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MNT 03-215 – QUERI Project

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MNT 03-215
Expanding and Testing VA Collaborative Care Models for Depression
Lisa V. Rubenstein MD MSPH
VA Greater Los Angeles Healthcare System, Sepulveda, CA
Sepulveda, CA
Funding Period: July 2004 - June 2008

BACKGROUND/RATIONALE:
Based on the published evidence, collaborative care for depression is both necessary and sufficient for improving care and outcomes for depressed patients in primary care settings. The Translating Initiatives in Depression into Effective Solutions (TIDES) project, upon which ReTIDES is based, developed a VA-adapted version of collaborative care through input from veterans, clinicians, and managers. The initial TIDES project resulted in a clinically stable and effective model as tested in seven primary care practices in three VISNs. This positive result provided the basis for spreading and sustaining the TIDES model and initiating the study of national implementation strategies and issues.

OBJECTIVE(S):
The objective of this grant was to carry out preparatory steps toward national implementation, including developing and investigating TIDES sustainability and partnering and marketing strategies. The project supported VISNs as learning organizations in the area of depression care improvement, and ultimately aimed to support as many as 8% to 10% of veterans nationally in improving their health and quality of life. Preparatory steps included 1) development of easily disseminated tools, including CPRS decision support, panel monitoring, and care manager and team training materials, 2) national and local dissemination to support TIDES model sustainability and spread and 3) evaluation using tools that would assess not only the success of this project, but could be used for quality monitoring during roll-out.

METHODS:
Tools: We used the Chronic Illness Care model and Evidence Based Quality Improvement methods to develop tools for disseminating TIDES to additional medical centers and practices in 3 TIDES VISNs and two medical centers (with 10 practices) in one additional VISN. These tools were then used for national implementation. Dissemination: We served as technical expert consultants by 1) carrying out national and regional training; 2) linking to national patient care services, employee education, and information technology methods and priorities; and 3) supporting evidence-based quality improvement in new sites.We organized these efforts through a national dissemination plan.
Evaluation: We developed and applied 1) formative evaluation tools; 2) fine-tuned performance measure tools based on electronic data, and applied in a non-randomized quasi-experimental design (untreated control group with pretest and posttest); 3) a web-based survey for primary care clinicians and 4) an innovative implementation cost assessment approach. We also used 5) qualitative information on the process of dissemination , including links to national resources and 6) a randomized design to evaluate long term (18-month) cost effectiveness of TIDES.

FINDINGS/RESULTS:
Tool development and access: We completed, verified, and validated a comprehensive set of tools available on VA SharePoint. Tools include Class I CPRS decision support, a comprehensive training manual for care managers and their supervisors, clinical redesign and site engagement tools, and patient education and resource information. Tools were reviewed and approved by appropriate national bodies. Dissemination: TIDES became a national standard for primary care/mental health integration in 2006. ReTIDES provided intensive on-site training during 9 training events to 188 VA clinicians and program or practice leaders from 17 VISNs. Total attendance at training was 308 including repeat attendees. Attendees included 90 depression care managers. Tools have been accessed by VA's from all VISNs. Evaluation: Construct validation of quality improvement data against research nurse data showed validity. Evaluation using tested ReTIDES performance measures awaits availability of 2008 data from Pharmacy Benefits Management. The primary care clinician survey shows benefit in clinician comfort with depression care. Qualitative evaluation shows the utility of the ReTIDES national dissemination plan.

IMPACT:
This project developed, documented and evaluated strategies for sustaining and spreading an evidence-based care model nationally in VA. In 2008, ReTIDES made high quality depression care more accessible to approximately 300,000 - 500,000 veterans receiving primary care at clinics in 17 medical centers supported by fully-implemented TIDES collaborative care including care management.

PUBLICATIONS:

Journal Articles

  1. Rubenstein LV, Chaney EF, Ober S, Felker B, Sherman SE, Lanto A, Vivell S. Using evidence-based quality improvement methods for translating depression collaborative care research into practice. Families, Systems & Health. 2010 Jun 1; 28(2):91-113.
  2. Foy R, Hempel S, Rubenstein L, Suttorp M, Seelig M, Shanman R, Shekelle PG. Meta-analysis: effect of interactive communication between collaborating primary care physicians and specialists. Annals of internal medicine. 2010 Feb 16; 152(4):247-58.
  3. Parker LE, Ritchie MJ, Kirchner JE, Owen RR. Balancing health care evidence and art to meet clinical needs: policymakers' perspectives. Journal of evaluation in clinical practice. 2009 Dec 1; 15(6):970-5.
  4. Luck J, Hagigi F, Parker LE, Yano EM, Rubenstein LV, Kirchner JE. A social marketing approach to implementing evidence-based practice in VHA QUERI: the TIDES depression collaborative care model. Implementation science : IS. 2009 Sep 28; 4:64.
  5. Fickel JJ, Yano EM, Parker LE, Rubenstein LV. Clinic-level process of care for depression in primary care settings. Administration and policy in mental health. 2009 Mar 1; 36(2):144-58.
  6. Liu CF, Bolkan C, Chan D, Yano EM, Rubenstein LV, Chaney EF. Dual use of VA and non-VA services among primary care patients with depression. Journal of general internal medicine. 2009 Mar 1; 24(3):305-11.
  7. 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.
  8. Smith JL, Williams JW, Owen RR, Rubenstein LV, Chaney E. Developing a national dissemination plan for collaborative care for depression: QUERI Series. Implementation science : IS. 2008 Dec 31; 3:59.
  9. Chaney E, Rabuck LG, Uman J, Mittman DC, Simons C, Simon BF, Ritchie M, Cody M, Rubenstein LV. Human subjects protection issues in QUERI implementation research: QUERI Series. Implementation science : IS. 2008 Feb 15; 3:10.
  10. Campbell DG, Felker BL, Liu CF, Yano EM, Kirchner JE, Chan D, Rubenstein LV, Chaney EF. Prevalence of depression-PTSD comorbidity: implications for clinical practice guidelines and primary care-based interventions. Journal of general internal medicine. 2007 Jun 1; 22(6):711-8.
  11. 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.
  12. Sherman SE, Fotiades J, Rubenstein LV, Gilman SC, Vivell S, Chaney E, Yano EM, Felker B. Teaching systems-based practice to primary care physicians to foster routine implementation of evidence-based depression care. Academic Medicine. 2007 Feb 1; 82(2):168-75.
  13. Rubenstein LV, Meredith LS, Parker LE, Gordon NP, Hickey SC, Oken C, Lee ML. Impacts of evidence-based quality improvement on depression in primary care: a randomized experiment. Journal of general internal medicine. 2006 Oct 1; 21(10):1027-35.
Reports

  1. Rubenstein LV, Williams JW, Danz M, Shekelle PG, Suttorp M, Johnson B. Determining Key Features of Effective Depression Interventions. Washington, DC: Department of Veterans Affairs; 2009 Mar 1. 67 p. Report No.: 9.
Conference Presentations

  1. Smith JL. TIDES Collaborative Care for Depression: From Research to Practice. Paper presented at: VA HSR&D Field-Based Quality Improvement in Parallel Circuits Meeting on VA System Redesign, Operational Systems Engineering, and Implementation Research; 2010 Jul 14; Indianapolis, IN.
  2. Magnabosco JL, Seelig MD, Lanto A, Rubenstein LV, Chaney EF, Yano EM, Simon B. Barriers in Implementing Evidence-based Collaborative Care for Depression: Providers’ Perspectives on Comfort and Difficulty Delivering Depression Care in Primary Care. Paper presented at: AcademyHealth Annual Research Meeting; 2010 Jun 26; Boston, MA.
  3. Cully J, Kirchner JE, Kivlahan DR, Lysell K. Research-Clinical Partnerships. Paper presented at: VA HSR&D Field-Based Mental Health and Substance Use Disorders Meeting; 2010 Apr 29; Little Rock, AR.
  4. Parker LE, Ritchie MJ, Owen RR. Balancing Health Care Evidence and Art to Meet Clinical Needs: Policy Makers' Perspectives. Poster session presented at: AcademyHealth Annual Research Meeting; 2009 Jun 30; Chicago, IL.
  5. Chaney EF, Simon B, Bonner L, Simons C, Ober S, Rubenstein LV, Cody M. Ensuring Patient Safety and Confidentiality in Multi-Site Quality Improvement Research: A Proactive Partnership Approach to Risk Management. Presented at: VA HSR&D National Meeting; 2009 Feb 12; Washington, DC.
  6. Owen R, Smith JL, Francis J, Rick C, Alt-White AC, Charns MP, Haddock KS, Kinsinger L. Enhancing Clinical-Research Partnerships to Maximize the Benefits of Research in the Context of Urgent Policy Changes and System Needs. Paper presented at: VA QUERI National Meeting; 2008 Dec 12; Phoenix, AZ.
  7. Vivell S, Austin C, Miner M, Slaughter A, Rubenstein LV. TIDES VistA-Based Informatics Support for Depression Care Management. Paper presented at: VA QUERI National Meeting; 2008 Dec 11; Phoenix, AZ.
  8. 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.
  9. Pyne JM, Fortney JC, Curran GM. An implementation planning tool for depression care management. Poster session presented at: VA QUERI National Meeting; 2008 Dec 10; Phoenix, AZ.
  10. Rubenstein LV, Kirchner J, Yano EM, Richie M, Vivell S. The Science of Tool Development Framework for Sustainability and Spread of Evidence-Based Depression Care. Poster session presented at: VA QUERI National Meeting; 2008 Dec 10; Phoenix, AZ.
  11. Smith L, Ritchie, Owen R. VA Leadership Perceptions of QUERI Role In Disseminating Evidence-Based Practices. Paper presented at: VA QUERI National Meeting; 2008 Dec 10; Phoenix, AZ.
  12. Yano EM, Young AS, Cohen AN, Hamilton A, Rubenstein LV. Can Six Blind Men Find Apples & Oranges: Using Multiple Data Sources to Describe Variable Implementation of QI Interventions. Paper presented at: VA QUERI National Meeting; 2008 Dec 8; Phoenix, AZ.
  13. 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.
  14. Yano EM. Evaluating implementation of depression collaborative care by integrating multiple data sources. Paper presented at: AcademyHealth Annual Research Meeting; 2008 Jun 11; Washington, DC.
  15. Seelig MD, Magnabosco JL, Chaney EF, Simon BF, Yano EM, Rubenstein LV. Resident perceptions of depression care after exposure to depression care management. Poster session presented at: AcademyHealth Annual Research Meeting; 2008 Jun 10; Washington, DC.
  16. Smith JL, Ritchie M, Owen RR. VA Leadership Perceptions of Quality Enhancement Research Initiative (QUERI) Role in Disseminating Evidence-Based Practices. Paper presented at: AcademyHealth Annual Research Meeting; 2008 Jun 8; Washington, DC.
  17. Fickel JJ, Yano EM, Parker LE, Rubenstein LV. Clinic-level process of care for depression in VA primary care settings. Poster session presented at: VA HSR&D National Meeting; 2008 Feb 14; Baltimore, MD.
  18. Bonner LM, Chaney EF, Rubenstein VL, Vivell S, Lysell K, Fortney JC. Informatics Supporting Chronic Illness Care: An Implementation Challenge. Poster session presented at: VA HSR&D National Meeting; 2008 Feb 13; Baltimore, MD.
  19. Chaney EF, Rubenstein LV, Yano EM, Liu CF, Bolkan CR. Evaluating Implementation of Best Practices for Depression Care: 18 Month Results. Poster session presented at: VA HSR&D National Meeting; 2008 Feb 13; Baltimore, MD.
  20. Bolkan C, Chaney EF, Rubenstein LV, Uman J, Yano EM. Perceptions of depression and primary care provider behavior in older and younger veterans. Paper presented at: American Psychological Association Annual Convention; 2007 Aug 19; San Francisco, CA.
  21. Chaney EF, Rubenstein LV. Implementing Collaborative Care for Depression in Primary Care: Paradigms and Partners. Paper presented at: VA MIRECC Annual Best Practices in Mental Health Conference; 2007 Jul 18; Alexandria, VA.
  22. Fickel JJ, Yano EM, Parker LE, Rubenstein LV. Clinic-level process of care for depression in primary care settings. Paper presented at: AcademyHealth Annual Research Meeting; 2007 Jun 4; Orlando, FL.
  23. Owen RR, Rubenstein L, Chaney E, Smith JL. Bridging Evidence-Based Practices into Regional and National Use: The ReTIDES Example (workshop). Paper presented at: VA HSR&D National Meeting; 2007 Feb 23; Arlington, VA.
  24. Chaney EF, Rubenstein LV, Yano EM, Liu C-F, Felker B. Evaluating Implementation of Best Practices for Depression Care: Impacts on Process and Outcomes. Poster session presented at: VA HSR&D National Meeting; 2007 Feb 22; Arlington, VA.
  25. Kirchner J, Bolkan CR, Owen RR, Chaney EF, Rubenstein L, Ritchie M, Lanto A, Smith JL, Yano E, Fortney JC. Self-Reported Health Care Utilization Rats of Older and Younger Veterans with Depressive Symptomology. Poster session presented at: VA HSR&D National Meeting; 2007 Feb 22; Arlington, VA.
  26. Smith J, Williams J, Owen R, Rubenstien L, Chaney E. Building QuERI research-clinical partnerships to disseminate collaborative care for depression. Poster session presented at: VA HSR&D National Meeting; 2007 Feb 21; Arlington, VA.
  27. Chaney E, Rubenstein LV. Improving depression treatment in Primary care: Dissemination and implementation. Paper presented at: AcademyHealth Annual Research Meeting; 2006 Jun 26; Seattle, WA.
  28. 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.
  29. 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.
  30. 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.
  31. 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.
  32. Parker LE, Kirchner JE, Bonner L, Fickel JJ, Yano EM, Ritchie MJ. Creating a Two-Way Intervention Dialogue: Practical Suggestions for Facilitating Quality Improvement within Healthcare Organizations. Poster session presented at: AcademyHealth Annual Research Meeting; 2006 Jun 25; Seattle, WA.
  33. Seelig M, Yano EM, Gelberg L, Asch SM, Rubenstein LV. The essential elements of primary care physician-mental health specialist collaboration. Paper presented at: AcademyHealth Annual Research Meeting; 2006 Jun 1; Seattle, WA.
  34. Yano EM, Kirchner JE, Fickel JJ, Parker LE, Ritchie MJ, Liu CF, Chaney E, Rubenstein LV. The quality of penetration of organizational interventions: A case study of depression collaborative care. Paper presented at: AcademyHealth Annual Research Meeting; 2006 Jun 1; Seattle, WA.
  35. Kirchner JE. What Does it Take to Implement Evidence-Based but Major Changes in Routine Care: The VA Care for Depression Example. Paper presented at: Society of General Internal Medicine Annual Meeting; 2006 Apr 27; Los Angeles, CA.
  36. Rubenstein LV, Kirchner JE, McDougall S, Whittle J, Yano EM. Challenges in implementing evidence-based care models. Paper presented at: Society of General Internal Medicine Annual Meeting; 2006 Apr 1; Los Angeles, CA.
  37. Yano EM. National rollout of depression collaborative care: How do we get from here to there? Paper presented at: Society of General Internal Medicine Annual Meeting; 2006 Apr 1; Los Angeles, CA.
  38. 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.
  39. Rubenstein LV, Chaney E, Kirchner JE, Yano EM. Beauty is in the eye of the beholder: Care and outcomes for patients referred to depression care management by researchers vs. primary care clinicians. Paper presented at: VA HSR&D National Meeting; 2006 Feb 1; Arlington, VA.
  40. Rubenstein LV. Translating Initiatives in Depression into Effective Solutions (TIDES). Paper presented at: VA Chief Medical Officers Annual Meeting; 2006 Jan 1; Washington, DC.


DRA: Mental, Cognitive and Behavioral Disorders
DRE: none
Keywords: Depression
MeSH Terms: none

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