TIDES Collaborative Care for Depression: From Research to Practice

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TIDES Collaborative Care for Depression From
Research to Practice

• Jeffrey L. Smith, PhD(c)
• Implementation Research Coordinator
• VA Mental Health QUERI
• Little Rock, ARJeffrey.Smith6_at_va.gov
• July 14, 2010

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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

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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

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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

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Collaborative Care for Depression
Primary Care Clinician
Nurse Care Manager
Patient
Psychiatrist
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Translating Initiatives for Depression into
Effective Solutions (TIDES)

• PIs 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

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Regional TIDES Spread (ReTIDES)

• PIs 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

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TIDES Primary Care Clinic Sites
TWIN PORTS
SEATTLE
BLACK HILLS
SIOUX FALLS
PORTLAND
AKRON
HOT SPRINGS
VISN 23
CANTON
NEW YORK
YOUNGSTOWN
CINCINATTI
LONG
BEACH
WEST LA
LUFKIN
PENSACOLA
BEAUMONT
SHREVEPORT
HOUSTON
Prospective Sites
Participating Sites
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TIDES Research-to-Practice Implementation
BRIDGE to National Rollout
WAVES COVESEvaluations of TIDES Implementation
TIDESPhase 2Implementation Trial
ReTIDESPhase 3 Implementation Trial

• Leadership
• Planning
• Guidelines Performance
• Measures
• Education Training
• Informatics Decision Support

Adaptation to VA
Black Hills Twin Ports Sioux Falls
Depression symptoms Depression severity Antidepres
sant meds
VISN 23
Depression Collaborative Care Model
Akron Canton Youngstown
Outpatient utilization Patient satisfaction Hospit
alization rates
VISN 10
VISN 16
Beaumont Pensacola Lufkin
Barriers Collaborative care costs Implementation
fidelity
Implementation
Sustainability in 1st-generation sites(VISNs 10,
16, 23) Spread to 2nd-generation sites (VISN 22)
1st-generation sites
TIDES
WAVES
ReTIDES

• Efficacy studies
• Effectiveness studies
• Group Health
• Kaiser Permanente
• Sepulveda VA (n1)
• VA Puget Sound HCS (n2)

Outcomes Evaluation (Group RCT)
Process Evaluation
Impact Evaluation Cost Analysis Leadership
planning Process tools
DESIGN PROGRESSION
COVES
Formative EvaluationCost Assessment
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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

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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

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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

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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

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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 Initiative Guidelines
Performance Indicators 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
ReTIDES
TIDES
Adaptation to VA
Black Hills Twin Ports Sioux Falls
Sustainability in 1st-generation sites(VISNs
10, 16, 23)
VISN 23
Depression Collaborative Care Model
Akron Canton Youngstown
VISN 10
Spread to 2nd-generation sites (VISNs 10, 16,
22, 23)
VISN 16
Beaumont Pensacola Lufkin
Efficacy / effectiveness studies (VA and other)
Implementation
1st-generation sites
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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

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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

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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.g
  ov/mh/default.cfm

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• 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 [phone]
• Email Jeffrey.Smith6_at_va.gov