BACKGROUND/RATIONALE:
Collaborative care for depression is a highly evidence-based care model that improves the quality of care for depression in primary care but has rarely been sustained or spread outside of research projects. This objective is a preparatory step toward national implementation. This project will support VISNs as learning organizations in the area of depression care improvement, and will ultimately support as many as 8% to 10% of veterans nationally in improving their health and quality of life.
OBJECTIVE(S):
This project hypothesizes that research-based care models can be implemented successfully in practice if their benefits to patients, clinicians, and organizations are made apparent, their complexity is reduced, and their fit with local priorities is maximized. It will develop and implement sustainable collaborative care administration methods and test methods for spreading the model to new sites.
METHODS:
This project is a continuation and expansion of Translating Initiatives for Depression into Effective Solutions (TIDES) QUERI implementation research project. In the depression collaborative care model, a nurse depression care manager (DCM) and mental health specialist (MHS) assist PCPs in the diagnosis and ongoing management of depressed patients. At a minimum, patients being followed in primary care receive follow-up calls from the DCM at one week, two weeks, 4-6 weeks, 8-12 weeks and 24 weeks. The collaboration takes place with full input from the patient regarding treatment preferences and includes telephone assessment and follow-up by the DCM, treatment plans based on depression algorithms selected by the PCP, regular supervision of the DCM by the MHS and consultation between the MHS and PCP as needed.
We will use a randomized design to evaluate long term (18-month) cost effectiveness of TIDES collaborative care in six intervention clinics with fully-implemented collaborative care compared to three matched and randomly-assigned usual care clinics. We will use a non-randomized quasiexperimental design (untreated control group with pretest and posttest) to measure impacts on clinician performance, knowledge, and attitudes in 6 newly-implemented collaborative care intervention clinics compard to 6 matched usual care clinics. We will collect process evaluation data on the costs and characteristics of spread, and pilot data on proposed VISN add-ons or changes to the TIDES collaborative care model. Finally, we will prepare a national dissemination package that includes potential design choices for collaborative care as well as all necessary information, materials and methods.
FINDINGS/RESULTS:
Clinical outcomes of 590 patients referred to TIDES through December, 2005, including depression remission, are highly favorable. Approximately 90% of patients are able to complete the baseline assessment, and 80% of those are appropriate for inclusion in depression care management. 80% of panel members are followed in primary care, 20% in mental health. Of veterans beginning care management, only 12% drop out before completing six months of symptom assessment and education. Active panel members keep 90% of their follow-up appointments, and 71% of those on anti-depressant medication are compliant. 80% of patients followed in primary care and 50% of patients followed in mental health resolve their depressive symptoms over the course of 24 weeks of care management as measured by the PHQ-9.
IMPACT:
At the conclusion of this project, we will know the extent to which a national implementation package for collaborative care for depression can be developed that is attractive to stakeholders. We will also understand and anticipate how to institutionalize and spread the model, including barriers to accomplishing these goals. We will know whether collaborative care clinicians improved performance measures, knowledge or attitudes. Finally, we will know whether reliable, valid, and feasible performance measures that reflect model impacts can be developed.
PUBLICATIONS:
Journal Articles
- Fickel JJ, Parker LE, Yano EM, Kirchner JE. Primary care - mental health collaboration: an example of assessing usual practice and potential barriers. Journal of Interprofessional Care. 2007; 21(2): 207-16.
- Sherman SE, Fotiades J, Rubenstein LV, Gilman SC, Vivell S, Chaney E, Yano EM, Felker B. Teaching systems-based practice to primary care physicians to foster routine implementation of evidence-based depression care. Academic Medicine. 2007; 82(2): 168-75.
