Improving Depression Treatment in Primary Care: Dissemination and Implementation
Edmund Chaney, PhD Department of Veterans Affairs, Seattle
AcademyHealth Summer 2006
Opening up the Black Box of Quality Improvement Interventions: Lessons from a Formative Evaluation of Routine Care Implementation of Depression Collaborative Care
• JoAnn Kirchner MD, Chair • Edmund Chaney PhD • Louise Parker PhD • Elizabeth Yano PhD
AcademyHealth Seattle, June 2006
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Impact of Mental Illnesses
Mental Illnesses
Alcohol & Drug Use Disorders Alzheimer’s Disease & Dementias Musculoskeletal Diseases Respiratory Diseases Cardiovascular Diseases Sense Organ Diseases Injuries (Disabling) Digestive Diseases
Communicable Diseases Cancer (Malignant Neoplasms) Diabetes Migraine All Other Causes of Disability
(of which Depression is the most prevalent)
Causes of Disability / US, Canada, and Western Europe, 2000 (WHO)
0%
3
5%
10%
15%
20%
25%
Depression: Elephant in the primary care exam room
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The Gap Between Primary Care and Mental Health Specialty
PC MHS
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Translating Initiatives for Depression into Effective Solutions (TIDES)
• Collaborative Depression Nurse Care
Management fills the gap between primary
care and mental health specialty care.
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TIDES Dissemination/Implementation Processes
• GOAL - Help interested VA VISNs,
VAMCs, & CBOCs to adopt evidencebased depression care
– Partner with VA VISNs – Foster local adaptation – Provide tools and training – Assist with ongoing evaluation – Sustain clinician-researcher partnerships
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TIDES Components
Leadership Buy-in/Support Depression Care Manager Provider Education Informatics Support Patient Education Performance Feedback
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TIDES Site First Steps
• Initial VISN leader communication • Expert panel with horizontal and vertical
organizational representation • Identify preferences and action items • Form ongoing task groups • Initial site visit
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TIDES Components
• Clinic screens for depression (registry) • Primary care clinic refers appropriate • DCM assesses depression and
depressed patients to care manager (DCM) comorbidities & suggests treatment plan to PCP
– DCMs are supervised by MH clinicians
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Depression Care Manager Activities
• Patient Assessment • Treatment Planning • Communication with primary care and
mental health providers • Patient Interactions
– Education – Self management support – General Social Support
• Monitoring progress
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Informatics
• Depression screening reminder • Consults • Electronic Health Record (CPRS)
enhancements
– DCM assessment & follow-up templates
• Encounter coding • Program evaluation support
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Performance Feedback
• Patient Level • Clinic Level
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PHQ-9 Scores
14 12 10 8 6 4 2 0 Baseline 4-6 Wks 8-12 Wks 24 Wks
7.3
5.8 12.4
4.8
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VISN Participation in TIDES & ReTIDES
9 New VAMCs
(90,000 PC Patients)
2 New VAMCs
(40,000 PC Patients)
2 New VAMCs 2 New VAMCs
(90,000 PC Patients) (40,000 PC Patients)
ReTIDES Expansion
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TIDES Intervention Outcomes
• Stepped care
– 82% of patients are treated for depression in primary care
• Patient satisfaction • Care Management
– 89% remain in care management
– Veterans engaged in care management have a high degree of treatment compliance
• 74% stay on medication • 90% of clinic appointments are kept
• Six-month symptom outcome
– 90% of PC patients and 50% of MHS patients achieved resolution of their depressive symptoms
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TIDES Long Term Plan
• Assist VA to make collaborative care for
– Update Best Practice Guidelines – Improve Performance Measurement
depression in primary care into routine care
• Assist VA to support the primary care/mental
health interface through usual practices and services, i.e., Patient Care Services, Office of Quality & Performance, Employee Education Service, Office of Information, et al.
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TIDES Final Product
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