**Transcript of Cyberseminar**

**Timely Topics of Interest**

**Comparative Effectiveness of Collaborative Chronic Care Models for Mental Health Conditions: Systematic Review, Meta-Analysis & Implementation Strategies**

**Presenters: Mark S. Bauer, MD; Amy M. Kilbourne, PhD, MPH**

**November 29, 2012**

**Comparative Effectiveness of Collaborative Chronic Care Models for Mental Health Conditions: Systematic Review, Meta-Analysis & Implementation Strategies**

**November 29, 2012**

Molly:We are at the top of the hour now. I would like to introduce our speakers. Speaking first we have Dr. Mark Bauer. He is the Associate Director at the Center for Organization Leadership and Management Research known as COLMR at VA Boston Healthcare Center. He is also a Professor of Psychiatry at Harvard Medical School. Joining him today is Dr. Amy Kilbourne. She is the acting Director for the VA Quality Enhancement Research Initiative also known as QUERI and an Associate Professor of Psychiatry at the University of Michigan. I'd like to thank them and our audience for joining us today and with that I will turn it over to you now, Mark. 

Mark:Thanks very much, Molly. Slides up for everybody? 

Molly:Yes. We are ready to go. 

Mark:So we are delighted to be here today to talk about a long line of research that started really back in 1992 in terms of intervention development and now moving into the implementation phase. Part of the journey along this for Amy’s and my research has been to pause and ask some systematic questions about the state of the field. Overall, in terms of the effects of collaborative chronic care models on mental health conditions overall and that is what we will be presenting today. And then moving on to talk about some data and approaches to implementation strategies. 

First, a couple of disclosures. Amy and I both receive a small amount of royalties which we list at the top of the slide. At this rate we will be ready to be retired in about 340 years, I think. Nonetheless, we do want to acknowledge that we do write treatment manuals that are related to chronic care models. 

What we’ll do today is really in three parts. First, I will take about 20 minutes to review our meta-analysis of chronic care models for mental health conditions overall. This will be a summary of a much longer exposition that can be found in the Weltman article listed at the bottom of the slide which appeared at the end of the summer in the American Journal of Psychiatry. I’ll then turn it over to Amy to talk about implementation strategies using in particular the bipolar collaborative care model that we have worked on and developed over a number of years and then hoping to have at least 20 minutes for audience discussion and questions and answers. 

So to begin with, how do we define chronic care models? The goal as stated by Wagner and von Korff initially in the mid 90's and then updated by Wagner, Coleman and others more recently is to be able to achieve evidence-based, anticipatory, continuous, and collaborative care. Now each of those words is somewhat of a truism and almost trite, but they could be unpacked to have some real content if you think about them each in turn. Evidence-based care for this group probably needs no further explication. It really means using the best evidence we have available scientifically to the justification problems. Anticipatory care is really a different model of understanding healthcare than we typically have in the United States and many other countries. Typically, healthcare is rendered from crisis to crisis. Patient gets sick, patient comes in, clinician does something, patient gets better. They don't think about each other until the next time something bad goes down and then the cycle starts again. 

Anticipatory care is facilitated in these models. It really asks about secondary and tertiary prevention. How you keep from getting sick? How do you intervene early? In order to do that, care really has to be continuous. It is not a matter of leaping from appointment to appointment but setting up systems to make use of the in between times. 

Collaborative here really means collaborative in two directions. One is collaborating among caregivers, particularly generalists and specialists. The other is collaborating with that undertapped resource in treatment which is collaborating with the patients themselves. The model has been operationalized fairly specifically as having several of the following six elements: practice redesign to support these goals, patient self-management support to optimize patient interactions and self management of their conditions, expert systems either through onsite consultation with experts or guidelines, information systems for managing flow of data, linkage to community resources, and leadership and organizational commitment. 

These last two bullets are gray rather than black because they were added somewhat later in the evolution of the chronic care model. The majority of the studies, particularly the early ones, use some of the top four items and a small number have used five and six. To drill down a little bit into what these elements are like, here are examples of the five more clinically relevant elements. Practice redesign typically entails changes in scheduling, such as advanced clinic access, perhaps, or shifting appointments from onsite to telephone. This often or almost always involves work role redesign of some sort, sometimes changing what people do, sometimes bringing other people into the care team as clinician extenders. Then a different approach often to follow-up because particularly in systems like the VA, follow-ups get sort of rote responses. Sometimes a follow-up appointment can be or follow-up interaction, even if it is not an appointment, can be critical for implementing anticipatory care. 

Under patient education and patient side support there is self-management skills, behavioral change strategies, collaborative approaches, interaction with patients, and increasingly shared decision making where that is appropriate clinically. Around expert systems we talk about sort of the lightest touch systematic provider education, but also decision support, guidelines and specialty consultation or easy access to specialists particularly on a timely basis. 

Information management can be one of two large families of types of strategies. One is population based strategy such as registry. So you can keep track and track all of the people you are responsible for with condition X. And the other is an individual patient/clinician interactions a series of feedback resources that either give you clinical reminders when things are due, track outcome, allow measurement-based care, give you feedback on how you are doing and also facilitate integrated care plans. 

Then among community linkages there is linkage to additional resources because we are increasingly recognizing that a single healthcare system cannot serve all patient needs to improve quality of life and of substantial interest, especially recently, to the VA is peer-based support, which Kate Lorig and others have pioneered in medical disorders and VA's really taken the lead in terms of mental health interventions. In fact, in August, President Obama signed an executive order that rolls out several hundred mental health peer support specialists to the VA so we are going to see this grow substantially. In this case the community linkage is actually within the VA. The goals of these are really again, anticipatory, population-based, partnered care that prevents and/or minimizes problems before they happen. 

These are the main elements and a little bit of a drill down. CCMs, or collaborative chronic care models, have been extensively tested in medical situations, particularly in primary care, and there’s substantial evidence that the intervention framework is effective in diabetes, asthma, arthritis, CHF, frail/elderly and also depression treated in primary care. This is kind of where we entered our interest in looking at the issues of applying CCMs to mental health conditions because we were aware starting a couple of years ago that there was really a growing evidence base across a number of mental health conditions treated both in primary care and the mental health specialty sector. And also there was an increasing amount of depression work going on outside of the primary care setting in medical specialty clinics, for instance. 

So the question then and the goal of our systematic review and meta-analysis was really how broad and consistent are these effects on mental health outcomes? That is to say colloquially are mental health conditions like diabetes, like asthma, like CHF in this regard or are they different? So can we expect the same things out of CCMs for mental health conditions broadly defined? 

There are a number of challenges to undertaking this kind of a review and it really took several years to get the dataset together and analyzed. One is the definitions of the CCMs and we have a head start because there are some operational elements as we described above. We are also talking about trying to draw conclusions across multiple populations, multiple outcome domains, multiple settings and most trials are complex and expensive and they generate multiple articles rather than a single article with a single outcome variable. Often we’re faced with an embarrassment of riches of outcome domains measured over multiple time points over multiple articles in multiple varieties from the same trial. And most of these are, excuse me, fairly long-term trials addressing chronic outcomes when you get into the broader mental health sector as opposed to depression in primary care alone. And this leads very often to complex adjusted or modeled analyses. These are some of the challenges we faced in doing the meta-analysis. 

For the CCM definition we specified a trial as using a CCM if they had at least three of the six Wagner/von Korff criteria, whether or not that lineage was specifically cited. We did see some evidence of some trials that cited the lineage but didn't actually meet criteria for CCM. And a large number, I guess you might not be surprised to hear that had never heard of or never mentioned Wagner/von Korff but were actually doing CCM interventions. We excluded mobile treatment teams because this is really an intervention that, although they nominally fit CCM criteria, typically, they are not based in the outpatient clinics alone and it gets into a separate set of populations and interventions. We were able to reliably identify whether a trial used the CCM or not and even could with high reliability identify and agree on the number of the six elements that were included in the trial. Just to remind you, these are the elements we are looking at for at least three of six of these practice redesigns: self management support, expert systems, information systems, community linkages, and leadership and organizational commitment. 

Then with that in mind as our fishing hook, as it were, on the intervention side, what outcome domains did we look for? We gathered together studies based on the outcome analyses, not the population, so if a study measured mental health symptoms such as depression, mania, anxiety, etc., we included that in our outcome or in our outcome pool, our study pool. Or if they measured mental quality of life so starting by targeting trials that looked at mental health outcomes. When we identified a trial that met one of these two criteria by looking at these outcomes with the CCM, we also extracted overall quality of life, social role function, physical quality of life, and costs. 

As I mentioned earlier, these trials are typically complex to do and complex in their reporting. So we had a – we developed a hierarchic overview schema to identify going into these articles or families of articles from an individual trial how we would pick out what we would meta-analyze or count in our systematic review. We identified only one analysis for outcome domains such as depression or mania or anxiety and often multiple measures were taken. We identified outcomes for the whole sample in preference to any subsamples. We took only the most global outcome in a domain for instance a number of studies reported on not only the effects on depression but the effects on sleep. So we looked only at the most global outcome. We took the longest follow-up interval and I will show you an example of that in a few slides. It is in fact on the analysis. We used continuous variables in favor of categorical variables. For instance, if you had a depression rating scale score reported and then also a response/non-response, remission/non-remission variable derived from that, we used the raw score. 

When unadjusted analyses were provided we used those data in favor over adjusted analyses and we included all analyses whether or not they were primary outcome variables. So we know that we included a lot of under-powered analyses. 

This is kind of a typical outcome panel that illustrates how some of these studies look. This is from my friend Craig Simon who published a telephone care management trial in depression. In this case they looked at three different conditions, usual care and two levels of CCM. You can see that longitudinally these data are quite rich and longitudinal analyses are typically what’s reported primarily here, but you can't consolidate those sorts of numbers into an effect size with those that you can meta-analyze. So we by convention a priori took the final data points and [inaudible] from studies that report like this. As you can see there is not always the same separation by the end of the study as there would be implied or seen through the entire course. And so we limited ourselves to looking at the highest bar, the longest point outcome. So it would be this last data point that provides typically from a table somewhere else in the article, the effect sizes that we worked with in meta-analysis. 

So what did we find? This is a summary of what is called a prisma diagram which is the systematic review analog of the consort diagram that is used in clinical trials. It asks questions and you sort of “decision tree” out how many articles you reviewed, how many made criteria for inclusion and how many were excluded at different steps. We reviewed over 2,100 articles, did full-text reviews on 272 and [inaudible] with the systematic review of the broader set of analyses which I won't talk about today but are in the article, we identified 57 randomized controlled trials that produced data across 78 articles, 161 unique analyses. 

The meta-analysis totals were a little over half of the RCTs and this, I thought, was interesting and is worth noting that we’re very  impressed with  meta-analytic data but we have to also recognize that in most situations studies that make it into meta-analysis usually represent a fraction of the relevant studies. So typically, I wouldn't say typically, but optimally, meta-analysis would be accompanied by a systematic review that allows you to cross reference studies that did or didn’t make it into the quantitative analysis. 

Down below the next four lines are four major groupings that we had in terms of the populations that were studied. Depression still provides the majority of analyses of RCTs, bipolar disorder in 4 trials, anxiety disorders in three, and this interesting growing heterogeneous group looking at other conditions where there are sort of a “one off” for this or for that. Also a substantial number of CCMs that were geared toward multiple mental health conditions at the same time, which I will talk about in terms of future directions. 

This is a typical meta-analysis report slide for those of you that are not familiar with these we will talk just briefly about how to read these. It is very much a picture and you will get the impressions going through the subsequent slides of the results that get consolidated into one bottom line which is essentially the blue diamond which you see at the lower end at the bottom of the screen. To start at the top, each study that is included in a meta-analysis has its own line. The, I think you can see my pointer. The dot is the effect size translated from the difference in the means and standard deviations. The 95% confidence intervals are the horizontal bars. The size of this black, this gray, square reflects the weight of the study, how much it contributed to the meta-analysis. So this symbol is translated into numbers across the right. 

Lines and dots that fall to the left indicate that the comparison condition is better and to the right the collaborative care model is better. We have standardized all of the slides that will follow to the same direction. Each of these lines is a study, as I mentioned. Although our outcome here is depression, not all of these studies were on major depressive disorder. They may have been anxiety disorders, they may have been bipolar disorder, they may have been multiple or other conditions. But they all measured some depression measures and outcome. 

They summary accumulation of all the individual lines is expressed in this blue triangle here with the vertical corners delineating essentially an effect size that in this case is better than zero. The width of the diamond itself is essentially the confidence interval. So if the left apex of the diamond it crosses zero, the confidence interval crosses zero and if it doesn't then it doesn't. So the summary for this slide for depression would be across this number of studies. CCM has significant effects compared to control across a heterogeneous diagnostic group of studies that nevertheless measured depression as one of their outcome variables. It may not have been the primary, it may have been secondary. 

The next half dozen or so slides will be very similar in format to this, reporting the meta-analysis results. Mental quality of life: a smaller number of studies, but also significant in favor of CCMs. Physical quality of life, the same. 

Overall quality of life, two studies only. Not significant because that left apex of the diamond, left corner of the diamond crosses zero and you can see the non-significant rendering of the confidence interval. Also, two studies in global mental health are not significant. 

Social role function which is not commonly tracked, but also significant in aggregate. All of the clinical outcomes lined up. You can see the cascade of blue diamonds pretty much to the right with the exception of these two “two-fers” that we have. 

In terms of economic outcomes, the news is actually also good. In this case, we’re glad to see the diamond cross the zero mark because it means that on the whole with not actually, some [inaudible] but not a lot of heterogeneity, CCMs don't cost any different than control conditions. So we seem to be seeing fairly robust clinical effects across multiple conditions, multiple settings, multiple outcome domains at little to no increased cost. 

Major conclusions: significant clinical effects for all of the domains except for those for which we only had two studies and those were invariably tertiary or quaternary analyses. This is looking at a group of studies across diagnostic groups, across care settings, and the economics suggest that although we may not save money and reduce the deficit there is no added cost over the long-term in terms of how costs are counted for in randomized controlled trials. Of course there’s a limitation compared to the real world. 

The systematic review, which is in the article, but I won't present today for reasons of time, [inaudible] the broader sample studies. There are some limitations: the majority of studies are still on depression. Most, but not all anymore, come from primary care depression. There’s some from cancer clinics and a variety of other specialty clinics. CCMs are no longer needed to be considered just a depression in primary care intervention. 

The meta-analysis has a conservative bias toward negative results the way we implemented it. We used primary, secondary, tertiary analyses so we know that we included under-powered analyses, particularly some of the non-symptom related measures. We excluded adjusted outcomes and used only those studies that had unadjusted outcomes and still saw fairly robust effects and so we’re fairly confident that CCMs are quite reasonable fundamental care across mental health settings and populations. 

So that is the state of the art. The reason to look at the state of the art is to figure out what the next steps are. We identified three areas for next steps: one is enhancing CCMs in the traditional facility- based model. The second is moving beyond clinical [inaudible] with the model. And the third is identifying implementation strategies that will help these interventions get adopted and sustained in clinical practice. In terms of enhancing clinic-based CCMs there is clearly more work that can be done to enhance CCM effects. For instance, I didn’t talk about this explicitly, but it is hard to move depression and bipolar disorder although mania works quite well with this group. So we are in the process in our bipolar work and enhancing the depression side intervention that comes along with patient self-management skills. 

Also identify and try to figure out what are the active ingredients so that you can get the most slimmed down version for implementation. Cross diagnosis considerations are quite important and interesting. You saw that growing number of trials, a substantial number of trials that used other or multiple conditions. 

Issues of critical mass within facilities and clinics is quite important. You may not have enough patients with body dysmorphic disorder to put together a body dysmorphic disorder CCM. But you may have one if you can work cross diagnosis with a variety of somatic disorders, for instance. The other consideration is really thinking about these cross diagnosis considerations as being across physical and mental health both, particularly around cardiovascular risk. Amy can talk a little bit more about that. 

Moving beyond clinic walls is another way to address the issue of needing a critical mass of patients and expertise in the same place. One obvious avenue is through telehealth delivery. In 2011, VA Office of Telehealth Services in conjunction with Office of Mental Health Services developed and has rolled out the VA National Bipolar Telehealth Program which is now active in four VISNs across the country and if people are interested in that, please do give me a call, drop me an email and we can talk about interest in expanding to your medical centers. 

There is also additional work outside the VA at the super clinic level. There are state-level initiatives such as the Diamond Initiative in Minnesota for depression, which is a combination of collaborations with the state, the insurance companies and the healthcare facilities. Then there is the opportunity to work with commercial insurers who are all over the place doing what they call disease management which is really kind of partial CCM. There are very, very few that are doing full CCM type work outside of the walls of staff-model HMOs. 

The third area is implementation strategies and the agenda includes both identifying optimal implementation strategies which Amy will talk about. And then also studying interactions with contexts and then the quickly moving field of medical homes in the VA. This is something we want to think about in terms of how mental health needs can be taken care of in a coordinated way in the interaction of the context of medical homes. 

What we will do now and with one more slide I will turn this over to Amy to talk in particular about the bipolar disorder CCM that we worked on for a long period of time and really now is both spreading in terms of its purview and in terms of implementation strategies. I won't go into any of the details around the model itself but it is highly evidence-based at this point endorsed by two national guidelines, the Canadian Network for Mood and Anxiety Disorder Treatments six and now it is considered a fundamental of care in the VA/DoD guidelines that were released in 2010. SAMSHA is also in the process of reviewing and moving it through the process for listing on their national registry of evidence-based programs and practices. 

So that is where we stand. I will pause now and turn it over to Amy. 

Amy:Great. Thanks, Mark.

Molly:You should see a pop-up. Go ahead and click on that. 

Amy:Wonderful. I will be talking about an implementation study that we recently have completed on implementing a bipolar disorder version of the collaborative care model. This is a study mainly conducted outside the VA, but it really has a lot of relevance to some of the ongoing work in QUERI and other places in terms of conducting hybrid implementation designs in the VA and elsewhere. So we wanted to do the study in part because we felt that the next generation of the collaborative care models was to take them off the shelf and from the research setting to more community-based practices. In particular, community mental health as well as primary care practices. So the recovery-oriented collaborative care study was born to really close this research to practice gap where we found that after a research study of the collaborative care model had ended a lot of these practices went back to doing their usual type of care. We found that CCMs were really not fully disseminated in the real world. There were some organizational barriers in terms of their adoption. And not just sort of financial issues, but in terms of organization in terms of how you actually reorganize care to support care management and self management approaches. 

There wasn't really a lot of specificity or training for providers on how you actually implement a collaborative care model in their practice and what the specific components were. In addition to that there really needed to be a strategy or business model to align organizational and financial incentives. Even in outside VA settings you often are dealing with closed healthcare systems like Kaisers or Group Health,****for example. But you also have network model HMOs that were wanting to adopt collaborative care models and in a sense not only faced financial barriers in terms of reimbursement, but organizational reimbursement in terms of lack of staffing to do some of these programs. 

So we wanted to use implementation theory to adapt – to not only adapt the collaborative care models for bipolar disorder to get it further implemented but really to specify an implementation intervention to do that to promote the uptake of the collaborative care model and return on investment. 

The goals in the next slide of the recovery-oriented collaborative care study essentially works to apply the enhanced version of the CDC’s Replicating Effective Programs or Rapid Implementation Framework to implement a bipolar disorder version of the collaborative care model in mental health, community mental health and primary care practices. And so we wanted to do this by doing a comparative effectiveness study really of two types of implementation strategies. The first was an enhanced version of REP in which we had expanded the original REP implementation framework to address some more complicated issues around the adoption and adaptation of the collaborative care model in complex organizations such as community mental health programs. And then compare that to the standard process that the CDC had developed in REP. We did a hybrid type II implementation study design because we still wanted to track patient outcomes because we were essentially taking the collaborative care model to more community based practices that were not closed healthcare systems. And then we also wanted to measure provider acceptance as well as return on investment. 

This next slide describes the REP conceptual framework and what the specific components of the implementation strategy that we used. Now REP was developed by the CDC back in the 90's to rapidly translate behavioral interventions developed for HIV prevention programs in community based settings. It derives its origins in social learning theory and Rogers Diffusion Model. In terms of the enhanced REP part that really includes some additional components based on the PARIHS framework really to develop and promote provider self efficacy using the concept of facilitation, much of which has been further operationalized in the mental health QUERI under work by JoAnn Kirchner and the office of Mental Health Operations. We are doing a more external facilitation model for this program. 

So the three main phases of REP really start with the first phase, the pre-implementation where it is really about a needs assessment at the provider and organization level where what you want to do is essentially go into those practices or talk to the providers and essentially find out where are they struggling in terms of their day to day practice. Is it that it’s hard for them to manage the physical health problems of their community mental health clients? Is it coming down to the lack of training in terms of or have the lack of tools for management based care to promote the uptake of using a PHQ9 in routine practice? A lot of the elements of the collaborative care model really have advantages in terms of implementing for other types of programs too. In a sense you try to promote your own program by seeing where it can also be a win/win for other initiatives or other things that the sites and the providers have to do as well. At the time when we were implementing the bipolar collaborative care model in these community based practices many of them were really also under pressure from state Medicaid programs to see more individuals in primary care settings and they needed an infrastructure to provide integrated mental health within their community based primary care settings that they were affiliated with. It came at a fortunate time in which we were able to provide some specifics on how to do that. 

In addition to the pre-implementation phase it is about identifying those appropriate evidence based practices. In this case we used the collaborative care model. I think one of the most crucial aspects of the pre implementation phase is to really re-write the manual and to write the manual for the collaborative care model so it is really ultimately user friendly to the frontline providers. Not only give them a copy of your paper, which you know, is one thing. It is great that you have a published article on your intervention. But actually a manual that describes step by step what are the things that need to happen to get collaborative care models implemented. We included in that an implementation manual that really talked about not only the nuts and bolts of okay these are the materials you need to do self management programs. This is how you establish a registry of patients. These are the key outcomes you want to track and how often you want to track them. 

In addition to that also here are some talking points or selling points you can promote this program to your clinic directors, leadership, to the state Medicaid office, to VA central office, or whatever. So it is really the whole package in terms of how you help that frontline provider implement this program on a day to day basis. In addition to that, getting feedback from those frontline providers about how they could adapt the collaborative care model and in this case the bipolar disorder collaborative care model in ways that they could perhaps adapt it without compromising some of the key core elements of that model. For example, if they could not – if they didn't have enough space to conduct group self management sessions, finding the opportunity for them to do self management sessions on an individual basis or by telephone. Or if they didn't have an electronic medical record, which is in some cases something we take for granted in the VA, but in many community based practices they don't have that. How do you use paper charts to still be able to track or do measurement based care over time? 

In the second phase is really the implementation part where once you have your intervention package you really get – what you want to do is really three important things. The first thing is to have a cross-functional team of healthcare leaders and frontline providers to continue to get advice from in terms of the overall implementation of the program. The second piece is to provide the training to the actual frontline providers in the implementation of their collaborative care model. And then also provide structured technical assistance. What we mean by this is actually actively reaching out to those providers as they are rolling out the intervention, as they are actually implementing it, and basically, probing for any barriers or facilitators to its implementation. 

In addition to that for what we did for enhanced REP is we also provided for up to a year what we called external facilitation, which again, was the process by which you would not only provide the technical assistance on how to implement the collaborative care model, but to also provide some guidance on how it can be sustained over time. 

And then in the final phase is really the dissemination phase where this is after you have provided technical assistance or facilitation you again go back to your cross functional team and to your front line providers and talk about okay, how do you actually sustain this in routine practice. What do you need to do to change the workings in your practice to make the chronic care model sustainable and perhaps come up with a business plan or business case, which was actually a really important issue for a lot of the primary care providers and mental health providers we worked with who are again, at the time, grappling with their state Medicaid programs to come up with a model, a bundle payment model, for reimbursement care management or even existing fee for service models. 

So this is an outline in this slide what we want to provide here is really just a general outline, a table that describes the enhanced and standard REP components that we compared the effectiveness of in this particular study. So, again, really looking at the enhanced REP really being about the customized package based on the cross-functional team or community working group input and most importantly the long-term facilitation where we not only provided technical assistance to the sites on the actual implementation of the collaborative care model, but we had active calls on a regular basis to the site frontline providers and leadership in terms of facilitating the implementation of the collaborative care model. 

Then facilitation for enhanced REP included five key components. One was a continued, sort of an initial and a continued needs assessment of the barriers to the implementation in the collaborative care model. In addition to that it involves relationship building across providers. So if the frontline provider who is basically in charge of implementing the collaborative care model whether that be a care manager or a social worker or frontline provider finding out what some of the barriers might be and being able to work with that provider to leverage opportunities in which that collaborative care model could be implemented in ways that could also benefit other providers. If other providers felt, for example, that they were getting a lot of patients and having to do a lot of screenings that might be something where the collaborative care model can maybe manage that more effectively. 

In addition to that we consistently provided feedback and benchmarked the progress of the implementation of the collaborative care model over time and then sent that back to the frontline providers as well as to the managers of that clinic. And then used that information to further adapt, if need be, the collaborative care model implementation with the site needs and then also provided us some data to show that the collaborative care model was effective for improving patient outcomes in those particular clinics and feeding that data back to the leaders of those clinics and organizations to really show the value of that program. 

Another key component of REP is really the concept of balancing fidelity and flexibility. One of the things, just to get back to the original pre-implementation components of REP and especially with enhanced REP was this idea of what you want to do in your intervention package is really distill your intervention into the core elements. Mark did a really great job in terms of distilling what the six core components of the collaborative care model were. So part of the having a package is to really specify exactly what the information systems should look like, what care management should look like, what the self management programs should look like because these are really the core theory or internal logic of the program that achieves the desired effects in terms of outcomes. 

In addition to that just allowing, in the manual, allowing some options for the frontline providers and stakeholders to what we call menu options to adapt components of the collaborative care model. This really enhances buy in because in a sense you are really getting information from these front line providers about what works and what doesn't in a way of feeding it back in a practical way so that they are able to still be able to implement the core elements of your program but in ways that are appropriate in terms of how it can be adapted over time. 

So what we also did as part of the R01 is we wanted to cost out or at least determine how much time and effort the enhanced REP, additional enhanced REP component had basically how much more time it really took compared to standard REP in terms of developing a package and a training and technical assistance program. This is sort of a very brief summary, a thumbnail sketch of the five main components of the facilitation and enhanced REP that really point to I think importance of how much time this can really take. Part of that is really demonstrating the value or the added value of this time. So we had a master’s level social worker with extensive experience who pretty much did most of the external facilitation in one of our studies. And she had done I think most of her time really was spent in relationship building with not only the front line providers who were implementing the collaborative care model, but with the healthcare leaders and also the other providers at the clinic. In addition to that she also spent a good amount of time in terms of doing needs assessments, especially of organizational barriers and facilitators and then also helping those front line providers with marketing and publicity of the program. 

So we costed that out at basically the added value or the added cost of external facilitation really turned out to be probably the amount shown at the bottom there which is a little bit less than $6,000 a year, but that was just for a single site. This isn't each site level. It still gives us you know essentially something to work with if we were to develop an implementation intervention based on enhanced REP in terms of what this would look like in the real world. We are still working on the business case for that as well. 

In terms of future directions I think not only the business case for enhanced REP and for the collaborative care model. We are also looking at analyzing our final data on the recovery coordinated collaborative care study outcomes and a cost effectiveness analysis. Using that information in the lessons learned from the enhanced REP model we are also conducting a number of initiatives in the VA including the further manualization of the enhanced REP implementation intervention program. One of the most exciting things we are doing now is applying that enhanced REP program to an initiative called the SMI Re-Engage Program which is actually sponsored by the Office of Mental Health Services in conjunction with SMITREC and also Mental Health QUERI where we are essentially using enhanced REP to roll out care management and management based care to 159 sites to help those frontline providers re-engage Veterans who have been lost to care and lost to follow-up and a number of us were trained in the facilitation model that JoAnn Kirchner had operationalized in Mental Health QUERI. And we’re out and providing external facilitation to a number of those sites right now and in doing so we are conducting what we call an adaptive implementation study where we are comparing the effectiveness of enhanced versus standard REP to the sites that are less responsive to the implementation of the program. 

This is actually a study that is part of the larger homelessness health service research initiative because a major component of that study is to prevent homelessness by re-engaging these veterans into care. And finally, I think we are still working with the Office of Mental Health Operations to further develop and promote facilitation training in particular, for primary care mental health integration programs and then to really reach out and to think about conducting these types of facilitation programs for other types of initiatives in the VA as well. 

I think that is it. I guess at this point we will turn it over to any questions or comments at this stage. 

Molly:Great. Thank you both. For those attendees that joined us after the top of the hour I just want to remind you that to submit a question please do so in writing. Just simply type it into the question section of the GoTo Webinar dashboard that is located on the right-hand side of your screen. 

The first question we have: Chronic care models are complex interventions as we think about moving forward to implementation is there any evidence that certain components are essential or superfluous? 

Mark: We are actually in the process of doing those analyses now. Looking at the body of studies that went into the initial meta-analysis and looking at depression and quality of life outcomes. We are not finding any quantitative or qualitative evidence that jumps out and says this is really a key mechanism regardless of the presence or absence of others. And, in fact, what we know is that these elements are pretty inter-related particularly work role redesign being necessary to accommodate and accomplish some of the others. 

What we can say though is the vast majority of studies that we have looked at had three or four of the original components and community linkages and healthcare organization support were much less in evidence. However, for all of the reasons that Amy has described we do think that healthcare organizational support is critically important. 

It looks like the package that works of a piece. There is some work yet to be done. Some questions about the relative importance of things that could be separated such as patient side management interventions versus system or provider side interventions. And whether those are both necessary or the degree to which they are or whether they’re synergistic. The story remains to be told but if you are going to go out and do one of these things tomorrow, I think what we would say would be to utilize the four original components with healthcare organizational support as much as you can. 

Amy:This is Amy. That is a great response. I would also add too just from our boots on the ground perspective and Office of Mental Health Services and especially with the primary care mental health integration program it is really coming down to that team based care which is not only having a care manager performing functions such as measurement based care, identifying and anticipating which patients might need more care more immediately versus later on and then relaying that information to providers but really ensuring that care manager is well integrated and communicating with the other providers, which is essentially the spirit of the patient-aligned care teams as well. 

Molly:Great. Thank you both for those responses. That is the only pending question we had at this time. So if either of you would like to make some concluding comments we will go ahead and start with you, Mark. 

Mark:Well, I think I am about talked out. I just want to say thank you for people's attention; happy to serve as a resource for further questions about these. Feel free to contact me by email or by phone. If there are sites there that are interested in exploring the feasibility of bipolar telehealth I would be more than happy to talk to you about that. We do have a pretty solid and growing program that is based essentially on the model that Amy and I have described. 

Molly:Great. Dr. Kilbourne, would you like to give any concluding comments?

Amy: Sure. I thank everyone again for their participation as well. I guess I would add too if you have any particular questions or thoughts around the implementation models that we have been talking about in terms of REP or facilitation or in general in terms of maybe designing the implementation studies to promote the uptake of evidence based practices, please reach out to me as well. 

Molly:Excellent. Thank you both again for lending your expertise. And thank you to our audience members for joining us. It looks like we do have one last question that came in. Can you elaborate on the physical WOL? 

Mark:Physical quality of life. I am not sure what specifically to elaborate on. Amy, you have done a good bit of work in this area as well. The measurement was typically almost uniformly using the SF36 or SF12 physical component scale which measures things like can you walk up stairs easily, can you carry bags of groceries easily and such. Virtually all the studies that we used that we included in our meta-analysis use that scale. 

I think it is interesting in terms of the evolution of the development of these models that, for instance, with the bipolar literature which I know the best, the initial studies resulted in a co-op study and an R01, didn't show much impact on quality of life physically because we didn't focus on it. Some of Amy's work which you may want to describe a little more in detail, Amy, said well let's focus on quality of life physically and see if we can move it and we have. Amy, do you want to pick up and talk a little bit about the studies as you have done since? 

Amy:Sure, absolutely. So we had one study using the bipolar collaborative care model where we focused on a population with cardiovascular disease risk and we showed that improved physical health related quality of life for that population. In part because I think that population had a lot of complex co-morbidities to begin with. We have since expanded that literature and just had a paper accepted where we adapted the bipolar collaborative care model to also address health and wellness goals around cardiovascular/cardiometabolic risk factors. Because so much of the self management support given to mood disorders really overlaps a lot with what is being taught in terms of motivational interviewing and health behavior change for healthy lifestyles associated with weight loss as well as with other cardiometabolic risk factors. In that paper we have actually been able to show physical health care improvements in addition to the SF12 scores also reduced blood pressure for example and reduced heart disease risk over time. 

I think this type of literature is also being published as well. Wayne Katon has done a couple of studies showing the impact of the collaborative care models on physical health as well as mental health outcomes and especially for folks with mood disorders and co-occurring conditions. 

Molly:Great. We have another question that has come in. This one is for Mark. My sense is that  there is much more evidence for collaborative care in mental health compared to the physical conditions. Are you aware of a systematic review or meta-analysis for CCM for physical conditions? 

Mark: There have been a number of them. If you take a look at our article in the American Journal that we listed in the third slide or so, there is a complete bibliography that includes some...Bodenheimer has done a two-part review, Coleman’s in 2009 that I cited in the slides is another one. Tsai also did another one on physical conditions. They’ve been fairly well worked over. This is really the first meta-analysis across mental health conditions. There has also been a couple of nice meta-analyses on depression in primary care, one by Gil Botti and an earlier one by [inaudible]. Take a look at the reference list in the article and you will find a pretty good guide to the literature. 

Molly:Great. Thank you for that reply. It doesn't look like we have any other questions pending. So at this time I would like to once again thank everybody for joining us. As you exit today's session please wait just a moment and a feedback survey will populate on your screen. Please do provide us your feedback it helps us improve the program and get presentations on the topics you are interested in. 

So with that I will say this does conclude today's HSR&D cyber seminar. Everybody enjoy the rest of your day. 

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