Implementing and Sustaining Team-Based Telecare for Bipolar Disorder: Lessons Learned from a Model-Guided, Mixed Methods Analysis.

BACKGROUND: Telemental health interventions have empirical support from clinical trials and structured demonstration projects. However, their implementation and sustainability under less structured clinical conditions are not well demonstrated. INTRODUCTION: We conducted a follow-up analysis of the implementation and sustainability of a clinical video teleconference-based collaborative care model for individuals with bipolar disorder treated in the Department of Veterans Affairs to (a) characterize the extent of implementation and sustainability of the program after its establishment and (b) identify barriers and facilitators to implementation and sustainability. MATERIALS AND METHODS: We conducted a mixed methods program evaluation, assessing quantitative aspects of implementation according to the Reach, Efficacy, Adoption, Implementation, and Maintenance implementation framework. We conducted qualitative analysis of semistructured interviews with 16 of the providers who submitted consults, utilizing the Integrated Promoting Action on Research Implementation in the Health Services implementation framework. RESULTS: The program demonstrated linear growth in sites (n = 35) and consults (n = 915) from late 2011 through mid-2016. Site-based analysis indicated statistically significant sustainability beyond the first year of operation. Qualitative analysis identified key facilitators, including consult content, ease of use via electronic health record, and national infrastructure. Barriers included availability of telehealth space, equipment, and staff at the sites, as well as the labor-intensive nature of scheduling. DISCUSSION: The program achieved continuous growth over almost 5 years due to (1) successfully filling a need perceived by providers, (2) developing in a supportive context, and (3) receiving effective facilitation by national and local infrastructure. CONCLUSION: Clinical video teleconference-based interventions, even multicomponent collaborative care interventions for individuals with complex mental health conditions, can grow vigorously under appropriate conditions.

Team-Based Telecare for Bipolar Disorder.

INTRODUCTION: Numerous randomized controlled trials indicate that collaborative chronic care models improve outcome in a wide variety of mental health conditions, including bipolar disorder. However, their spread into clinical practice is limited by the need for a critical mass of patients and specialty providers in the same locale. Clinical videoconferencing has the potential to overcome these geographic limitations. MATERIALS AND METHODS: A videoconference-based collaborative care program for bipolar disorder was implemented in the Department of Veterans Affairs. Program evaluation assessed experience with the first 400 participants, guided by five domains specified by the American Telemedicine Association: treatment engagement, including identification of subpopulations at risk for not being reached; participation in treatment; clinical impact; patient safety; and quality of care. RESULTS: Participation rates resembled those for facility-based collaborative care. No participant characteristics predicted nonengagement. Program completers demonstrated significant improvements in several clinical indices, without evidence of compromise in patient safety. Guideline-based quality of care assessment after 1 year indicated increased lithium use, decreased antidepressant use, and increased prazosin use in individuals with comorbid post-traumatic stress disorder, but no impact on already high rates of lithium serum level monitoring. DISCUSSION: Clinical videoconferencing can extend the reach of collaborative care models for bipolar disorder. The next step involves assessment of the videoconference-based collaborative care for other serious mental health conditions, investigation of barriers and facilitators of broad implementation of the model, and evaluation of the business case for deployment and sustainability in clinical practice.

Corelease of bioactive VEGF and HGF from viscous liquid poly(5-ethylene ketal ε-caprolactone-co-D,L-lactide).

The potential of a viscous liquid injectable delivery system composed of poly(5-ethylene ketal ε-caprolactone-co-D,L-lactide) (PEKCDLLA) to release bioactive vascular endothelial growth factor (VEGF) and hepatocyte growth factor (HGF) using an osmotic pressure release mechanism for the purpose of treating critical limb ischemia was investigated. VEGF and HGF were lyophilized separately with trehalose and bovine serum albumin (BSA) and incorporated into the polymer by simple mixing. VEGF and HGF were released by convective flow through superhydrated regions formed within the polymer as a result of the osmotic activity generated upon dissolution of the particles, along with the contributions of polymer degradation at later time points. A sustained release of highly bioactive VEGF and HGF for over 40 days with minimal burst was achieved under conditions of multidirectional delivery. The solubility of the growth factors in the concentrated trehalose solution formed upon dissolution of the particle within the polymer was determined to be a key parameter governing the rate and extent of growth factor release. This formulation approach, of using a low viscosity polymer delivery vehicle, is potentially useful for localized delivery of acid and temperature sensitive proteins, such as VEGF and HGF. This system may also serve as a platform for controlled and predictable delivery patterns for other therapeutic proteins in other clinical settings.

Home telemental health implementation and outcomes using electronic messaging.

In 2007, the VA Connecticut Healthcare System began a home electronic messaging programme for mental health patients. During the first two years, 76 patients with diagnoses of schizophrenia, post traumatic stress disorder, depression and substance-use disorders received a home messaging device, which was connected via an ordinary telephone line. There were daily questions, which were based on disease management protocols, and included alerts, data and educational components. Patient data were sent to a nurse practitioner each day for triage and follow-up. Patients used the device for at least six months. In the six months prior to enrolment, 42 patients were hospitalized for 46 admissions. In the following six months, six patients were hospitalized for nine admissions (P < 0.0001). In the six months prior to enrolment, 47 patients had a total of 80 ER visits. In the following six months, 16 patients had a total of 32 ER visits (P < 0.0001). Questionnaire responses indicated a high level of satisfaction with the home messaging programme.