PACT Cyberseminar:

Improving Depression Care Following 

Psychiatric Hospitalization

Paul N. Pfeiffer, MD

VA Center for Clinical Management Research

VA Ann Arbor Healthcare System
Poll Question 1

What is your primary relationship to VA patients 

with depression after they have been discharged 

from inpatient psychiatry?

a)Provide direct patient care

b)Oversee patient care (administrator)

c)Other clinician/administrator

d)Researcher 

e)Other
Suicide Risk After Hospitalization

113-178x SMR

126-117x SMR

SMR = standardized mortality ratio Troister, 2008

213-134x SMR

Next slide
Suicide Risk Among Depressed 

VA Patients 

Suicides per 100k py

Valenstein, 2009
Efforts to Reduce Suicide Risk 

• Timely outpatient follow-up visit: 

 VA and national standard

• High-risk list & case management: 

current VA practice

• Inpatient-based interventions: 

ongoing DoD work using CBT

• Insuring highest quality depression 

care: follow-up, medications (lithium?), 

and therapy
Patient Characteristics 
Post-hosp Treatment Indicators

• Timely outpatient follow-up 

→7 or 30 days post-discharge

• Adequate antidepressant coverage

→72 out of 90 days supply (80%)

• Psychotherapy 

→8 visits in 90 days
Trends in depression care following a psychiatric 

hospitalization for depression

0%

10%

20%

30%

40%

50%

60%

70%

80%

2005 2006 2007 2008

7-day follow-up

Psychotherapy

Antidepressant

Rehospitalization
Trends in depression care following a psychiatric hospitalization 

for depression

0%

10%

20%

30%

40%

50%

60%

70%

80%

2005 2006 2007 2008 2009 2010

7-day follow-up

Psychotherapy

Antidepressant

Rehospitalization

Goals:

– Assess barriers and preferences for posthospital depression care

Survey:

– Mailed survey 2-4 weeks post-discharge

– Excluded only dementia patients

– VA Ann Arbor and Battle Creek 
 Ann Arbor Battle Creek Total

Eligible Mailed* 453 313 766

Surveys Completed 189 99 288

Survey Response Rate 41.72% 31.63% 37.60%

Surveys Completed 

w/HIPAA 160 82 242

Survey w/HIPAA Response 

Rate 35.32% 26.20% 31.59%

Table 1. Response Rate
Table 3. Unmet needs for existing post-hospital services 

(N = 291)

Desired but did not

Service receive the service

 n % 

Individual counseling 69 23.7% 

Housing assistance 47 16.2% 

Employment assistance 47 16.2% 

Group counseling or support group 42 14.4% 

Family or couples counseling 42 14.4% 

Review of medications 33 11.3% 

Daily intensive outpatient program 27 9.3% 

Electroconvulsive therapy 10 3.4% 
Table 4. Barriers to post-hospital counseling (N = 291)

Reported barrier as 

moderately

Barrier difficult to impossible

 n % 

Problems with transportation 129 44.3% 

Talking about upsetting issues 106 36.4% 

Lack of energy or motivation 104 35.7% 

Physical symptoms (fatigue, pain, etc.) 95 32.6% 

Lack of available services 94 32.3% 

Daily responsibilities 93 32.0% 

Cost 89 30.6% 

Problems aren't severe enough 89 30.6% 

Means cannot solve own problems 79 27.1% 

Physical problems getting around 77 26.5% 

Don't expect it to be helpful 74 25.4% 

Having family/friends know 72 24.7% 

Heard about or had bad experiences with 

counseling 71 24.4% 

Having counseling in medical record 70 24.1% 
Table 5. Preferences for telemental health counseling 

(N = 274) 

N % 

Prefer in-person counseling at hospital 212 77.4 

Prefer counseling over the phone 36 13.1 

Prefer counseling using internet video 

chat 4 1.5 

Prefer no counseling 22 8.0 
Table 6. Preferences for new post-hospital services (N = 291)

Reported service as

Service moderately to very helpful

 n % 

Increasing support from family/friends 203 69.8%

One-to-one support from other Veteran 182 62.5%

Home visit from VA clinician 114 39.2%

Internet-based Veteran support group 64 22.0%

Internet self-help program 60 20.6%
STAIRS: Initial Qualitative Findings

• Patients appreciate phone calls to “check in”, 

want to know someone cares

– Doesn’t matter much the discipline of the person 

calling as long as they have had some training in 

working with mental health

• Want therapy at the hospital clinic, but not 

necessarily every week
Peer Support Interventions

• Peers can:

– Provide various types of social support: emotional, 

tangible, informational, companionship

– Support outside and between health visits

– Role model recovery

– Identify red flags

– Assist in navigating/advocating within health 

system
Post-hospital Peer Support

• Observational studies suggest peer support 

services helpful in reducing use of crisis 

services and readmission

• Most trials of mixed SMI population

• None of VA population

• Only 1 single-site, small RCT (N = 74), positive 

effect of peer support on readmission*

*Sledge, 2011
Peer Support vs. UC for Depression

Pfeiffer, 2011 
Peer Support vs. Grp CBT for Depression
Peer Support Implementation in 

VHA

• VHA has hired 800+ Peer Specialists in past 1-2 

years

• VA Peer Specialists often experience role 

confusion and could benefit from “more 

training, supervision, and discussion about the 

content and process of their jobs” 

 Chinman (2008)
Post-hospital Intervention Model
Current Pilot Intervention

• Acceptability:

– Out of 42 patients approached:

• 21 chose Peer Specialist, 7 chose family/friend

• Mean calls completed: 9

• 90-day outcomes (N = 17)

– Change in PHQ-9: 16.7 (baseline) to 11.8

– Readmission: 12%
Acknowledgments 

• Co-Investigators: Marcia Valenstein, Fred 

Blow, John McCarthy, Kara Zivin, Nick 

Bowersox, Jane Foreman, John Piette

• Research Coordinators: Erin Miller, 

Jennifer Burgess, Jennifer Henry

• Data Analyst: Dara Ganoczy

• Funding: VA Ann Arbor PACT Demo Lab, 

QUERI
1. Pfeiffer PN, Ganoczy D, Zivin K, McCarthy JF, Valenstein M, Blow FC. Outpatient 

follow-up after psychiatric hospitalization for depression and later readmission and treatment 

adequacy. Psychiatr Serv. 2012;63(12):1239-42. 

2. Troister T, Links PS, Cutcliffe J. Review of predictors of suicide within 1 year of 

discharge from a psychiatric hospital. Curr Psychiatry Rep. 2008;10(1):60-5. 

3. Valenstein M, Kim HM, Ganoczy D, McCarthy JF, Zivin K, Austin KL, et al. Higher-risk 

periods for suicide among VA patients receiving depression treatment: Prioritizing suicide 

prevention efforts. J Affect Disord. 2009;112(1-3):50-8. 

4. Bowersox NW, Bohnert ASB, Ganoczy D, Pfeiffer PN. Inpatient Psychiatric Care 

Experience and Its Relationship to Posthospitalization Treatment Participation. Psychiatr Serv. 

2013;64(6):554-62. 

5. Pfeiffer PN, Ganoczy D, Bowersox NW, McCarthy JF, Blow FC, Valenstein M. 

Depression Care Following Psychiatric Hospitalization in the Veterans Health Administration. 

Am J Manag Care. 2011;17(9):E358-E64. 

6. Sledge WH, Lawless M, Sells D, Wieland M, O'Connell MJ, Davidson L. 

Effectiveness of peer support in reducing readmissions of persons with multiple psychiatric 

hospitalizations. Psychiatr Serv. 2011;62(5):541-4. 

7. Pfeiffer PN, Heisler M, Piette JD, Rogers MA, Valenstein M. Efficacy of peer support 

interventions for depression: a meta-analysis. Gen Hosp Psychiatry. 2011;33(1):29-36. 

8. Chinman M, Lucksted A, Gresen R, Davis M, Losonczy M, Sussner B, et al. Early 

experiences of employing consumer-providers in the VA. Psychiatr Serv. 2008;59(11):1315-21. 

References 
VETERANS HEALTH ADMINISTRATION 

Reductions in Ambulatory Care Sensitive Condition (ACSC)-Related 

Hospitalizations among Veterans with Mental Illness seen in the VHA Patient 

Centered Medical Home

Ranak Trivedi, PhD

Center for Innovation to Implementation, VA Palo Alto Health Care System

Dept. of Psychiatry and Behavioral Sciences, Stanford University
VETERANS HEALTH ADMINISTRATION

Acknowledgements

• Phillip Sylling, MS

• Karin Nelson, MD, MSHS

• Stephan D. Fihn, MD, MPH

• Dan Kivlahan, PhD

• Edward Post, MD, PhD

• Andrew Pomerantz, MD

• Idamay Curtis, MS

• Paul L. Hebert, PhD

• Edwin Wong, PhD

• Chuan-Fen Liu, PhD

Funding:

• PACT Demonstration Lab Coordinating Center, Office of Analytics and Business Intelligence

• VA HSR&D CDA-09-206 (Trivedi) and VA HSR&D CDA 13-024 (Wong)
VETERANS HEALTH ADMINISTRATION

Poll Question #1

• What is your primary role in VA? 

– student, trainee, or fellow

– clinician

– researcher

– manager or policy-maker

– Other
VETERANS HEALTH ADMINISTRATION

Poll Question #2

• What, if any, is your involvement with patient aligned care teams (PACT)?

– VA Operations

– Physician

– Nurse Practitioner

– Case manager

– Social worker

– Mental health provider (psychologist, psychiatrist)

– Trainee (intern, resident, postdoctoral fellow)

– Other staff

– Not involved with PACT

4 
VETERANS HEALTH ADMINISTRATION

Background

 Ambulatory care sensitive conditions (ACSCs) are medical

conditions though to be sensitive to the receipt of high

quality primary care

 Mental illness is associated with higher ACSC-related

hospitalization rates

 Veterans have a high rate of mental illness and may be

especially vulnerable

– Depression: 13.5%

– PTSD: 9.5%
VETERANS HEALTH ADMINISTRATION

Background

• To address the needs of Veterans with mental illness, VA

integrated mental health in primary care in 2007

• In April 2010, the VA further implemented a patient centered

medical home model, Patient Aligned Care Teams (PACT)

• Therefore, it is important to evaluate effect of PACT rollout on

outcomes among mentally ill Veterans
VETERANS HEALTH ADMINISTRATION

Objective

To determine the association of PACT on the rate of 

ACSC-related hospitalizations among Veterans with 

depression and PTSD
VETERANS HEALTH ADMINISTRATION

Methods

 Included Veterans seen in VHA primary care

between 2003Q4 to 2012Q3 (N= 8,068,030)

 ICD9 codes used to determine a diagnosis of

depression (296.XX, 300.4, 311) or PTSD (309.81)

 1+ inpatient or 2+outpatient dx in previous year

 Observation unit: facility-diagnosis cohortquarter level
VETERANS HEALTH ADMINISTRATION

Methods

 Interrupted time series analysis with Poisson model of 

hospitalizations

 Changes in hospitalizations using a PACT indicator = 1 

after FY10 Q3

 Control for seasonality, existing trend in hospitalizations, 

patient age, sex, health risk, facility size, and facility area 

economic climate

 Include facility-cohort level random effects for time trend 

and pre-PACT and post-PACT intercepts
VETERANS HEALTH ADMINISTRATION

Methods

• Predicted rate of admissions based on pre-PACT

ACSC hospitalization data

• Calculated differences between observed and

predicted rate of ACSC-related admissions

• Separate models:

– Depression and PTSD

– Veterans ≥65 y and <65 y
VETERANS HEALTH ADMINISTRATION

Table 1: ACSC-hospitalization rates among Veterans with 

depression

<65 y ≥65 y

Depression 5.34% 16.19%

No Depression 2.68% 4.48%
VETERANS HEALTH ADMINISTRATION

Trends in ACSC-related hospitalizations

PACT Rollout
VETERANS HEALTH ADMINISTRATION

PACT Rollout
VETERANS HEALTH ADMINISTRATION

Table 2: ACSC-hospitalization rates among Veterans with 

PTSD

<65 y ≥65 y

PTSD 4.59% 9.95%

No PTSD 3.10% 5.04%
VETERANS HEALTH ADMINISTRATION

PACT Rollout
VETERANS HEALTH ADMINISTRATION

PACT Rollout
VETERANS HEALTH ADMINISTRATION

Discussion

 ACSC–related hospitalization rates high among 

Veterans with depression or PTSD

 Veterans with depression or PTSD show 

decreases in ACSC-related hospitalizations since 

PACT

 Especially among those <65 y
VETERANS HEALTH ADMINISTRATION

Limitations

• Use of administrative data

– Cannot determine illness severity of depression or

PTSD

• Observational data limits causal inferences

• Limited to Veterans seen in primary care and

patients seen in an integrated medical systems
VETERANS HEALTH ADMINISTRATION

Conclusions

• Depression and PTSD are potentially modifiable causes of

ACSC-related hospitalizations

• The PACT model of patient centered medical home may

result in better management of these conditions

– In addition to VA’s PCMHI and primary care program
VETERANS HEALTH ADMINISTRATION

Questions?

Contact Information: 

Email: Ranak.trivedi@va.gov

Ph: 650493500 x25225 (2 for Menlo Park) 

Paul Pfeiffer, MD

E-mail: paul.pfeiffer@va.gov

Phone: 734-845-3645