NR 705A Week 4 Baseline Description Example

Baseline Description Write-Up: First Behavioral Health Visit Within a Month of a Positive Depression Screen, January to June 2026, Week by Week and Rerunnable

Student Name

College of Nursing, Chamberlain University

NR 705A: DNP Project & Practicum II

Instructor Name

Month Day, Year

Baseline Description Write-Up: First Behavioral Health Visit Within a Month of a Positive Depression Screen, January to June 2026, Week by Week and Rerunnable

Dates, Defended

Baseline period: 1 January to 30 June 2026, 26 weeks. Long enough to include the winter respiratory season, a spring holiday week and a six-week vacancy in the behavioral health assistant's post, which together cover the ordinary variation the site sees. Short enough that the service was the same throughout: the same consultant, the same psychologist days, the same screening process on tablets introduced in 2025. July to December 2026 was not used because the assistant's leave from November would make it unrepresentative.

The Pull, Written to Be Rerun

A baseline is only useful if it can be produced again the same way. Source tables: adult primary care visits with a PHQ-9 total in the structured field; behavioral health encounters; the referral log status field. Run by: the quality analyst, using the query saved as "PHQ9_BH_30day_v2" in the analytics folder.

Rules: include visits at the site's adult primary care department, patients aged 18 or older on the visit date, PHQ-9 total of 10 or more. For a patient with more than one qualifying visit in the period, count only the first. Numerator: a behavioral health encounter, of any type, completed within 30 days after the visit date, counting the visit date as day 0. Exclude: patients whose record shows death or a transfer of care inside the 30-day window.

Anyone with the query and access to the tables should get the same counts, and the query's comments explain each rule in plain words.

The Figure

189 of 580 eligible patients had a behavioral health encounter inside the 30 days: 32.6%. January to March: 91 of 293, 31.1%. April to June: 98 of 287, 34.1%.

Week by Week

A single figure for 26 weeks would hide how much the result moves from week to week. | Weeks | Eligible patients | Completed within 30 days | Share |

The four-week blocks range from 29% to 36%. Single weeks ranged from 19% to 47%, because each week holds only about 22 patients, which is why the run chart will use weekly points with the median rather than any single week.

Exclusions, With Counts

Second and later qualifying visits for the same patient: 47 visits. Deaths or transfers of care inside the window: 6. Visits where the PHQ-9 was recorded only in a note: not counted, since the query uses the structured field; the analyst's sample of notes found 4 such visits in a month, so perhaps 24 in the period.

What the Figure Does Not Establish

That patients not seen by behavioral health went without care; some may have been seen elsewhere. That the 30-day window is the right one clinically; it is the health center's choice. That the 6-week assistant vacancy, in February and March, had no effect; the four-week blocks covering it were slightly lower, but within normal variation.

Context for the Measure

On the PHQ-9, a total of 10 is the usual cut point for moderate depression (Kroenke et al., 2001). The weekly figures will be plotted on a run chart, which is suited to detecting shifts and trends in small samples over time (Perla et al., 2011).

Why a Baseline This Long

The test will run for 12 weeks. A baseline of 26 weeks gives a stable median and shows how much the figure moves when nothing changes, which is what any later shift must be judged against. A shorter baseline, such as eight weeks, would have missed the vacancy months and made the median less reliable.

What the Baseline Says About Where Patients Are Lost

Combining the baseline with the referral log's status field, as in the first term, about 37% of eligible patients were never reached by phone, 23% were reached but did not attend, 20% declined, 12% were seen after day 30 and 8% had no recorded call attempt. The same-day introduction is aimed at the first and last groups, those never reached and those never called, which together make up about 45% of eligible patients. If the change reached half of them, the figure would rise by about 22 points, which is why the target of 50% is plausible.

How the Baseline Compares With What Integrated Care Expects

Collaborative care models assume most patients identified with depression will have early contact with a care manager or behavioral health clinician (Archer et al., 2012). A third reaching that contact within a month is well short of that assumption, which is the gap the project addresses.

Seasonal and Staffing Context

January brought the year's highest volume of respiratory visits, which crowded the schedule but did not change the number of positive screens much. The behavioral health assistant's post was vacant for six weeks in February and March; callbacks were covered by the consultant between patients, and the four-week blocks covering those weeks were among the lowest. The spring holiday week had fewer visits and fewer positive screens. None of these produced a block outside the 29% to 36% range, which supports treating the 26 weeks as one stable baseline rather than splitting it at the vacancy.

How the Test Period Will Be Compared

The 12-week test will be plotted on the same run chart, after the 26 baseline weeks, with the baseline median extended across. Each test week's outcome becomes known 30 days after the week ends, so the chart will lag by about a month; the same-day contact measure, known within the week, will give an earlier signal. If same-day contacts rise in the first two weeks but the 30-day outcome has not yet caught up, the team will know the change is happening before it knows whether it is working, which is the right order to learn things in.

Who Checked It

The quality analyst reran the query on 22 January 2027 and obtained the same counts, to the patient, which confirms the method is written down well enough to repeat. The director of behavioral health reviewed the exclusions and agreed with them.

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

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

Perla, R. J., Provost, L. P., & Murray, S. K. (2011). The run chart: A simple analytical tool for learning from variation in healthcare processes. BMJ Quality & Safety, 20(1), 46-51. https://doi.org/10.1136/bmjqs.2009.037895