3103 — Implementing Telehealth to Extend the Reach of Collaborative Care for Serious Mental Illness: the First 400 VA National Bipolar Telehealth Referrals
Bauer MS, VA Boston Healthcare System & Harvard Medical School; Krawczyk LV, VA Boston Healthcare System & Harvard Medical School; Abel E, VA Connecticut Healthcare System & Yale School of Medicine; Osser DN, VA Boston Healthcare System & Harvard Medical School; Miller CJ, VA Boston Healthcare System & Harvard Medical School; Franz A, VA Connecticut Healthcare System & Yale School of Medicine; Brandt C, VA Connecticut Healthcare System & Yale School of Medicine; Rooney M, Richmond VAMC; Fleming J, VA Boston Healthcare System & Harvard Medical School; Godleski L, VA Connecticut Healthcare System & Yale School of Medicine
Collaborative chronic care models have an extensive evidence base for serious mental health conditions, including bipolar disorder. However, implementing diagnosis-specific models depends on facilities having a critical mass of patients with the condition plus providers with required specialty expertise. Telehealth technologies can overcome such limitations by utilizing "hub-and-spokes" systems with specialists providing services at remote sites.
In 2011 the VA Office of Telehealth Services and Mental Health Services implemented a clinical roll-out of the VA National Bipolar Disorders Telehealth Program (BDTH), based on the evidence-based collaborative chronic care model for bipolar disorder endorsed by the VA/DoD Clinical Practice Guidelines. This program includes semi-structured, evidence-based assessment, evidence-based psychopharmacologic consultation, and manualized self-management skills enhancement (the Life Goals Program) delivered via clinical video teleconferencing from two VAMCs, targeting especially under-resourced VAMCs and CBOCs. Structured a priori analysis of the first 400 consults assessed uptake and outcome in the target sites. Structured formative evaluation of provider experience identified barriers and facilitators to uptake.
From 2011 through 2014, the BDTH spread to 16 sites across 10 states. Among the first 400 consults mean age was 50.2+/-13.2, 18.6% were women, 77.5% were > / = 50% disabled, and 14.9% were from minority populations. Medical and psychiatric comorbidity rates resembled those of the VA national bipolar population. 296 (78.1%) completed videoconference intake, and the remainder received chart review consultation. 254 (85.8%) were appropriate for ongoing management and 181 (71.3%) entered Life Goals follow-up. 50 (27.6%) dropped out, while the remainder either completed follow-up or are still active, similar to face-to-face rates. Program completer VR-12 mental component scores improved significantly (30.0+/-14.0 to 36.9+/-13.5, p < 0.001). Referring providers identified centralized VA telehealth support and the evidence-based approach as facilitators, and complexity of telehealth scheduling as a potential barrier.
The implementation of a complex collaborative care intervention via hub-and-spokes videoconference-based format was achieved with population characteristics and participation rates similar to face-to-face formats, yielding significant clinical improvement for program completers.
Telehealth technologies can overcome geographic and critical mass barriers to extend the reach even of complex evidence-based interventions such as the collaborative chronic care model.