TIDES Collaborative Care for Depression: From Research to Practice

1. TIDES Collaborative Care for Depression: From Research to Practice Jeffrey L. Smith, PhD(c) Implementation Research Coordinator VA Mental Health QUERI Little Rock, ARJeffrey.Smith6@va.gov July 14, 2010

2. Presentation Outline • Depression care in VA • Collaborative care for depression as evidence-based practice • TIDES & ReTIDES projects to implement collaborative care in VA • MH QUERI VA activities to implement and spread TIDES collaborative care

3. Depression Care in VA • Depression present in 5-13% of patients seen in primary care; 44% receive all or most of their treatment in primary care • Patients treated exclusively in primary care have fewer visits than those seen in mental health specialty care • Less than half (45%) of patients started on antidepressants receive adequate dose for guideline-recommended duration

4. Collaborative Care for Depression • An integrated package of intervention tools / strategies, including… • Clinician education and decision support • Care management (monitor symptoms, treatment adherence, side effects • Active collaboration between primary care and mental health specialists • Patient education and self-management support • Consistent with Chronic Care Model (Wagner) • Improves depression treatment, symptoms, functioning, work-related outcomes, quality-of-life, and is cost-effective

5. Collaborative Care for Depression Primary Care Clinician Nurse Care Manager Patient Psychiatrist

6. PI’s: Lisa Rubenstein MD, Ed Chaney PhD Collaborators: VISNs 10, 16 & 23 Evidence-based quality improvement (EBQI) process for tailored implementation Key findings Patients keep 90% of follow-up appointments Twice as many patients receiving collaborative care are treatment adherent Depression symptoms significantly improved at 8-12 weeks Improved work/social functioning at 6 months Translating Initiatives for Depression into Effective Solutions (TIDES)

7. PI’s: Rubenstein, Chaney Sustainability in 1st generation TIDES sites (VISNs 10, 16, 23) Spread collaborative care to new sites (VISN 22) Evaluate impact of implementation on patient care, clinical outcomes, and costs Build and leverage system support for further implementation and spread Regional TIDES Spread (ReTIDES)

8. Tentative Sites TIDES Primary Care Clinic Sites TWIN PORTS SEATTLE BLACK HILLS SIOUX FALLS PORTLAND AKRON HOT SPRINGS VISN 23 CANTON NEW YORK YOUNGSTOWN CINCINATTI LONG BEACH WEST LA LUFKIN PENSACOLA BEAUMONT SHREVEPORT HOUSTON Prospective Sites Participating Sites

9. TIDES Research-to-Practice Implementation BRIDGE to National Rollout WAVESCOVESEvaluations of TIDES Implementation TIDESPhase 2Implementation Trial ReTIDESPhase 3 Implementation Trial • Leadership • Planning • Guidelines & Performance • Measures • Education & Training • Informatics & Decision Support Adaptation to VA Black Hills Twin Ports Sioux Falls Depression symptoms Depression severity Antidepressant meds VISN 23 Depression Collaborative Care Model Akron Canton Youngstown Outpatient utilization Patient satisfaction Hospitalization rates VISN 10 VISN 16 Beaumont Pensacola Lufkin Barriers Collaborative care costs Implementation fidelity Implementation Sustainability in 1st-generation sites(VISNs 10, 16, 23) Spread to 2nd-generation sites (VISN 22) 1st-generation sites TIDES WAVES ReTIDES • Efficacy studies • Effectiveness studies • Group Health • Kaiser Permanente • Sepulveda VA (n=1) • VA Puget Sound HCS (n=2) Outcomes Evaluation (Group RCT) Process Evaluation Impact Evaluation + Cost Analysis Leadership planning Process tools DESIGN PROGRESSION COVES Formative EvaluationCost Assessment

10. Leadership Planning for TIDES Spread • Obtain leadership input on strategies for facilitating spread • Develop marketing plan to promote spread of collaborative care • Keep key VA leaders, offices and advisory groups apprised of implementation progress

11. Guidelines and Performance Measurement • Update VA depression treatment guidelines to include evidence base for collaborative care • MH QUERI worked with VA Office of Quality & Performance to modify performance measure for follow-up visits following depression diagnosis • Allow visits with Nurse Care Managers, and phone contacts

12. Education and Training • Develop training materials for primary care clinicians, nurse care managers, psychiatrists • Develop position descriptions for depression care managers • Develop materials to train clinical managers and leaders on EBQI approach

13. Informatics and Decision Support • Need informatics tools to support collaborative care • Support care management in monitoring treatment adherence and patient outcomes • Enhance evidence-based decision-making at point of care • Enhance patient education and self-management

14. TIDES Research-to-Practice Implementation (revisited) Clinical / Research Partnerships to Facilitate Spread Leadership Support■Input on ‘TIDES National Dissemination Plan’■OMHS Uniform MH Services Handbook; Primary Care / Mental Health Integration Initiative Guidelines & Performance Indicators ■Updated depression CPGs to include evidence for collaborative care (released May 2009)■ ‘Guidance for Program Integrity’ developed, identifying key features of TIDES and related QI models (with performance targets) Training & Education ■ TIDES Depression Care Manager Manual■ TIDES resources accessible to all VA facilities via Sharepoint website■EES-sponsored TIDES trainings Informatics Tools ■ IT Expert Panel conference hosted by TIDES team resulted in plans to integrate TIDES software into VA ‘Mental Health Assistant’ ReTIDES TIDES Adaptation to VA Black Hills Twin Ports Sioux Falls Sustainabilityin 1st-generation sites(VISNs 10, 16, 23) VISN 23 Depression Collaborative Care Model Akron Canton Youngstown VISN 10 Spreadto 2nd-generation sites (VISNs 10, 16, 22, 23) VISN 16 Beaumont Pensacola Lufkin Efficacy / effectiveness studies (VA and other) Implementation 1st-generation sites

15. Policy and Program Support for TIDES Implementation • Uniform Mental Health Services Handbook (VHA Handbook 1160.01; released by VA Office of MH Services Sept ’08) • Requires VAMCs and very large CBOCs to offer integrated MH services in primary care clinics • Care management component of PC-MH integration must include: • Monitoring adherence to treatment, treatment outcomes, and medication side effects • Decision support • Patient education and activation • Assistance in referral to specialty mental health care, when needed. • TIDES is one of only two evidence-based care models named in Handbook for fulfilling care management component

19. Other Ongoing or Recently Completed MH QUERI Research Related to TIDES Implementation • Test adapted TIDES model to improve depression care in HIV clinics • Test external and internal facilitation strategies to support implementation of TIDES and other evidence-based PC-MH integration models

20. For more information… • Primary Care Mental Health Integration Initiative (OMHS)http://vaww4.va.gov/pcmhi • TIDES Sharepointhttp://vaww.portal.gla.med.va.gov/sites/Research/HSRD/ClinicalPart/default.aspx • Mental Health QUERIhttp://www.queri.research.va.gov/mh/default.cfm

21. Contact information Address: Jeffrey Smith VA Mental Health QUERI Central Arkansas Veterans Healthcare System 2200 Fort Roots Drive, Building 58 (152/NLR) North Little Rock, AR 72114 Phone (501)257-1066 Email Jeffrey.Smith6@va.gov