Implementation of collaborative care for depression is the highest priority for Mental Health Quality Enhancement Research Initiative (QUERI), and the national rollout of collaborative care is a high priority for VHA. Small Contract CBOCs present unique challenges to implementation of collaborative care because of their distinct organizational characteristics, long distances to parent VAMCs, and lack of onsite psychiatrists. The Telemedicine Enhanced Antidepressant Management (TEAM) study, successfully used telemedicine technologies to adapt the collaborative care model for small CBOCs lacking onsite psychiatrists.
The purpose of the proposed RIPPLE study was to implement and evaluate this telemedicine-based collaborative care model in small Contract CBOCs. The goals and aims of the RIPPLE study were: Goal 1 - To adapt and apply implementation strategies developed for TIDES in order to deliver telemedicine-based collaborative care services in small contract CBOCs. Goal 2 - To evaluate the implementation of this evidence based best-practice with respect to its clinical impact on the population of patients with depression and the system of care. The corresponding specific aims were: Specific Aim 1 - Document and evaluate the process of implementing, refining, and sustaining telemedicine-based collaborative care at contract CBOCs. Specific Aim 2 - Estimate the clinical impact of telemedicine-based collaborative care at implementation sites relative to usual care at control sites. Specific Aim 3 - Estimate the system-level cost-effectiveness of telemedicine-based collaborative care at contract CBOCs.
The study was conducted in 26 contract CBOCs in VISN 16 and VISN 22. The analyses was based on a pre-post quasi experimental study design with a non-equivalent control group. The telemedicine-based collaborative care program was implemented at 11 contract CBOCs without onsite psychiatrists and cost/outcomes were compared to those at 15 similar control sites.
Data was collected from VISTA and the Austin Automation Center. Descriptive statistics were used to describe the degree of adoption (i.e., reach, effectiveness, adoption, implementation, and maintenance). The clinical impact on the patient population was estimated using random effects models with individual patients as the unit of analysis. The impact on the system was estimated using a Systems Cost Effectiveness Analysis.
The telemedicine-based program had an excellent adoption rate by primary care providers (60%). Reach into the target patient population was relatively low overall (7% penetration into the targeted population), but some "high implementation" CBOCs achieved excellent penetration into the target population (>15%). Of those enrolled in the telemedicine-based collaborative care program, fidelity to the care manager protocol was excellent when telephone encounters were completed, but only 42.5% of follow-up encounters during the acute stage were completed within the pre-specified timeframe. Clinical outcomes were comparable to intervention patients in a prior randomized effectiveness study of telemedicine-based collaborative care (17.5% remitted and completed the continuation phase of treatment and another 21.7% responded to treatment and completed the continuation phase without relapsing. Importantly, the telemedicine-based collaborative care programs continued to be used in a sustained manner after HSR&D research funds were withdrawn. Likewise, the telemedicine-based collaborative care programs became highly institutionalized into the operations of the parent VAMCs. Compared to patients diagnosed with depression at control CBOCs, those at implementation CBOCs were significantly more likely to have a tele-psychiatrist encounter (OR=5.4, p<0.01) as intended, but had an equal number of specialty mental health encounters overall. Patients at implementation CBOCs prescribed an antidepressant had significantly greater probability of having medication possession ratios >0.9 than patients at control CBOCs (OR=1.51, p<0.01). Compared to patients at control CBOCs, patients at implementation CBOCs were significantly more likely to contribute to the numerator of the Provider Follow-Up performance measure (OR=1.48, p<0.05) and were significantly more likely to contribute to the numerator of the Medication Coverage performance measure (OR=2.21, p<0.001). Pre-implementation planning costs were $51.62 per patient targeted by the telemedicine-based collaborative care program. Compared to patients diagnosed with depression at control CBOCs, those at implementation CBOCs (and high implementation CBOCs) had slightly lower implementation healthcare costs (-$22.34). For high implementation CBOCs (>15% reach), the systems level cost effectiveness ratio was $3,253.33 per additional patient responding to treatment (i.e., 50% reduction in depression severity).
Telemedicine-based collaborative care model has been demonstrated to significantly and substantially improve depression outcomes in these small rural CBOCs. While the implementation of collaborative care in large VA-staffed clinics is an immensely challenging task, implementing collaborative care in small contract clinics is even more challenging. For national rollout, it is imperative that implementation strategies be developed and evaluated for these difficult settings. National rollout strategies must target contract CBOCs to ensure access to collaborative care for all veterans and to prevent future health disparities.
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Mental, Cognitive and Behavioral Disorders, Health Systems
Depression, Implementation, Management