Barriers in Implementing Evidence-Based Collaborative Care for Depression:

1. Barriers in Implementing Evidence-Based Collaborative Care for Depression: Providers’ Perspectives on Comfort and Difficulty Delivering Care in Primary Care Jennifer L. Magnabosco, PhD, 1,2; Michelle D. Seelig, MD, MSHS,1,3,4; Andrew Lanto, MA, 1; Lisa V. Rubenstein, MD, MSPH, 1,5,7; Edmund Chaney, PhD, 1, 6; Elizabeth M. Yano, PhD, MSPH, 1,7; Barbara Simon, MA, 1 1 VA Greater Los Angeles HSR&D Center of Excellence Center for the Study of Healthcare Provider Behavior, North Hills, CA; 2 Center for Implementation Practice & Research Support, US Department of Veterans Affairs, North Hills, CA; 3 Group Health, Seattle, WA; 4 Department of Health Services, University of Washington School of Public Health and Community Medicine; 5 David Geffen School of Medicine, UCLA, Department of Family Medicine, Los Angeles, CA; 6 VA Puget Sound Healthcare System, HSR&D Center of Excellence, Seattle, WA; 7 UCLA School of Public Health, Department of Health Services, Los Angeles, CA STUDY DESIGN BACKGROUND/DISRUPTIVEINNOVATION CONTRIBUTIONS CONCLUSIONS & IMPLICATIONS • PCPs who were more comfortable co-managing depression with a DCM, and/or were more experienced providing care, were more likely to be more comfortable delivering depression care. • PCPs had more difficulty delivering care if they saw more persons with depression, and less difficulty if they were more experienced providing care and/or received more MHS communications. • Hence, both provider & work environment/organizational factors may impact the successful integration of CCM models for depression into PC settings. • Methods & strategies that make care easier to deliver to persons with depression, especially for PCPs with less experience (e.g., MD residents, non-MD providers) with depression care. • Specific strategies to address factors which impact PCP comfort providing depression care. Access to DCMs alone, without support from MHSs, may promote comfort with depression care but may be insufficient to reduce the difficulty in managing large loads of persons with depression in PC settings. • Specific strategies that help to increase quantity and/or quality of formal (e.g., emails, joint treatment planning) & informal (e.g., curbside consultation) communication & collaboration between PCPs & MHSs. Conclusions • Research Question:During the initial implementation of an evidence-based CCM model for depression care in the VA (ReTIDES)*, what factors predict PCPs’ comfort, and difficulty, in providing depression care? • Methods: A cross-sectional 49 item self-administered survey wasdistributed using multiple data collection methods(web and paper & pencil formats; solicitation letters; study information sheets; meetings; raffle incentive process; reminders; fliers; and follow up telephone calls) during Fall 2006 – September 2008 to coincide with 8 CCM staged site launches. • Scale Development: Principal Components Analyses (with varimax rotation) was used to define 4 scales using survey data: • PCP Comfort Providing Depression Care • PCP Experience Providing Depression Care • MHS Communication with PCP • PCP Difficulty Providing Depression Care • Participant Response: A 54% response (N=186/346 eligible PCPs) resulted from survey participation of 4 PCP types in VA PC settings required to deliver depression care: • internal medicine residents (47%) • residents (35%) • nurse practitioners (15%) • physician assistants (4%) • Depression ranks as the leading cause of disability worldwide, effecting more than 120 million people in the U.S. at any one point in time, with more than two thirds of suicides associated with depression, annually (WHO, 2010). • Collaborative care management (CCM) models for mental heath (MH)/primary care (PC) integration, in which evidence-based PC depression treatment is supported by nurse care managers & mental health specialists (MHS), have been shown to be necessary and sufficient to improve care/outcomes for persons with depression. • While diffusion of CCM is a U.S. Department of Veterans Affairs (VA) priority, knowledge of factors associated with the adoption/implementation of CCM as a quality of care approach is limited. • Previous research suggests provider perspectives impact readiness to adopt/implement CCM models. Therefore, we investigated work environment/organizational and provider level factors associated with PCPs’ comfort & difficulty providing depression care during initial implementation of a CCM (ReTIDES)* within VA. • Reasons Why This Study Can Contribute to Disruptive Innovation in Behavioral Health: • CCM models challenge the status quo of how PCPs deliver MH care in the U.S. Use of these models balances & integrates provider roles & significantly increases depression care effectiveness & efficiency. This research investigates under-explored aspects of delivering CCM, thereby shedding light on implementation factors that are critical to forging change and achieving successful organizational & individual outcomes. Implications for Clinical & Management Practice.Implementers of CCM models in PC settings should consider: RESULT HIGHLIGHTS Table 2: Univariate Results Highlights Table 3: Multivariate Results Highlights Table 1: Survey Scales • Two separate regression models testing the effects of a defined set of independent variables (IV) hypothesized to be associated with delivery of depression care on two dependent variables (DV), the PCP Comfort Scale, and PCP Difficulty Scale, were investigated. • IVs included: gender, provider type, tenure in VA, MHS co-location, number of patients treated with depression, experience providing depression care (PCP Experience Scale), communication with MHS (MHS Communication Scale) & experience co-managing depression care with a DCM. • Definitions • *ReTIDES, or Regional Expansion of TIDES (Translating Initiative in Depression into Effective Solutions) is the VA’s adapted version of the collaborative depression care model that is part of the VA’s Mental Health Services Package, VHA Handbook 1160. Source: Collaborative Care for Depression in the Primary Care Setting: A Primer on VA’s Translating Initiatives for Depression into Effective Solutions (TIDES) Project. VA Health Services Research and Development Service, Office of Research and Development, Dept. of Veterans Affairs 2000. http://www.hsrd.research.va.gov/publications/primer/ • **Co-management refers to the active & explicit sharing of pertinent clinical information, joint treatment planning, shared monitoring of patient’s progress & shared responsibility for patient care. • ***A depression care manager (DCM), most commonly a nurse, participates in care of patients by providing services such as screening & conducting full assessments for persons with depression, educating patients about depression, and monitoring patient progress. • References: • www.who.int/mental_health/management/depression; Felker, Bradford; Chaney, Edmund; et al. (2006). Developing effective collaboration between primary care and mental health providers. Prim Care Companions J Clin Psychiatry 2006; 8(1).Department of Veterans Affairs, HSR&D Center of Excellence for the Study of Healthcare Provider Behavior. • Contact: Jennifer L. Magnabosco, PhD, jlmagnabosco@mindspring.com, 310-948-1758. • Acknowledgements: Poster Design, Cynthia Gammage, BA