FORUM translating research 

into quality health care 

for veterans

A publication of the VA Office of Research 

& Development, Health Services Research 

& Development Service, Center for 

Information Dissemination and Education 

Resources, in conjunction with AcademyHealth 

November 2005 VA Health Services Research & Development Service 

Contents 

Director’s Letter 2 

Response to Commentary 3 

Research Highlights 4-7 

Organizational Profile 8 

Meeting the Challenges of Veterans with Chronic 

Illnesses 

By Madhulika Agarwal, M.D., M.P.H., Chief Patient Care Services Officer 

Today, an estimated 125 million Americans suffer from one or more chronic conditions such 

as high blood pressure, diabetes, and asthma. 

Compared to the general population, veterans 

served by the Veterans Health Administration 

suffer from three additional non-mental health 

diagnoses and one additional mental health 

diagnosis.1 

Once a health care system designed to care 

largely for those with acute illnesses and in 

need of episodic care, the VA has transformed 

itself over the last decade. This transformation 

has led to significant improvements in care for 

patients with chronic illnesses. VA has invested 

heavily in its primary care framework, informatics infrastructure, and performance measurement system to improve quality of care and 

decrease treatment gaps. These investments 

have resulted in demonstrably better care for 

veterans with chronic illnesses. In fact, one 

recent study found that VA patients were more 

likely than patients in a national sample to 

receive needed care for chronic illnesses. In 

particular, patients in the VA sample received 

significantly better care for depression, diabetes, hyperlipidemia, and hypertension.2 

Despite VA’s transformation, substantial 

opportunities for improvement in the quality 

of care delivered to veterans with chronic medical conditions remain. The Office of Patient 

Care Services (PCS) has an ambitious vision to 

identify and improve health care delivery to 

chronically ill veterans. This agenda was highlighted in a PCS—Office of Information retreat, 

as well as a more recent PCS strategic planning retreat. Participants explored common 

themes that emerged from the primary care 

model, specialty care, care coordination program, the hub and spoke model of care for 

specialized populations, as well as clinical 

research and education programs in mental il

nesses, geriatrics, and neurological diseases. 

Many of these models incorporate the six key 

dimensions that characterize the Chronic Care 

Model (CCM): organization of health care, clin

ical information systems, delivery system 

design, decision support, self-management 

support, and community resources.3 

“Despite VA’s transformation, substantial opportunities for improvement in the quality of care delivered 

to veterans with chronic medical 

conditions remain.” 

The essential elements of chronic care management that need further enhancement and 

implementation within the VA include the fol

lowing. 

Patient-focused system. For many chronically 

ill patients, self-management remains the cornerstone of their care. In fact, patients with 

chronic illnesses spend only a few hours a yea

continued on page 
2 ■ Forum/November 2005 

with health care professionals. Most of the 

time, these patients take care of themselves. 

As a result, patients and their families must 

be knowledgeable, empowered to manage 

their own care, and have access to a full 

continuum of care at their point of entry 

into the health system. 

Together with proactive patient education, 

VA’s patient web-portal, My HealtheVet offers 

great promise in this arena. My HealtheVet 

gives veterans information and tools to 

improve their health, as well as easy access 

to their medical record. Veterans can also 

add personal information and share with 

VA and non-VA doctors. My HealtheVet can 

help make patients partners in their own 

care by providing evidence-based preventive 

care information, health reminders, shareddecision making, individualized health education information, and easier access to 

VA’s centers of excellence and experts. 

Full support for appropriate level of care 

matched to the level of need. Care and services across the continuum must be patient 

centered, accessible, coordinated, delivered 

in the most appropriate settings, and 

matched to the patient’s level of need. Since 

chronically ill patients have different levels 

of need during the course of their illness— 

from fully functional to conditions requiring hospitalization—strong collaboration 

between primary care staff and specialists 

and a clear understanding of responsibilities are critical. It is essential to have relationships with the right professionals and 

multidisciplinary teams to achieve better 

outcomes. Care coordination and telehealth 

offer the best blend of technologies, informatics, and care management to improve 

access to health care and to shift health 

care delivery into the home and community when appropriate. 

Evidence-based decision support system. 

VA’s computerized patient record system 

with clinical reminders allows for clinical 

decision support integrated into the daily 

practice of busy clinicians. The success of 

VA’s electronic health record (EHR) has 

raised expectations. VA clinicians expect an 

integrated, user-friendly EHR system that 

will allow clinical and temporal abstractions, integrate evidence-based guidelines 

into care plans, and “define patterns” for 

protocols (combination of lab, meds, diagnosis, etc). We hope that this future system 

will provide better statistical information 

and allow health professionals to spot 

trends early and take action promptly. We 

also hope that this system will have the 

ability to identify those patients at risk for 

chronic illnesses, as well as provide risk 

stratification. 

Use of Clinical Information Systems 

VA has made major investments in clinical 

information systems that inform decision 

makers and improve patient care. For 

example: 

■ Over the course of the last several years

VA’s performance measurement system 

has led to significant improvements in 

health care processes and outcomes. This 

system has enabled the routine collection 

of data to support process measures and, 

in some cases, to achieve target values in 

chronic diseases such as diabetes, hypertension, and congestive heart failure with 

reporting of results and feedback to clinica

groups. 

continued on page 

Director’s Letter 

Fiscal Year 2005 has been a busy and productive year for HSR&D. In addition to 

ongoing work in HSR&D’s many funded 

projects, this year’s highlights include the 

implementation of a Polytrauma & BlastRelated Injuries Quality Enhancement 

Research Initiative (QUERI), and implementation of the HSR&D Cyber Seminars 

program conducted with our Resource 

Centers on subjects such as health economics, measurement theory, and using 

VA databases. 

In the aftermath of one of the greatest 

natural disasters our nation has faced, 

HSR&D utilized the cyber seminars platform to assist the National Center for 

Post-Traumatic Stress Disorders (NCPTSD) 

to reach out to the field. We worked quickly 

to provide assistance to NCPTSD by hosting an important seminar that disseminated 

critical information to VA caregivers about 

PTSD treatment for victims of Hurricanes 

Katrina and Rita. 

We also are working to enhance investigator initiated research (IIR) funding percentages. The IIR program enables VA 

clinicians and social scientists to pursue 

their personal research interests while 

advancing HSR&D priorities and contributing to the quality, effectiveness, and 

efficiency of VA health care. Overall, 

HSR&D reviewed 161 research proposals 

at our August review, and we expect to 

fund 22 percent of them, with a focus on 

veteran-centric research. This rate is up 

from 16 to 17 percent during the previous 

two reviews. We have also selected four 

Merit Review Entry Program candidates 

for funding and hope to fund four career 

development awards. Additionally, we 

have implemented a web-based orientation program for reviewers that has been 

well-received by users. 

We look forward to a productive Fiscal 

Year 2006! 

Shirley Meehan, M.B.A., Ph.D. 

Acting Director, HSR&D 

“My HealtheVet can help make 

patients partners in their own 

care by providing evidence-based 

preventive care information, 

health reminders, shared-decision 

making, individualized health 

education information, and easier 

access to VA’s centers of excellence and experts.” 
Forum/November 2005 ■ 

■ Use of disease registries and databases 

for population health management, data 

mining, and data warehousing capabilities 

gives health managers new insights into 

health trends and enables them to manage 

resources better. These tools also monitor 

and analyze process measures, indicating 

whether treatment protocols are being followed. 

■ Timely access to texts, online journals, 

and research trials provides clinicians and 

trainees with important, up to date medical 

knowledge. 

■ Follow-up and reminder systems track 

results for future actions for both providers 

and patients. 

The concept of disease management is not 

new to clinicians as they have always managed patients with chronic illnesses; however, it is a challenge to provide integrated 

evidence-based care for multiple chronic illnesses that affect our patients without adequate ancillary support. Our goal is to be a 

patient-centric, compassionate, evidencebased information driven system that is 

continually improving and innovating. The 

future paradigm entails focusing on an 

individual’s personalized health education 

aimed at prevention, early risk identification, and stratification, as well as evidencebased practices that provide opportunity for 

the most optimal health possible.3 ■ 

References 

1 Perlin JB, Moving Strategies to Action— 

12 Priorities in 12 Months, Senior 

Management Conference, VHA, August 4, 

2004, Washington DC. 

2 Asch SM, McGlynn EA, Hogan MM, et al. 

Comparison of Quality of Care for Patients 

in the Veterans Health Administration and 

Patients in a National Sample. Annals of 

Internal Medicine 21 December 2004; 

141(12): 938-45. 

3 Wagner EH, et al. Organizing Care for 

Patients with Chronic Illness. Milbank 

Quarterly 1996; 74:511-544. 

Response to Commentary
 

VA Research: Meeting the Challenge of Managin

Chronic Diseases 

By Joel Kupersmith, M.D., Chief Research and Development Officer, VA Office of Research a

Development 

VA is uniquely committed to managing oping others. One of the strengths of VA 

chronic illnesses and injuries among veter­ research is that clinical care and research 

ans. VA delivers this care with superior are under the same roof, which creates 

quality as a result of its information systems, opportunities for translating research into 

its continuum of services, and its emphasis clinical practice and for having clinical care 

on evidence-based practice. Because the settings inform our research agenda. 

mission of VA research is to help veterans, 

it should come as no surprise that our Implementation. Although the process of 

efforts have aligned with the chronic disor­ translating research from the laboratory to 

ders prevalent among veterans. In fact, much the bedside has been likened to a pipeline, 

of the evidence base that underlies the cur­ better analogy is a cycle in which the needs 

rent management of chronic conditions of the system drive the questions asked by 

such as hypertension, diabetes, ischemic researchers. Researchers’ outputs are, in 

heart disease, lipid disorders, and mental turn, spread through actions taken by cliniillness has resulted from VA research. cal leaders, policymakers, and “activated” 

patients. This process must be done withou

In her commentary, Dr. Agarwal points out compromising high standards for rigorous 

that the continued transformation of VA design and sound analysis. VA’s Quality 

into a patient-focused delivery system Enhancement Research Initiative (QUERI) 

requires patient self-management in home provides a case study of how this can be 

settings, timely evidence-based decision done, but collaborative inquiry really needs 

support, and care that is customized to the to occur throughout the full spectrum of ou

individual. For VA research, there are three work. 

corresponding challenges if we are to manage chronic diseases effectively: Genomics. Patients with chronic disease ar

heterogeneous in terms of disease course 

■ Improve how we generate knowledge and response to treatment. Even when a 

from real-world practice settings (methods); given approach is supported by RCT evi­

■ Enhance the integration of research and dence, the management of the individual 

clinical care (implementation); and patient remains largely trial-and-error. This 

■ Understand the determinants of disease approach may soon change. Genetic factors 

trajectory and treatment response at the underlie the course of a disease and dictate 

individual level (genomics). therapeutic responses, drug clearance, and 

adverse effects. A major ORD initiative is 

Methods. VA needs both to examine and to the development of a genomic database tha

develop new research methods to look at would link patient genetic information with 

chronic illness and care. Although the ran­ longitudinal health outcomes using our 

domized controlled trial (RCT) remains the electronic health record. While considerable 

gold standard, more generalizable approach­ issues remain, few areas hold as much 

es may be needed in the case of chronic promise for changing everyday practice. 

conditions. At the Office of Research and ORD looks forward to collaborating with th

Development (ORD), we will be utilizing Office of Patient Care Services to meet the 

some of these approaches as well as devel­ challenges of managing chronic diseases. ■ 
4 ■ Forum/November 2005 

Research Highlights
 

Clinical Decision-Support for Managing Chronic 

Disease in Primary Care: ATHENA DSS 

By Mary K. Goldstein, M.D., M.S., VA Palo Alto Health Care System GRECC, Eugene 

Oddone, M.D., M.H.Sc., Durham VAMC, Center for Health Services Research in Primary 

Care, and Brian B. Hoffman, M.D., VA Boston-West Roxbury Medical Service 

Clinical practice guidelines assist clinicians adherence to clinical practice guidelines for 

by summarizing current evidence and rec­ treatment of patients with hypertension. We 

ommending best practices; however, publi­ then compared their self-assessments with 

cation of guidelines alone is not effective in their actual adherence to guideline recomchanging clinician behavior. Many experts mendations for medication regimens and 

believe that such information must be blood pressure control. We found that, overincorporated into everyday clinical work­ all, clinicians overestimated their adherence 

flow. Specific strategies such as automated to medication guidelines and also substanrecommendations at the time of medical tially overestimated their success in meeting 

decision-making for individual patients blood pressure targets for their patients. 

may enhance clinician guideline adherence. 

Feedback to clinicians about their perforThe Automated Treatment for Hypertension: mance may be particularly useful as a 

Evidenced-based Advice (ATHENA) project “priming” strategy, alerting clinicians that 

was initiated to develop and evaluate meth­ they are not achieving guideline targets and 

ods of guideline implementation by provid­ thereby increasing their receptivity to intering recommendations to primary care clini­ ventions. The ATHENA DSS shows the 

cians at the time of outpatient clinic visits clinician whether or not a patient’s clinical 

for patients with chronic disease. The pro­ data indicate that the clinician is guidelineject selected hypertension as a model for adherent, both for blood pressure and for 

initial study because it is highly prevalent medication choice. 

and has serious consequences that can be 

ameliorated with treatment. In addition, The overall aim of clinical practice guidehypertension has evidence-based guidelines lines is to improve patient health, so the 

and offers substantial opportunity to ultimate test of guideline implementation is 

improve quality of care. The ATHENA team its impact on patient outcomes. However, it 

developed an automated decision support is also useful to study the extent to which 

system, ATHENA DSS, in collaboration clinicians do or do not follow specific guidewith Stanford Medical Informatics (SMI), line recommendations. Assessing clinician 

using the Protege and EON architecture response to guideline-based drug recomdeveloped at SMI. mendations requires a detailed analysis of 

patient pharmacy data in relation to recomOne possible explanation for why guide­ mendations at specific points in time. We 

lines fail to improve quality of care is that analyzed VA pharmacy data to determine 

individual clinicians may perceive that they what prescriptions were active just prior to 

are already practicing high-quality medi­ and just following each primary care clinic 

cine. When clinicians overestimate their visit. We then developed an Adherence 

own adherence to guidelines, they may not Advisory Evaluator (AAE) program to comfully recognize opportunities for improve­ pare the changes to each patient’s prescripment. As part of baseline data collection, tions following a visit with the changes (if 

we surveyed clinicians about their perceived any) recommended by the guidelines. 

We developed the ATHENA DSS for qualit

improvement and with patient safety in mind

however, new technologies for health care 

providers can be expected to introduce new 

and unanticipated sources of error. In addi

tion to taking care to minimize the likelihoo

of errors and pre-testing the system, we 

instituted procedures for ongoing monitoring of the system. Our monitoring detected 

some rarely occurring problems in data 

extraction in a timely manner so that they 

could be corrected promptly. Such ongoing 

monitoring should be a routine part of 

deployment of new automated systems. 

Deployment of the ATHENA DSS system 

has been a success. However, technical suc

cess in implementing automated clinical 

decision support may not translate directly 

into use by clinicians. For Athena DSS, we 

found rates of use that were much higher 

than those published by other groups, suggesting that clinicians found the system 

both usable and useful. 

The technology developed using hypertension as a model in the ATHENA project can 

be applied to other clinical domains. Future 

research studies will be needed to understand the best methods of presenting infor

mation to busy primary care clinicians. 

Furthermore, the underlying knowledge 

base and guideline execution engine for 

ATHENA DSS, with a revised user interface, could also be used to generate recommendations for presentation directly to 

patients, for example through the patient 

portal, My HealtheVet. ■ 

References 

Steinman MA, Fischer MA, Shlipak MG, e

al. Clinician awareness of adherence to 

hypertension guidelines. American Journal 

of Medicine 2004. 117(10):747-54. 

Goldstein MK, Coleman R, Tu S, et al. 

Translating Research Into Practice: 

Organizational Issues in Implementing 

Automated Decision Support. Journal of the 

American Medical Informatics Association 

2004. 11(5):368-76. 
Forum/November 2005 ■ 

Reaching Out to Chronically-Ill Veterans: 


The Potential of Interactive Voice Response Calls
 

By John D. Piette, Ph.D., VA Ann Arbor Healthcare System, Center for Practice 

Management and Outcomes Research 

Chronic illnesses present enormous day-today challenges, and self-care can be difficult 

under even the best of circumstances. Many 

VA patients face additional problems such as 

barriers to outpatient clinic use and inadequate social supports. While some patients 

need weekly or even daily assistance, such 

services can be impossible to provide in most 

outpatient clinics. Telephone care programs 

can help patients manage their illness, but 

standard telephone care services are labor 

intensive, and many health systems are 

reluctant to devote the necessary staff time. 

Internet-based, self-management support 

services offer one potential solution to the 

challenge of providing between-visit chronic 

illness care. Unfortunately, many veterans 

lack computers in their homes or the reliable, 

high-speed Internet access that these services often need. Other patients have health 

literacy deficits that limit their ability to use 

text-based Internet communication. Interactive 

voice response systems (IVR) can deliver 

recorded messages to large numbers of 

chronically-ill veterans at low cost. Patients 

interact with IVR services using their 

touch-tone keypad or voice response technology. IVR systems can strengthen the 

link between patients and clinicians without requiring the use of personal computers (PCs) or other computer hardware. 

IVR-Based Interventions Can Be 

Effective 

Like all clinical services, IVR-based interventions are most effective when they have 

clearly defined goals. One of the biggest 

challenges for chronically-ill patients is 

coordinating their many self-management 

tasks and visits with VA providers. Not surprisingly, clinic “no-show” rates for people 

with chronic diseases are notoriously high, 

and patients often have difficulty taking 

their medication as prescribed. IVR 

reminder calls can reduce no-show rates 

and promote medication adherence. The 

evidence for the effectiveness of IVR 

reminders is sufficiently strong that VA 

facilities should consider adopting these services more broadly in chronic illness care. 

IVR monitoring calls can gather up-to-date 

information about patients’ health status and 

behavioral needs. We have found that VA 

patients with diabetes will complete regular 

IVR assessments, and that these assessments 

accurately identify groups at high risk for 

adverse outcomes. However, results of the 

VA Ambulatory Care Quality Improvement 

Project (ACQUIP) trial suggest that IVR 

screening with feedback to clinicians will 

have little benefit if clinicians are limited in 

their ability to change treatment plans or if 

treatment changes are not tightly linked 

with health outcomes. To achieve its potential, IVR monitoring must be part of a coordinated effort to give clinicians and chronically-ill patients the resources they need to 

act on the information collected. 

Patients with chronic illnesses require 

extensive self-management education, but 

busy VA providers often are unable to provide this education in the context of periodic 

outpatient visits. IVR calls can increase 

patients’ access to tailored self-management 

information at a time and pace that is comfortable for them. Furthermore, studies 

show that patients are interested in accessing IVR messages about their self-care. 

IVR Exchange Can Facilitate Peer 

Support 

Peer support (i.e., support between individuals living with the same illness or selfmanagement challenges) can reduce selfmanagement problems and relieve the menta

stress of living with chronic disease. Unfortunately, most peer support programs such 

as group visits require frequent face-to-face 

meetings and can be inaccessible to many 

veterans. With funding from a VISN 11 

telemedicine initiative, we developed a prototype chronic disease, peer-support program 

facilitated by an IVR exchange. Diabetes 

patients were paired and asked to contact 

their partner at least once a week using the 

toll-free IVR calling line. Participants used 

their own phone number as a “PIN” to link 

with their partner while protecting their 

anonymity. IVR reminders encouraged frequent peer contact so that patients were no

solely responsible for ensuring that they 

talked regularly. Overall, we found that the 

IVR intervention was easy for veterans to 

use. In fact, 92 percent of participants in 

the pilot said that they would be more satis

fied with VA care if IVR-facilitated peer 

support services were available. A randomized trial evaluating the impact of this inter

vention on diabetes outcomes is planned. 

VA remains at the forefront of innovative 

research on using communication technology to improve chronic illness care, and 

studies of IVR interventions are a key com

ponent of that agenda. With the support of 

creative VA research, IVR interventions 

may strengthen communication with 

chronically-ill patients, improve the timeliness of their medical care, support more 

effective self-management, and ultimately 

improve patients’ health. ■ 

References 

Piette JD. Using Telephone Support to 

Manage Chronic Disease. The California 

Health Care Foundation, 2005. Also available at www.chcf.org/topics/chronicdisease/index.cfm. 
6 ■ Forum/November 2005 

Research Highlights
 

Measuring Quality at the End of Life 

By James A. Tulsky, M.D., and Karen E. Steinhauser, Ph.D., Durham HSR&D Center of Excellence 

“How do we measure quality 

for a condition which, by 

definition, leads to increasing 

disability and dependence? 

How do we measure quality 

when gains are likely not to 

be found in traditional biomedical markers but, rather, 

in spiritual or existential 

domains?” 

The VA has committed to improving the quali­ five-point Likert scale. We administered the 

ty of care for patients approaching the end of instrument to 200 patients with cancer, conlife. In doing so, it has also assumed many gestive heart failure, end stage renal disease, 

challenges. Among these is the problem of how and chronic obstructive lung disease. Using 

one measures improvement in quality at the factor analysis, we arrived at a final instrument 

end of life. Some efforts will be easily quantifi­ with 24 items in five distinct domains that 

able, such as reducing pain scores or increas­ closely matched the domains identified empiriing the access of hospice care. However, intu­ cally. 

itively we know that assessing quality at the 

end of life is far more complicated. How do we We then took this instrument, called the 

measure quality for a condition which, by defi­ QUAL-E, and conducted another validation 

nition, leads to increasing disability and study with 248 different patients with the same 

dependence? How do we measure quality disease profiles in order to further assess the 

when gains are likely not to be found in tradi­ instrument’s psychometric properties, includtional biomedical markers but, rather, in spiri­ ing its associations with existing measures, 

tual or existential domains? evaluation of robustness across diverse sample 

groups, and stability over time. We confirmed 

Over the past seven years we have conducted a a four-domain structure including life compleseries of studies toward the goal of developing tion, symptoms, relationship with health care 

an instrument to measure quality of life at the provider, and preparation for end of life. 

end of life. We began with the premise that we Convergent and discriminant validity were 

did not know what ought to comprise such a demonstrated with multiple comparison meameasure. We conducted focus groups and a sures. Test-retest reliability assessment showed 

national survey with patients, bereaved family stable scores over a one-week period. We now 

members, physicians and non-physician know that the QUAL-E demonstrates accepthealth care providers to learn what was impor­ able validity and reliability, is easy to administant at the end of life. We identified six key ter, performs consistently across diverse demodomains considered essential for a “good graphic and disease groups, and is acceptable 

death”: pain and symptom management, clear to seriously ill patients. We offer it as a new 

decision-making, preparation for death, com­ instrument to assist in the evaluation of the 

pletion, contributing to others, and affirmation quality and effectiveness of interventions tarof the whole person. What we found most geting improved care at the end of life. ■ 

interesting was the tremendous importance of 

factors not traditionally considered within the References 

biomedical framework of care. 1 Steinhauser KE, Christakis NA, Clipp EC, et 

al. Factors considered important at the end of 

life by patients, family, physicians, and other With this empirical assessment of the underly­ care providers. Journal of the American Medical ing important factors, we set about construct­ Association 2000; 284:2476-82. 

ing a new multidimensional measurement 2 Steinhauser KE, Clipp EC, Bosworth HB, et tool to assess the quality of life at the end of al. Measuring quality of life at the end of life: life. Our first version included 54 items cover­ Validation of the QUAL-E. Palliative & 

ing six domains derived from the focus groups Supportive Care, 2004; 2:3-14. 

and surveys, and which were measured on a 
Forum/November 2005 ■ 

Mental Health Care Improvements Need New 

Care Models 

By Lisa Rubenstein, M.D., M.S.P.H., VA Greater Los Angeles and Ed Chaney, Ph.D., VA Puget 

Sound 

Depression treatment—whether antidepres­ Depressed patients who do not wish to go 

sants or psychotherapy—has the potential to MHS or who must wait months for an 

not only to improve patient satisfaction, but appointment may receive no treatment or 

also to reduce job loss and improve patient may start treatment in primary care but fail 

quality of life. While this is good news, the due to inadequate follow-up support. 

VA—like other providers—faces challenges 

in providing timely and effective mental 

health care particularly for depression. What Works 

This problem can be solved. Depression The main problem is that most patients 

with collaborative care models have been exten­ depression are detected in primary care sively tested in randomized trials and found settings, and there is a gap between primary to be clinically effective and cost-effective. care detection and mental health treatments. Studies have shown that about 20 In these models, trained nurse care managers promptly assess and triage patients percent of primary care patients screen pos­ referred by primary care clinicians for pos­ itive for major depression symptoms. About sible depression. Based on patient needs half of these screen-positive patients are 

and preferences, care managers either sup­ being treated for mental health issues withport MHS referral or support medication in the VA health care system. Referring the 

management in primary care. remaining 10 percent of the primary care 

population for mental health treatment, 

We know that achieving successful treat­ however, as is done in many clinics, is not ment completion requires that patients necessarily a good solution. First, only receive active, frequent support and moni­ about half to three quarters of the screentoring from clinicians, particularly during positive patients need depression treatment; 

the early treatment phases. Care managers the remainder has subthreshold depression 

can successfully provide this support or other conditions for which antidepresthrough brief phone calls, thus avoiding sants or psychotherapy are not indicated. unnecessary primary care visits. Mental Second, many patients refuse mental health health specialists support the care manager specialty (MHS) treatment. Third, mental and primary care clinician by reviewing health referrals for screen-positive patients 

care manager cases weekly. Since care man­ use a large fraction of available MHS visits agers regularly monitor depression symp­ for depression assessment and triage alone. toms, any patients followed in primary care

Demand for MHS appointments results in who are not improving can be identified for

case review and treatment adjustment. long scheduling delays, reduced access to 

appropriate follow-up care for depression, 

and fewer appointment slots available to TIDES Produces Positive Outcomes patients with other mental health conditions; all this occurs in sharp contrast to the Translating Initiatives for Depression into goals of advanced clinic access. Yet most Effective Solutions (TIDES) is a quality primary care clinicians have neither the improvement project that works with VISN time nor expertise to assess fully and triage partners and their primary care, mental these patients prior to MHS referral. 

health, nursing, and administrative leaders 

to improve depression care by implementing evidence-based collaborative care models

TIDES support helps VISNs and their med

ical centers implement all elements of the 

chronic illness care model that underlies 

collaborative care, including Computerized 

Patient Record System informatics solutions, education and training tools and sup

port, templates for identification of local 

resources, and active panel management. 

The TIDES program also provides ongoing 

quality monitoring of TIDES depression 

care and outcomes. 

The TIDES program has achieved early suc

cess. The program has seen over 1,000 

patients in VISNs 10, 16, and 23. Eighty 

percent of these patients are followed in pri

mary care without MHS visits. Patient 

adherence to treatment under the program 

is 80 percent. Recovery at six months is 70 

percent among primary care patients and 

50 percent among the more severely ill 

patients referred to MHS. TIDES is now 

being adopted by VISN 22 and additional 

medical centers in the three original VISNs

TIDES is committed to ongoing outcome 

assessment and evidence-based innovation 

as it continues to address a key dilemma: 

how to provide appropriate mental health 

care in today’s overloaded primary care and 

mental health settings. Serving as depression care managers, TIDES nurses have 

had a significant positive impact on veteran 

health and quality of life. 

Programs like TIDES have the potential for 

improving outcomes among veterans suffering from mental illness, especially 

depression. ■ 

Further information on TIDES is available 

through the Mental Health Quality 

Enhancement Research Initiative (QUERI) 

Center in Little Rock at www.hsrd.research.va

gov/queri/exec_summaries.cfm and the 

TIDES Web site at www1.va.gov/tides_waves/
Organizational Profile: CCDOR–Improving the 

Quality of Chronic Disease Care 

By Hanna E. Bloomfield, M.D., M.P.H., Minneapolis VA HSR&D Center of Excellence 

The Center for Chronic Disease Outcomes One of CCDOR’s strengths lies in its ability 

Research (CCDOR) at the Minneapolis VA to span the research spectrum from develMedical Center is one of 15 VA Health oping the evidence base for clinical practice 

Services Research and Development to determining how best to translate that 

(HSR&D) Centers of Excellence. Our mis­ evidence into clinical practice. We have clinsion is to enhance—through research, edu­ ical research expertise in observational epication and dissemination activities, the demiology, clinical trials, and evidence syndelivery and accessibility of high-quality, thesis. In addition, we have expertise in 

cost-effective health care that will result in developing and testing theory-based interoptimal clinical, psychosocial, and functional ventions for translating research evidence 

outcomes for veterans with chronic disease. (i.e., clinical best practices) into practice. 

CCDOR’s research focuses on improving CCDOR staff includes a multidisciplinary 

the quality of chronic disease care. Our pri­ team of 60 doctorate level, clinical, and 

mary goal is to understand and improve other research staff. Investigators include 

provider, patient, and system level factors social psychologists, sociologists, epidemioland interactions to enhance the quality of and ogists, statisticians, clinical psychologists, 

access to care. CCDOR’s research covers a general internists, and a health economist, 

broad range of content areas and employs a medical anthropologist, geriatrician, and 

variety of research methodologies. Content dermatologist. CCDOR is also home to sevareas include preventive cardiology, smoking eral other centers including an Agency for 

cessation, vaccine preventable disease, cancer Healthcare Research and Quality supported 

detection and prevention (prostate and colon Evidence-based Practice Center; the 

cancer), abdominal aortic aneurysm, urolog­ VA/National Cancer Institute Colorectal 

ical disease, osteoporosis, effects of trauma Cancer Quality Enhancement Research 

on health, patient self management, quality Initiative (QUERI) Center; the VA 

of care, effect of race/ethnicity on access to Polytrauma and Blast-related Injuries 

care, health literacy, and systems interventions. QUERI Center; and one of two VA Clinical 

CCDOR uses a variety of research method­ Research Centers of Excellence, the Center 

ologies, including clinical trials, observa­ for Epidemiological and Clinical Research. 

tional epidemiology, systematic reviews and 

meta-analysis, surveys, qualitative methods, CCDOR’s recent work has resulted in: 

and database and economic analyses. ■ Evidence that short and long term smoking cessation rates in VA are significantly 

improved by implementing a telephone 

quit-line. 

■ An automated system that identifies 

system level processes needed to improve 

colorectal cancer screening performance. 

■ Development and dissemination of an 

award winning patient education pamphlet 

to help men make informed choices about 

whether to be screened for prostate cancer. 

■ Revised guidelines from the U.S. 

Preventive Services Task Force on screenin

criteria for abdominal aortic aneurysms. ■ 

FORUM 

Geraldine McGlynn, Editor-in-Chief 

Margaret Trinity, Editor 

Editorial Board 

Martin P. Charns, D.B.A., Director, VA HSR&D 

Center of Excellence, Boston, MA 

Phil Crewson, Ph.D., Assistant Director, 

VA HSR&D, Central Office 

Joseph Francis, M.D., M.P.H., Director, HSR&D 

QUERI, Central Office 

Rodney A. Hayward, M.D., Director, VA HSR&D 

Center of Excellence, Ann Arbor, MI 

Shirley Meehan, M.B.A., Ph.D., Acting Director, 

VA HSR&D, Central Office 

Michael J. Miller, M.D., Ph.D., Chief Medical 

Officer, VA Network #1, Bedford, MA 

Eugene Z. Oddone, M.D., M.H.Sc., Director, 

VA HSR&D Center of Excellence, Durham, NC 

Alan S. Perry, M.H.A., FACHE, Director, 

VA Medical Center, Fresno, CA