Providing mental health care to rural Veterans in geographically accessible Community Based Outpatient Clinics (CBOCs) is a major priority of the Office of Rural Health. Likewise, the Primary Care-Mental Health Integration (PCMHI) initiative is one of the highest priorities of Mental Health Services and the Office of Mental Health Operations. The Uniform Mental Health Services Handbook mandates the blending of the two predominant, evidence-based models of integrated care (the Care Management model and the Co-Located model) at VAMCs, very large CBOCs, and large CBOCs. Because there is no scientific evidence to support its implementation, the "Blended Model" is not mandated at medium CBOCs or small CBOCs that serve rural Veterans. At most smaller CBOCs, on-site mid-level providers and/or off-site tele-psychiatrists and tele-psychologists deliver traditional referral-based specialty treatment (Referral Model) rather than integrated care.
This project contributes to Specific Aim 3 (Test clinical interventions to improve quality and outcomes of mental health care at CBOCs) of the Little Rock CREATE. The goal of this proposed Hybrid Type 2 pragmatic effectiveness-implementation trial is to generate the scientific evidence needed to justify the national dissemination of the Blended Model adapted using telemedicine technologies to accommodate the clinical context of smaller CBOCs that lack on-site psychiatrists and PhD psychologists. The resulting Blended Model (tele-PCMHI) will be compared to usual care (Referral Model) in a pragmatic trial, where the intervention will be delivered via interactive video by centrally located clinical staff and fidelity will be monitored but not controlled. Specific Aim 1: Use an expert panel comprised of clinical providers and managers who are applying telemedicine to provide a Blended model for CBOCs lacking on-site PhD psychologists and psychiatrists to document the core components of a Telemedicine Blended model and using a PDSA process, implement this model in six CBOCs. Specific Aim 2: Conduct a Hybrid Type 2 pragmatic effectiveness-implementation trial of the adapted tele-PCMHI model by assessing RE-AIM outcomes including: provider Reach into the patient population, Effectiveness at improving clinical outcomes, Adoption by providers and Implementation Fidelity.
In conjunction with national, regional and local partners, including providers and managers who have experience with tele-PCMHI delivery, the Blended Model of PCMHI will be adapted for smaller CBOCs using telemedicine technologies and pilot tested to generate a standardized treatment protocol. We will use a stepped wedge design with randomization of sites to sequential implementation steps, and CBOC patients who screen positive for depression or alcohol disorders will be recruited and consented to participate in the Hybrid Type 2 pragmatic effectiveness-implementation trial. Data about Reach and Adoption will be obtained from the Corporate Data Warehouse. Data about Implementation Fidelity will be obtained from chart review. Data about clinical Effectiveness will be obtained from telephone survey.
The expert panel process identified core components of the Telemedicine Blended or tele-PCMHI model in five domains: Access, Primary Care Providers, PCMHI Services, Technology, and Virtual Teamness. An Implementation Checklist was developed to guide sites in implementing the core tele-PCMHI components. At this phase in the project, there are no findings for Aim 2.
If the Tele-PCMHI Model improves clinical outcomes compared to usual care, results will be used to justify and facilitate the implementation of this model at smaller CBOCs that have inadequate on-site capacity to meet Veterans' needs for access to PCMHI services. This project is timely given expansion of telehealth services (e.g., for specialty mental healthcare), and interest in the field in using telehealth technologies to improve access to PCMHI services for Veterans receiving care in CBOCs.
- Owen RR, Woodward EN, Drummond KL, Deen TL, Oliver KA, Petersen NJ, Meit SS, Fortney JC, Kirchner JE. Using implementation facilitation to implement primary care mental health integration via clinical video telehealth in rural clinics: protocol for a hybrid type 2 cluster randomized stepped-wedge design. Implementation science : IS. 2019 Mar 21; 14(1):33.
- Bauer MS, Miller C, Kim B, Lew R, Weaver K, Coldwell C, Henderson K, Holmes S, Seibert MN, Stolzmann K, Elwy AR, Kirchner J. Partnering with health system operations leadership to develop a controlled implementation trial. Implementation science : IS. 2016 Feb 24; 11:22.
Mental, Cognitive and Behavioral Disorders, Health Systems
Treatment - Comparative Effectiveness
Adaptation, Depression, Effectiveness, Implementation, Models of Care, Rural, Telemedicine/Telehealth