BACKGROUND/RATIONALE:
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.

OBJECTIVE(S):
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.

METHODS:
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.

FINDINGS/RESULTS:
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).

IMPACT:
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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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Fortney JC, Pyne JM, Steven CA, Williams JS, Hedrick RG, Lunsford AK, Raney WN, Ackerman BA, Ducker LO, Bonner LM, Smith JL. A Web-based clinical decision support system for depression care management. The American journal of managed care. 2010 Nov 1; 16(11):849-54. [view]
2. Fortney J, Enderle M, McDougall S, Clothier J, Otero J, Altman L, Curran G. Implementation outcomes of evidence-based quality improvement for depression in VA community based outpatient clinics. Implementation science : IS. 2012 Apr 11; 7:30. [view]
3. Fortney JC, Enderle MA, Clothier JL, Otero JM, Williams JS, Pyne JM. Population level effectiveness of implementing collaborative care management for depression. General hospital psychiatry. 2013 Sep 1; 35(5):455-60. [view]
4. Fortney JC, Pyne JM, Burgess JF. Population-level cost-effectiveness of implementing evidence-based practices into routine care. Health services research. 2014 Dec 1; 49(6):1832-51. [view]
5. Fortney JC, Pyne JM, Smith JL, Curran GM, Otero JM, Enderle MA, McDougall S. Steps for implementing collaborative care programs for depression. Population health management. 2009 Apr 1; 12(2):69-79. [view]

Conference Presentations

1. Fortney JC, Booth BM, Pyne JM, Mittal D, Hudson TJ. Comparative Effectiveness Study of Rural Collaborative Care Models: The Outreach Study. Paper presented at: National Institute of Mental Health Mental Health Services Research Annual Conference; 2009 Jul 23; Washington, DC. [view]
2. Fortney JC. Implementation of Collaborative Care Models in Rural Primary Car Practices. Paper presented at: Western Interstate Commission for Higher Education (WICHE): From the Bench to the Ranch: Enhancing the Transfer of Science to Service in Rural and Frontier Mental Health Meeting; 2009 Mar 5; Denver, CO. [view]
3. Otero JM, Fortney. Implementation of Telemedicine-Based Depression Care Management in Contract CBOCs, Transforming Research into Practice. Paper presented at: VA Transforming Mental Health Care Conference; 2008 Jul 21; Washington, DC. [view]
4. Fortney JC. Implementation Research within Research Clinical Partnerships. Paper presented at: VA MIRECC Implementation Conference; 2011 Sep 19; Houston, TX. [view]
5. Fortney JC. Implementing Telemedicine-based Collaborative Care for MDD in Contract CBOCs. Paper presented at: VA Implementing a Public Health Model for Meeting the Mental Health Needs of Veterans Annual Mental Health Conference; 2010 Jul 27; Baltimore, MD. [view]
6. Fortney JC, Pyne JM. Implementing Telemedicine-Based Collaborative Care for MDD in Contract CBOCs. Paper presented at: VA HSR&D National Meeting; 2011 Feb 18; National Harbor, MD. [view]
7. Fortney JC. Implementing Telemedicine-Based Depression Care Management in Contract CBOCs. Paper presented at: VA Leadership Board Annual Meeting; 2011 Feb 15; Crystal City, VA. [view]
8. Fortney. NetDCMS: Web-Based Depression Care Management System, Developments in Information Health Technology. Paper presented at: VA HSR&D National Meeting; 2007 Feb 20; Arlington, VA. [view]
9. Fortney. NetDCMS: Web-Based Depression Decision Support System. Paper presented at: VA Transforming Mental Health Care Conference; 2007 Jul 21; Arlington, VA. [view]
10. Fortney JC, Pyne JM, Steven C, Williams J, Hedrick R, Lunsford A, Raney W, Ackerman B, Ducker L. NetDSS: A Web-Based Clinical Decision Support System for Care Management. Poster session presented at: Community Health Institute and Expo Annual Conference; 2013 Aug 25; Chicago, IL. [view]
11. Fortney JC, Pyne JM, Burgess JF. Practice-level cost-effectiveness of implementing collaborative care management for depression. Paper presented at: AcademyHealth Annual Research Meeting; 2014 Jun 9; San Diego, CA. [view]
12. Fortney JC, Pyne JM. Telemedicine-Based Collaborative Care. Paper presented at: AcademyHealth Annual Research Meeting; 2010 Jun 27; Boston, MA. [view]
13. Fortney JC. Telemedicine-Based Collaborative Care Models for Rural Primary Care Practices. Paper presented at: National Institutes of Health Future of Telehealth Workshop; 2009 Jun 25; Washington, DC. [view]
14. Fortney JC, Pyne JM, Mittal D, Hudson TJ. Telemedicine-Based Depression Collaborative. Paper presented at: National Association of Community Health Centers Financial, Operations Management and Information Technology Conference; 2010 Nov 16; Las Vegas, NV. [view]

DRA: Mental, Cognitive and Behavioral Disorders, Health Systems
DRE: none
Keywords: Depression, Implementation, Management
MeSH Terms: none