TIDES Collaborative Care for Depression:
From Research to Practice
Jeffrey L. Smith, PhD(c)
Implementation Research Coordinator
VA Mental Health QUERI
Little 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
Nurse Care
Patien
Manager
t
Psychiatrist
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
TIDES Primary Care Clinic Sites
TWIN PORTS
SEATTLE
BLACK HILLS SIOUX FALLS
PORTLAND
HOT SPRINGS AKRON
VISN 23
CANTON
NEW YORK
YOUNGSTOWN
CINCINATTI
LONG
BEACH
WEST LA
LUFKIN
PENSACOLA
BEAUMONT
Tentative Sites
SHREVEPORT
Prospective Sites HOUSTON
Participating Sites
TIDES Research-to-Practice Implementation
BRIDGE
WAVES to
TIDES ReTIDES
Phase 2
COVES
Phase 3
National
Evaluations of
Implementation TIDES Implementation Rollout
Trial Implementation Trial
Black Hills Depression symptoms Leadership
Twin Ports Depression severity Planning
Sioux Falls Antidepressant meds
Depression Akron Outpatient utilization Guidelines &
Collaborative VISN 10 Canton Patient satisfaction
Performance
Care Model Youngstown Hospitalization rates
Measures
Beaumont Barriers
Pensacola Collaborative care costs
Lufkin Implementation fidelity Education
1st-generation sites Sustainability in & Training
1st-generation sites
(VISNs 10, 16, 23)
Informatics
Spread to & Decision
2nd-generation sites (VISN 22) Support
PROGRESSION
Efficacy studies TIDES WAVES ReTIDES
Effectiveness studies Outcomes
DESIGN
Process Impact
• Group Health Evaluation Evaluation Evaluation
• Kaiser Permanente (Group RCT) +
• Sepulveda VA (n=1) Cost Analysis
• VA Puget Sound HCS (n=2) COVES Leadership planning
Formative Evaluation Process tools
Cost Assessment
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)
Clinical / Research Partnerships
to Facilitate Spread
Leadership Support
■ Input on ‘TIDES National Dissemination Plan’
■ OMHS Uniform MH Services Handbook;
Primary Care / Mental Health Integration
TIDES ReTIDES Initiative
Guidelines & Performance
Black Hills Sustainability
Twin Ports in Indicators
Sioux Falls ■ Updated depression CPGs to include evidence
1st-generationsites
Depression Akron for collaborative care (released May 2009)
(VISNs 10, 16, 23) ■ ‘Guidance for Program Integrity’ developed,
Collaborative VISN 10 Canton
Care Model Youngstown Spread identifying key features of TIDES and
related QI models (with performance targets)
Beaumont to
Efficacy / Pensacola 2nd-generation sites Training & Education
effectiveness Lufkin (VISNs 10, 16, 22, 23)
■ TIDES Depression Care Manager Manual
studies 1st-generation sites ■ TIDES resources accessible to all VA
(VA and other) 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’
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 Sharepoint
http://vaww.portal.gla.med.va.gov/sites/Research/HSRD/C
linicalPart/default.aspx
• Mental Health QUERI
http://www.queri.research.va.gov/mh/default.cfm
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