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Screening Individuals with Cardiac Intervention for Depression

Policy Proposal

In 1995, John Kingdon proposed a policy stream model to explain how policy is effectively formed or rectified. In Kingdon’s model three streams; the problem stream, the policy stream, and the politics stream, must come together to pass through a policy window simultaneously. (Mason, Gardner, Hopkins Outlaw, & O’Grady, 2016). For a policy to be considered by lawmakers, each stream must combine at the right time to pass through the policy window and become active. For this paper, the proposed policy to screen individuals who have recently received a major cardiac intervention for depression will be broken down following Kingdon’s policy streams for evaluation.

Problem Stream

Medical conditions can be affected tremendously by psychological conditions. After receiving a cardiac intervention such as a Coronary Artery Bypass Graft (CABG), valve replacement/repair, or Percutaneous Coronary Intervention (PCI), patients receive specific discharge instructions. In the discharge instructions, the patient obtains all the information they will need regarding follow-up visits, physical activities and limitations, dietary guidelines, and medication schedules.

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However, there are no instructions or suggestions on how to handle any psychological effects due to the surgery or recuperation time. A patient can begin to feel down or depressed after surgery due to the surgery itself or a change in their lifestyle. Post-operatively, a patient may experience fatigue or physical limitations that will affect their mood. Depressive mood or sadness then has an adverse effect on a patient’s participation in cardiac rehabilitation. The increase in the depressive state can then exacerbate a patient’s cardiac condition; leading to worsening of physical health, complications of primary cardiac intervention, and possible hospital re-admissions.

Multiple studies show that depression in a post-cardiac intervention patient increases hospital re-admissions for complications and increase mortality rates. Niewuwsma et al., (2017), found that 65% of patients who had an acute coronary treatment had elevated depressive symptoms subsequently. Also, another 20% qualified for the diagnosis of major depression after discharge. Freedland et al., (2016) found that “depression is an independent risk factor for multiple all-cause re-hospitalizations of a patient with heart failure,” (Freedland et al., 2016, p. 7). In their study, 19.2% of their patients have been readmitted to the hospital within the first 30 days of discharge (Freedland et al., 2016).

The American Academy of Family Physicians (AAFP) developed a guideline for the detection and management of post-myocardial infarction in 2009. In the AAFP guideline, it is recommended to regularly screen and treat post-myocardial infarction patients for depression. Treatment of depression is considered secondary prevention for cardiac patients (“AAFP guideline,” 2009).

The Center for Disease Control and Prevention (CDC) issued a recommendation to screen and treat anyone over the age of sixty-five for depression. In the recommendation, the CDC ascertained that depression could be common in individuals who have a chronic medical condition such as congestive heart failure or diabetes, or in individuals who have developed any physical or functional limitation associated with significant medical conditions, such as a CABG or a stroke. While the feelings of depression are common, they should be treated and not ignored merely due to the initial medical condition. The CDC pointed out that depression in older adults is often misdiagnosed or undertreated due to the belief that depression is typical for those over the age of sixty-five.

Misdiagnosis or under treatment can lead to worsening of chronic conditions and increased hospitalizations for physical ailments. Depression is reported in 1-5% of individuals over the age of sixty-five, regardless of medical conditions. For patients who are are hospitalized, as well as those needing home health care, show an increase in depression: 11.5% and 13.5% respectively (“CDC recommendation,” 2018). The number of patients affected by depression is significant enough to warrant a policy developed to limit the number of patients who experience depression and go untreated.

Policy Stream

In the Policy stream, the proposed policy should be a suggested alternative to current policies, in order for the proposed policy to become effective. The proposed policy’s goals are threefold. First, to screen post-cardiac intervention patients for depression. Post-cardiac intervention patients are evaluated for depression by answering the Patient Health Questionnaire, PHQ-9, within the first 30 days of discharge.

The second goal is to treat post-cardiac intervention patients who do show symptoms of a depressive disorder. The third is to decrease hospital re-admissions rates for patients who have been depressed after the cardiac intervention. A patient may not avoid depression, but early detection and treatment may lead to minimal effects on recuperation time by diminishing the chances of hospital re-admissions and complications associated with cardiac interventions.

The screening of patients will coincide with the patient’s cardiac rehabilitation. Cardiac rehabilitation nurses and cardiac physical therapists will be trained in how to communicate with patients regarding their feelings and how to offer help. Medical staff will be trained under the Healthy IDEAS program by Baylor College of Medicine on how to screen, educate and assess patients’ depressive states while working with them.

Healthy IDEAS stands for Identifying Depression and Empowering Activities for Seniors. The program is one of three recommended program in the CDC Recommendation, “CDC Recommendation,” 2018. Healthy IDEAS teaches the patient how to decrease depression symptoms, reduce physical pain, and physical and mental self-care (Healthy IDEAS, 2017). The program is available for other sites to use. Cardiac rehabilitation nurses and physical therapists can be trained by a certified Healthy IDEAS regional trainer and provided consultation as well.

Prior to training, the Healthy IDEAS program requires new sites to complete four readiness tasks. The tasks are designed to help develop a strong foundation and support in order to allow the program to become beneficial for the patients. The tasks include; creating a leadership team, developing effective partnerships with local providers to evaluate and treat depression, installing the core Healthy IDEAS components into policies, forms, and documentation, and finally to establish a system for collecting and monitoring client outcomes. Once all readiness tasks are completed staff training can begin (Healthy IDEAS, 2017).

The patient’s PHQ-9 will be administered by a cardiac rehabilitation nurse, ideally at the first cardiac rehabilitation treatment. The nurse will score the questionnaire and provide referral information if a patient scores high enough to be considered moderate to severely depressed. Each patient who qualifies for depression treatment will be offered counseling and medication to help with their depression. Patients will be given the PHQ-9 several times during their cardiac rehabilitation program. Patients will be followed throughout their cardiac rehabilitation program and offered treatment if at any time they high score enough to meet criteria for care psychological care.

Political Stream

Individuals within our national and state government will be pivotal in assisting the proposed policy to be developed and implemented. Medicare/Medicaid, Department of Economic Security- Division of Aging and Adult Services, and Arizona Center for Aging are some of the organizations that could benefit from the proposed policy. Medicare covers cardiac rehabilitation after a major cardiac intervention. Depression screening is covered as well by Medicare. Coverage of these two areas will benefit the proposed policy’s program.

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Several political and governmental factors are involved in the political stream for the proposed policy. The first factor is the aging baby boomers. The average age of a patient undergoing a CABG or a percutaneous coronary intervention (PCI) is seventy-four (Weintraub et al., 2012). As baby boomers age, the need for cardiac interventions will continue to rise as well. An issue that affects a significant number of the population will have significant political power to develop policy changes.

Another factor is the financial ramifications of caring for patients medically after the cardiac intervention. Baqar et al., (2018), found that depression, ethnicity and gender were all associated with increase hospital costs in heart failure patients. The average cost of hospitalization of a heart failure patient was $77,417. This was 45% higher than the average hospitalization cost of a patient without heart failure. The authors determined that the screening and treatment of depression reduced hospital costs (Baqar et al., 2018). The cost of the proposed policy should be less than hospitalization.

Economically the proposed policy will be beneficial to insurance companies, Medicare/Medicaid and hospitals. The proposed policy would decrease patient’s hospital readmission rates, saving companies money due to re-hospitalization. Tully et al., (2008) showed post-operative depression in CABG patients predicted hospital readmission independently to any other medical condition. Tripathi et al. estimated that 12% of post-cardiac intervention patients were re-hospitalized within the first 30 days after discharge. The mean cost of hospital readmission after major cardiac surgery is $39,634 (Tripathi et al., 2017). Having the proposed policy can decreased post-operative complications which will be financial fiscal.

Health care costs are continuing to rise. According to the Office of the Actuary at the Centers for Medicare & Medicaid Services (CMS), national health care spending increased by 5.8 % in 2015 and another 4.3 % in 2016. CMS anticipates the cost of health care to continue to grow at an average rate of 5.5 % yearly till 2026 (National Conference of State Legislatures, 2018).

The Hospital Reduction Program (HRRP) monitors several medical conditions that have a high incident of hospital re-admissions. Two of the conditions, congestive heart failure (CHF) and acute myocardial infarction (AMI), are directly affected by the proposed policy. The HRRP reduces Medicare reimbursement to hospitals by three percent if they view the hospital re-admission rates to be above national averages for those conditions (“MPA Commission,” 2018).

In the current political landscape, Medicare benefits and costs are up for political discussion and change. Government downsizing and decreased budgets are at the center of the Medicare coverage debate. Policies that indorse decreasing the overall financial burdens on Medicare have a strong stance in the political stream. Hospitals and insurance companies are motivated to see changes that would financially benefit them. The Medicare’s potential revenue loss due to the HRRP reimbursement reduction can facilitate policy changes from a local level to insurance lobbyists, and to the government.

Policy Window

Guldbrandsson & Fossum describe the policy streams approach as focusing, “on the continual interplay and sharing of agendas between decision makers,”(Guldbrandsson & Fossum, 2009, table 1). The three streams listed by Kingdon are self-involved streams that are independent of each other. However, in order for a policy to be adequately developed and accepted all three streams must enter the policy window concurrently.

The adage that may be used is when the policy becomes the “perfect storm.” The proposed policy is a perfect storm. The lack of acknowledgment regarding post-operative patients having depression and treatment for the psychological well-being of a patient after a significant medical condition or procedure should lead to the development of a policy to combat the deficiencies. An increase in patients affected by the proposed policy due to an aging baby boomer population and a political environment desiring to cut health care costs nationally creates the right climate to develop and engage the proposed policy. The cost of the proposed policy would be less than the current financial burden of hospital readmissions and death.


  • Baqar, A., Husaini, D.T., Norris, K., Adhish, S.V., Moonis, M., & Levine, R. (2018). Depression effects on hospital cost of heart failure patients in California: an analysis by ethnicity and gender. Indian Journal of Community Medicine, 43(1), 49-52
  • CDC promotes public health approach to address depression among older . (2018). Retrieved from
  • Freedland, K. E., Carney, R. M., Rich, M. W., Steinmeyer, B. C., Skala, J. A., & Davila-Roman, V. G. (2016). Depression and multiple rehospitalizations in patients with heart failure. Clinical Cardiology39(5), 257-262.
  • Guideline summary: AAFP guideline for the detection and management of post-myocardial infarction depression. (2009). Retrieved from
  • Guldbrandsson, K., & Fossum, B. (2009, December 1). An exploration of the theoretical concepts policy windows and policy entrepreneurs at the Swedish public health arena. Health Promotion International24(4), 434-444.
  • Healthy IDEAS. (2017).
  • Mason, D. J., Gardner, D. B., Hopkins Outlaw, F., & O’Grady, E. T. (2016). Policy & politics in nursing and health care (7th ed.). St. Louis, MO: Elsevier.
  • National Conference of State Legislatures. (2018).
  • Nieuwsma, J. A., Williams, J. W., Namdari, N., Washam, J., Raitz, G., Blumenthal, J., … Sanders, G. D. (2017, November 21). Diagnostic accuracy of screening tests and treatment for post-acute coronary syndrome depression. Annuals of Internal Medicine167(10), 725-735.
  • Report to the Congress: Promoting greater efficiency in Medicare. (2018). Retrieved from
  • Tripathi, A., Abbott, J. A., Fonarow, G. C., Khan, A. R., Barry, S. I., Coram, R., … Bhatt, D. L. (2017). Thirty-day readmission rate and costs after percutaneous coronary intervention in the United States. Cardiovascular Interventions.
  • Tully, P., Baker, R., Turnbull, D., & Winefield, H. (2008). The role of depression and anxiety symptoms in hospital readmissions after cardiac surgery. Journal of Behavioral Medicine,31(4), 281-90.
  • Weintraub, W. S., Grau-Sepulveda, M. V., Weiss, J. M., O’Brien, S. M., Peterson, E. D., Kolm, P., … Edwards, F. H. (2012, April 19). Comparative effectiveness of revascularization strategies. New England Journal of Medicine366(16), 1467-1476.


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