1. Improving Depression Treatment in Primary Care: Dissemination and Implementation Edmund Chaney, PhD Department of Veterans Affairs, Seattle AcademyHealth Summer 2006

2. 2 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 JoAnn Kirchner MD, Chair Edmund Chaney PhD Edmund Chaney PhD Louise Parker PhD Louise Parker PhD Elizabeth Yano PhD Elizabeth Yano PhDAcademyHealth Seattle, June 2006

3. 3 Impact of Mental Illnesses (of which Depression is the most prevalent) Causes of Disability / US, Canada, and Western Europe, 2000 (WHO) Mental Illnesses Alcohol & Drug Use Disorders Alzheimers Disease & Dementias Musculoskeletal Diseases Respiratory Diseases Cardiovascular Diseases Sense Organ Diseases Injuries (Disabling) Digestive Diseases Communicable Diseases Cancer (Malignant Neoplasms) Diabetes Migraine All Other Causes of Disability 0%5%10%15%20% 25%

4. 4 Depression: Elephant in the primary care exam room

5. 5 The Gap Between Primary Care and Mental Health Specialty PCMHS

6. 6 Translating Initiatives for Depression into Effective Solutions (TIDES) Collaborative Depression Nurse Care Management fills the gap between primary care and mental health specialty care. Collaborative Depression Nurse Care Management fills the gap between primary care and mental health specialty care.

7. 7 TIDES Dissemination/Implementation Processes GOAL - Help interested VA VISNs, VAMCs, & CBOCs to adopt evidence- based depression care GOAL - Help interested VA VISNs, VAMCs, & CBOCs to adopt evidence- based depression care –Partner with VA VISNs –Foster local adaptation –Provide tools and training –Assist with ongoing evaluation –Sustain clinician-researcher partnerships

8. 8 TIDES Components Leadership Buy-in/Support Depression Care Manager Provider Education Informatics Support Patient Education Performance Feedback

9. 9 TIDES Site First Steps Initial VISN leader communication Initial VISN leader communication Expert panel with horizontal and vertical organizational representation Expert panel with horizontal and vertical organizational representation Identify preferences and action items Identify preferences and action items Form ongoing task groups Form ongoing task groups Initial site visit Initial site visit

10. 10 TIDES Components Clinic screens for depression (registry) Clinic screens for depression (registry) Primary care clinic refers appropriate depressed patients to care manager (DCM) Primary care clinic refers appropriate depressed patients to care manager (DCM) DCM assesses depression and comorbidities & suggests treatment plan to PCP DCM assesses depression and comorbidities & suggests treatment plan to PCP –DCMs are supervised by MH clinicians

11. 11 Depression Care Manager Activities Patient Assessment Patient Assessment Treatment Planning Treatment Planning Communication with primary care and mental health providers Communication with primary care and mental health providers Patient Interactions Patient Interactions –Education –Self management support –General Social Support Monitoring progress Monitoring progress

12. 12 Informatics Depression screening reminder Depression screening reminder Consults Consults Electronic Health Record (CPRS) enhancements Electronic Health Record (CPRS) enhancements –DCM assessment & follow-up templates Encounter coding Encounter coding Program evaluation support Program evaluation support

13. 13 Performance Feedback Patient Level Patient Level Clinic Level Clinic Level

14. 14 PHQ-9 Scores 12.4 4.8 5.8 7.3

15. 15 2 New VAMCs (90,000 PC Patients) 9 New VAMCs (90,000 PC Patients) 2 New VAMCs (40,000 PC Patients) 2 New VAMCs (40,000 PC Patients) VISN Participation in TIDES & ReTIDES ReTIDES Expansion

16. 16 TIDES Intervention Outcomes Stepped care Stepped care –82% of patients are treated for depression in primary care Patient satisfaction Patient satisfaction –89% remain in care management Care Management Care Management –Veterans engaged in care management have a high degree of treatment compliance 74% stay on medication 74% stay on medication 90% of clinic appointments are kept 90% of clinic appointments are kept Six-month symptom outcome Six-month symptom outcome –90% of PC patients and 50% of MHS patients achieved resolution of their depressive symptoms

17. 17 TIDES Long Term Plan Assist VA to make collaborative care for depression in primary care into routine care Assist VA to make collaborative care for depression in primary care into routine care –Update Best Practice Guidelines –Improve Performance Measurement 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. 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.

18. 18 TIDES Final Product