# Presentation: 111802

## Improving VA Depression Care: TIDES, WAVES and COVES

***VISNs 10, 16 and 23***
***VISN, VAMC & Clinic leaders and staff******Project Faculty******Lisa Rubenstein, MD, MSPH, Edmund Chaney, PhD, co-PIs******VA HSR&D MH-QUERI Projects****** ***

## Why is Depression QI Important?

- Depression is the second leading cause of disability worldwide (WHO)
- Treatable - low intensity collaborative care interventions significantly reduce job loss
- Depression is more prevalent among veterans (8% vs. 12%)
- 30% of outpatients in Veterans Health Study have symptoms (Kazis et al, 1999)

## Usual Care Findings from VA Research

- Little systematic symptom assessment
- results in under and over-treatment
- For MDD, appropriate treatment rates are about 50%
- VA recent study 45% adequate antidepressant duration (Charbonneau)
- Varies by gender, ethnicity, location (primary care worse)

## Chronic Care Model Components

- Community
- Health System
- Delivery System Design
- Self-management Support
- Decision Support
- Clinical Information System

## Determinants of Adoption of Collaborative Care for Depression in VA

**Environment**
**Reimbursement **
**Regulations**
**Performance measures**
**Resources**

**Organization **
**& Practice**
**Authority structure**
**Reward structure**
**Culture**
**Resources**

**Provider**
**Attitudes**
**Knowledge**
**Habits**
**Cost/Value tradeoffs**

**Patient**
**Attitudes**
**Knowledge**
**Habits**
**Cost/Value tradeoffs**

**Adoption of **
**Collaborative Care for Depression**

**Health Outcomes**

## What is TIDES (Translating Initiatives for Depression into Effective Solutions)?

- Helps VISNs to locally adapt depression care research (Evidence Based QI)
- Research shows that collaborative care is necessary and sufficient to improve outcomes
- Care management supports patient self-management
- Adjunctive to primary care clinician
- Mental health specialist collaboration supporting primary care clinicians and care managers

## Why Collaborative Care?

- Most patients drop out of medication management or psychotherapy in the first few weeks
- Care management, by telephone or in person, keeps patients in treatment
- Mental health specialist reviews care manager case load weekly
- Interaction with MH necessary for pts not improving in first 4 wks and not symptom-free by 12 weeks

## Collaborative Care Uses Stepped Care Philosophy

- “The right care for the right patient at the right time”
- Treatment distribution between MHS and PC in collaborative care can vary depending on local resources
- Most patients can be treated successfully using either approach

## Primary Care Patients

- Depressive Sx

- Depression

- Complications

- Difficult to Manage

- Detect

- Assess

- Consult

- Specialist Management

- Manage

- MH Specialty Involvement levels

## Telephone Care Management by RN’s

- A key TIDES VISN design choice
- Arguments for it
- Patients prefer no extra physical visits, especially in rural sites
- Research shows equal effectiveness (2 large randomized trials)
- More affordable on a regional basis

## Predicted Probability of Appropriate Care at 6 MonthsPIC

| 
Patients with | QI-MEDS
(N=327)
% Appropriate | QI-THER
(N=367)
% Appropriate |
| --- | --- | --- |
| No initial visit | 21 | 24 |
| Initial visit; no care manager  follow-up | 23 | 44  |
| Initial visit; low care manager follow-up2 | 43  | 81  |
| Initial visit; moderate care manager follow-up3 | 65  | -- |
| Initial visit; high care manager follow-up4 | 82  | -- |

## PIC Study Findings

***Extent of care manager follow-up*** predicted ***improved intermediate outcomes***
- More appropriate care                              (p<.001 QI-MEDS and QI-THER)
- Increased patient knowledge of depression (p<.01 QI-MEDS, p<.10 QI-THER)
- More active coping                                       (p<.05 QI-MEDS, ns QI-THER)
- Study improved mental health, job retention

## TIDES Depression Management

- Clinical Reminder screen to primary care provider to care manager
- Care manager assessment, education/activation, initial care plan suggestions
- Primary care clinician treatment or referral initiation and adjustment as needed

## Educate, Activate Patients with Depressive Symptoms

- Based on patient activation research
- Nurse case manager uses depression record and mailed educational materials (also web-accessible - **http://www.va.gov/tides_waves/****)**
- Encourages behavioral activation
- Problem-solves treatment barriers

## Assess Patients With Depressive Symptoms

- 1) Emergent symptoms?
- Require immediate access to mental health specialty or hospitalization
- Suicidal
- Elderly failing to thrive
- Psychotic
- TIDES: On-call system

## Assess Patients With Depressive Symptoms (Cont)

- 2)  Meets criteria for major depression or dysthymia or other problem?
- Grief
- Substance abuse
- PTSD
- Manic depressive disorder (bipolar)
- TIDES:  Primary care provider and care manager assessments with mental health consultation as requested

##  Initial Management Suggestions

- Initiate antidepressants, psychotherapy, watchful waiting or specialty referral
- Psychotherapy (CBT, IPT) and medications equally effective for most primary care patients
- Medication for vegetative symptoms
- Manualized psychotherapy for psychosocial stressors and behavioral activation

## What is WAVES?

- Reprise:  What is TIDES?
- A depression quality improvement intervention undertaken by VISNs with support from implementation researchers
- Researchers act as consultants and support staff
- Randomized trial that sends a representative sample of all clinic patients with major depression to the TIDES intervention
- Researchers act as researchers

## Well-Being Among Veterans Enhancement Study (WAVES)

- Clinics within 3 VISNs randomized to intervention or usual care (2 intervention, 1 usual care)
- Evaluate process of care, patient outcomes, and cost for TIDES sites versus usual care control sites
- 6-month results available 2005

## Cost &Value Evaluation Study (COVES)

- Understand stakeholder perceptions of cost and value tradeoffs in TIDES
- Carried out through structured key informant interviews
- Measure costs

## Expected Outcomes of TIDES

- Improved well-being among veterans
- Improve primary care quality and performance
- Better treatment
- Reduced primary care and mental health visits per successfully treated case
- Reduced inappropriate medications
- Enhanced collaboration between primary care, mental health, and nursing

## Performance Goals for TIDES

- AT LEAST
- 80% of patients screened positive for depression are assessed
- 70% of assessed patients who have major depression are treated appropriately
- Psychotherapy
- Antidepressants
- 60% of patients with major depression remit

## Performance So Far For TIDES

- TIDES:  85% Assessed (n = 228)
- Goal    :  80% Assessed
- TIDES:  90% Completed Care Management (n = 55)
- GOAL:  70% Treated Appropriately
- TIDES:    78% Remission (n = 55)
- GOAL:    60%  Remission

## National Quarterly Report

- <date/time>

**National Quarterly Report**

## TIDES Incentives

-  Training and experience for staff in
- Collaborative care and chronic care models
- Case management
- Disease registries
- Learn more about system performance
- Practice patterns
- Outcomes research

## Incentives (cont)

- Joint Commission, EPRP, HEDIS performance improvements
- National leadership and visibility
- Research development opportunities

## TIDES Chronic Care Model Summary

- Community –
- Depression in context of other chronic illnesses
- VA in context of other health care systems
- Health System –
- Leadership design, involvement & support
- Expert Panel, ongoing Working Groups
- Delivery System Design –
- Improve Primary Care/Mental Health integration

## Chronic Care Model Summary (Cont)

- Self-management Support
- Care Manager, behavioral activation, information
- Decision Support
- Structured DCM assessment protocol
- Treatment suggestions for primary care provider with outcome assessment

## Chronic Care Model Summary (Cont)

- Clinical Information System - maximize CPRS functionality and compensate for weaknesses
- Clinical Reminder
- Templated Consults and Notes
- Program Evaluation – ongoing clinic level feedback