John Fortney, PhD Jeff Pyne, MD Dinesh Mittal, MD Teresa Hudson, PharmD

1. Comparative Effectiveness Study of Practice-Based vs. Telemedicine-BasedDepression Collaboratives John Fortney, PhD Jeff Pyne, MD Dinesh Mittal, MD Teresa Hudson, PharmD Division of Health Services Research Department of Psychiatry University of Arkansas for Medical Sciences

2. Funding • National Institute of Mental Health • R01 MH076908

3. Partnership • Community Health Centers of Arkansas • Boston Mountain Rural Health Centers Inc. • Community Clinic at St Francis House • Corning Area Healthcare Inc. • East Arkansas Family Health Center Inc. • Jefferson Comprehensive Healthcare System Inc. • University of Arkansas for Medical Sciences • Department of Psychiatry • Division of Health Services Research

4. Practice-Based Depression Collaborative • 20/28 randomized trials of depression collaboratives significantly improved outcomes1: • Median effect for response: +18% • Median effect for remission: +16% 1) Williams J et. al. Systematic review of multifaceted interventions to improve depression care. General Hospital Psychiatry, 29, 91-116, 2007

5. Components of Practice-Based Depression Collaborative • Provider education • Screening • Patient education, activation, and self-management • Regularly scheduled follow-up assessments • Use of clinical information systems and TX guidelines • Delegation of key clinical activities to non-physician members of a practice team • Ready access to mental health specialists • Stepped care

6. Barriers to Implementing Practice-Based Depression Collaborative in CHCs • On-site mental health specialists are typically unavailable. • Linkages to off-site mental health specialists are weak. • Depression Collaboratives are more effective if they include MH services1. • Depression Collaborative is effective in urban practices, but NOT rural practices.2 1) Gilbody S, Bower P, Fletcher J, Richards D, Sutton AJ. Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes. Archives of Internal Medicine 2006;166:2314-21. 2) Adams S, Xu S, Dong F, Fortney J, Rost K. Differential Effectiveness of Depression Disease Management for Rural and Urban Primary Care Patients, Journal of Rural Health, 2006 22(4):343-50.

7. Telemedicine-Based Depression Collaborative • Offsite depression care team at UAMS Dept. of Psychiatry • Nurse care manager • Pharmacist • Psychologist • Psychiatrist • Telephones • Care manager encounters with patients at home • Interactive Video • Evidence-Based Psychotherapy with patients at CHC • Psychiatric evaluations with patients at CHC • Web-based Decision Support System for Care Manager • NetDSS

8. NetDSS - https://www.NetDSS.net/ • NetDSS has the following functional capabilities: • patient registry and panel management • trial and phase management • encounter scheduler • decision support • progress note generator • Workload/Outcomes report generator • NetDSS guides the care manager through a self-documenting and evidence-based patient encounter using scripts and self-scoring instruments which support: • patient education and activation • barrier assessment • comorbidity assessment • depression severity monitoring • suicide risk assessment • adherence monitoring • side-effect monitoring • self-management activities

9. Comparison of Models

10. Advantages and Disadvantages of Telemedicine-Based Depression Collaborative

11. Research Question • Compare outcomes of telemedicine-based depression collaborative to practice-based depression collaborative.

12. Exclusion Criteria • Self-reported treatment with MH specialist • Self-reported Schizophrenia • Self-reported bereavement • Self-reported pregnancy/post partum • Bipolar Disorder (MDQ) • Substance Dependence (MINI) • Cognitive Impairment (Blessed) • Acute Suicide Ideation (HRSA risk assessment) • No phone

13. 9 Primary Care Practices 54,145 Patient Visits PHQ9 Screens 19,285 (36%) Positive Screens 2,863 (15%) Eligible/enrolled 364 (55%) Consented 829 (62%) 6-Month Follow-Up 316 (87%) Ineligible 316 (45%) 12-Month Follow-Up 271 (82%) Not located/refused 134 (16%) 18-Month Follow-Up 193 (88%) Enrollment Flowchart

14. Demographic Characteristics

15. Clinical Characteristics

16. Face to Face Service Utilization Specialty MH Encounters Depression PC Encounters

17. Tele-Mental Health Utilization • Tele - Cognitive Behavioral Therapy • 30 (17%) had an interactive video encounter • 33% Completed CBT manual • 47% Attended ≥ 8 sessions • 53% Dropped out and attended <8 sessions • 422 scheduled interactive-video sessions • 57% Interactive-video sessions attended • 40% Interactive-video sessions canceled by patients • 3% Canceled due to technical difficulties • Tele - Psychiatric Evaluations • 22 (12%) following two failed trials • 45% had an interactive video encounter • 55% had a telephone encounter • 5 (3%) for telephone suicide risk assessment

18. Care Manager FidelityTelemedicine-Based Depression Collaborative • Completed Baseline Assessments – 94.5% • Completed Follow-ups • Acute Stage – 1,191 (74%) • Mean days between assessments = 24 days • Continuation Stage – 295 (86%) • Mean days between assessments = 32 days • Final Disposition • 49% - Remitted and completed continuation phase • 12% - Responded and completed continuation phase • 12% - Did not respond within twelve months or relapsed • 2% - Requested deactivation • 25% - Baseline assessment not completed or lost to follow-up

19. ?Care Manager Fidelity?Practice-Based Depression Collaborative • NetDSS • Only 3 sites Used NetDSS • HRSA Patient Electronic Care System • Only 4 Sites Reporting Data • Patient Self-Report • Inaccurate • Chart Review • Currently underway

20. Six Month Follow-upResponse and Remission Rates (n=318) OR=6.0 p<0.0001 OR=10.5 P<0.0001

21. Twelve Month Follow-upResponse and Remission Rates (n=269) OR=5.3 p<0.0001 OR=3.6 P=0.0003

22. Eighteen Month Follow-upResponse and Remission Rates (n=192) OR=16.7 p<0.0001 OR=10.8 P<0.0001

23. Conclusions • Telemedicine-based depression collaborative required few PC visits than practice-based depression collaborative. • Telemedicine-based depression collaborative is more clinically effective than practice-based depression collaborative. • CHCs and CHCA should consider pooling resources to fund off-site depression care team.

24. Future Research • Partnership for Implementation of Evidence-Based Practices (EBPs) • NIMH R24 MH085104 • Objectives • Develop and sustain an Implementation Partnership to promote the adaptation, adoption, and evaluation of EBPs • In two Demonstration Projects, use QI methods to implement EBPs for Bipolar Disorder and Alcohol Use Disorders