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2015 HSR&D/QUERI National Conference Abstract

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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

Objectives:
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.

Methods:
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.

Results:
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.

Implications:
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.

Impacts:
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.