3045 — Clinic-level Process of Care for Depression in VA Primary Care Settings

Fickel JJ (Sepulveda COE), Yano EM (Sepulveda COE), Parker LE (Little Rock COE), Rubenstein LV (Sepulveda COE)

Objectives:
Multi-component, collaborative care models that use a coordinated set of strategies to implement evidence-based process of care into usual PC practice, and improve coordination with MH services, are targeted at the practice group rather than at individual providers. This study assesses the usual processes for depression management in VA primary care (PC) practices in order to better understand concordance with care guidelines, and as a basis for tailoring quality improvement activities. We identify which aspects of concordance with guidelines--including screening, assessment/diagnosis, treatment, and referral—are the most problematic to clinics, and which barriers to care provide guidance for remedying the areas of difficulty.

Methods:
We use a case comparison strategy to describe common patterns and particularities in the process of depression care in 10 PC practices, which were located in three regional networks (VISNs). This cross-sectional study was one component of the pre-intervention phase of a multi-site implementation of a collaborative care model for depression. It uses two types of data: qualitative descriptions of care processes, from interviews with PC and mental health (MH) clinical leaders, supplemented by data from administrative sources describing organizational structures.

Results:
Many care processes were generally similar across practices in this study: screening was routine, assessment and diagnosis were done informally, PC providers used pharmacological treatment and sometimes supportive counseling, and referrals were made to MH using the electronic consult system. However, local variations also occurred in each step of the care process, most notably that three practices rarely diagnosed or treated depression in PC. The only step that generally conformed with evidence-based guidelines was screening. Reported barriers to depression management included inadequate time and number of PCPs, and inadequate MH training for PCPs.

Implications:
Although there was general similarity in the process of care across the practices, local individuality was notable. The greatest concordance with guidelines was in the process of screening for depression; other steps showed substantial differences from guideline recommendations.

Impacts:
The variation noted among clinics suggests that individual practices will have specific needs for tailoring evidence-based quality improvement activities and interventions to local context.