Measuring TIDES Implementation and Story

1. Measuring TIDES Implementation and Story QUERI National Meeting, Dec 2008

2. Purpose • What is TIDES? • Summary of the TIDES intervention/evaluation • Did TIDES meet SQUIRE publication standards for quality improvement research?

3. What is TIDES? • TIDES is an evidence-based quality improvement project • Means Translating Initiatives in Depression into Effective Solutions • TIDES purpose • Effectiveness of new care models to improve health outcomes for depression already known (over 36 high quality randomized trials) • Can this evidence be used by VA to systematically improve routine VA care?

4. TIDES As A Research-Clinical Partnership • VA clinical management makes the decisions • Informed by research partners regarding the evidence • Research partners support implementation from a distance • No hands on any practice directly • Assist with development of tools, materials, and training • Assist with quality monitoring

5. Goals • Design and test a VA context-synchronous and evidence-based care model • Clinical managers as decision-makers • Researchers as evidence reviewers, tool developers and trainers • Use Plan Do Check Act Cycles • Alpha and beta test in 7 CBOCs in 3 VISNs • Stagger implementation by several months • Spread final stable model

6. Overview of TIDES Story from the Intervention Point of View • In 2000, prior to any funding, Drs. Chaney and Rubenstein began approaching VISNs • Work in the 1990’s showed what was effective • Challenge was to integrate effective models seamlessly into routine care • We conducted planning meetings in six VISNs • Out of six VISNs recruited, three decided to participate

7. TIDES: Initially A Two-Year QUERI-Funded Project • Began in 2001 • Purpose: Develop a successful prototype VA depression care improvement model based on evidence • Engaged VISNs in QI Planning Expert panel methodology to gain structured VISN input into design • Rubenstein, Joint Commission Journal, HSR • Spread prototype regionally and nationally

8. TIDES Prototypes • By design, PDSA’s implemented in 7 low complexity CBOCs • Prior research showed complex VA med centers had difficulty implementing high quality primary care • Limited number engaged • Engagement of VISNs and CBOCs was successive, not simultaneous • Theory was to reduce design time for later sites

9. Comparison Built In • Anticipated a randomized trial • We asked VISNs to identify three to four matched CBOC’s each, and randomly selected two as intervention sites • We later applied for and received HSR&D funding for WAVES • Goal of WAVES was to test the effectiveness of TIDES across representative patients and providers

10. Success of TIDES and WAVES • TIDES: intervention as developed by VISNs proved viable • Synchronous with VA policies, procedures, and CPRS • Sustained on no research funding for over 1 yr after end of TIDES • Spread throughout one entire VISN on VISN funding alone

11. ReTIDES (Regional Spread) • Funded 2004 • Goal: Prepare for national implementation • Finalize tools for spread (see poster) • Finalize engagement of Patient Care Services and EES • Assist revision of depression guidelines to address care model issues • Spread to one new VISN

12. National Implementation • Model taken up nationally in 2006 • Combined with White River Junction collocated care and Behavioral Health Lab method in a national RFP • New mandate (the mental health Uniform Services Package) includes key TIDES and BHL elements (2008) • TIDES is currently active in over 70 practices • 120 clinicians trained in 2007-2008

13. TIDES Quality Improvement Method: Evidence-Based Quality Improvement • Design choices by VISN leadership based on evidence • Expert panel meeting: Like a collaborative, but focused on regional leadership, key design choices, and evidence • VISN leadership picks sites, hires care managers, engages VISN leadership team who engage local medical center and CBOC leadership & local QI “teams”

14. Work Groups • Mirrored the Chronic Illness Care Model • Senior leaders, IT, Education and Decision Support, Care Management and Self-Management Support, Collaboration (MH/PC/Nursing) • Supported administratively and technically by researcher team acting as technical experts • Across-VISN work groups support training, tool development

15. Qualitative and Quantitative Evaluations of TIDES • A series of projects with PI’s/CoPIs including • Ed Chaney, Fen Liu (Seattle) • JoAnn Kirchner, Rick Owen, Mona Ritchie (Little Rock) • John Williams (Durham) • Lisa Rubenstein, Becky Yano, Jackie Fickel (GLA) • Clinical Leaders Randy Petzel, Mike Davies, Cathy Henderson, Clyde Parkis, Susan McCutcheon, Skye McDougal, Ken Clark, Ron Norby, and many others

16. Data Describing the Intervention and Outcomes • Historical data • Study files kept systematically; ACCESS data bases • E-mails kept and classified • Document review undertaken • Qualitative data • Semi-structured interviews • Site visits • Randomized trial data • Quality improvement data • Performance measure type data • Provider survey data • Organizational administrative and survey data

17. A C C O U N T A B I L I T Y T I D E S W A V E S C O V E S R I P P L E RET I D E S H I T I D E S QUERI Water PIPELINE Revise Guidelines Depression Care Guidelines Depression Collaborative Care Model PIC, MHAP, MOOD,IMPACT, RESPECT, TEAM Implementation Science Implementation Policy HSR

18. Cost Data • Planned distribution of labor between clinical partners and technical experts occurred • High number of clinical partners involved • Researchers did more labor • Staggered implementation occurred with somewhat decreasing time to implementation • Intervention costs $$’s

19. Phases of Quality Improvement Process First Contact Date Expert Panel Date Site Visit Date TIDES1 Implementation Date PDSA Cycle Maintenance BasicDesign Practice Engagement Preparation 6 months 6 months Implementation Design 1Date of first patient referral

21. QI Participants, Person Hours and Costs

22. Person Hours and Cost by Phase

23. Goals and Methods Used to Meet Them (cont) • Model fidelity • Semi-structured qualitative data collection • QI data collection • Document review • Effectiveness across representative patients and providers • Randomized trial • Program quality and safety • Quality improvement data

24. TIDES Quality Improvement Outcomes • QI data collected by care managers • Care managers trained to administer depression symptom measure (PHQ 9) • Data entered into Excel spreadsheets • Analyzed in SPSS

25. Results #1: Enrollment & F/U • Among 858 pts referred to TIDES, 738 (87%) were eligible for initial assessment • 24 refused (2.8%) • 86 could not be contacted (10%) • 10 misc. (e.g., too sick) (1%) • Of 738 eligibles, 86% (636) got a full initial assessment by the DCM • 81% of these (516) completed 6 mos.PHQ f/u

26. #2: Depression Symptom Outcomes • PHQ 9 > 10 = probable major depression • PHQ 9 < 5 = probably no significant depression • Baseline PHQ 9 mean = 12.2 • F/u PHQ 9 at 24 weeks = 7.4 ___________________________________ • Mean pre-post drop in PHQ 9 = 5.8 points

27. #3: Mean PHQ Change: Referral Type (TIDES vs WAVES) • P=.002, controlling for baseline PHQ, VISN, pt complexity, interactions • Interactions not significant (VISN, pt complexity)

28. #4: Mean PHQ Change: VISNs (includes TIDES and WAVES pts) • P=.02, controlling for referral type, pt complexity, int. • No significant interactions (referral type, pt complexity)

29. #5:Contact New Referrals Promptly • 81% enrolled within 1 month (48% in 1 wk) • TIDES referral: 81 % enrolled in 1 month • WAVES referral: 74% enrolled in 1 month • VISN #1: 91% • VISN #2: 81% • VISN #3: 78%

30. #6: Enrollment and f/u calls • Mean enrollment calls/pt = 3.7 • TIDES and WAVES were equivalent • Proportion of pts completing adequate TIDES care (at least 4 treatment contacts) was significantly lower for WAVES-referred pts (p = .01) • Pts receiving at least 4 calls had significantly better outcomes (p < .05)

31. TIDES QI Formative Findings: Reach • Reach: • Clinics varied from 46% to 100% of clinicians who referred to TIDES at least once; 0% to 36% who referred at least 10 pts • Sustainability: • Least ready site performed, but did not sustain (in a favorable VISN) • Most ready site did not perform or sustain (in an unfavorable VISN)

32. Additional Data • Meta-analysis of trials to identify program features for use in national guidelines • Performance measure data on ReTIDES sites (pre-post with comparision) • Qualitative data pre-post on sites, consumers • Provider survey data on sites with comparison • Document review with educational theory on provider education approach

33. Standards for QI Research: The SQUIRE Guidelines • Published Oct. 2008 Ogrinc: Quality and Safety in Health Care Davidoff: Annals of Internal Medicine • Provides criteria for quality improvement publication • Used here to look at what types of data need to be incorporated into QI studies • Does TIDES have the data to meet these criteria?

34. TIDES may meet SQUIRE Guidelines