Organizational Context & Penetration of QI Case Studies from Implementing

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Organizational Context & Penetration of QI

Interventions: Case Studies from Implementing

Depression Collaborative Care

Elizabeth Yano PhD 1, 2 ; JoAnn Kirchner MD 3, 4 ;

Jacqueline Fickel PhD 1 ; Louise Parker PhD 3 ;

Mona Ritchie MSW 3 ; Chuan-Fen Liu PhD 5,6 ;

Edmund Chaney PhD 5,6 ;

Lisa Rubenstein MD 1,7,8

1 VA Greater Los Angeles HSR&D Center of Excellence; 2 UCLA School of Public Health; 3 Center for

Mental Health Outcomes Research, Little Rock AR; 4 University of Arkansas Medical Sciences;

5 Northwest Center for Outcomes Research, Seattle WA; 6 University of Washington, Seattle;

7 UCLA School of Medicine; 8 RAND Health

Background

“It’s not your father’s Army any more…”

– It’s not your father’s VA any more either

VA’s quality transformation

(1990s to current)

– Reorganization towards primary care

– Adoption of electronic medical records

– Incentivized performance audit-and-feedback

– Capitated budgets/resource allocation

Parallel with substantial HSR investment

Quality Enhancement Research

Initiative (QUERI)

National disease targets  QUERI Centers

Research-clinical partnerships designed to implement research into practice

Mental Health QUERI

– Depression particularly common and disabling

– Implementation of depression collaborative care as national strategic priority for primary care

Depression Collaborative Care

Forges shared care between PC and MH

PC provider education

Informatics-based decision support

Leadership support

Depression care manager

– Telephone assessment of + screens

– Telephone management and follow-up

– Based in PC but supervised by MH specialist

Substantial Evidence Base Demonstrates

Effectiveness of Collaborative Care

Feasible, cost-effective care models show

– Improved quality of life for up to five years

– Reduced job loss

– Improved financial status

– Higher satisfaction and participation in care

– Reduced disparities in care and outcomes

– Improved chronic disease status (HbA1C)

More than 10 randomized controlled trials

Models Increase Efficiency…

Reduce primary care visits

Maintain current rate of MHS visits

Use MHS resources more effectively

Cost-saving (due to reduced medical care costs) after first year

– One randomized trial, included VA

Research Objective

Routine-care implementation of depression collaborative care in VA primary care practices

– Little known about factors underlying intervention penetration

– Objective: To evaluate influences of organizational characteristics on degree of penetration during implementation

Factors Associated with Adoption and Diffusion of

Collaborative Care as an Organizational Innovation

INDIVIDUAL (LEADER)

CHARACTERISTICS

INTERNAL

CHARACTERISTICS OF

ORGANIZATIONAL

STRUCTURE

Centralization (-)

Complexity (+)

Formalization (-)

Interconnectedness (+)

Organizational slack (+)

Size (+)

ORGANIZATIONAL

INNOVATION

Collaborative Care for

Depression in VA

EXTERNAL

CHARACTERISTICS OF

THE ORGANIZATION

System openness

Source: Adapted from Rogers EM. Diffusion of innovations. New York: The Free Press, 1995.

Study Design & Sample

Part of larger group RCT of collab care

Implementation thru evidence-based QI

– Expert-panel consensus development among

PC and MH leaders

Implementation priorities

Care model specifications

Seven 1 st -generation primary care practices

– Across 3 VA networks spanning 5 states

Data Sources & Measures

VA administrative data (“Austin”) (caseload)

Organizational site surveys

– Measures of internal organizational structure (e.g., centralization, complexity)

– Measures of external organizational context (e.g., urban/rural location)

Intervention penetration reports

– % PC providers referring patients, # consults/FTE

Validated by qualitative data from semistructured stakeholder interviews

– Senior/mid-level health care managers, PC/MH providers, depression care managers

Principal Findings

Practices ranged from 4,600-14,000 patients among 4-11 PCPs

Depression diagnosis ranged from 1-10% of population of PC patients

Reported level of implementation high (7-9 out of

9-point scale)

Sense of PC-MH collaboration variable

– Difficulty deciding if PC or MH responsible

Penetration highly variable

Limited regional consistency

– One VISN high penetration but different approaches

PC Provider Penetration

% PCPs Started 1 st 6 Months

60

50

40

30

20

10

0

100

90

80

70

A1 A2 B1

Network #1

B2

Network #2

B3 C1 C2

Network #3

PC Provider Penetration

50

40

30

20

10

0

% PCPs Started 1 st 6 Months

100

90

80

% PCPs Started

Consults/FTE

70

60

A1 A2

Network #1

B1 B2

Network #2

B3

Referrals/PCP FTEs

30

C1 C2

Network #3

25

20

15

10

5

0

Organizational Context & Penetration

Referrals/PCP FTE

30

25

20

15

MED

10

MED

MED

Levels of early PCP penetration

5

HIGH HIGH

HIGH

LOW

0

A1 A2 B2 C1 C2 B3 B1

# Months: 16 20 18 2 6 9 21

Small Small Rural Small Small SemiRural city city city city rural

Organizational Context & Penetration

High Penetration

Low practice authority

Variable resources

QI activity variable

PC education ~low

No PC-MH case confs

Low Penetration

Med-to-high authority

Variable resources

QI activity variable

PC education med-hi

No PC-MH case confs

Organizational Context & Penetration

Speed or extent of penetration not influenced by:

– PC and MH provider relationships

– Area characteristics (eg, urban/rural location)

– Practice size

Except for largest practice (>14,000 patients)

Initiating early collaborative care referral did not predict future referral behavior

Highest referral rates typically among practices with lowest perceived MH staffing

Implications

VA an exceptional laboratory in which to translate research into practice

– Common electronic medical records

– Identifiable management structures

– Common policies and procedures

Effective penetration may have less to do with these enablers than local clinic characteristics, needs and approach

– Moderate penetration  time for PDSA

– Time to adopt/adapt  as opposed to “high burn”

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