, for 10 to 20 minutes: introduction, brief assessment, a plan for the next contact, booked before the patient leaves.

Behavioral health assistant. Checks the daily list at 16:30 for any positive screen that did not get a same-day contact, and at 08:30 the next business day calls those patients, using a script in the patient's language.

The Dose

Every qualifying adult visit, Monday to Friday, 08:30 to 16:00: about 20 a week, or 4 a day. One same-day contact per eligible patient, 10 to 20 minutes. One next-business-day call for any eligible patient not seen the same day, with up to three attempts over three days. The change runs for 12 weeks in the test term, from 1 March to 24 May 2027.

What It Displaces

Two 30-minute booked follow-up slots a day on the consultant's template, at 10:00 and 14:00, become open-access slots for same-day contacts. That removes about ten booked follow-up visits a week. The behavioral health director will shift those follow-ups to the psychologist's Tuesday and Thursday sessions and to telehealth slots in the late afternoon. The behavioral health assistant's afternoon callback work shifts to 08:30 the next morning, displacing the time currently used for appointment reminders, which move to an automated text system already licensed.

This is the element a unit notices first, and it is written down so that the team can see exactly what it gives up.

Edge Conditions

Consultant with another patient and no open slot left: the medical assistant books the patient into the next day's open slot, and the behavioral health assistant calls that afternoon to confirm.

Positive screen after 16:00 or on Saturday: no same-day attempt; next-business-day call by 12:00.

Patient declines a same-day introduction: recorded with the reason in the patient's words; next-business-day call still offered.

Patient reports active suicidal thoughts: the existing safety protocol takes over, and the clinician and consultant manage the patient together; the warm handoff design does not change safety procedures.

Patient's preferred language not spoken by the consultant: telephone or video interpreter, as for any visit.

Patient already in behavioral health care at the health center: the consultant is still messaged and decides whether to see them or notify their current clinician.

Why This Design

In the IMPACT trial, collaborative care helped older adults with depression partly because a care manager made early, structured contact (Unützer et al., 2002). A warm handoff applies the same principle at the moment of the visit. The design keeps the next-business-day call because one study found that warm handoffs did not work equally well for all groups (Horevitz et al., 2015), and patients who decline a same-day meeting should still be reached quickly.

How the Design Was Built

The design came from the workflow map made in the first term, which showed patients leaving the building before anyone from behavioral health knew about them, and from the behavioral health team's meeting, where the consultant said, "If I could just meet them, they'd come back." The medical assistants suggested messaging before the clinician enters, since the clinician's visit is when the patient is most likely to agree. The scheduling office suggested the two fixed open slots rather than a floating block, because fixed slots are easier to protect from overbooking. Integrated care research describes the same need for routine, low-friction contact between primary care and behavioral health (Archer et al., 2012).

What Would Make Staff Abandon It

Every change has a point at which the people carrying it give up, and it is better to name it in advance. A day when four positive screens arrive at once and the consultant is booked: the edge conditions handle it, but if it happens often, staff will stop messaging. The design counts handoff requests weekly so that falling use is seen early. If requests fall below two thirds of eligible visits for two weeks running, the student and the director of behavioral health will meet the medical assistants to find out why before anything else changes. Asking the people who carry a change why they stopped is cheaper than guessing.

A Day in the Test, Described

A Tuesday in March: at 09:40 a medical assistant rooms a 46-year-old patient for a diabetes visit, the PHQ-9 total is 14, and the assistant messages the group and asks the patient about meeting the counselor. The consultant replies "in 20 minutes." The clinician sees the patient, discusses the score and, at 10:05, walks the patient to the consultant's office for the 10:00 open slot, which the consultant has held. The consultant spends fifteen minutes with the patient and books a follow-up for the next week. At 16:30 the assistant's list shows one positive screen from a 17:15 visit the previous day; the call is made at 08:35.

What the Design Does Not Change

The PHQ-9 screening process, the safety protocol, behavioral health treatment after the first contact and the electronic record. Each is outside the project's scope and stays as it is.

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

Horevitz, E., Organista, K. C., & Arean, P. A. (2015). Depression treatment uptake in integrated primary care: How a "warm handoff" and other factors affect decision making by Latinos. Psychiatric Services, 66(8), 824-830. https://doi.org/10.1176/appi.ps.201400085

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