# Presentation: 766696

## Measuring TIDES Implementation and Story

- QUERI National Meeting, Dec 2008

## Purpose

- What is TIDES?
- Summary of the TIDES intervention/evaluation
- Did TIDES meet SQUIRE publication standards for quality improvement research?

## What is TIDES?

- TIDES is an evidence-based quality improvement project
- Means *Translating Initiatives in Depression into Effective Solutions*
- TIDES purpose
- Effectiveness of new care models to improve health outcomes for depression already known (over 36 high quality randomized trials)
- Can this evidence be used by VA to systematically improve routine VA care?

## TIDES As A Research-Clinical Partnership

- VA clinical management makes the decisions
- Informed by research partners regarding the evidence
- Research partners support implementation from a distance
- No hands on any practice directly
- Assist with development of tools, materials, and training
- Assist with quality monitoring

## Goals

- Design and test a VA context-synchronous and evidence-based care model
- Clinical managers as decision-makers
- Researchers as evidence reviewers, tool developers and trainers
- Use Plan Do Check Act Cycles
- Alpha and beta test in 7 CBOCs in 3 VISNs
- Stagger implementation by several months
- Spread final stable model

## Overview of TIDES Story from the Intervention Point of View

- In  2000, prior to any funding, Drs. Chaney and Rubenstein began approaching VISNs
- Work in the 1990’s showed what was effective
- Challenge was to integrate effective models seamlessly into routine care
- We conducted planning meetings in six VISNs
- Out of six VISNs recruited, three decided to participate

## TIDES:  Initially A Two-Year QUERI-Funded  Project

- Began in 2001
- Purpose:  Develop a successful prototype VA depression care improvement model based on evidence
- Engaged VISNs in QI Planning Expert panel methodology to gain structured VISN input into design
- Rubenstein, *Joint Commission Journal, HSR*
- Spread prototype regionally and nationally

## TIDES Prototypes

- By design, PDSA’s implemented in 7 low complexity CBOCs
- Prior research showed complex VA med centers had difficulty implementing high quality primary care
- Limited number engaged
- Engagement of VISNs and CBOCs was successive, not simultaneous
- Theory was to reduce design time for later sites

## Comparison Built In

- Anticipated a randomized trial
- We asked VISNs to identify three to four matched CBOC’s each, and randomly selected two as intervention sites
- We later applied for and received HSR&D funding for WAVES
- Goal of WAVES was to test the effectiveness of TIDES across representative patients and providers

## Success of TIDES and WAVES

- TIDES:  intervention as developed by VISNs proved viable
- Synchronous with VA policies, procedures, and CPRS
- Sustained on no research funding for over 1 yr after end of TIDES
- Spread throughout one entire VISN on VISN funding alone

## ReTIDES (Regional Spread)

- Funded 2004
- Goal:  Prepare for national implementation
- Finalize tools for spread (see poster)
- Finalize engagement of Patient Care Services and EES
- Assist revision of depression guidelines to address care model issues
- Spread to one new VISN

## National Implementation

- Model taken up nationally in 2006
- Combined with White River Junction collocated care and Behavioral Health Lab method in a national RFP
- New mandate (the mental health Uniform Services Package) includes key TIDES and BHL elements (2008)
- TIDES is currently active in over 70 practices
- 120 clinicians trained in 2007-2008

## TIDES Quality Improvement Method:  Evidence-Based Quality Improvement

- Design choices by VISN leadership based on evidence
- Expert panel meeting:  Like a collaborative, but focused on regional leadership, key design choices, and evidence
- VISN leadership picks sites, hires care managers, engages VISN leadership team who engage local medical center and CBOC leadership & local QI “teams”

## Work Groups 

- Mirrored the Chronic Illness Care Model
- Senior leaders, IT, Education and Decision Support, Care Management and Self-Management Support, Collaboration (MH/PC/Nursing)
- Supported administratively and technically by researcher team acting as technical experts
- Across-VISN work groups support training, tool development

## Qualitative and Quantitative Evaluations of TIDES

- A series of projects with PI’s/CoPIs including
- Ed Chaney, Fen Liu (Seattle)
- JoAnn Kirchner, Rick Owen, Mona Ritchie (Little Rock)
- John Williams (Durham)
- Lisa Rubenstein, Becky Yano, Jackie Fickel (GLA)
- Clinical Leaders Randy Petzel, Mike Davies, Cathy Henderson, Clyde Parkis, Susan McCutcheon, Skye McDougal, Ken Clark, Ron Norby, and many others

## Data Describing the Intervention and Outcomes

- Historical data
- Study files kept systematically; ACCESS data bases
- E-mails kept and classified
- Document review undertaken
- Qualitative data
- Semi-structured interviews
- Site visits
- Randomized trial data
- Quality improvement data
- Performance measure type data
- Provider survey data
- Organizational administrative and survey data

## QUERI Water PIPELINE

- PIC, MHAP,
- MOOD,IMPACT,
- RESPECT, TEAM

**HSR**

**Implementation Science**

**Implementation Policy**

**A**
**C**
**C**
**O**
**U**
**N**
**T**
**A**
**B**
**I**
**L**
**I**
**T**
**Y**

**Depression**
**Care **
**Guidelines**

**Depression**
**Collaborative**
**Care Model**

**Revise Guidelines**

## Cost Data

- Planned distribution of labor between clinical partners and technical experts occurred
- High number of clinical partners involved
- Researchers did more labor
- Staggered implementation occurred with somewhat decreasing time to implementation
- Intervention costs $$’s

## Slide 19

## Slide 20

## QI Participants, Person Hours and  Costs

|  |        Individuals participating     in TIDES |  | 
Total Person Hours |  | Total Costs |  |
| --- | --- | --- | --- | --- | --- | --- |
| Participants | 

   % | 

Person
Counts | 

% | Hours | 

% | Dollars |
| Technical Expert Team
MD and PhD investigators
Staff | 
33% | 
42 | 
66% | 2,147
(1,786 – 2,583) | 
70% |         $197,787
(181,778 - 216,951) |
| Clinical Partners
Senior leaders from regions and medical centers
Local leaders and clinical staff
Care managers | 
67% | 
86 | 
34% | 
1,086
(952 - 1231) | 
30% | 
$84,438
(75,676 - 93,901) |
| All Participants | 100% | 128 | 100% | 3,233
(2,738 - 3,813) | 100% |        $282,225
(257,454 - 310,852) |

## Person Hours and Cost by Phase

|   | Clinical Team |  | Technical Expert Team |  |
| --- | --- | --- | --- | --- |
| Project Phase | Person Hours | Cost | Person Hours | Cost |
| Preparation and design  | 742 | $61,795 | 1,639 | $177,193 |
| Implementation  |  |  |  |  |
|     PDSA cycle | 179 | $11,860 | 278 | $11,287 |
|     Routine care  | 164 | $10,784 | 230 | $9,307 |

## Goals and Methods Used to Meet Them (cont)

- Model fidelity
- Semi-structured qualitative data collection
- QI data collection
- Document review
- Effectiveness across representative patients and providers
- Randomized trial
- Program quality and safety
- Quality improvement data

## TIDES Quality Improvement Outcomes

- QI data collected by care managers
- Care managers trained to administer depression symptom measure (PHQ 9)
- Data entered into Excel spreadsheets
- Analyzed in SPSS

## Results #1:  Enrollment & F/U

- Among 858 pts referred to TIDES, 738 (87%) were eligible for initial assessment
- 24 refused (2.8%)
- 86 could not be contacted (10%)
- 10 misc. (e.g., too sick) (1%)
- Of 738 eligibles, 86% (636) got a full initial assessment by the DCM
- 81% of these (516) completed 6 mos.PHQ f/u

## #2: Depression Symptom Outcomes 

- PHQ 9 _>_ 10 = probable major depression
- PHQ 9 < 5 = probably no significant depression
- Baseline PHQ 9 mean = 12.2
- F/u PHQ 9 at 24 weeks = 7.4
- ___________________________________
- Mean pre-post drop in PHQ 9 = 5.8 points

## #3: Mean PHQ Change: Referral Type (TIDES vs WAVES)

|  | Baseline
Mean PHQ | 6 Mos 
Mean PHQ |
| --- | --- | --- |
| TIDES (n = 310) | 12.1 | 5.8 |
| WAVES (n = 206) | 14.0 | 9.6 |

- P=.002, controlling for baseline PHQ, VISN, pt complexity, interactions
- Interactions not significant (VISN, pt complexity)

## #4:  Mean PHQ Change: VISNs (includes TIDES and WAVES pts)

| VISN | Baseline
Mean PHQ | 6 Mos 
Mean PHQ |
| --- | --- | --- |
| #1 | 12.6 | 6.1 |
| #2 | 12.7 | 7.5 |
| #3 | 13.4 | 9.17 |

- P=.02, controlling for referral type, pt complexity, int.
- No significant interactions (referral type, pt complexity)

## #5:Contact New Referrals Promptly

- 81% enrolled within 1 month (48% in 1 wk)
- TIDES referral: 	81 % enrolled in 1 month
- WAVES referral: 	74% enrolled in 1 month
- VISN #1: 91%
- VISN #2:  81%
- VISN #3: 78%

## #6: Enrollment and f/u calls

- Mean enrollment calls/pt = 3.7
- TIDES and WAVES were equivalent
- Proportion of pts completing adequate TIDES care (at least 4 treatment contacts) was significantly lower for WAVES-referred pts (p = .01)
- Pts receiving at least 4 calls had significantly better outcomes (p <  .05)

## TIDES QI Formative Findings: Reach

- Reach:
- Clinics varied from 46% to 100% of clinicians who referred to TIDES at least once; 0% to 36% who referred at least 10 pts
- Sustainability:
- Least ready site performed, but did not sustain (in a favorable VISN)
- Most ready site did not perform or sustain (in an unfavorable VISN)

## Additional Data

- Meta-analysis of trials to identify program features for use in national guidelines
- Performance measure data on ReTIDES sites (pre-post with comparision)
- Qualitative data pre-post on sites, consumers
- Provider survey data on sites with comparison
- Document review with educational theory on provider education approach

## Standards for QI Research:  The SQUIRE Guidelines

- Published Oct. 2008
- Ogrinc:  *Quality and Safety in Health Care*
- Davidoff:  *Annals of Internal Medicine*
- Provides criteria for quality improvement publication
- Used here to look at what types of data need to be incorporated into QI studies
- Does TIDES have the data to meet these criteria?

## TIDES may meet SQUIRE Guidelines