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BACKGROUND/RATIONALE:
Depression is a common concern among persons with spinal cord injury (SCI); prevalence estimates ranging from 20 to 44%. Expert consensus as reflected in the Consortium for Spinal Cord Medicine (CSCM) clinical practice guideline (CPG) for depression after SCI is that interdisciplinary care is required to address the complicated interplay of biological, psychological, and social factors important to depression among persons with SCI. According to the CSCM CPG, treatment plans should be developed and coordinated by an interdisciplinary team of SCI specialists utilizing various modalities including psychopharmacological agents, psychological and social work interventions. However, delivery of effective care for depression is notoriously difficult, even when the definition of effective care is limited to a single modality. For example, recent SCI QUERI work has shown that among veterans with SCI diagnosed with depression, 28% received no antidepressant medication, and 67% received abbreviated treatments. Much less is known about how well psychotherapy or other aspects of interdisciplinary care recommended in the CSCM CPG are implemented in the SCI system of care.
The SCI/D system of care consists of an integrated network of "hub" and "spoke" facilities. Multidisciplinary specialty and primary care is located at 23 SCI centers (hubs) and primary care is available at 164 other facilities (spokes). It may be especially difficult to deliver CPG-consistent care for depression among SCI populations at spoke facilities, where interdisciplinary SCI specialty care may not be available. Therefore, current SCI QUERI projects have been examining the feasibility and acceptability of telephone-delivered interventions for depression conducted from SCI centers, as one means to reduce healthcare disparities related to rural residence and mobility challenges. This research has included a partnership with psychologists at the Richmond VAMC to develop a screening protocol for depression (and other psychosocial concerns) with telephone outreach procedures to bring CPG-consistent interdisciplinary care for depression to veterans with SCI who cannot regularly visit the SCI center due to mobility problems. A logical extension of this project would be to expand the telephone outreach program to spoke facilities, and to otherwise enhance access to CPG-consistent care for depression among veterans with SCI who receive the bulk of their care at spoke facilities, where rural residence may compound healthcare disparities. Critical to the first stages of this effort will be formative evaluation to 1) understand spoke facility operations and needs in relation to the CSCM CPG for depression following SCI, 2) monitor progress towards implementation goals, and 3) provide timely feedback allowing for program adjustments that optimize implementation.
OBJECTIVE(S):
This project will 1) characterize current practices and determinants of current practices in caring for depression at SCI/D spoke facilities, 2) pilot a program coordinated between hub and spoke facilities to implement the CSCM CPG for depression after SCI, in part through the telephone outreach program. The project will focus on one SCI center and 3 of its spoke facilities in the SCI/D system of care. Organizational and operational factors that have potential bearing on delivery of CPG-consistent care for depression will be assessed. Strategies to promote delivery of guideline-consistent care for depression at spoke facilities will be identified and tested, and adjustments to the program will be made to enhance its effectiveness and promote generalizability to other spoke facilities.
METHODS:
Study design. Questionnaires, semi-structured interviews, a face-to-face meeting and monthly phone conferences will be utilized to address study objectives. The questionnaire will include queries about current practices related to the primary recommendations in the CSCM CPG for depression following SCI. Semi-structured interviews will follow-up on questionnaire data related to the CSCM CPG for depression in order to further understand each spoke facility's capabilities for following CPG recommendations. The interviews will query participants regarding the feasibility and acceptability of coordinated implementation of the CSCM CPG for depression between hub and spoke facilities, with a focus on the telephone outreach program and identification of other interventions to promote delivery of guideline-consistent care for depression at spoke facilities. A face-to-face meeting will be held at the Richmond VA between the SCI coordinators from the 3 spoke facilities, SCI center psychologists and social workers, and the SCI center chief. The aim of the meeting will be to identify actionable strategies for implementing the CSCM CPG for depression after SCI at spoke facilities, including ways to address implementation barriers identified in the questionnaires and interviews. Participants. The sample will include 39 spoke facility personnel and 7 SCI center personnel. Questionnaires will be administered to the three members of the SCI Primary Care teams at each of the 13 spoke facilities associated with the Hunter Holmes McGuire VA Medical Center in Richmond, VA. Interview participants will include the SCI Coordinator at each spoke facility. In addition, key informants at the SCI Center will be interviewed including: the Chief of the SCI Service and representatives of the social work and psychology services. In addition to SCI Center personnel, participants in the face-to-face meeting will include the SCI Coordinators from three spoke facilities selected based upon remoteness from the center, level of spoke facility resources, interest in the project, and capacity for travel to the face-to-face meeting. Data collection and analysis. Questionnaires will be administered by mail. Interviews of SCI Center personnel will be conducted on-site; interviews of spoke personnel will be conducted via telephone. Questionnaire data will be analyzed descriptively. Interviews will be recorded, and recordings transcribed and analyzed descriptively to understand each facility's capacity for implementing recommendations in the CSCM CPG for depression following SCI, and to otherwise address project objectives. The face-to-face meeting will occur over the course of one day at the SCI Center with the agenda including review of CSCM CPG for depression after SCI, review of findings from questionnaires and interviews, discussion of strategies for implementing the CPG that were gained from questionnaires and interviews, and development of an action plan for implementing the CPG and addressing any barriers that were identified. Thereafter, monthly follow-up calls will be scheduled for discussion of progress, problem-solving, and adjustments to strategies. Questionnaire measures will be administered to spoke personnel 6 months following the face-to-face meeting to measure outcomes including current practices in relation to the specific recommendations in the CPG, and completion of the action plan developed at the face-to-face meeting.
FINDINGS/RESULTS:
No findings yet; project is in the start up phase.
IMPACT:
This project will prepare for implementation of the CSCM CPG for depression at other spoke facilities associated with the Richmond, VA SCI Center, by identifying appropriate implementation interventions such as the telephone outreach program underway at the Richmond VAMC.
PUBLICATIONS:
None at this time.
DRA:
Mental Illness
DRE:
Quality of Care, Rehabilitation
Keywords:
Depression, Spinal cord injury
MeSH Terms:
none
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