Implementing a Blended Care Model That Integrates Mental Healthcare and Primary Care Using Telemedicine and Care Management for Patients With Depression or Alcohol Use Disorder in Small Primary Care Clinics
| Status: | Enrolling by invitation |
|---|---|
| Conditions: | Depression, Depression, Psychiatric |
| Therapuetic Areas: | Psychiatry / Psychology |
| Healthy: | No |
| Age Range: | 18 - Any |
| Updated: | 3/24/2019 |
| Start Date: | July 25, 2017 |
| End Date: | February 1, 2021 |
Adapting and Implementing the Blended Collaborative Care Model in CBOCs
Integrating mental health treatments into the primary care delivered at Community Based
Outpatient Clinics(CBOCs) that are geographically accessible to rural Veterans is a major
priority for the Department of Veterans Affairs. However, there is no scientific evidence
that integrating mental health and primary care is clinically effective at smaller CBOCs that
have limited mental health staffing. The goal of this proposed project is to implement a
"blended" combination of integrated care models that have been adapted for smaller CBOCs
using telemedicine technologies, and evaluate the acceptability and effectiveness of the
blended, telemedicine-based, integrated care model. If clinical outcomes are improved
compared to usual care, findings will be used to justify and facilitate the implementation of
this telemedicine-based integrated care model at smaller CBOCs in order to increase rural
Veterans' access to effective mental health treatments.
Outpatient Clinics(CBOCs) that are geographically accessible to rural Veterans is a major
priority for the Department of Veterans Affairs. However, there is no scientific evidence
that integrating mental health and primary care is clinically effective at smaller CBOCs that
have limited mental health staffing. The goal of this proposed project is to implement a
"blended" combination of integrated care models that have been adapted for smaller CBOCs
using telemedicine technologies, and evaluate the acceptability and effectiveness of the
blended, telemedicine-based, integrated care model. If clinical outcomes are improved
compared to usual care, findings will be used to justify and facilitate the implementation of
this telemedicine-based integrated care model at smaller CBOCs in order to increase rural
Veterans' access to effective mental health treatments.
Background: Providing mental health care to rural Veterans in geographically accessible
Community Based Outpatient Clinics (CBOCs) is a major priority of the Office of Rural Health.
Likewise, integrating mental health into primary care is one of the highest priorities of the
Office of Mental Health Services and the Office of Mental Health Operations. The Uniform
Mental Health Services Handbook mandates the blending of the two predominant, evidence-based
models of integrated care (the Care Management model and the Co-Located model) at VAMCs, very
large CBOCs, and large CBOCs. Because there is no scientific evidence to support its
implementation, the "Blended model" is not mandated at medium CBOCs or small CBOCs that serve
rural Veterans. At most smaller CBOCs, on-site mid-level providers and/or off-site
tele-psychiatrists and tele-psychologists deliver traditional referral-based specialty
treatment (Referral model) rather than integrated care.
Objective: This project contributes to Specific Aim 3 (Test clinical interventions to improve
quality and outcomes of mental health care at CBOCs) of the Little Rock CREATE application.
The goal of this proposed Hybrid Type 2 pragmatic effectiveness-implementation trial is to
generate the scientific evidence needed to justify the national dissemination of the Blended
model adapted using telemedicine technologies to accommodate the clinical context of smaller
CBOCs that lack on-site psychiatrists and PhD psychologists. The resulting Telemedicine
Blended model will be compared to usual care (Referral model) in a pragmatic trial, where the
intervention will be delivered via interactive video by centrally located clinical staff and
fidelity will be monitored but not controlled. Specific Aim 1: Use an expert panel comprised
of clinical providers and managers who are applying telemedicine to provide a Blended model
for CBOCs lacking on-site PhD psychologists and psychiatrists to document the core components
of a Telemedicine Blended model and using a PDSA process, implement this model in six CBOCs.
Specific Aim 2: Conduct a Hybrid Type 2 pragmatic effectiveness-implementation trial of the
adapted Telemedicine Blended model by assessing RE-AIM outcomes including: provider Reach
into the patient population, Effectiveness at improving clinical outcomes, Adoption by
providers and Implementation Fidelity.
Methods: In conjunction with national, regional and local partners, including providers and
managers who have experience with the Telemedicine Blended model, the Blended model will be
adapted for smaller CBOCs using telemedicine technologies and pilot tested to generate a
standardized treatment protocol. We will use a stepped wedge design with randomization of
sites to sequential implementation steps, and CBOC patients who screen positive for
depression or alcohol disorders will be recruited and consented to participate in the Hybrid
Type 2 pragmatic effectiveness-implementation trial. Data about Reach and Adoption will be
obtained from the Corporate Data Warehouse. Data about Implementation Fidelity will be
obtained from chart review. Data about clinical Effectiveness will be obtained from telephone
survey.
Impact: If the Telemedicine Blended model improves clinical outcomes compared to usual care,
results will be used to justify and facilitate the implementation of the Telemedicine Blended
model at smaller CBOCs.
Community Based Outpatient Clinics (CBOCs) is a major priority of the Office of Rural Health.
Likewise, integrating mental health into primary care is one of the highest priorities of the
Office of Mental Health Services and the Office of Mental Health Operations. The Uniform
Mental Health Services Handbook mandates the blending of the two predominant, evidence-based
models of integrated care (the Care Management model and the Co-Located model) at VAMCs, very
large CBOCs, and large CBOCs. Because there is no scientific evidence to support its
implementation, the "Blended model" is not mandated at medium CBOCs or small CBOCs that serve
rural Veterans. At most smaller CBOCs, on-site mid-level providers and/or off-site
tele-psychiatrists and tele-psychologists deliver traditional referral-based specialty
treatment (Referral model) rather than integrated care.
Objective: This project contributes to Specific Aim 3 (Test clinical interventions to improve
quality and outcomes of mental health care at CBOCs) of the Little Rock CREATE application.
The goal of this proposed Hybrid Type 2 pragmatic effectiveness-implementation trial is to
generate the scientific evidence needed to justify the national dissemination of the Blended
model adapted using telemedicine technologies to accommodate the clinical context of smaller
CBOCs that lack on-site psychiatrists and PhD psychologists. The resulting Telemedicine
Blended model will be compared to usual care (Referral model) in a pragmatic trial, where the
intervention will be delivered via interactive video by centrally located clinical staff and
fidelity will be monitored but not controlled. Specific Aim 1: Use an expert panel comprised
of clinical providers and managers who are applying telemedicine to provide a Blended model
for CBOCs lacking on-site PhD psychologists and psychiatrists to document the core components
of a Telemedicine Blended model and using a PDSA process, implement this model in six CBOCs.
Specific Aim 2: Conduct a Hybrid Type 2 pragmatic effectiveness-implementation trial of the
adapted Telemedicine Blended model by assessing RE-AIM outcomes including: provider Reach
into the patient population, Effectiveness at improving clinical outcomes, Adoption by
providers and Implementation Fidelity.
Methods: In conjunction with national, regional and local partners, including providers and
managers who have experience with the Telemedicine Blended model, the Blended model will be
adapted for smaller CBOCs using telemedicine technologies and pilot tested to generate a
standardized treatment protocol. We will use a stepped wedge design with randomization of
sites to sequential implementation steps, and CBOC patients who screen positive for
depression or alcohol disorders will be recruited and consented to participate in the Hybrid
Type 2 pragmatic effectiveness-implementation trial. Data about Reach and Adoption will be
obtained from the Corporate Data Warehouse. Data about Implementation Fidelity will be
obtained from chart review. Data about clinical Effectiveness will be obtained from telephone
survey.
Impact: If the Telemedicine Blended model improves clinical outcomes compared to usual care,
results will be used to justify and facilitate the implementation of the Telemedicine Blended
model at smaller CBOCs.
Inclusion Criteria:
- The investigators will enroll Veterans who screen positive on routinely administered
VA mental health screens for depressive disorders, alcohol use disorders, and PTSD at
the 6 study CBOCs.
Exclusion Criteria:
- Patients receiving specialty mental health treatment in the 6 months prior to
recruitment and those who have a diagnosis of PTSD
- Those with a diagnosis of substance dependence
- Those with a psychotic disorder diagnosis:
- schizophrenia
- bipolar disorder
- other psychotic disorders
We found this trial at
1
site
2200 Fort Roots Drive
North Little Rock, Arkansas 72114
North Little Rock, Arkansas 72114
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