Improving Depression Treatment in Improving Depression Treatment in Primary Care:Primary Care:

Dissemination and Implementation Dissemination and Implementation

Edmund Chaney, PhDEdmund Chaney, PhDDepartment of Veterans Affairs, Department of Veterans Affairs,

SeattleSeattle

AcademyHealthAcademyHealthSummer 2006Summer 2006

22

Opening up the Black Box of Opening up the Black Box of Quality Improvement Quality Improvement Interventions: Lessons from a Interventions: Lessons from a Formative Evaluation of Routine Formative Evaluation of Routine Care Implementation of Care Implementation of Depression Collaborative CareDepression Collaborative Care

• JoAnn Kirchner MD, ChairJoAnn Kirchner MD, Chair• Edmund Chaney PhDEdmund Chaney PhD• Louise Parker PhDLouise Parker PhD• Elizabeth Yano PhDElizabeth Yano PhD

AcademyHealthAcademyHealthSeattle, June 2006Seattle, June 2006

33

Impact of Mental IllnessesImpact of Mental Illnesses(of which Depression is the most prevalent)(of which Depression is the most prevalent)

Causes of DisabilityCauses of Disability / US, Canada, and Western Europe, 2000 / US, Canada, and Western Europe, 2000 (WHO)(WHO)

Mental Mental IllnessesIllnessesAlcohol & Drug Use Alcohol & Drug Use DisordersDisordersAlzheimer’s Disease & DementiasAlzheimer’s Disease & Dementias

Musculoskeletal DiseasesMusculoskeletal Diseases

Respiratory DiseasesRespiratory Diseases

Cardiovascular DiseasesCardiovascular Diseases

Sense Organ Sense Organ DiseasesDiseasesInjuries (Disabling)Injuries (Disabling)

Digestive DiseasesDigestive Diseases

Communicable DiseasesCommunicable DiseasesCancer (Malignant Neoplasms)Cancer (Malignant Neoplasms)

DiabetesDiabetes

MigraineMigraine

All Other Causes of All Other Causes of DisabilityDisability

0% 5% 10% 15% 20% 25%

44

Depression:Depression: Elephant in the primary care Elephant in the primary care

exam roomexam room

55

The Gap Between Primary Care The Gap Between Primary Care and Mental Health Specialtyand Mental Health Specialty

PCPC MHSMHS

66

Translating Initiatives for Translating Initiatives for Depression into Effective Depression into Effective

Solutions (TIDES)Solutions (TIDES)• Collaborative Depression Nurse Care Collaborative Depression Nurse Care

Management fills the gap between Management fills the gap between

primary care and mental health primary care and mental health

specialty care.specialty care.

77

TIDES TIDES Dissemination/ImplementatioDissemination/Implementatio

n Processesn Processes

• GOAL - Help interested VA VISNs, GOAL - Help interested VA VISNs, VAMCs, & CBOCs to adopt VAMCs, & CBOCs to adopt evidence-evidence-basedbased depression care depression care– Partner with VA VISNsPartner with VA VISNs– Foster local adaptationFoster local adaptation– Provide tools and trainingProvide tools and training– Assist with ongoing evaluationAssist with ongoing evaluation– Sustain clinician-researcher Sustain clinician-researcher

partnershipspartnerships

88

TIDES ComponentsTIDES Components

Leadership Buy-in/SupportLeadership Buy-in/Support

Depression Care ManagerDepression Care Manager

Provider EducationProvider Education

Informatics SupportInformatics Support

Patient EducationPatient Education

Performance FeedbackPerformance Feedback

99

TIDES Site First StepsTIDES Site First Steps

• Initial VISN leader communicationInitial VISN leader communication

• Expert panel with horizontal and Expert panel with horizontal and vertical organizational representationvertical organizational representation

• Identify preferences and action itemsIdentify preferences and action items

• Form ongoing task groupsForm ongoing task groups

• Initial site visitInitial site visit

1010

TIDES ComponentsTIDES Components

• Clinic screens for depression (registry)Clinic screens for depression (registry)

• Primary care clinic refers appropriate Primary care clinic refers appropriate depressed patients to care manager depressed patients to care manager (DCM)(DCM)

• DCM assesses depression and DCM assesses depression and comorbidities & suggests treatment plan comorbidities & suggests treatment plan to PCPto PCP

– DCMs are supervised by MH cliniciansDCMs are supervised by MH clinicians

1111

Depression Care Manager Depression Care Manager ActivitiesActivities• Patient AssessmentPatient Assessment• Treatment PlanningTreatment Planning• Communication with primary care and Communication with primary care and

mental health providersmental health providers• Patient InteractionsPatient Interactions

– EducationEducation– Self management supportSelf management support– General Social SupportGeneral Social Support

• Monitoring progressMonitoring progress

1212

InformaticsInformatics

• Depression screening reminderDepression screening reminder

• ConsultsConsults

• Electronic Health Record (CPRS) Electronic Health Record (CPRS) enhancementsenhancements– DCM assessment & follow-up templatesDCM assessment & follow-up templates

• Encounter codingEncounter coding

• Program evaluation supportProgram evaluation support

1313

Performance FeedbackPerformance Feedback

• Patient LevelPatient Level

• Clinic LevelClinic Level

1414

PHQ-9 ScoresPHQ-9 Scores

0

2

4

6

8

10

12

14

Baseline 4-6 Wks 8-12 Wks 24 Wks

12.412.4

4.84.85.85.8

7.37.3

1515

2 New VAMCs(90,000 PC Patients)

9 New VAMCs(90,000 PC Patients)

2 New VAMCs(40,000 PC Patients)

2 New VAMCs(40,000 PC Patients)

VISN Participation in TIDES & ReTIDESVISN Participation in TIDES & ReTIDES

ReTIDES Expansion

1616

TIDES Intervention OutcomesTIDES Intervention Outcomes

• Stepped careStepped care– 82% of patients are treated for depression in primary care82% of patients are treated for depression in primary care

• Patient satisfactionPatient satisfaction– 89% remain in care management89% remain in care management

• Care ManagementCare Management– Veterans engaged in care management have a high degree of Veterans engaged in care management have a high degree of

treatment compliancetreatment compliance• 74% stay on medication74% stay on medication• 90% of clinic appointments are kept90% of clinic appointments are kept

• Six-month symptom outcomeSix-month symptom outcome– 90% of PC patients and 50% of MHS patients achieved 90% of PC patients and 50% of MHS patients achieved

resolution of their depressive symptomsresolution of their depressive symptoms

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TIDES Long Term PlanTIDES Long Term Plan

• Assist VA to make collaborative care for Assist VA to make collaborative care for depression in primary care into routine depression in primary care into routine carecare– Update Best Practice GuidelinesUpdate Best Practice Guidelines– Improve Performance MeasurementImprove Performance Measurement

• Assist VA to support the primary Assist VA to support the primary care/mental health interface through usual care/mental health interface through usual practices and services, i.e., Patient Care practices and services, i.e., Patient Care Services, Office of Quality & Performance, Services, Office of Quality & Performance, Employee Education Service, Office of Employee Education Service, Office of Information, et al.Information, et al.

1818

TIDES Final ProductTIDES Final Product