Opening up the Black Box of Quality
Improvement Interventions: Lessons
from a Formative Evaluation of Routine
Care Implementation of Depression
Collaborative Care
Improving Depression Treatment in
Primary Care:
Dissemination and Implementation
• JoAnn Kirchner MD, Chair
• Edmund Chaney PhD
• Louise Parker PhD
• Elizabeth Yano PhD
Edmund Chaney, PhD
Department of Veterans Affairs, Seattle
AcademyHealth
Summer 2006
2
AcademyHealth
Seattle, June 2006
Depression:
Elephant in the primary care
exam room
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’
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
0%
5%
10%
15%
20%
3
25%
4
The Gap Between Primary Care and
Mental Health Specialty
PC
MHS
Translating Initiatives for Depression
into Effective Solutions (TIDES)
• Collaborative Depression Nurse Care
Management fills the gap between primary
care and mental health specialty care.
5
6
1
TIDES
Dissemination/Implementation
Processes
• GOAL - Help interested VA VISNs,
VAMCs, & CBOCs to adopt evidenceevidencebased depression care
– Partner with VA VISNs
– Foster local adaptation
– Provide tools and training
– Assist with ongoing evaluation
– Sustain clinicianclinician-researcher partnerships
7
TIDES Components
Leadership BuyBuy-in/Support
Depression Care Manager
Provider Education
Informatics Support
Patient Education
Performance Feedback
8
TIDES Site First Steps
TIDES Components
• Initial VISN leader communication
• Expert panel with horizontal and vertical
• Clinic screens for depression (registry)
organizational representation
• Identify preferences and action items
• Form ongoing task groups
• Initial site visit
• 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
9
10
Depression Care Manager Activities
Informatics
• Patient Assessment
• Treatment Planning
• Communication with primary care and
• Depression screening reminder
• Consults
• Electronic Health Record (CPRS)
mental health providers
• Patient Interactions
– Education
– Self management support
– General Social Support
enhancements
– DCM assessment & followfollow-up templates
• Monitoring progress
• Encounter coding
• Program evaluation support
11
12
2
Performance Feedback
PHQPHQ-9 Scores
• Patient Level
• Clinic Level
14
12.4
12
10
7.3
8
5.8
6
4.8
4
2
0
13
Baseline
4-6 Wks 8-12 Wks
24 Wks
14
VISN Participation in TIDES & ReTIDES
TIDES Intervention Outcomes
• Stepped care
– 82% of patients are treated for depression in primary care
9 New VAMCs
(90,000 PC Patients)
2 New VAMCs
• Patient satisfaction
– 89% remain in care management
(40,000 PC Patients)
• Care Management
– Veterans engaged in care management have a high degree of
treatment compliance
2 New VAMCs
(40,000 PC Patients)
2 New VAMCs
• 74% stay on medication
• 90% of clinic appointments are kept
(90,000 PC Patients)
• SixSix-month symptom outcome
– 90% of PC patients and 50% of MHS patients achieved resolution of
of
their depressive symptoms
ReTIDES Expansion
15
16
TIDES Long Term Plan
TIDES Final Product
• 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.
17
18
3