1. Assessment and Management of Depression, Anxiety, and Alcohol Problems in Primary Care: The BHL Program VISN 4 MIRECC VA Philadelphia University of Pennsylvania David Oslin, MD

2. MIRECC – VISN 4 / Philadelphia CESATE Development of a Sustainable Clinical Innovation Conceptualization and Investment Implementation Re-engineering Sustainable Service Stakeholder input Marketing/Dissemination

3. MIRECC – VISN 4 / Philadelphia CESATE Development Principals Adaptability Efficiency Targets need Scalable Reproducible Ease of use Compassion

4. MIRECC – VISN 4 / Philadelphia CESATE Inception Key issues Scope: Cognition, depression, anxiety, alcohol Functions: Triage, decision support, monitoring Flexibility: ability to profile patients Enrollment: how to get patients to come

5. MIRECC – VISN 4 / Philadelphia CESATE BHL Clinical Process Patient Identification By screening or clinical assessment BHL Initial Assessment Referral to MH/SA care Provider Recommendations Disease Management in Primary Care No treatment / “False positive” screen Patient Education and Promote self-care Watchful Waiting/ Brief Interventions

6. MIRECC – VISN 4 / Philadelphia CESATE Inception Other issues Scalability Ease of use Interface with CPRS

7. MIRECC – VISN 4 / Philadelphia CESATE Initial Beta Version Small scale: self programmed in access Limited features: interview only, expanded to registration function Enrollment: partnership with primary care around screening

8. MIRECC – VISN 4 / Philadelphia CESATE Contracting out No to CPRS integration – a big decision Interviewing software firms Developing design features for the programming: scalability, integration of change, building on Development of a mechanism to track, test, and deploy changes

9. MIRECC – VISN 4 / Philadelphia CESATE Quality Control Data: range checks, limited input, limited capacity to change values (administrator) Input: staff training Acceptability: provider use, patient satisfaction, completion rates Algorithms: comparison to clinical interviews, randomized trials of key components, long term outcomes Program: EPRP measures, acceptability, management

10. MIRECC – VISN 4 / Philadelphia CESATE

11. Core Assessment Module During the last 12 months  3779 patients were referred (from 2 VAMCs)  81.7% had a complete assessment  PTSD (84%)  Alcohol or drug problems (73%).  no differences in completion rates between the Medical Center and CBOCs.

12. MIRECC – VISN 4 / Philadelphia CESATE Treatment Components Core Assessment – comprehensive Depression Module  2, 6, 9 Weeks  Adherence, Depressive symptoms, Side effects Watchful Waiting  8 weekly calll Alcohol Brief intervention and followup Referral management

13. MIRECC – VISN 4 / Philadelphia CESATE Addressing Quality Indicators Access – The triage and tracking mechanisms allow for seemless referral and the ability to reduce waiting times, prioritize care, and provide administrative support for monitoring. Screening – The BHL has been associated with greater screening rates as well as changes in the proportion that screens positive. Follow-up of positive screens – The BHL is directly addressing assessment of those with positive screens. Monitoring of new initiated treatment – The depression monitoring provides a straightforward mechanism for ongoing monitoring.

14. MIRECC – VISN 4 / Philadelphia CESATE Web Resources http://www.va.gov/visn4mirecc/bhl/ (Behavioral Health Laboratory) http://www.va.gov/visn4mirecc/bhl/