Veterans from Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) present with high rates of post-traumatic stress disorder (PTSD) and depressive disorders, but may experience barriers to specialty mental health (MH) care. Recent research suggests the majority of OEF/OIF veterans referred to MH for PTSD or depression fail to attend the recommended number of appointments within the first year. The TIDES (Translating Initiatives for Depression into Effective Solutions) model of collaborative care management for depression is an evidence-based option for VA primary care settings. However, patients in TIDES care management often have co-morbid PTSD, and the current model does not include PTSD-specific tools.
The primary objectives of the project were to assess feasibility and acceptability of (1) adapting TIDES tools and protocols to include PTSD and depression in the management of OEF/OIF patients, and (2) implementing the adapted model to augment treatment as usual in the VA Seattle-Puget Sound Deployment Health Clinic (DHC).
We conducted a pilot implementation of the TIDES/PTSD model in a single site that provides integrated care specifically for OEF/OIF veterans. TIDES CPRS (Computerized Patient Record System) templates were adapted to include assessment and monitoring for PTSD. Phone-based care management protocols were expanded to include PTSD in three clinical domains: (1) medication management, (2) psychosocial support, and (3) patient self-management support, including the optional workbook "Strategies for Managing Stress After the War: Veterans Workbook." The templates were written in VA Class 1 Software, and clinical data were coded as Health Factors, allowing for automatic collection into the VISN 20 Data Warehouse. TIDES Care Managers were trained to use these templates, protocols, and workbook. Clinical staff received an orientation to the model of care. We enrolled 20 patients, newly initiating care at the DHC, who had a clinical diagnosis of PTSD and score of 50 or greater on the PTSD Check List-Military version (PCL-M). Co-morbid depression, if present, was defined by clinical diagnosis and a score of 10 or greater on the nine-item Patient Health Questionnaire (PHQ-9). Patients were followed by a Care Manager for up to six months. Formative evaluation included utilization data, clinical data, and qualitative data from semi-structured interviews of clinical staff and patients on their experiences with the model.
Findings suggest that TIDES/PTSD care management helped with access to care, support of patients, and monitoring and adjustment of treatments. Patients attended an average of 9.3 mental health visits during the six months of being followed by a Care Manager, and missed fewer than two mental health appointments. Clinical findings were also suggestive of a possible trend towards improved screening scores for both PTSD and depression. The mean PCL-M score decreased from 53.7 initially to a mean of 46.7 at the fourth follow-up call. The mean PHQ-9 score decreased from 13.5 initially to 9.7 at the fourth follow-up. These results indicate that adaptation of the TIDES model to include PTSD was feasible, and that it could be successfully implemented in the DHC. The model was generally well-received by patients and providers. Improved access to VA care was especially noted for patients living in remote areas or with busy schedules.
Adaptation of the TIDES model to include patients with PTSD as well as depression can provide additional collaborative care tools for care of OEF/OIF veterans. Given the high rates of OEF/OIF veterans with depression and PTSD who do not accept referrals to specialty mental health services, this model could help improve access to care for this population. Further studies are needed to assess whether this adaptation of TIDES care management for PTSD is feasible and acceptable in other VA primary care settings. Additional adaptations of Care Management protocols may be helpful, based on patient and provider reports.
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