Improving Depression Treatment in Primary Care: Dissemination and Implementation

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

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 • Edmund Chaney PhD • Louise Parker PhD • Elizabeth Yano PhD AcademyHealth Seattle, June 2006

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 Alzheimer’s 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 25% 0% 5% 10% 15% 20%

4. Depression: Elephant in the primary careexam room

5. The Gap Between Primary Care and Mental Health Specialty PC MHS

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.

7. TIDES Dissemination/Implementation Processes • 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. TIDES Components Leadership Buy-in/Support Depression Care Manager Provider Education Informatics Support Patient Education Performance Feedback

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

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

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

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

13. Performance Feedback • Patient Level • Clinic Level

14. PHQ-9 Scores 12.4 7.3 5.8 4.8

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

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

17. TIDES Long Term Plan • 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.

18. TIDES Final Product