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MNT 02-209 – QUERI Project

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MNT 02-209
Cost & Value of Evidence Based Solutions for Depression (COVES)
JoAnn E. Kirchner MD
Central Arkansas Veterans Healthcare System Eugene J. Towbin Healthcare Center, Little Rock, AR
No. Little Rock, AR
Funding Period: April 2003 - December 2006

BACKGROUND/RATIONALE:
Although studies have shown that the collaborative care model for depression management improves care quality and outcomes, it has not been widely adopted. Further, not all practices that utilize the model adopt all of its essential elements. This problem is not unique to collaborative care; translating research into practice is often difficult.

OBJECTIVE(S):
We sought to identify facilitators of and barriers to the successful translation of research into practice. Towards this end, we first examined key stakeholders' assessments of a VHA collaborative care initiative (TIDES) and perceptions about how to implement and sustain such initiatives. Second, we examined TIDES design, implementation, and maintenance costs and effects on system cost. Finally, we sought to develop tools to assess readiness to adopt the model and to identify the best evidence-based design choices for a particular practice.

METHODS:
We assessed key stakeholder groups' perceptions in five primary care practices across three VISNs. We conducted semi-structured qualitative interviews at the VISN, VAMC and clinic levels and conducted a content analysis of the resulting verbatim interview transcripts. We also conducted a cost analysis on the design and implementation of TIDES at seven clinics, as well as its effects on system costs.

FINDINGS/RESULTS:
Stakeholders believed that it is important to include staff members from all organizational levels in QI program implementation and described unique roles for individuals at each level. Although informants also believed that local customization was essential, many recognized the importance of adhering to evidence and providing consistent care across facilities. Thus, it is important to create a dialogue between frontline staff members and experts. Stakeholders offered suggestions for structuring such a dialogue and argued that frontline staff members have protected time to participate in it. Additionally, stakeholders emphasized the value of local champions. They suggested that a group of individuals could share champion duties so as to make best use of particular talents and reduce burden. With respect to the TIDES model, stakeholder groups placed different relative value on the model's components. We determined that the length of time required for TIDES adaptation decreased with the order of participation. We also determined that research team contributed more person hours and costs than did clinical partners. We did not find significant shifts in provider staffing level between primary care and mental health care clinics after the implementation or significant differences in changes in utilization patterns between the intervention and control groups. Although we did find that the patients in the high penetration intervention sites had significantly more primary care, primary care depression, and mental health visits than control patients, there were no significant differences in utilization measures between the two groups.

IMPACT:
We provide substantial insight into the perspectives of VHA stakeholders regarding quality improvement implementation, especially for evidence based practices. Stakeholders provided clear and practical suggestions for fostering adoption and sustainability of new initiatives. We also offer detailed information regarding the costs of implementing one such initiative, depression collaborative care, and offer these as a basic framework to account for research translation costs in VHA. Finally, we have developed tools to facilitate implementation.

PUBLICATIONS:

Journal Articles

  1. Kirchner JE, Parker LE, Bonner LM, Fickel JJ, Yano EM, Ritchie MJ. Roles of managers, frontline staff and local champions, in implementing quality improvement: stakeholders' perspectives. Journal of evaluation in clinical practice. 2012 Feb 1; 18(1):63-9.
  2. Bonner LM, Simons CE, Parker LE, Yano EM, Kirchner JE. 'To take care of the patients': Qualitative analysis of Veterans Health Administration personnel experiences with a clinical informatics system. Implementation science : IS. 2010 Aug 20; 5:63.
  3. Liu CF, Rubenstein LV, Kirchner JE, Fortney JC, Perkins MW, Ober SK, Pyne JM, Chaney EF. Organizational cost of quality improvement for depression care. Health services research. 2009 Feb 1; 44(1):225-44.
  4. Parker LE, Kirchner JE, Bonner LM, Fickel JJ, Ritchie MJ, Simons CE, Yano EM. Creating a quality-improvement dialogue: utilizing knowledge from frontline staff, managers, and experts to foster health care quality improvement. Qualitative Health Research. 2009 Feb 1; 19(2):229-42.
  5. Liu CF, Fortney J, Vivell S, Vollen K, Raney WN, Revay B, Garcia-Maldonado M, Pyne J, Rubenstein LV, Chaney E. Time allocation and caseload capacity in telephone depression care management. The American journal of managed care. 2007 Dec 1; 13(12):652-60.
  6. Fickel JJ, Parker LE, Yano EM, Kirchner JE. Primary care - mental health collaboration: an example of assessing usual practice and potential barriers. Journal of Interprofessional Care. 2007 Mar 1; 21(2):207-16.
Conference Presentations

  1. Ritchie MJ, Parker LE, Fickel JJ, Yano EM, Simons CE, Bonner LM, Kirchner JE. Organizational Context and New Clinical Practice Adoption. Presented at: AcademyHealth Annual Research Meeting; 2009 Jun 30; Chicago, IL.
  2. Bonner LM, Chaney EF, Fortney JC, Williams JW, Oslin D, Dobscha S, Campbell DG. Telephone Contact with Suicidal Patients: How Does Research Experience Address Patient Safety? Poster session presented at: VA QUERI National Meeting; 2008 Dec 10; Phoenix, AZ.
  3. Bolkan C, Bonner L, Chaney E, Rubenstein L, Yano E, Uman J, Lanto A. Relationships between social support and treatment adherence among men with depression. Paper presented at: American Psychological Association Annual Convention; 2008 Aug 15; Boston, MA.
  4. Liu CF, Bolkan C, Chan D, Yano E, Chaney E. Dual Use of VA and Non-VA Services among Primary Care Patients with Depression. Poster session presented at: American Society of Health Economists Biennial Conference; 2008 Jun 23; Durham, NC.
  5. Bonner L, Chaney EF, Fortney JC, Goldstein MK, Nichol P, Oslin D, Perrin R. Developments in information health technology: Integrating and evaluating IT to improve management of complexity in chronic care (Workshop). Paper presented at: VA HSR&D National Meeting; 2007 Feb 23; Arlington, VA.
  6. Engle CC, Williams JW, Magruder KM, Kirchner JE, Schnurr PP. VA and Dod are innovating to improve primary care for soldiers and veterans with mental disorders: Research and implementation efforts. Paper presented at: VA HSR&D National Meeting; 2007 Feb 23; Arlington, VA.
  7. Kirchner JE, Owen RR, Ritchie MJ, Smith JL, Fortney JC. Building research-clinical partnerships to improve care for depression. Poster session presented at: VA HSR&D National Meeting; 2007 Feb 21; Arlington, VA.
  8. Liu CF, Forney J, Vivell S, Vollen K, Raney W, Revay B. Care Manager Caseload Capacity and Activities: Time Tracking Results from Two Depression Collaborative Care Projects. Poster session presented at: AcademyHealth Annual Research Meeting; 2006 Jun 26; Seattle, WA.
  9. Rubin HR, Rubenstein LV, Kirchner JE, Nemeth L, Ruhe M. Triangulating for Truth: Using Qualitative Research Methods to Understand Quality Improvement. Paper presented at: AcademyHealth Annual Research Meeting; 2006 Jun 26; Seattle, WA.
  10. Kirchner J, Parker LE, Yano EM, Chaney E. Opening up the black box of quality improvement interventions: Lessons from a formative evaluation of routine-care implementation of depression collaborative care. Paper presented at: AcademyHealth Annual Research Meeting; 2006 Jun 25; Seattle, WA.
  11. Kirchner JE, Parker LE, Bonner L, Yano EM, Ritchie M, Chaney EF. The QI Implementation Process: Perspectives from Providers and Managers. Poster session presented at: AcademyHealth Annual Research Meeting; 2006 Jun 25; Seattle, WA.
  12. Kirchner JE, Parker LE, Yano EM. The Implementation Process: Perspectives from Frontline Providers and Managers. Paper presented at: Society of General Internal Medicine Annual Meeting; 2006 Apr 27; Los Angeles, CA.
  13. Luck J, Parker LE, Hagigi F, Yano EM, Kirchner JE. Marketing: An essential component for effectively implementing evidence-based interventions in VA. Paper presented at: VA HSR&D National Meeting; 2006 Feb 16; Arlington, VA.
  14. Kirchner JE, Chaney EF, Rubenstein L, Liu CF, Yano EM, Parker LE. Improving depression treatment in primary care: dissemination and implementation. Poster session presented at: Scientific Basis of Health Services International Annual Conference; 2005 Sep 1; Montréal, Canada.
  15. Ritchie MJ, Kirchner JE, Garcia-Maldonado M, Parker LE, Yano EM. Stakeholder perspectives: Value of depression collaborative care components. Poster session presented at: National Institute of Mental Health Mental Health Services Research Annual Conference; 2005 Jul 19; Bethesda, MD.
  16. Liu CF. What does it take to implement an evidence-based depression treatment in primary care. Paper presented at: International Health Economics Association Biennial World Congress on Health Economics; 2005 Jul 2; Barcelona, Spain.
  17. Kirchner JE, Chaney E, Rubenstein LV, Liu CF, Yano EM, Parker LE. The Trajectory Toward National Rollout of Improved Depression Care: Building Villages, Not Empires. Paper presented at: Agency for Healthcare Research and Quality Translating Research Into Practice and Policy Annual Meeting; 2005 Jul 1; Washington, DC.
  18. Chaney E, Rubenstein LV, Garcia-Maldonado M, Kirchner JE, Yano EM, Liu CF. The Trajectory Toward National Rollout of Improved Depression Care: Building Villages, Not Empires. Paper presented at: VA HSR&D National Meeting; 2005 Feb 18; Baltimore, MD.
  19. Yano EM, Luck J, Hagigi F, Liu CF, Rubenstein LV. Building the VA Business Case for Quality Improvement and Health Services Research. Paper presented at: VA HSR&D National Meeting; 2005 Feb 18; Baltimore, MD.
  20. Liu CF, Kirchner JE, Fortney JC, Perkins M, Ober S, Chaney EF, Rubenstein L. What Does It Take To Implement An Evidence-Based Depression Treatment In Primary Care? Poster session presented at: VA HSR&D National Meeting; 2005 Feb 17; Washington, DC.
  21. Ritchie MJ, Garcia-Maldonado M, Parker LE, Cody M, Yano EM, Kirchner JE. Comparison of Stakeholder Perspectives on the Value of Care Management Activities. Paper presented at: VA HSR&D National Meeting; 2005 Feb 1; Baltimore, MD.
  22. Fickel JJ, Parker LE, Yano EM, Kirchner JE, Ritchie MJ. Improving Depression Care Through Primary Care-Mental Health Collaboration. Paper presented at: AcademyHealth Annual Research Meeting; 2004 Jun 6; San Diego, CA.
  23. Kilbourne AM, Yano EM, Kirchner JE, Schutte K, Haas GL. Mental health care coordination and referral in VA primary care facilities [panel]. Paper presented at: VA HSR&D National Meeting; 2004 Mar 10; Washington, DC.
  24. Fickel JJ, Parker LE, Yano EM, Kirchner J, Ritchie MJ. Improving Depression Care Through Primary Care-Mental Health Collaboration. Paper presented at: VA QUERI National Meeting; 2003 Dec 10; Washington, DC.


DRA: Health Systems, Mental, Cognitive and Behavioral Disorders
DRE: Epidemiology, Treatment - Observational
Keywords: Depression, Translation
MeSH Terms: none

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