1. 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

2. 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

3. 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

4. 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

5. Collaborative Care for Depression Primary Care Clinician Psychiatrist Nurse Care Manager Patien t

6. 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

7. Regional TIDES Spread (ReTIDES)  PI’s: Rubenstein, Chaney  Sustainability in 1 st 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

8. HOT SPRINGS BLACK HILLSSIOUX FALLS TWIN PORTS CANTON YOUNGSTOWN AKRON PENSACOLA BEAUMONT LUFKIN Prospective Sites Participating Sites TIDES Primary Care Clinic Sites NEW YORK WEST LA LONG BEACH PORTLAND SEATTLE Tentative Sites HOUSTON CINCINATTI SHREVEPORT VISN 23

9. TIDES Research-to-Practice Implementation Efficacy studies Effectiveness studies Group Health Kaiser Permanente Sepulveda VA (n=1) VA Puget Sound HCS (n=2) DESIGN PROGRESSION Process Evaluation Outcomes Evaluation (Group RCT) Formative Evaluation Cost Assessment WAVES COVES TIDES ReTIDES Impact Evaluation + Cost Analysis Leadership planning Process tools Depression Collaborative Care Model Black Hills Twin Ports Sioux Falls Beaumont Pensacola Lufkin Akron Canton Youngstown Depression symptoms Depression severity Antidepressant meds Barriers Collaborative care costs Implementation fidelity Outpatient utilization Patient satisfaction Hospitalization rates WAVES COVES Evaluations of TIDES Implementation Adaptation to VA Implementation VISN 23 VISN 16 VISN 10 TIDES Phase 2 Implementation Trial ReTIDES Phase 3 Implementation Trial Sustainability in 1 st -generation sites (VISNs 10, 16, 23) Spread to 2 nd -generation sites (VISN 22) 1 st -generation sites BRIDGE to National Rollout Leadership Planning Guidelines & Performance Measures Education & Training Informatics & Decision Support

10. 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

11. 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

12. 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

13. 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

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

15. 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

19. 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

20. 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

21. 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 EmailJeffrey.Smith6@va.gov