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
(of which Depression is the most prevalent)
Causes of Disability / US, Canada, and Western Europe, 2000 (WHO)
Cardiovascular Diseases
Sense Organ Diseases Injuries (Disabling) Digestive Diseases
Communicable Diseases Cancer (Malignant Neoplasms)
Diabetes Migraine All Other Causes of Disability
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 4.8 12.4
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VISN Participation in TIDES & ReTIDES
(90,000 PC Patients)
9 New VAMCs
(40,000 PC Patients)
2 New VAMCs
(90,000 PC Patients)
2 New VAMCs
(40,000 PC Patients)
2 New VAMCs
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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