Introduction to QUERI Implementation Research for VHA Operations Staff: What It is and Why It is HelpfulRichard R. Owen, MDDirector, Mental Health QUERIJeffrey L. Smith, PhD(c)Implementation Research Coordinator, Mental Health QUERIApril 28, 2009

Quality Enhancement Research Initiative

Overview
        - Clinical Research Translation Roadblocks and the Quality Chasm
        - Introduction to QUERI and Implementation Science
        - Examples of QUERI Projects
        - Barriers to and Opportunities for Greater Involvement of Policymakers and Managers
        - Discussion

The problem
        - Clinical research translational roadblocks

	Significant barriers impede timely progression of innovations from basic science to clinical application to routine use and population benefit
        - The healthcare quality chasm

	Pervasive gaps exist in the quality, safety, equity, efficiency, timeliness and patient-centeredness of healthcare 

Translational roadblocks:IoM Clinical Research Roundtable

Sung NS, Crowley WF et al.,  Central challenges facing the national clinical research enterprise, JAMA 2003.

Implementation gaps and the quality chasm

	Most healthcare quality gaps result from insufficient implementation of evidence-based practices

	Strategies and programs to accelerate implementation and to improve quality are similar and generally involve organizational and professional behavior change

Possible Solutions
        - “Push” research into practice – researchers get involved in implementation of research findings
        - “Pull” research into practice – policymakers, managers get involved in prioritization and planning of research

VHA Example

ORD

PCS

OQP

EES

...

HSR&D

OMHS

Prog Eval Centers

10N

Gap

OMHS Policy Initiative:  MIRECCs 

ORD

PCS

OQP

EES

...

HSR&D

OMHS

MIRECCs, COEs

Prog Eval Centers

10N

ORD/HSR&D Policy Initiative:  QUERI 

ORD

PCS

OQP

EES

...

HSR&D

QUERI

MH QUERI

OMHS

MIRECCs, COEs

Prog Eval Centers

10N

QUERI R&M

MHQ EC

US Department of Veterans Affairs Quality Enhancement Research Initiative (QUERI)

	QUERI MissionTo enhance the quality, outcomes and efficiency of VA health care by systematically implementing evidence-based clinical guidelines and innovations into routine clinical practice

Just a reminder--our mission remains the same.  

How to operationalize this mission is the focus of our meeting this year.

We know that it’s working but need to begin to fill in the details of what we do, what works and what does not.

Your active input during this meeting will help put some of the pieces of this amazing puzzle into place.

Nine QUERI coordinating centers
        - Chronic Heart Failure
        - Diabetes
        - HIV/AIDS
        - Ischemic Heart Disease
        - Mental Health
        - Polytrauma/Blast-Related Injuries
        - Spinal Cord Injury
        - Stroke
        - Substance Use Disorders

“Implementation research in health”

	Implementation research is the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice, and, hence, to improve the quality and effectiveness of health services.  It includes the study of influences on healthcare professional and organizational behavior. 

	-- Eccles and Mittman, Implementation Science 2006

Implementation research policy/practice goals
        - Develop effective strategies for improving health-related processes and outcomes
        - Improve health-related processes and outcomes within participating study sites
        - Facilitate widespread adoption (or ‘spread’) of these strategies

Implementation research science goals
        - Generate new insights and generalizable knowledge regarding implementation processes, barriers, facilitators, strategies
        - Develop, test and refine implementation theories, hypotheses, models and principles
        - Develop improved approaches and methods for studying implementation

The Classic Six-Step QUERI Process

Identify high risk/high burden conditions

Identify best practices

Define existing practice patterns in VA and variations from best practices

Identify (or develop) and implement programs to promote best practices 

Document outcome and system improvements

Document improvements in health related quality of life 

Expanded QUERI Six-Step Process

Step 1: Select Diseases/Conditions/Patient Populations

1A.	identify and prioritize high risk/high burden clinical conditions

1B.	identify high priority outcomes and areas of practice within a selected condition 

Step 2: Identify Evidence-Based Guidelines, Practices 

2A.	identify evidence-based clinical practice guidelines and recommendations

2B.	identify evidence-based clinical practices, care models

Prioritize recommendations for implementation (based on gap, importance for outcomes, feasibility of improvement)

Expanded QUERI Six-Step Process

Step 3: Measure and Diagnose Quality/Performance Gaps 

3A. measure existing practice patterns and outcomes and identify variations from evidence-based practices and benchmark outcomes (quality, outcome and performance gaps)

3B. identify determinants of current practices 

3C. diagnose quality gaps

3D. identify barriers and facilitators to improvement 

Expanded QUERI Six-Step Process

Step 4: Implement Improvement Programs

4A.	identify implementation/quality improvement strategies, programs and program components or tools (e.g., via literature reviews, formative evaluation techniques)

4B.	develop implementation/quality improvement strategies, programs, program components or tools

4C. implement quality improvement strategies and programs

Step 5/6: Evaluate Improvement Programs 

5.	assess improvement program feasibility, implementation and impacts on patient, family and system outcomes

6.	assess improvement program impacts on health-related quality of life (HRQOL)

Implementing evidence-based depression treatment model in VA primary care(Example of Clinical-Research Partnerships at VISN- / National-Level)

Depression Care in VA

7% of patients have depression diagnosis; 44% receive all or most treatment in primary care

Patients treated exclusively in primary care have fewer visits than those seen in mental health specialty care

Less than half (45%) of patients started on antidepressants receive adequate dose for guideline-recommended duration 

I SHOULD AND AM PROUD TO SAY HERE THAT THE NEWS IS NOT ALL BAD, AS SEVERAL RECENT STUDIES HAVE FOUND THAT THE QUALITY OF CARE FOR DEPRESSION IN THE VA IS AS GOOD OR BETTER THAN THAT PROVIDED BY HEALTHCARE ORGANIZATIONS IN THE PRIVATE SECTOR.

HOWEVER, THE INFORMATION ON THIS SLIDE SUGGESTS THAT THERE IS STILL ROOM FOR IMPROVEMENT, AND WE BELIEVE THERE IS SUBSTANTIAL EVIDENCE TO SUGGEST THAT IMPLEMENTING COLLABORATIVE CARE FOR DEPRESSION WILL GO A LONG WAY TOWARD HELPING US REALIZE MEANINGFUL IMPROVEMENTS IN TREATMENT, CLINICAL OUTCOMES AND QUALITY-OF-LIFE FOR VETERANS WITH DEPRESSION

Collaborative Care for Depression

Integrated package of intervention tools / strategies, including...

 Clinician education and decision support

 Care management

 Active collaboration between primary care and mental health specialists

 Patient education and self-management support

Consistent with Chronic Care Model (Wagner)

BULLET 1:  WHAT IS COLLABORATIVE CARE FOR DEPRESSION??

BULLET 2:  THE FACT THAT COLLABORATIVE CARE IS CONSISTENT WITH THE CHRONIC CARE MODEL IS IMPORTANT BECAUSE MUCH OF WHAT WE LEARN IN IMPLEMENTING THIS MODEL TO IMPROVE DEPRESSION CARE MAY ALSO BE APPLICABLE TO IMPLEMENTING SIMILAR MODELS TO IMPROVE CARE FOR OTHER CHRONIC CONDITIONS THAT ARE PREVALENT AMONG VETERANS, SUCH AS DIABETES AND HYPERTENSION

Collaborative Care for Depression

Primary Care Clinician

Psychiatrist

Nurse Care Manager

Patient

THIS SLIDE ILLUSTRATES LINES OF COMMUNICATION AND INTERACTION AMONG THE KEY PLAYERS IN THE COLLABORATIVE CARE MODEL.

IN THE IMPLEMENTATION OF THIS CARE MODEL, PRIMARY CARE CLINICIANS AND PSYCHIATRISTS RECEIVE TRAINING ON EVIDENCE-BASED CARE FOR DEPRESSION AND ON HOW TO INTERACT EFFECTIVELY WITH NURSE CARE MANAGERS.  TOOLS TO ENHANCE CLINICAL DECISION-MAKING AT THE POINT OF CARE ARE ALSO INCLUDED.  

NURSE CARE MANAGERS RECEIVE TRAINING AND TOOLS TO SUPPORT THEIR EFFORTS TO IDENTIFY PATIENT TREATMENT PREFERENCES, MONITOR ADHERENCE TO PRESCRIBED TREATMENT, AND ASSESS PATIENT RESPONSE TO CARE ON AN ONGOING BASIS.  THIS INFORMATION  IS SYSTEMATICALLY FED BACK TO THE TREATING PRIMARY CARE CLINICIAN OR PSYCHIATRIST TO STIMULATE ADJUSTMENTS TO TREATMENT, AS NEEDED.  

MATERIALS FOR PATIENT EDUCATION ON DEPRESSION AND ITS TREATMENT ARE ALSO INCLUDED.

AS THIS GRAPHIC ILLUSTRATES, THE NURSE CARE MANAGER PLAYS A CENTRAL AND CRITICAL ROLE BY MAINTAINING REGULAR IN-PERSON AND TELEPHONE CONTACT WITH PATIENTS TO MONITOR THEIR RESPONSE TO CARE AND ENSURE THAT THEY DON’T FALL THROUGH THE CRACKS IN BUSY VA MEDICAL CENTERS.

Collaborative Care for Depression

Improves depression treatment, symptoms, functioning, work-related outcomes, quality-of-life, and is cost-effective

Achieving the Promise: Transforming Mental Health Care in VA –“Develop... a VA-adapted collaborative care model dissemination package as the basis for national rollout”

SO,WHAT DOES COLLABORATIVE CARE DO FOR PATIENTS??  WELL, STUDY AFTER STUDY HAS SHOWN THAT COLLABORATIVE CARE...[BULLET 1]  --  INCLUDING STUDIES OF PATIENTS RECEIVING CARE IN THE VA

BULLET 2 – THIS IS LIKELY DUE TO THE FACT THAT COLLABORATIVE CARE REQUIRES REORGANIZATION OF ESTABLISHED CARE PROCESSES IN PRIMARY CARE (WHICH HAVE HISTORICALLY BEEN ORGANIZED TO DEAL WITH ACUTE, RATHER THAN CHRONIC, ILLNESS.  THE MODEL ALSO REQUIRES INCREASED COLLABORATION BETWEEN PRIMARY CARE AND MENTAL HEALTH, AND NEW ROLES FOR NURSES OR OTHER ALLIED CLINICAL STAFF TO CARRY OUT THE CARE MANAGEMENT ACTIVITIES.   FOR THE MODEL TO BE IMPLEMENTED EFFECTIVELY, WE BELIEVE A CLOSE PARTNERSHIP BETWEEN CLINICAL LEADERSHIP AND RESEARCHERS IS IMPORTANT TO TAILOR IMPLEMENTATION TO LOCAL NEEDS AND RESOURCES, WHILE ENSURING THAT THE ADAPTED MODEL RETAINS THE KEY DESIGN FEATURES THAT HAVE BEEN SHOWN TO BE NECESSARY TO IMPROVE PATIENT CARE AND OUTCOMES.

BULLET 3 – IN RESPONSE TO THE REPORT FROM THE PRESIDENT’S NEW FREEDOM COMMISSION ON MENTAL HEALTH, VA MENTAL HEALTH LEADERS PREPARED A REPORT TITLED...[BULLET 3]...WHICH INCLUDED A RECOMMENDATION TO...[BULLET 3].  THE TIDES / ReTIDES PROJECTS, WHICH I WILL DISCUSS NEXT, REPRESENT MENTAL HEALTH QUERI’S EFFORTS TO PUT FEET TO THIS RECOMMENDATION.

Translating Initiatives for Depression into Effective Solutions (TIDES)

PI’s: Lisa Rubenstein, Ed Chaney

Implement collaborative care for depression in VAMCs from 3 VISNs (VISNs10, 16 & 23)

Use evidence-based quality improvement (EBQI) processes for tailored implementation

Findings

Patients kept 90% of follow-up appointments

Twice as many patients receiving collaborative care were treatment adherent

Depression symptoms significantly improved at 8-12 weeks

Improved work/social functioning at 6 months

TIDES WAS THE FIRST MENTAL HEALTH QUERI DEMONSTRATION PROJECT TO IMPLEMENT COLLABORATIVE CARE, IN PARTNERSHIP WITH LEADERS IN VISNS 10, 16 AND 23

EBQI PROCESS INVOLVES A COLLABORATION BETWEEN RESEARCHERS AND NETWORK LEADERS TO TAILOR IMPLEMENTATION TO NETWORK PRIORITIES AND RESOURCES, WHILE RETAINING THE CORE FEATURES OF THE MODEL IN THE FINAL IMPLEMENTATION DESIGN  

THESE FINDINGS ARE IMPORTANT NOT ONLY BECAUSE THEY REFLECT IMPROVED CARE AND CLINICAL BENEFITS FOR PATIENTS RECEIVING COLLABORATIVE CARE, BUT ALSO BECAUSE THEY SUGGEST THAT THE RESEARCH-CLINICAL PARTNERSHIP WAS SUCCESSFUL IN TAILORING IMPLEMENTATION TO LOCAL NEEDS WHILE RETAINING THE MODEL’S POTENCY

THIS SUCCESS ENCOURAGED NETWORK LEADERS AND RESEARCHERS TO WORK TOGETHER ON A FOLLOW-UP PROJECT TO SPREAD THE COLLABORATIVE CARE MODEL TO ADDITIONAL SITES

Regional TIDES Spread (ReTIDES)

PI’s: Rubenstein, Chaney

Sustainability in 1st generation TIDES sites (VISNs 10, 16, 23)

Spread collaborative care to new sites (VISN 22)

Evaluate impact of implementation on patient care, clinical outcomes, and costs

Build and leverage system support for further spread 

ReTIDES IS AN ONGOING 2ND -GENERATION DEMONSTRATION PROJECT FOCUSING ON SUSTAINING THE COLLABORATIVE CARE MODEL IN 1ST-GENERATION TIDES SITES AND SPREADING THE CARE MODEL TO NEW SITES IN VISNS 10, 16, 22 & 23

Implementing and Spreading Collaborative Care for Depression

Depression

Collaborative

Care Model

Black Hills

Twin Ports

Sioux Falls

Beaumont

Pensacola

Lufkin

Akron

Canton

Youngstown

Efficacy / effectiveness studies (VA and other)

Adaptation to VA

Implementation

VISN 23

VISN 16

VISN 10

TIDES

ReTIDES

Sustainability in

1st-generation sites(VISNs 10, 16, 23)

1st-generation sites

Clinical / Research Partnerships

Leadership Support■ Input on ‘TIDES National Dissemination Plan’■ OMHS Primary Care / Mental Health      Integration Initiative

Guidelines & Performance

Indicators

■ Updated depression guidelines      (release pending internal VA review) ■ ‘Guidance for Program Integrity’ developed,      identifying key features of TIDES and      related QI models (with performance targets) 

 Training & Education

■ TIDES Depression Care Manager Manual■ TIDES resources accessible to all VA     facilities via Sharepoint website■ EES-sponsored TIDES trainings

Informatics Tools

■ IT Expert Panel conference hosted by    ReTIDES team resulted in plans to integrate    TIDES software into VA ‘Mental Health    Assistant’ tool

Spread to 2nd-generation sites

(VISNs 10, 16, 22, 23)

THIS SLIDE HELPS ILLUSTRATE THE PROGRESSION OF COLLABORATIVE CARE IMPLEMENTATION TO DATE THROUGH THE QUERI 4-PHASE IMPLEMENTATION MODEL FROM THE SLIDE I SHOWED YOU EARLIER.  BEGINNING AT THE LEFT SIDE OF THE SLIDE, EFFICACY AND EFFECTIVENESS TRIALS LED INITIALLY BY RESEARCHERS AT GROUP HEALTH IN SEATTLE, AND LATER BY OTHERS, DEMONSTRATED THE CLINICAL AND COST EFFECTIVENESS OF COLLABORATIVE CARE.  

TIDES WAS A PHASE 2 PROJECT TO ADAPT COLLABORATIVE CARE FOR IMPLEMENTATION IN ROUTINE VA TREATMENT SETTINGS,  THE ReTIDES PROJECT SIGNALS PROGRESSION TO PHASE 3, TO SPREAD COLLABORATIVE CARE REGIONALLY TO NEW SITES AND PREPARE THE SYSTEM TO SUPPORT NATIONAL IMPLEMENTATION.  IN ‘BUILDING A BRIDGE’ TO NATIONAL ROLLOUT, MENTAL HEALTH QUERI HAS TARGETED SEVERAL KEY AREAS TO FOCUS ON - INCLUDING LEADERSHIP SUPPORT PLANNING, GUIDESLINES AND PERFORMANCE MEASURES, TRAINING, AND DEVELOPMENT OF INFORMATICS TOOLS TO SUPPORT COLLABORATIVE CARE.

Improving metabolic side effect monitoring for veterans taking antipsychotic medications(Example of Clinical-Research Partnershipat VISN- / Facility-Level)

Background
        - Psychotic disorders highly disabling and burdensome in VA
        - 1.3% prevalence of schizophrenia; over 90,000 vets treated annually
        - Vets w/ schizophrenia account for 12% of annual VA healthcare costs
        - Second-generation antipsychotics (SGAs) are a key component of treatment
        - Prescribed to over 80% of veterans with psychosis
        - SGAs can cause adverse metabolic side effects
        - Weight gain
        - Diabetes
        - Dyslipidemia
        - VA guidelines and ADA/APA consensus statement recommend monitoring and management of metabolic   side effects for patients started on new antipsychotic

A Study of Strategies to Improve Schizophrenia Treatment (ASSIST)

Objectives:  Develop and test intervention strategies/tools to improve metabolic side effect monitoring for patients taking APs

Increase baseline monitoring for weight gain, diabetes onset, dyslipidemia

ASSIST Tools / Strategies

Educational tools (for clinicians and patients)

Clinical support tools

Pocket-sized booklet with AP side effect monitoring recommendations

CPRS clinical reminder for side effect monitoring

Performance monitoring tools

Monthly site-level performance reports

Weekly provider-specific feedback on side effect monitoring

Facilitated Team QI and Opinion Leader strategies

External Facilitation in ASSIST 
        - Facilitator
        - Maintained regular contact w/ local QI team
        - Email communication
        - Participate in monthly ASSIST Team meetings
        - Monitored implementation of project tools/strategies; performance on AP side effect monitoring and dosing
        - Identified and problem-solved barriers to implementation
        - Assisted in adapting tools/strategies as needed or suggested by local QI team to meet project goals

External Facilitation ‘Products’ (Facility A)
        - Collaborative research-clinical partnership
        - Placement of recommendations for antipsychotic side effect monitoring on medication order screens
        - Enhanced monthly performance reports, tailored to clinician preferences and specifications
        - Development of weekly reporting system identifying patients   in need of metabolic side effect monitoring
        - Provider name, patient identifier, AP fill date, medication name,   info on monitoring parameters
        - Now fully automated

AP Side Effect Monitoring at Facility A

Weekly reports implemented

%

VISN 16 Performance Measures – FY06

Clinical-Research Partnerships:Barriers and Opportunities

Barriers to “Clinical-Research Partnerships”
        - As part of the ReTIDES project, we interviewed 26 VHA leaders and key staff about perspectives on EBP implementation.
        - Barriers:
        - Research takes too long
        - Research isn’t practical
        - Researchers’ pursue their own career goals 
        - Research tends to focus on single diseases
        - Managers have to balance available evidence with clinical needs

Opportunities for Enhanced Collaboration and Partnerships
        - QUERI centers and other initiatives to bridge the gap, while being recognized for their impact, haven’t solved the problem

Clinical-research partnership should include early and active involvement of managers in research prioritization and design 

Clinical-research partnership should include capacity for rapid research response to high priority needs of managers

QUESTIONS?

Contact:  

Rick Owen (Richard.Owen2@va.gov)

Jeff Smith (Jeffrey.Smith6@va.gov)

VA Mental Health QUERI

http://www.queri.research.va.gov/mh/default.cfm