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1. Process of Care in Innovative and Traditional Treatments for Depression in VA Primary Care: Reallocating Resources

SC Hedrick, HSR&D COE, Seattle; EF Chaney, VA PSHCS MHS; CF Liu, HSR&D COE, Seattle; BL Felker, VA PSHCS MHS; R Bagala, VA PSHCS SW; GR Paden, VA PSHCS GIMC

Objectives: Most depression treatment takes place in primary care, where, in spite of improvement efforts, the condition continues to be under-detected and under-treated. A collaborative care model based on principles of managing chronic illness has been successful in improving care in non-VA settings. VA primary care patients have significantly greater functional impairment and more treatment barriers than patients for whom this model has been tested. This translation study attempted to adapt collaborative care to the VA primary care setting and compared the resulting innovative integrated team care approach (team) with traditional consult-liaison treatment (CL). Our objective was to determine whether outcomes could be improve through reallocating rather than increasing depression treatment resources.

Methods: Patients within a VA primary care clinic were randomly assigned by firm to the two interventions. In the CL intervention, the primary care provider referred study patients to Psychiatry residents in-clinic for treatment. Residents were funded by the VA PRIME training initiative. In the team intervention, a team of a psychiatrist, psychologist, and social worker developed a treatment plan, based on an initial assessment, that was provided to the primary care provider. Primary care providers' treatment efforts were then supported by patient education materials followed by brief telephone calls made by supervised students designed to support adherence, address treatment barriers, and monitor symptomatology. Treatment results were systematically reviewed and suggestions for treatment modification were fed back to the primary providers. Several screening methods were used to recruit 168 team and 188 CL study patients who met criteria for major depression and/or dysthymia based on structured interview. Outcome data on a depression symptomatology measure and the SF-36V were collected at baseline, 3 and 9 months. Utilization information was extracted from the VISN data warehouse for one year periods prior to and after initiation of the study.

Results: Outcome data showed that Team care resulted in significantly greater improvement in depressive symptomatology and functional status as compared with CL. Utilization information showed that this was achieved without an overall increase in depression-related visits. During the 3 month acute treatment phase, on the Team arm, primary care provider visits increased significantly, as did antidepressant medication prescriptions. On the CL arm, there were significantly more visits with mental health staff in the primary care clinic and in the Mental Health specialty clinic.

Conclusions: The collaborative care model was translated successfully to the VA primary care setting by reorganizing mental health resources in primary care from a direct care Consult-Liaison model to a team care model supporting the treatment efforts of the primary care provider. This reorganization resulted in improved patient outcomes without increasing overall utilization.

Impact: The positive results of this study should encourage the application of collaborative care models in the VA for the treatment of depression and other chronic conditions.