Barriers in Implementing Evidence-Based Collaborative Care for Depression:
VA HSR&D Center for the
Study of Healthcare
Provider Behavior
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
BACKGROUND/DISRUPTIVE INNOVATION
CONTRIBUTIONS
•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.
STUDY DESIGN
•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 was distributed 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%)
CONCLUSIONS & IMPLICATIONS
Conclusions
•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.
Implications for Clinical & Management Practice. Implementers of CCM models in PC settings should
consider:
• 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.
RESULT HIGHLIGHTS
Table 2: Univariate Results Highlights
Table 1: Survey Scales
Scale
Statistics
Variables
PCP Comfort Providing Depression Care Scale
How comfortable are you doing the following activities?
Cronbach’s Alpha, .85;
(Responses: very, moderately, fairly, not at all, don’t know)
Mean 48.9; S.D. 21.44
Work Environment/Organizational Level Variables
Patient Load
•62% of PCPs saw 5-8 patients on average & in 1 half day session.
Patients Treated with
•51% of PCPs had more than 8 of their continuity patients with depression as part of their patient load.
Depression
•Managing depression
•Diagnosing depression according to DSM IV criteria
•Educating patients about their condition and self-management strategies including relapse prevention
•Treating depression with medication
•Assessing which patients would benefit from group therapy (e.g., cognitive behavioral therapy)
PCP Experience Providing Depression Care Scale
Think about the patients with suspected or diagnosed depression that you may have seen during the past 6 months.
For approximately what percentage of those patients did you …?
(Responses: All/Almost All, 91-100%; Most 61-80%; Almost Half 41-60%; Some 21-40%; Few 3-20%; None 0%;
Don’t Know)
•Proceed with further primary-care based assessment after a positive depression screen (e.g., PHQ-2), rather
than refer to a MHS
•Assume primary responsibility for managing their depression
•Diagnose depression according to DSM IV criteria
•Educate them about their condition and self-management strategies and/or relapse prevention
•Treat their depression with medication
•Modify their treatment (i.e., medication and/or counseling) when they did not adequately respond to initial
regimens
(Higher Score=Higher
Comfort)
Cronbach’s Alpha, .88;
Mean 47.9; S.D. 23.72
(Higher Score=More
Experience)
PCP Difficulty Providing Depression Care Scale
Cronbach’s Alpha, .80;
Think about your current VA practice environment, including available support form other VA clinicians and staff.
In this environment, how difficult is it to carry out the following for your depressed patients?
(Responses: Usually do with no difficulty, with some difficulty, with much difficulty; does not apply; don’t know)
Mean 58.2; S.D. 24.99
•Same question items as for the PCP Experience Providing Depression Care Scale
MHS Communication with PCP Scale:
Types of feedback from MHS about their (PCPs’) patients with depression n the last 6 months.
•See Table 2, PCP Communication with MHS Items
(Higher Score=More
Difficulty)
Cronbach’s Alpha, .83;
Mean 41.6; S.D. 29.03
(Higher Score=More
Communication)
MHS Co-Located on Site
Result Highlights (Mode Reported Unless Otherwise Indicated)
•48% of PCPs had a MHS co-located in their primary care clinic.
PCP Provider Level Variables
Gender
•53% of PCPs were male.
Tenure
•44% of PCPs had practiced in their VA clinic for 5 years or more.
Comfort Providing
•Over 70% of PCPs were moderately or fairly comfortable managing, diagnosing, treating (with medication) or educating
Depression Care Activities their patients about depression.
•74% of PCPs were fairly or not comfortable at all assessing which patients would benefit from group therapy
Experience Providing
•PCPs varied in their experience providing the range of depression care activities noted in Table 1, Items for PCP
Depression Care Activities Experience Providing Depression Care Scale.
•30% of PCPs usually did not assume primary responsibility for managing their patients depression.
Difficulty Providing
•About 30% of PCPs usually diagnosed depression according to DSM IV criteria and treated depression with medication
Depression Care Activities with no difficulty.
•40% of PCPs usually provided further primary-care assessment after a positive depression screen, assumed primary
responsibility for managing their patients’ depression (vs. 30% who did not), educated their patients about depression &
modified their treatment when patients did not response to initial regimens with some or much difficulty.
PCP Co-Management* * •53% of PCPs were very or moderately comfortable co-managing patients with depression with a DCM.
with Depression Care
•24% of PCPs usually co-managed with a DCM with no difficulty; 17% usually did this with some or much difficulty.
Manager (DCM)***
•50% of PCPs co-managed few or none of their patients with depression with a DCM.
PCP Co-Management and
Communication with MHS
Co-Management
•34% of PCPs co-managed their patients with depression with MHS with no difficulty; 25% did this with some or much
difficulty.
•34% of PCPs co-managed few or none of their patients with depression with a MHS.
Communication
•76% of PCPs received notes in their patients’ electronic records (vs. emails, in-person or phone communication)
from a MHS.
•48% of PCPs shared clinical information with a MHS.
•45% of PCPs monitored patients’ treatment responses with a MHS.
•41% of PCPs shared responsibility for patients’ outcomes with a MHS.
•30% of PCPs developed joint treatment plans with a MHS.
Table 3: Multivariate Results Highlights
•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.
Regression
Model
Statistics
Model with DV= PCP
Comfort Scale
•Significant, F (8, 121) = 13.12, •PCPs’ comfort co-managing depression with a DCM
p < .0001.
(p < .0001) & PCPs’ experience providing depression care
(PCP Experience Scale; p < .0001).
•R2 =.46
Model with DV= PCP
Difficulty Scale
IV Predictors
•Residents (p=.084), nurse practitioners & physician assistants
(p =.092), tended to be less comfortable managing, diagnosing,
educating & assessing depression than MDs.
•Significant, F (8,119) = 15.68, •Number of persons with depression a PCP saw during a half day
p < .0001.
session (p =.019), PCPs’ experience providing depression care
(PCP Experience Scale; p<.0001) & PCPs’ communications with
•R2 =.51
a MHS (MHS Communication Scale; p=.042).
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