TIDES Collaborative Care for Depression: From Research to Practice

Jeffrey L. Smith, PhD(c)Implementation Research Coordinator

VA Mental Health QUERILittle Rock, AR

Jeffrey.Smith6@va.gov

July 14, 2010

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

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

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

Collaborative Care for Depression

Primary Care Clinician

Psychiatrist

Nurse Care Manager Patien

t

Translating Initiatives for Depression into Effective Solutions (TIDES)

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

Regional TIDES Spread (ReTIDES)

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

HOT SPRINGS

BLACK HILLS SIOUX FALLS

TWIN PORTS

CANTON

YOUNGSTOWN

AKRON

PENSACOLA

BEAUMONT

LUFKIN

Prospective Sites

Participating Sites

TIDES Primary Care Clinic Sites

NEW YORK

WEST LA

LONGBEACH

PORTLAND

SEATTLE

Tentative Sites

HOUSTON

CINCINATTI

SHREVEPORT

VISN 23

TIDES Research-to-Practice Implementation

Efficacy studiesEffectiveness studies • Group Health• Kaiser Permanente• Sepulveda VA (n=1)• VA Puget Sound HCS (n=2)

DE

SIG

NP

RO

GR

ES

SIO

N

Process Evaluation

Outcomes Evaluation (Group RCT)

Formative EvaluationCost Assessment

WAVES

COVES

TIDES ReTIDES

ImpactEvaluation

+Cost Analysis

Leadership planningProcess tools

DepressionCollaborativeCare Model

Black HillsTwin PortsSioux Falls

BeaumontPensacola

Lufkin

AkronCanton

Youngstown

Depression symptomsDepression severityAntidepressant meds

BarriersCollaborative care costsImplementation fidelity

Outpatient utilizationPatient satisfaction

Hospitalization rates

WAVES COVES

Evaluations of TIDES

Implementation

Adaptation to VA

Implementation

VISN 23

VISN 16

VISN 10

TIDESPhase 2

ImplementationTrial

ReTIDESPhase 3

Implementation Trial

Sustainability in1st-generation sites(VISNs 10, 16, 23)

Spread to 2nd-generation sites (VISN 22)

1st-generation sites

BRIDGEto

NationalRollout

Leadership Planning

Guidelines & Performance Measures

Education & Training

Informatics & Decision Support

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

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

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

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

TIDES Research-to-Practice Implementation (revisited)

DepressionCollaborativeCare Model

Black HillsTwin PortsSioux Falls

BeaumontPensacola

Lufkin

AkronCanton

Youngstown

Efficacy / effectiveness

studies (VA and other)

Adaptation to VA

Implementation

VISN 23

VISN 16

VISN 10

TIDES ReTIDESSustainability

in1st-generation sites(VISNs 10, 16, 23)

1st-generation sites

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 & PerformanceIndicators■ 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’

Spread to

2nd-generation sites(VISNs 10, 16, 22, 23)

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

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

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

Contact information

Address: Jeffrey SmithVA Mental Health QUERICentral Arkansas Veterans Healthcare System2200 Fort Roots Drive, Building 58 (152/NLR)North Little Rock, AR 72114

Phone (501)257-1066

Email Jeffrey.Smith6@va.gov