In spite of modern medicine’s success in developing effective treatment programs for a variety of chronic illness and lifestyle problems, the recognition and treatment of individuals with behavioral health problems is often sub-optimal. Our team has previously documented a high degree of multimorbidity among VHA patients, including 5 key behavioral health conditions (depression, chronic pain, obesity, tobacco dependence, and alcohol dependence). These behavioral health problems impair quality of life and constitute an important group of modifiable risk factors for adverse short- and long-term outcomes. In the VHA, as in many other health care systems, organizational barriers and competing demands often thwart attempts to implement and sustain evidence-based practices for behavioral health problems. Wagner’s Chronic Care Model (CCM) however, provides an organizational roadmap to quality improvement for chronic health problems. The model identifies a common core of services for chronic illnesses that need not be re-invented for each disease: patient self-management support, provider decision support, clinical information systems support, delivery system redesign, health care system support, and community linkages. The CCM is consistent with systematic reviews which indicate that multi-component interventions are more successful than single strategies to implement evidence-based practices. It is also congruent with Complexity Science theory, which stresses the importance of local adaptation, participatory decision-making, and a systems approach when attempting quality improvement.
To promote the use of the CCM to implement evidence-based practices for 5 behavioral health problems in VHA primary care clinics using a facilitated, tailored, quality improvement approach, the Multimethod Assessment Process/Participatory Quality Improvement (MAP/PQI).
The project will use a quasi-experimental, interrupted time series design, using replication with concurrent and staggered implementation across multiple sites. Each of the 3 health care systems within VISN 17 will receive funds (through this grant and matching VISN support) to hire one full-time Behavioral Health Coordinator (BHC). Over a 1-year period, each of the three BHCs will actively facilitate the MAP/PQI process with expert guidance, resources, and support provided by the VERDICT at two facilities (the largest VAMC and largest free-standing Outpatient Clinic) within their assigned health care system. These 6 VA-staffed facilities will serve as primary facilitation sites. During the 2nd year, facilitation will be withdrawn at the primary sites, and the BHCs will actively facilitate the intervention at 3 additional VA-staffed facilities that will serve as delayed facilitation sites. In addition, the BHCs will also remotely facilitate implementation at the remaining VA-staffed facilities in VISN 17 that will serve as dissemination or spread sites in Year 2. The effectiveness of the intervention will be evaluated by comparing the proportions of patients at each clinic with improved processes of care and patient outcomes for the 5 behavioral health conditions at 12- and 24-months follow-up, compared to a 12-month baseline period prior to the intervention. Barriers and facilitators to implementation will be assessed at baseline and prospectively. In addition, we will describe the prioritization, quantity, and adaptations of CCM strategies that were implemented at each clinic.
None at this time.
Improvements in the quality of care for behavioral health problems will enhance quality of life and health status of veterans.
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