**Transcript of Cyberseminar**

**Patient Aligned Care Teams (PACT) Demonstration Labs**

**PACT: Part 1) Improving Depression Care Following Psychiatry Hospitalization; Part 2) Relationship of Mental Illness and Ambulatory Care Sensitive Condition (ACSC)-Related Hospitalizations among Veterans seen in VA Primary Care**

**Presenter:  Paul N. Pfeiffer, MD**

**May 21, 2014**

*This is an unedited transcript of this session. As such, it may contain omissions or errors due to sound quality or misinterpretation. For clarification or verification of any points in the transcript, please refer to the audio version posted at www.hsrd.research.va.gov/cyberseminars/catalog-archive.cfm or contact Ranak.Trivedi@va.gov or Paul.Pfeiffer@va.gov*

*Dr. Paul Pfeiffer:*Thanks you Molly for the introduction. Today I am going to be talking about a line of research I have been involved with as part of a VA Career Development Award. It has also partially been supported by our PACT demo labs here in Ann Arbor. Before we get to depression care after psychiatric hospitalization for depression and the first thing I wanted to do is get a quick poll of the audience just to see a little bit more about who I am speaking to and maybe I can target some comments that would be more specific to the audience. I think people are supposed to, okay, everyone is putting their votes in. 

*Moderator:*Excellent, thank you so much. As you can see the question is what is your primary relationship to VA patients with depression after they have been discharged from inpatient psychiatry. Do you have direct patient care; oversee patient care; other clinical administrative duties; researcher or other. Simply click the circle next to the answer. It looks like we have a varied group – we have eleven percent provide direct patient care; eleven percent other clinicians or administrators; seventy percent are researchers and nine percent identify as others. Paul are you hearing that echo at all?

*Dr. Paul Pfeiffer:*I am not. 

*Moderator:*Okay perhaps it is just on my end of the line, just want to make sure all the speakers were muted. We will get back to it. 

*Dr. Paul Pfeiffer:*Okay. A fair amount of researchers, that is good to know. I am going to give a little bit of quick background on the topic. One of the main reasons it is an area of interest and I think it is a lot of people interested is because of the suicide risk after psychiatric hospitalization. 

This is just a quick slide to show that it is actually international, one of the more robust findings in terms of suicide risk that after hospitalization the risk is greatly increased. The standardized mortality ratio or SMR is the risk over the sort of general population risk. You can see here there basically you have a hundred to two hundred times the rate per the general population right after a hospitalization. That sort of found across the globe. We have done similar types of work in the VA 

This is a study done by Marcia Valenstein, who has been a close collaborator of mine and mentor. She found that after hospitalization among specifically depressed patients in the VA that the risk as you can see there, is elevated and about four or five times higher than it would be during other periods of treatment for depression. So depressed patients are already at increased risk, they are at even much higher risk after discharge. 

The VA has made several attempts and efforts to try to reduce this risk or at least monitor and mitigate the risk. I put a few of those at the top of this slide so one thing is that it is now a requirement and performance measure that patients be seen almost immediately after discharge, seven days is the expectation. That can happen by phone and then within fourteen days it needs to happen in person. This has been something that we looked at and I will talk about that a little bit more later. The other thing is that patients that are at high risk for suicide get put on a high risk list and are managed by a suicide prevention coordinator and case managers and they are expected to be seen weekly for the first four weeks after discharge and have their care monitored for I think the next three months at least. There are case management services that go on. There are other interventions being studied outside of the VA, I have collaborated on a DoD project that puts inpatients cognitive behavioral therapy for CBT and then starting that on the inpatient really focusing on the suicide aspects and then providing booster sessions after discharge. My focus is then on how do we not necessarily target suicide directly, but how do we ensure that patients with depression are getting the highest quality care after discharge. There have been some concerns that patients are not necessarily getting all that they could be getting in terms of evidence-based treatment so my answer is what are the barriers to that and how do we do a better job of that. 

I am just going to go through some of the study findings that we have had so far. This is a very quick, I am not going to go through all the patient demographic characteristics, but I just want to make a quick note that this population, patients that are discharged with a diagnosis of major depression from psychiatric hospitals are a highly comorbid group. They opt in about half the time have a comorbid substance use disorder and about a third time have comorbid PTSD. We excluded people with bipolar disorder or schizophrenia that is why they are not on here. Just looking at the depressed folks, they are a highly comorbid group and roughly forty to sixty percent have had some kind of treatment prior to their hospitalization which means that a lot of them have been reengaged, but a lot have not already been engaged. We may think about those patients differently in terms of getting them into care after discharge. 

I wanted to review a study we did looking at that performance indicator I talked about earlier in terms of the seven day follow up performance measure. That is part of one of the performance indicators. Thirty days is also historical indicator reported by Princeton’s The Heated**Quality Measurement Dataset. Now the standard, higher expectation of the seven days. And we also looked at anti-depressant coverage as an indicator of prescribing quality and we also looked at psychotherapy, eight visit is often used a minimally adequate dose, it is a number of visits studied in randomized controlled trials. That is sort of how we picked that. 

We looked at these indicators and we wanted to see whether follow up within the 7 days after discharge, how that changed once it became a performance indicator in 2008. And how did that change relate to the change in these other measures. We also looked at re-hospitalization. What you see here is in 2008, this was sort of the snapshot of where things were and then once the measure hit, you can see on this next slide the VA did a really impressive job of getting people in within seven days after discharge. The rates went from forty up to about seventy-five percent within a few years. That is a pretty impressive story and I think teaches us a lesson about how powerful some of these performance measures can be in terms of immediate direct response from the health system. 

Now what unfortunately what is less of a positive story was the effect on the other indicators of care. I know that the 7- day follow up measure was really I think intended to be addressing any suicide risk that could be immediately occurring post-hospital. But the hope is that he would also improve later engagement and treatment and that the rest of their care parameters would get better as well. We really did not see much change there. Anti-depressant, coverage or adequacy stayed virtually the same. There was a bit of a tick up in the receipt of psychotherapy so we did see that. It was statistically significant but objectively just looking at it, it is a pretty minor increase. We do not know whether that was due to the 7-day follow up or the other things going on at the same time in the VA to try to improve access to evidence based psychotherapy. The other thing is that re-hospitalization did not change either. The expectation might be that you see people within 7 days, you can address any emergent issues and maybe prevent any re-hospitalization. That did not seem to pan out. 

What really the take home for me for this was that we need to do more than just seven day follow up. That is good and it is a safety measure, but we really need to do more to address patients longer term care to try to move that. 

What we did was this was a portion of our study supported by the PACT Demo Lab which was to look at the transition period and to look at what are the services that patients are getting, what are their preferences for care after discharge. Are they getting what they want? Then also what are the barriers to those services? Is there something getting in the way? We did a survey, I am not going to go through. A lot of the message we mailed out the surveys, about two to four weeks after discharge using the standard mail survey techniques. This was done at Ann Arbor and Battle Creek VA medical centers. We got decent response rates, this is a challenging population to get to respond to surveys. We were at about thirty-seven percent overall of those mailing the survey back. That is not great compared to most mailed surveys but compared to for instance the SHEP Satisfaction Survey we are about doubled their response rate. We are okay with it. 

This is what a patient said in terms of what they wanted. When we asked them what did you want after hospital discharge but did not get, the number one thing on there was individual counselling which we basically consider psychotherapy but we use counselling for patients because that term is a little more familiar to them. There is a good news bad news here in the sense that really only a quarter of patients said that they wanted the service and they were not getting it already. We could look at it three-quarters full saying that seventy-five percent were getting what they wanted or did not have an unmet need regarding that. That did come out on top, other for social services, recovery services were sort of in the middle. That is what we found there. 

What were the barriers to individual counseling and we really were going into the survey thinking that would be one of their top preferences. We found transportation at the top. Now that is not terribly surprising coming in for psychotherapy is more difficult probably than a lot of health services because your expectations of you coming every week so there is a lot of repeated visits to the hospital. But it is also a little bit surprising that in a sense that the VA does a lot already to help with transportation in terms of shuttles and reimbursing for travel expenses. .it basically reinforced the fact that that really is a lot of people’s main issue. Then the immediate sort of ration I think from a lot of people is what about telemental health and I am going to talk about that next. 

The other thing on here was just talking about upsetting issues is also pretty high on the list; lack of energy or motivation. Those things I think are a little bit more challenging in terms of how do we address those and that is something to be thinking about. 

Here is the mental health issues. We predicted this also would be something that would be an issue and we were really considering how much mental health can do and really were actually excited about this and possibly doing home based video services. So we asked about this specifically in our survey and for this population, again, these are patients that have depression, they were discharged from a psychiatric hospital stay but really severe ends of the spectrum. Among this group they really were not interested in any kind of internet video chat service. I did not put it on here, only half said they had reliable internet access. The most people still preferred in-person counselling at the hospital even though transportation was a major barrier. 

We also about a few other services that we were just exploring. We have a lot of interest, we have done some research around peer support and I am going to talk about that a little bit later as well and were interested in that, interested in getting more support from family and friends. So we asked about those services and those were rated quite highly among this group. Those are at the top of our list in terms of what they would like for us to work on or develop new services for. 

Total visits from the commission that has been studied in other parts of medicine as a post-hospital transition service. Here it is forty percent and looking for distribution, this is a little bimodal, people either seem to love or hate this idea and it ended up somewhere in the middle. Again the technology internet based services, when we thought about those were not really selling well with this group. 

We also did a number of surveys I am not going into the details of the method but we did about twenty to twenty-five individual qualitative interviews and we have not fully analyzed all the data. Having looked at a lot of the data so far and conducted a lot of the interviews myself, just an initial snapshot from the interview is that these patients actually really appreciate. And when you ask them what could be better, they actually say well what you are doing now which is calling me and asking me about how did your care go. What is the risks that you did wanted but for some reason  you are not getting and why and how can we address that. Patients really do appreciate the phone check in. I know that a part of what PACT does is in terms of calling all discharges within three days to check in with them about their care, they really do seem to appreciate that. That is one of the top things they say when you ask them in an interview what they want. They do not have much of a strong opinion about who does the check in. I mean they want it to be someone who is a professional or has had some mental health experience. It does not matter a whole lot who it is. What it comes down to is a lot of time they just say they want to know that someone cares, that they had the hospital stay, they were in a really bad place in terms of their mental health. Now they are out of the hospital, they want to know that someone still cares. Then again they do want therapy at the clinic but maybe not necessarily every week because of the transportation issues. If it can be spaced out they seem to be happier with that then doing a telehealth intervention which a lot of times what they commented on was either felt to be impersonal or they had concerns about privacy. 

This is one the interventions we are considering to try to provide more support to patients after discharger. There is a lot of theoretical advantages to using peers. Other than the fact that they can be lower cost than other healthcare providers they also can provide aspects to their interactions that other folks can in terms of being a role model for recovery, being able to provide this very earnest emotional support kind of I have been there too, we are in this together type of connection. They can do a lot of other things that maybe lower level trained providers can do in terms of just doing initial identifying red flags and helping navigate their care. 

There has been a lot of observational studies of post hospital peer support. Actually a lot of the older, decades ago, there were recovery based consumer driven organizations that really emerged out of a population of patients that had been previously hospitalized and wanting to continue supporting each other after the hospital stay. There is sort of a rich traditional of peers and being part of a recovery process after hospital discharge. In terms of the rigorous study, there has not been a whole lot of that. There has been one randomized control trial that I am aware that did find a positive effect, it was at a non-VA single site hospital but did find that was effective. 

We have done some work looking not just at depression in peers more broadly we did a meta-analysis looking at studies of how peer support helps people with depression. Commonly people think of peer support more in the serious mental illness realm or substance abuse realm. We analyzed the existing literature looking at depression. A small number of studies, there is probably some argument about the quality of these studies that can be made. But we did find in terms of what is out there is that the studies that were looked found that peer support was effective for depression compared to a usual care comparison or no additional care. Had similar results of two studies that use both peer support and group CBT as comparison, there was no statistical significant difference between those two arms. This is all suggestive that peer support can be effective for depression. 

Then the other thing to say about peers is that the VA has really invested in this pretty heavily. Obama signed an Executive Order to hire 800 peer specialists, that has more than been achieved over the past few years. So there has been a really big push, most of the facilities should have at this point I think at least three peer specialists if not more. The problem is there is an implementation issue around the hiring and deployment of all these peer specialists is what do they that is evidence based. One of the concerns about the implementation by Matt Chinman’s work has been the fact a lot of the peer subjects hired into vague roles where what they are doing is a little bit ill-defined the supervision may not be very clear. That has been an issue that we have been thinking about. 

So what we have done is melded. I know this is a busy slide, but we melded. I am just finishing up here. Talk about the pilot study that we are doing which is taking a peer specialist and giving them a very well defined role in the sense that their expectation is that they are going to call patients every week after discharge at least for the first three months. Obviously depending on the patient, the patient does not want that then we can do something else, but that is the general idea. On top of this there is a monitoring system that is something else we have used here in Ann Arbor. John Piette, a VA career scientist has developed for a lot of conditions and it is an IVR which is an automated phone system that monitors patients symptoms and medications, identifies red flags. What we do is use this sort of joint intervention that tries to hit at two things which is one providing personal support through the peer specialist. Then also a layer of extra monitoring that we know when people’s symptoms are thinking or if they stop taking their medication or are becoming suicidal. That is a highlight intervention that has been funded actually be QUERI as an RRP. So far we  are about halfway through the study, we approached forty-two patients on the unit, recruitment has been a little bit slow because we are taking a more pure sample of depression which is to say that we are  not taking patients with heavy substance use or psychotic illness or bipolar disorder. We have about forty-two patients so far. Interesting thing is we are actually offering them the option of working with a peer specialist or with a family member or friend if they would like to do that instead. It is about three to one choosing to go with the peer specialist. They seem to be engaging in the program, at three months we looked at how many calls they completed and it averages about nine. That is showing that we are actually engaging these calls. 

Then when we look at  outcomes. this is a single arm trial so we are really just looking at feasibility and trying to get a sense for our people having any response at all. and so far it looks like the PHQ-9 which is a measure of depression has gone down from 16.7 which we consider to be in the major depression threshold down to 11.8 which is still substantial number of symptoms. but it is five points better which we consider clinically significant. Then the readmission rate, again these are small numbers there is a target at this point but readmission rate is about twelve percent within ninety days. In the VA average it is about fifteen percent so I think we are within the same range, maybe it is not having as big effect at this point in readmission. 

That is just a very quick overview of the work we have been doing. I am going to end here with just some acknowledgement. I have these references. I think these slides are going to be available afterwards so if you want to look at those you can. I wills top here and be around for questions later. 

*Moderator:*Thank you Dr. Pfeiffer. I will turn it over to Dr. Trivedi now. 

*Dr. Ranak Trivedi:*Molly I do not see the takeover presentation button on my side. 

*Moderator:*There is no need to just click the right facing arrow down in the lower left hand corner of your screen. 

*Dr. Ranak Trivedi:*Okay, got it, thanks. I think I got confused with the presentation from yesterday. Good morning everybody or for some of you good afternoon, I am on the west coast so it is still morning for me. I am going to talk about Reductions in Ambulatory Care Sensitive Condition Related Hospitalizations, a little bit different from what Dr. Pfeiffer talked about but some of the same clinical populations which are Veterans with mental illness. 

I just want to start off by acknowledging my co-authors and collaborators as well as the funding. This work is funded by the PACT Demonstration Lab Coordinating Center under OABI and both Dr. Wong and I are on HSR&D funded career development awards. 

The background of this is that as many of you are or all of you know that the VA has implemented the PACT model of patients under medical home and some of us are involved in evaluating this program nationally. I am leading the mental health evaluation for Veterans who are seen in primary care. This is work that reflects our most recent findings. 

Start off with a quick poll which is – what is your primary role in the VA. We will give a minute or so to get some answers. 

*Moderator:*Thank you very much. For those of you who selected other when we put up the feedback survey at the end we will have a more extensive list for you to select from. We will gather that information eventually but right now the options are: student, trainee, or fellow; clinician; – researcher; manager or policy-maker; or other. It looks like we have quite a diverse audience. Some of the responses are still coming in but roughly we can say that four percent is a student trainee or fellow; about a quarter are clinicians; about a quarter are researchers; eight percent manager or policymakers and forty percent identify as other. Thank you to our respondents. 

*Dr. Ranak Trivedi:*I am going to follow up with a quick other second poll which is – what if any is s your involvement with patient aligned care teams or PACT? 

*Moderator:*Thank you and once again we know that you might have side roles and assisting some of these but please do select your primary involvement with the  PACT teams. We have: VA Operations; Physician; Nurse Practitioner; Case manager; Social worker; Mental health provider; Trainee; Other staff or  Not involved with PACT. It looks like the responses are still coming in so we will give people some more time to submit your answers. Do not be shy, these are anonymous. It looks like the answers have stopped streaming in. We have about four percent physicians; about twelve and a half are case managers; about sixteen are social workers; about four percent are mental health providers; about thirty-seven percent identify as other staff and twenty-five percent are not involved with PACT at this time. Thank you. 

*Dr. Ranak Trivedi:*Thank you everybody. This just gives me a sense of the audience. I am going to start with a little bit of background. Ambulatory Care Sensitive Conditions or ACSCs as it will say on the slides here on out. These are medical conditions that are thought to be sensitive to the receipt of high quality primary care. The idea is that these are conditions that have preventable hospitalizations. If they are managed at the outpatient level as they are expected to then that would delay or prevent inpatients hospitalization. Common conditions under this are heart failure; COPD; asthma; ischemic heart disease. So you get the idea of what kind of conditions we are talking about. Diabetes is a big one too. What we know from the literature is that mental illness is associated with higher Ambulatory Care Sensitive Conditions related hospitalization rates. Because our population in the VA has high incidence of mental illnesses they may be especially vulnerable. Some of our own work has looked at the incidence of mental illness in this PACT population nationally and we are finding that about thirteen and a half percent have a diagnosis of depression and about nine and a half percent have a diagnosis of PTSD. 

As some of you may be aware, the to address the needs of Veterans with mental illness, the VA actually started this primary care mental health integration program in 2007. This program was deployed nationally, it is being integrated with mental health. They co-locate mental health services within primary care settings which is great because it allows patients to have a warm handoff between the primary care providers and mental health providers. In April 2010, this program was further expanded and built on to implement a patient centered medical home model which in the VA is called the PACT, Patient Aligned Care Teams. What we believe is that it is important to evaluate the effect of the PACT roll out on outcomes among mentally ill Veterans. The idea was that this having an additional benefit over and above the PCMHI program. 

Our main objective was to determine the association of PACT on the rate of ambulatory care sensitive condition related hospitalizations among Veterans with depression and PTSD in particular because these are the two highest problems condition among Veterans. 

We included Veterans who were seen in the VHA primary care settings between quarter four of 2003 to quarter three of 2012 which amounts to about a little over eight million Veterans nationally. We determined their diagnosis of depression and PTSD using administrative data. For depression we used the diagnostic ICD-9 codes 296.XX, 300.4 and  311 and PTSD there was one diagnostic code, 309.81. we determined that they had these diagnosis if they had one inpatient or two outpatient diagnosis in the previous year that had these diagnosis listed. These are all from administrative data from the corporate data warehouse. Our observation unit was at the facility level. We rolled up the facility diagnosis cohort level to each quarter. 

We then conduced interrupted time series analysis with Poisson model of hospitalizations. We used a PACT indicator after fiscal year 201 10 quarter three. The PACT was rolled out at the beginning of fiscal year 2010 and by the third quarter it was expected that it was rolled out throughout the country. We used an indicator one-zero to show whether or not these were seen in PACT. Our covariates were seasonality so we wanted to control for the seasonal trend in hospitalization. We control for existing trends in hospitalizations, I will say a little bit more about that in a second. We also control for some demographics like age and sex, their health risk, facility size, and facility area economic climate which is primarily employment rates. We included facility-cohort levels random effects for time trends and then we included pre-PACT and post-PACT intercepts in our analyses. 

The idea behind this is that we use the data preceding the PACT which is the 2003 to 2010 data to see what was the existing trends in hospitalizations. And then use that to project what it would have looked like if PACT has not rolled out into 2010. We then compared those numbers to the observed hospitalization in the post-PACT era so that is post-2010 and any difference that we found in the projected trends and the actual trends observed trends we attributed to PACT. That is how we calculated the differences between observe and predicted rates. We connected separate models for depression and PTSD and because the hospitalization rates defer among the elderly and the younger folks and also because the older folks are also eligible for Medicare we conducted separate models for Veterans who were over sixty-five or less than sixty-five years old. 

These are our results. You can see in this, I will start with talking about the results related to depression. Among the depressed patients you can see that on the under sixty-five the rate of hospitalization was a little over five percent among the under sixty-five and a little over sixteen percent over in the over sixty-five. If you compare that to the folks who are not depressed, you can see that these are significantly different in each age group. Not surprisingly you would expect the older Veterans to have a higher incidence of hospitalization because they are more prone to having the chronic conditions that comprises the ambulatory care sensitive conditions. 

These are our projected interrupted time series. This nice accordion type graph pattern is a seasonal variation that is typically attributed to influenza. Related hospitalizations so those are kind of the peaks tend to be the winters and the valleys tend to be summer. You can see that we use the projected data. The dotted lines indicate the projected data based on the pre-PACT roll out. The vertical line indicates when the PACT was implemented. Then on the right we have the difference between the actual and the projected. Right here is the actual versus projected. 

The top lines are the depression cohort and the bottom lines are the non-depression cohort so you can see that the patients who were not depressed there was really no difference between pre-PACT and post-PACT. But among those who were depressed there is about a ten percent difference in drop in hospitalizations. 

In the over sixty-five this effect was similar, although slightly attenuated. We found a net difference of about 8.8% so there is an 8.8% drop. Once again, as you can see here, there was no differences between the pre-PACT and post-PACT for those who are not depressed. 

In switching to the PTSD cohort, we saw similar trends here and you can see among the folks who were under 65, patients who had PTSD, Veterans with PTSD had a higher rate of hospitalization rates than those who did not have PTSD. This trend held true even among the 65 and older population where about 10% sixty-five and older folks had an ambulatory care sensitive condition related hospitalization compared to about 5% hospitalization rate if you did not have PTSD. 

Here is similar analyses kind of continuing the same idea. This number indicates the net drop in hospitalizations across time. Here you can see that there is a little bit difference, this was a non-significant difference but there is a little bit difference in the trends. If possible as we project out, as we get more and more data we might start seeing this trend right here, it might get magnified we do not know, we are going to keep following that. Again, the takeaway here is that there is about ten and a half percent roughly drop in ambulatory care sensitive condition related hospitalizations among PTSD patients who are under sixty-five. 

A very similar number you can see here for those Veterans of PTSD who were sixty-five and over where we have again you can see here that overall the hospitalization rates are going down based on this data. That would suggest that there was kind of an overall trending downwards already in play here but that despite that the observed data was about ten percent fewer hospitalizations among Veterans of PTSD and over sixty-five. Once again we see that there is really no difference among patients who did not have PTSD in the pre-PACT and post-PACT era. 

From these data we concluded that we found two different things. One is that the ambulatory care sensitive condition related hospitalization rates were high among Veterans with depression or PTSD and that Veterans with depression or PTSD showed decreases in ambulatory care sensitive condition related hospitalization. This trend was especially true among patients who were under sixty-five although the trend existed in all of our age groups. 

There are a few limitations that we were thinking about. One is that we use administrator data so although we have data on eight million Veterans which makes it a humongous epidemiological study we also do not have really nuanced information. For example illness severity especially as illness severity changes over time, we do not have a sense of especially with PTSD we do not have the sense because only ICD-9 code is used. The other issue that we do not really capture really well with administrative data is a kind of treatment that depressed patients might be getting. As people know depression can be treated in many different ways as many medications or psychotherapy. There is combination therapy and the empirical evidence suggests that patients who are mild and moderately depressed may benefit from either psychotherapy or combination where those that are severely depressed definitely need to be on medication. This information is really hard to get out of administrative data. This becomes a limitation of our analyses.

Because we are tracking observational data, we cannot make any causal inferences from our data so we do not know if it is the depression that is leading to the Ambulatory Care Sensitive Conditions or hospitalization, that is what our assumption is but that may not be true. Also, that our data are limited to or the results may be limited to Veterans seeking primary care and patients seen in integrated medical system. If you are trying to apply these findings to another kind of medical system that is not integrated or that does not treat Veterans, these may not be generalizable. 

So in conclusion, depression and PTSD are potentially modifiable causes of Ambulatory Care Sensitive Conditions related hospitalizations and we believe that the PACT model of patents under medical home may result in better management of this condition and this is even in addition to the VA’s primary care mental health integration and existing primary care program. 

I think we can open it up to questions. 

*Moderator:*Excellent thank you very much Dr. Trivedi. I know that a lot of our attendees joined us after the top of the hour so to submit any questions or comments you have right now, simply use the Q&A box located in the upper right hand corner of your screen. Just type it into the lower box and press the speech bubble and we will get that in the queue The first question that came in, Paul this was during your presentation. What is the cost for follow up therapy?

*Dr. Paul Pfeiffer:*I have not looked at cost so I cannot answer that question specifically. Sorry I do not have an answer to that. 

*Moderator:*Not a problem thank you. Also what was the purpose of excluding psychotic disorder and bipolar patients?

*Dr. Paul Pfeiffer:*That is a really good question and it is something that we wrestled with. The bipolar patient question is pretty straightforward in the sense that we often look at anti-depressant treatment as a quality indicator. That makes less sense for patients with bipolar disorder because antidepressants are relatively contraindicated. We use them a lot if they have a loose stabilizer but there if there is some reason not to use an antidepressant someone with bipolar disorder. We exclude them for that reason. The patient with schizophrenia or psychotic illness is a bit more debatable. It basically has been historically we have done that again because the treatment for depression in the context of psychotic illness, the guidelines and the evidence for treatment is less well established then it would be in patients with the other comorbidities that I talked about. 

*Moderator:*Thank you for that reply. We have another question on your portion. Are transportation concerns confounded the amount of energy needed to overcome a motivational aspects of depression, etcetera?

*Dr. Paul Pfeiffer:*Yes I would say that is true. It seems to be that there is other work actually using the same set of barriers list that shows that basically the more depressed patients are the more likely they are to report barriers. It seems to be that is likely due to the depression itself, that patients that are more depressed, have lower energy, lower motivation are more likely to perceive things as barriers then maybe someone who is not depressed in the same situation. I do think that is a confounder. You can go back and try to address that, we have tried to adjust for and the model did not show for symptom severity and it seems the effects of the barriers is still there above and beyond severity in some of the models we have run. I think it is truly our cofounders but I do not think that is all that it is. 

*Moderator:*Thank you for that reply. While we are waiting for more questions to come in I am going to go ahead and put up the feedback survey for our attendees. Please do take just a  moment to fill that out it is your replies and requests for session that help guide where we go with the presentations. With that while we are still waiting, I will ask if either of you have any concluding comments and Paul we can start with you if you like. 

*Dr. Paul Pfeiffer:*Yes I would just summarize that it is a challenging problem in terms of looking at post hospital care. I mean I think initially when I proposed my research initially was actually to look at the immediate follow up issue and that seems to have largely resolved in terms of we do really well on that. Then it is sort of taking it to the next level in terms of what do we do with that to be more effective. What can we do longer term to be more effective. What is our most important outcome is it depression symptoms; is it readmission; is it suicide risk. Looking at all of those issues and looking at the effects of peers and increased monitoring on those outcomes. It is an active area and I was happy to be able to present some preliminary findings and what we found so far and I am happy to hear any feedback or suggestions from other folks. Thank you. 

*Moderator:*Thank you very much and I notice that you and Ranak did provide your contact information so if our attendees download the PDF handouts they do have access to that and we appreciate you making ourselves available after the fact. Dr. Trivedi do you have any concluding comments you would like to make. 

*Dr. Ranak Trivedi:*Just like Paul said it is nice to speak. This is what the data we presented are ongoing work. We are also evaluating some of these same questions in other clinical populations so patients with substance use disorder, serious mental illness which we are defining with schizophrenia and bipolar and anxiety. Then we are also very interested in the combination. If people are interested in doing this kind of work, please get in touch with me and we can talk about how we can proceed forward. There is obviously as you can see a ton of data and it would be great to start looking at some of these questions. I think Paul’s and my talk can talk about different aspects of providing care among mentally ill Veterans. I think that is an important thing to keep in mind as you do your own work. Whether the population is being seen in primary care more or seriously mental health care more or a combination. I think that is something as clinicians we can easily forget about and certainly as researchers we can get silo’d. So just something to think about as you go forward in your own work. 

*Moderator:*Great. I would like to thank our audience members for joining us today and I would like to invite you to join us for our next PACT presentation. These all take place on the third Wednesday of the month at noon so the next one will be on June eighteenth at 12:00 PM eastern. So please do join us for that. I would also like to thank Dr. Pfeiffer and Trivedi for presenting for us and lending your expertise to the field. We very much appreciate it. I just want to let you know that I will leave this feedback survey up for the next while so attendees please take the time to fill that out. There is no rush on that. Thank you once again everybody and have a wonderful afternoon. 

*Dr. Ranak Trivedi:*Thank you Molly. 

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