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Implementing Telemedicine-Based Collaborative Care for MDD in Contract CBOCs
Fortney JC, Pyne JM. Implementing Telemedicine-Based Collaborative Care for MDD in Contract CBOCs. Paper presented at: VA HSR&D National Meeting; 2011 Feb 18; National Harbor, MD.
Numerous effectiveness studies have demonstrated that collaborative care for depression improves outcomes for primary care patients. The Uniform Mental Health Services Package mandates the implementation of collaborative care in CBOCs. However, small CBOCs lack the capacity to delivery collaborative care on-site. A previous randomized trial of telemedicine-based collaborative care (TBCC) found that an off-site depression care management team significantly improves outcomes for CBOC patients. This study tested an implementation strategy (Evidence-Based Quality Improvement) to roll-out TBCC to small contract CBOCs.
The implementation group included 11 contract CBOCs associated with 3 VAMCs. The control group included 15 contract CBOCs associated with 7 VAMCs . The evaluation was based on the RE-AIM Framework. To have an impact at the population level, an intervention must be Adopted by providers, Reach a large proportion of targeted patients, be Implemented with fidelity, Effectively improve outcomes, and be Maintained after research funds are withdrawn.
There were 42 providers who diagnosed patients with depression at the implementation CBOCs during the first six months of the post-period and 60% referred at least one patient to the TBCC program. There were 1,797 patients diagnosed with depression at implementation CBOCs during the first six months of the post-period, and 7% were enrolled in the TBCC program. Fidelity to the care manager protocol was excellent (e.g., medication adherence was assessed at 99.1% of encounters). 39% of patients enrolled had positive outcomes, which is comparable to the prior randomized trial. Compared to patients diagnosed with depression at control CBOCs, patients at implementation CBOCs were significantly more likely to have a tele-psychiatrist encounter, but had slightly lower overall costs (-$22.34). Compared to patients diagnosed with depression at control CBOCs, patients at implementation CBOCs had significantly higher medication possession ratios. Compared to patients in the denominator of the depression performance measures at control CBOCs, patients at implementation CBOCs were significantly more likely to meet performance measure criteria for follow-up visits and antidepressant coverage. The TBCC programs were sustained after research funds were withdrawn.
TBCC can be successfully implemented in small contract CBOCs.
TBCC should be incorporated into the national Primary Care/Mental Health Integration Initiative.