Telemedicine-Based
TelemedicineCollaborative Care Models
John Fortney
Fortney, PhD
Jeff Pyne, PhD
VA HSR&D Center for Mental Healthcare and Outcomes Research
VISN 16 Mental Illness Research, Education and Clinical Center
Department of Psychiatry, University of Arkansas for Medical Sciences
Funding

VA Health Services Research and Development
p
 IIR 0000-078
078--3
 IMV 04
04--360
 MHI 0808-0981

National Institute of Mental Health
 R01 MH076908
Collaborative Care
75% of patients treated for depression
receive care in primary care settings
 20/28 randomized trials of collaborative
care significantly improved outcomes1:

 Median
effect for response rate: +18%
 Median
M di effect
ff t for
f remission
i i rate:
t +16%
16%
1) Williams J et. al. Systematic review of multifaceted interventions to
improve depression care. General Hospital Psychiatry, 29, 91-116,
2007
Components of Practice
Practice--Based
Collaborative Care

Provider education

Screening and comorbidity assessment

Patient education, activation, barrier assessment/resolution

Patient self
self--management

Regularly scheduled followfollow-up assessments

Use of clinical information systems and treatment guidelines

Ready access to mental health specialists

Delegation of key clinical activities to nonnon-physician members
off a practice
ti team
t
Barriers to Implementing PracticePractice-Based
Collaborative Care in Rural Primary Care



1)
2)
On-site mental health specialists are typically
Onunavailable.
Collaborative care interventions are more
effective if theyy include MHS1.
Collaborative care is effective in urban
practices, but NOT rural p
p
practices.2
Gilbody S, Bower P, Fletcher J, Richards D, Sutton AJ. Collaborative care for
depression: a cumulative meta
meta--analysis and review of longer
longer--term outcomes.
Archives of Internal Medicine 2006;166:23142006;166:2314-21.
21
Adams S, Xu S, Dong F, Fortney J, Rost K. Differential Effectiveness of Depression
Disease Management for Rural and Urban Primary Care Patients, Journal of Rural
Health,, 2006 22(4):343Health
22(4):343-50.
Telemedicine-Based Collaborative
TelemedicineCare for Small Rural PC Clinics

Offsite depression care team




T l h
Telephones


Care manager encounters with patients at home
Interactive Video


Nurse care manager
Psychiatrist
y
Other mental health specialists (pharmacist, psychologist)
Psychiatric evaluations with patients at PC clinic
Electronic Medical Records

Communication among on
on--site PCPs and offsite depression care
team
VA Telemedicine Enhanced Antidepressant
Management (TEAM) Effectiveness Study
•
Objective: Compare quality and outcomes of
telemedicine--based collaborative care to usual
telemedicine
depression care.
•
Study Design
•
•
•
•
•
Seven CBOCs lacking onon-site psychiatrists
Screened 18,000 patients
Enrolled 395 patients (excluded specialty MH
patients)
6 and 12 month followfollow-ups (88% FU rates)
Intent to treat analysis
y
TEAM Intervention Components
Component
Provider Education
Screening
Patient Education
Self--Management
Self
Monitoring
TX Recommendations
PharmD Management
Psychiatric Consult
Enhanced
Usual Care
Yes
Yes
No
No
No
No
No
No
TelemedicineTelemedicineBased
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Clinical Characteristics of Sample
Cli i l Casemix
Clinical
C
i
Current Major Depressive Disorder
Mean/Percent
M
/P
t
82.0%
Prior Depressive Episodes
2.7
27
Prior Depression Treatment
66.6%
Current Depression Treatment
41 0%
41.0%
SF12 Physical Component Summary
30.0
SF12 Mental Component Summary
36.5
Chronic Physical Health Conditions
5.5
Current Panic Disorder
9.6%
Current Generalized Anxiety Disorder
45.8%
Current PTSD
23.8%
Response
70
P
Probability
y
60
50
OR=2.0
p=0.02
p
OR=1.4
p=0.18
p
40
Usual Care
30
Intervention
20
10
0
Six Months
Twelve Months
Remission
70
P
Probability
y
60
50
40
30
OR=1.9
p=0 09
p=0.09
OR=2.4
p=0.02
20
10
0
Six Months
Twelve Months
Usual Care
Intervention
NIMH OUTREACH Comparative
Effectiveness Study
•
Obj ti
Objective:
C
Compare
quality
lit and
d outcomes
t
off
telemedicine--based collaborative care to
telemedicine
practice--based collaborative care.
practice
•
Study Design
•
•
•
•
•
Eight Community Health Centers lacking onon-site
mental health specialists
S
Screened
d 19,000+
19 000 patients
ti t
Enrolled 364 patients (excluded specialty MH
patients))
p
6, 12 and 18 month followfollow-ups (86% FU rates)
Intent to treat analysis
Outreach Intervention Components
Component
Practice
Practice--Based
Provider Education
Screening
Patient Education
Self--Management
Self
Medication Assistance
Monitoring
TX recommendations
PharmD Management
Psychotherapy
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
TelemedicineTelemedicineBased
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Psychiatric Consult
No
Yes
Clinical Characteristics of Sample
Cli i l Casemix
Clinical
C
i
Current Major Depressive Disorder
Mean/Percent
M
/P
t
83.2%
Prior Depressive Episodes
3.2
32
Prior Depression Treatment
75.8%
Current Depression Treatment
48 4%
48.4%
SF12 Physical Component Summary
37.4
SF12 Mental Component Summary
31.4
Chronic Physical Health Conditions
4.6
Current Panic Disorder
8.8%
Current Generalized Anxiety Disorder
62.1%
Current PTSD
15.9%
Tele--Mental Health Utilization
Tele

Tele - Cognitive Behavioral Therapy

30 (17%) h
had
d an iinteractive
t
ti video
id encounter
t




422 scheduled interactiveinteractive-video sessions




33% Completed CBT manual
47% Attended ≥ 8 sessions
53% Dropped out and attended <8 sessions
57% InteractiveInteractive-video sessions attended
40% InteractiveInteractive-video sessions canceled by patients
3% Canceled due to technical difficulties
Tele - Psychiatric Evaluations

22 (12%) following two failed trials



45% had an interactive video encounter
55% had a telephone encounter
5 (3%) for telephone suicide risk assessment
Response
70
60
P
Probability
y
50
OR=6.0
p<0.0001
OR=5.3
p<0.0001
OR=16.7
p<0.0001
40
Practiced Based
30
Telemedicine Based
20
10
0
6Months
12 Months
18 Months
Remission
70
60
P
Probability
y
50
40
OR=10.5
OR=10
5
p<0.0001
OR 3.6
OR=3.6
p=0.0003
OR 10.8
OR=10.8
p<0.0001
Practice-based
30
Telemedicine-based
20
10
0
6 Months
12 Months
18 Months
Effectiveness Summary
Telemedicine-based collaborative care
Telemedicinehas better outcomes than enhanced usual
care.
 Telemedicine
Telemedicine--based collaborative care
has better outcomes than practicepractice-based
collaborative care.
 Telemedicine
Telemedicine--based collaborative care
listed on SAMSHA’s Registry of Evidence
Based Practices
Practices.

VA Telemedicine Based Collaborative
Care Implementation Study

Objective: Test the effectiveness of EvidenceEvidence-Based
Quality Improvement as an implementation strategy to
disseminate telemedicinetelemedicine-based collaborative care.

Study
y Design
g

Twenty five CBOCs lacking on site
site--psychiatrists (11
received implementation intervention)

Evidence Based Quality Improvement intervention
strategy which embeds outside experts (with
knowledge of the evidence
evidence--base) into local
Continuous Quality Improvement efforts.
Intervention Strategy1
Evidence Based Quality Improvement




1.
Outside experts with knowledge of EBP
and implementation strategies.
Local experts with knowledge of local
needs
d and
d resources
Plan--DoPlan
Do-StudyStudy
y-Act
Web--based decision support system
Web
(NetDSS) to maintain fidelity
Fortneyy J, et. al. Steps
p for Implementing
p
g Collaborative Care Programs
g
for
Depression, Population Health Management,
Management, Volume 12, Number 2, 2009.
NetDSS - https://www.netdss.net/

NetDSS has the following functional capabilities:







patient registry and panel management
trial and phase management
encounter scheduler
decision support
progress note generator
Workload/Outcomes report generator
NetDSS guides the care manager through a self
self--documenting and
evidence--based patient encounter using scripts and selfevidence
self-scoring
instruments which support:








patient education and activation
barrier assessment
comorbidity assessment
depression severity monitoring
suicide risk assessment
adherence monitoring
side--effect monitoring
side
selfself
lf-managementt activities
ti iti
RE--AIM Evaluation
RE

RE--AIM Framework
RE
Adopted
p
byy p
providers
 Reach targeted patient population
 Implemented with fidelity
 Effectively improve outcomes
 Maintained after research funds are
withdrawn

Adoption
% off P
Providers
id
Referring
R f i to
t DCM
1.2
1
0.8
0.6
0.4
0.2
0
VA3 CBOC11
C
VA3 CBOC10
C
VA2 CBOC9
C
VA2 CBOC8
C
VA2 CBOC7
C
VA2 CBOC6
C
VA2 CBOC5
C
C
VA1 CBOC4
VA1 CBOC3
VA1 CBOC2
VA1 CBOC1
C
Reach
% of Patients Receiving DCM
0.35
03
0.3
0.25
0.2
0 15
0.15
0.1
0.05
0
VA3 CBOC11
C
VA3 CBOC10
C
VA2 CBOC9
C
VA2 CBOC8
C
VA2 CBOC7
C
VA2 CBOC6
C
VA2 CBOC5
C
VA1 CBOC4
C
VA1 CBOC3
VA1 CBOC2
VA1 CBOC1
C
Fidelityy

Enrolled Patients
309

Lost to followfollow-up
15.5%

Initial Encounters




Depression severity assessed with PHQ9
Ed
Education
ti provided
id d
Barriers assessed/addressed
100.0%
100 0%
100.0%
82.6%
Follow--up Encounters (acute
Follow
(acute phase)





Follow-ups completed on time
FollowDepression severity assessed with PHQ9
Medication adherence assessed
Side--effects assessed
Side
Self--management
Self
42.5%
100.0%
99.1%
92.4%
15 3%
15.3%
Effectiveness

Outcomes (n=309)








Lost to followfollow-up
Remitted and completed
Responded and completed
Referred to MH
Disenrolled at Patient’s request
Disenrolled at PCP’s request
No longer eligible
Other/Unknown
48
54
67
77
35
2
18
8
(15.5%)
(17.5%)
(21.7%)
(24.9
24.9%)
%)
(11.3%)
( 0.6%)
( 5.8%)
( 2.6%)
Maintenance
4
3
Producation
Managerial
Maintenance
S
Support
t
2
1
0
VAMC1
VAMC2
VAMC3
Antidepressant Possession Ratio
70
P
Probability
y
60
OR=1.5
p<0.01
50
40
Control
30
Implementation
20
10
0
MPR>90%
P
Probability
y
VA Performance Measures
100
90
80
70
60
50
40
30
20
10
0
OR=2.2
p<0 001
p<0.001
OR=1.5
p<0.05
Control
Implementation
FU Visits
Antidepressant
Coverage
Implementation Summary

P id Adoption
Provider
Ad ti was high,
hi h b
butt Reach
R
h into
i t th
the target
t
t
patient population was low.

Implementation Fidelity was high (facilitated by web
web-based decision support system).

Effectiveness was the same as in a controlled
randomized trial and antidepressant possession ratios
were higher at implementation sites than control sites.

Performance Measures were improved and the
telemedicine--based collaborative care program was
telemedicine
M i t i d after
Maintained
ft research
h funding
f di ended.
d d
VA Telemedicine Outreach for PTSD
(TOP) Effectiveness Study
•
Objective: Compare quality and outcomes of
telemedicine--based collaborative care to usual
telemedicine
PTSD care.
care.
•
Study Design
•
•
•
•
Eleven CBOCs lacking on
on--site psychiatrists
Patients recruited through provider/self referral
Enrolled 31 patients to date
Intent to treat analysis
TOP Intervention Components
Component
Provider Education
Screening
Patient Education
Self--Management
Self
Monitoring
TX recommendations
PharmD Management
Psychotherapy
Psychiatric Consult
Usual Care
Yes
Yes
No
No
No
No
No
No
No
TelemedicineTelemedicineBased
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Questions
and
Comments