1. Telemedicine-Based Collaborative Care Models John Fortney, PhD Jeff Pyne, PhD VA HSR&D Center for Mental Healthcare and Outcomes Research VISN 16 Mental Illness Research, Education and Clinical Center Department of Psychiatry, University of Arkansas for Medical Sciences

2. Funding VA Health Services Research and Development VA Health Services Research and Development IIR 00-078-3 IIR 00-078-3 IMV 04-360 IMV 04-360 MHI 08-0981 MHI 08-0981 National Institute of Mental Health National Institute of Mental Health R01 MH076908 R01 MH076908

3. Collaborative Care 75% of patients treated for depression receive care in primary care settings 20/28 randomized trials of collaborative care significantly improved outcomes 1 : Median effect for response rate: +18% Median effect for remission rate: +16% 1) Williams J et. al. Systematic review of multifaceted interventions to improve depression care. General Hospital Psychiatry, 29, 91-116, 2007

4. Barriers to Implementing Practice-Based Collaborative Care in Rural Primary Care On-site mental health specialists are typically unavailable. On-site mental health specialists are typically unavailable. Collaborative care interventions are more effective if they include MHS 1. Collaborative care interventions are more effective if they include MHS 1. Collaborative care is effective in urban practices, but NOT rural practices. 2 Collaborative care is effective in urban practices, but NOT rural practices. 2 1) Gilbody S, Bower P, Fletcher J, Richards D, Sutton AJ. Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes. Archives of Internal Medicine 2006;166:2314-21. 2) Adams S, Xu S, Dong F, Fortney J, Rost K. Differential Effectiveness of Depression Disease Management for Rural and Urban Primary Care Patients, Journal of Rural Health, 2006 22(4):343-50.

5. Telemedicine-Based Collaborative Care for Small Rural PC Clinics Offsite depression care team Offsite depression care team Nurse care manager Nurse care manager Psychiatrist Psychiatrist Other mental health specialists (pharmacist, psychologist) Other mental health specialists (pharmacist, psychologist) Telephones Telephones Care manager encounters with patients at home Care manager encounters with patients at home Interactive Video Interactive Video Psychiatric evaluations with patients at PC clinic Psychiatric evaluations with patients at PC clinic Electronic Medical Records Electronic Medical Records Communication among on-site PCPs and offsite depression care team Communication among on-site PCPs and offsite depression care team

6. VA Telemedicine Enhanced Antidepressant Management (TEAM) Effectiveness Study Objective: Compare quality and outcomes of telemedicine-based collaborative care to usual depression care. Objective: Compare quality and outcomes of telemedicine-based collaborative care to usual depression care. Study Design Study Design Seven CBOCs lacking on-site psychiatrists Seven CBOCs lacking on-site psychiatrists Screened 18,000 patients Screened 18,000 patients Enrolled 395 patients (excluded specialty MH patients) Enrolled 395 patients (excluded specialty MH patients) 6 and 12 month follow-ups (88% FU rates) 6 and 12 month follow-ups (88% FU rates) Intent to treat analysis Intent to treat analysis

7. TEAM Intervention Components Component Enhanced Usual Care Telemedicine- Based Provider Education YesYes ScreeningYesYes Patient Education NoYes Self-ManagementNoYes MonitoringNoYes TX Recommendations NoYes PharmD Management NoYes Psychiatric Consult NoYes

8. Clinical Characteristics of Sample Clinical Casemix Mean/Percent Current Major Depressive Disorder 82.0% Prior Depressive Episodes 2.7 Prior Depression Treatment 66.6% Current Depression Treatment 41.0% SF12 Physical Component Summary 30.0 SF12 Mental Component Summary 36.5 Chronic Physical Health Conditions 5.5 Current Panic Disorder 9.6% Current Generalized Anxiety Disorder 45.8% Current PTSD 23.8%

9. Response OR=2.0 p=0.02 OR=1.4 p=0.18

10. Remission Remission OR=1.9 p=0.09 OR=2.4 p=0.02

11. NIMH OUTREACH Comparative Effectiveness Study Objective: Compare quality and outcomes of telemedicine-based collaborative care to practice-based collaborative care. Objective: Compare quality and outcomes of telemedicine-based collaborative care to practice-based collaborative care. Study Design Study Design Eight Community Health Centers lacking on-site mental health specialists Eight Community Health Centers lacking on-site mental health specialists Screened 19,000+ patients Screened 19,000+ patients Enrolled 364 patients (excluded specialty MH patients) Enrolled 364 patients (excluded specialty MH patients) 6, 12 and 18 month follow-ups (86% FU rates) 6, 12 and 18 month follow-ups (86% FU rates) Intent to treat analysis Intent to treat analysis

12. Outreach Intervention Components ComponentPractice-Based Telemedicine- Based Provider Education YesYes ScreeningYesYes Patient Education YesYes Self-ManagementYesYes Medication Assistance YesYes MonitoringYesYes TX recommendations NoYes PharmD Management NoYes PsychotherapyNoYes Psychiatric Consult NoYes

13. Clinical Characteristics of Sample Clinical Casemix Mean/Percent Current Major Depressive Disorder 83.2% Prior Depressive Episodes 3.2 Prior Depression Treatment 75.8% Current Depression Treatment 48.4% SF12 Physical Component Summary 37.4 SF12 Mental Component Summary 31.4 Chronic Physical Health Conditions 4.6 Current Panic Disorder 8.8% Current Generalized Anxiety Disorder 62.1% Current PTSD 15.9%

14. Response OR=6.0 p<0.0001

15. Remission Remission OR=10.5 p<0.0001

16. VA Telemedicine Based Collaborative Care Implementation Study Objective: Test the effectiveness of Evidence-Based Quality Improvement as an implementation strategy to disseminate telemedicine-based collaborative care. Objective: Test the effectiveness of Evidence-Based Quality Improvement as an implementation strategy to disseminate telemedicine-based collaborative care. Study Design Study Design Twenty five CBOCs lacking on site-psychiatrists (11 received implementation intervention) Twenty five CBOCs lacking on site-psychiatrists (11 received implementation intervention) Evidence Based Quality Improvement intervention strategy which embeds outside experts (with knowledge of the evidence-base) into local Continuous Quality Improvement efforts. Evidence Based Quality Improvement intervention strategy which embeds outside experts (with knowledge of the evidence-base) into local Continuous Quality Improvement efforts.

17. RE-AIM Evaluation RE-AIM Framework RE-AIM Framework Adopted by providers Adopted by providers Reach targeted patient population Reach targeted patient population Implemented with fidelity Implemented with fidelity Effectively improve outcomes Effectively improve outcomes Maintained after research funds are withdrawn Maintained after research funds are withdrawn

18. Provider Adoption First Twelve Months (n=58)

19. Patient Reach First Twelve Months (n=298) Percentage

20. Fidelity (n=298) Initial Encounters Initial Encounters Depression severity assessed with PHQ9 100.0% Depression severity assessed with PHQ9 100.0% Education provided 100.0% Education provided 100.0% Barriers assessed/addressed 82.6% Barriers assessed/addressed 82.6% Follow-up Encounters (acute phase) Follow-up Encounters (acute phase) Follow-ups completed on time 42.5% Follow-ups completed on time 42.5% Depression severity assessed with PHQ9 100.0% Depression severity assessed with PHQ9 100.0% Medication adherence assessed 99.1% Medication adherence assessed 99.1% Side-effects assessed 92.4% Side-effects assessed 92.4% Psychotherapy attendance assessed 83.3% Psychotherapy attendance assessed 83.3% Self-management 15.3% Self-management 15.3%

21. Effectiveness (n=298) Outcomes Outcomes Lost to follow-up 16.1% Lost to follow-up 16.1% Remitted and completed 18.8% Remitted and completed 18.8% Responded and completed22.1% Responded and completed22.1% Referred to MH 24.2% Referred to MH 24.2% Disenrolled at PCP’s request 9.7% Disenrolled at PCP’s request 9.7% Disenrolled at Patients request 0.6% Disenrolled at Patients request 0.6% No longer eligible 7.7% No longer eligible 7.7% Unknown 0.8% Unknown 0.8%

22. VA Performance Measures OR=1.5 p<0.05 OR=2.2 p<0.001

23. Implementation Summary Provider Adoption was high, but Reach into the target patient population was low. Provider Adoption was high, but Reach into the target patient population was low. Implementation Fidelity was high (facilitated by web- based decision support system). Implementation Fidelity was high (facilitated by web- based decision support system). Effectiveness was the same as in a controlled randomized trial and antidepressant possession ratios were higher at implementation sites than control sites. Effectiveness was the same as in a controlled randomized trial and antidepressant possession ratios were higher at implementation sites than control sites. Performance Measures were improved and the telemedicine-based collaborative care program was Maintained after research funding ended. Performance Measures were improved and the telemedicine-based collaborative care program was Maintained after research funding ended.

24. VA Telemedicine Outreach for PTSD (TOP) Effectiveness Study Objective: Compare quality and outcomes of telemedicine-based collaborative care to usual PTSD care. Objective: Compare quality and outcomes of telemedicine-based collaborative care to usual PTSD care. Study Design Study Design Eleven CBOCs lacking on-site psychiatrists Eleven CBOCs lacking on-site psychiatrists Patients recruited through provider/self referral and opt-out letters Patients recruited through provider/self referral and opt-out letters Enrolled 100 patients to date Enrolled 100 patients to date Intent to treat analysis Intent to treat analysis

25. TOP Intervention Components Component Usual Care Telemedicine- Based Provider Education YesYes ScreeningYesYes Patient Education NoYes Self-ManagementNoYes MonitoringNoYes TX recommendations NoYes PharmD Management NoYes PsychotherapyNoYes Psychiatric Consult NoYes

26. Questions and Comments