Learning from national implementation of the Veterans Affairs Clinical Resource Hub (CRH) program for improving access to care: protocol for a six year evaluation.

BACKGROUND: The Veterans Affairs (VA) Clinical Resource Hub (CRH) program aims to improve patient access to care by implementing time-limited, regionally based primary or mental health staffing support to cover local staffing vacancies. VA's Office of Primary Care (OPC) designed CRH to support more than 1000 geographically disparate VA outpatient sites, many of which are in rural areas, by providing virtual contingency clinical staffing for sites experiencing primary care and mental health staffing deficits. The subsequently funded CRH evaluation, carried out by the VA Primary Care Analytics Team (PCAT), partnered with CRH program leaders and evaluation stakeholders to develop a protocol for a six-year CRH evaluation. The objectives for developing the CRH evaluation protocol were to prospectively: 1) identify the outcomes CRH aimed to achieve, and the key program elements designed to achieve them; 2) specify evaluation designs and data collection approaches for assessing CRH progress and success; and 3) guide the activities of five geographically dispersed evaluation teams. METHODS: The protocol documents a multi-method CRH program evaluation design with qualitative and quantitative elements. The evaluation's overall goal is to assess CRH's return on investment to the VA and Veterans at six years through synthesis of findings on program effectiveness. The evaluation includes both observational and quasi-experimental elements reflecting impacts at the national, regional, outpatient site, and patient levels. The protocol is based on program evaluation theory, implementation science frameworks, literature on contingency staffing, and iterative review and revision by both research and clinical operations partners. DISCUSSION: Health systems increasingly seek to use data to guide management and decision-making for newly implemented clinical programs and policies. Approaches for planning evaluations to accomplish this goal, however, are not well-established. By publishing the protocol, we aim to increase the validity and usefulness of subsequent evaluation findings. We also aim to provide an example of a program evaluation protocol developed within a learning health systems partnership.

Racial and ethnic disparities in telemental health usage among veterans.

It is essential for mental health services to be equitably accessible and utilized. The literature on mental health service utilization has, to date, been focused largely on in-person care. This quality assurance project evaluated telemental health (TMH) utilization rates among Veterans by race and ethnicity. Following the rapid expansion of TMH in response to the COVID-19 pandemic, we also explored whether TMH use across racial and ethnic Veteran groups changed after the onset of the pandemic. Using chi-square analyses, we compared the observed race and ethnicity of Veterans receiving TMH to the expected race and ethnicity of Veterans receiving TMH, controlling for rurality. We found that TMH was not being utilized by all racial and ethnic groups within the Veteran population as would be expected, both before and during the pandemic. Improvements were noted during the pandemic when much of outpatient mental health care was converted to telehealth. The strengths and limitations of this project, recommendations for TMH, and potential future directions are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Designing and Implementing TeleBehavioral Health Training to Support Rapid and Enduring Transition to Virtual Care in the COVID Era.

As telebehavioral health continues to advance and become part of routine care, there is a need to develop effective training methods. While a consensus on how to best train telebehavioral health has not yet been achieved, this commentary will describe how evidence-based implementation strategies were used to develop a framework to create and implement a telebehavioral health training program that is relevant and enduring for a given audience. Evidence-based implementation strategies included the PARiHS criteria which were used to organize the project. Re-AIM criteria was used to organize chosen outcome measures. Important partnerships were formed to help support infrastructure as well as regional and national reach. A series of Plan-Do-Study-Act loops were used to inform progressive training series. Since April 2020, the Behavioral Health Institute has developed and offered 6 unique telebehavioral health training series, employing both webinar and online formats, and addressing core components as well as more advanced concepts. These series have provided over 19,100 accredited continuing education hours of training through June 2022, to almost 3000 unique learners via webinar and nearly 6800 unique online learners, across 45 states. Evaluations rated these trainings as high quality, relevant, and that material would likely be implemented. Feedback from attendees was considered vital in series planning. This commentary discusses how evidence-based implementation strategies can be used to create a framework upon which to base a training program for health care providers. An example is given on how this framework was used to create successful, relevant, and enduring telebehavioral health training.

A comparison of patient-reported mental health outcomes for the Department of Veterans Affairs' regional telehealth and Community Care Programs.

OBJECTIVES: To compare patient-reported outcomes for veterans with limited access to Department of Veterans Affairs (VA) mental health services referred to the Veterans Community Care Program (VCCP) or regional telehealth Clinical Resource Hubs-Mental Health (CRH-MH). DATA SOURCES: This national evaluation used secondary data from the VA Corporate Data Warehouse, chart review, and primary data collected by baseline survey between October 8, 2019 and May 27, 2020 and a 4-month follow-up survey. STUDY DESIGN: A quasi-experimental longitudinal study design was used to sample 545 veterans with VCCP or CRH-MH referrals for new treatment episodes. Patient-reported outcomes included symptom severity, perceived access, utilization, and patient-centeredness. DATA COLLECTION: During the baseline and follow-up surveys, all veterans were administered the Patient Health Questionnaire-8 (PHQ-8) to assess depression severity, and veterans with a provisional diagnosis of posttraumatic stress disorder (PTSD) were also administered the PTSD Checklist for DSM-5 (PCL-5) to assess PTSD symptom severity. The 4-month follow-up survey also asked about perceived access using the Perceived Access Inventory, the number of encounters, and patient-centeredness of care using the Patient-Centered Care portion of the Veterans Satisfaction Survey. PRINCIPAL FINDINGS: Results indicated that compared to VCCP consults, veterans with CRH-MH consults reported 0.65 (CI95  = 0.51-0.83, p < 0.01) times the number of barriers to care, but a non-significant lower number of encounters (-0.792, CI95 -2.221, 0.636, p = 0.28). There was no significant (p = 0.24) difference in satisfaction with patient-centeredness, with both groups "agreeing" on average to positively worded questions. Veterans in both groups experienced little improvement in depression or PTSD symptom severity, and there were no clinically meaningful differences between groups. CONCLUSIONS: Overall findings indicate that the CRH-MH and VCCP generate similar patient-reported outcomes. Future research should compare the quality and cost of care delivered by the VCCP and CRH-MH programs.

Brief Cognitive-Behavioral Therapy for Suicide Prevention (BCBT-SP) via Video Telehealth: A Case Example During the COVID-19 Outbreak.

Although veterans living in remote/rural areas are at elevated risk for suicide, there is very little research specific to treating suicidal veterans who present with barriers to in-person care. The current study aims to examine the delivery of brief cognitive-behavioral therapy for suicide prevention (BCBT-SP) via Clinical Video Telehealth (CVT) to the home of a veteran discharged from the psychiatric inpatient unit after a recent suicide attempt. Preliminary data on acceptability, feasibility, and changes in symptoms were gathered. The veteran received treatment during the 2020 COVID-19 outbreak and additional adaptations were made accordingly. The veteran did not engage in any suicidal behavior during the course of treatment, and suicidal ideation, depression, and anxiety decreased as treatment progressed. The results provide initial support for the feasibility of BCBT-SP via CVT to the home.

Posttraumatic stress disorder collaborative care: A quality improvement study in veterans affairs primary care.

Introduction: Collaborative care improves depression and anxiety outcomes. In this naturalistic, observational case study, we adapted an evidence-based depression collaborative care protocol for the assessment and treatment of posttraumatic stress disorder (PTSD) and sought to demonstrate that the protocol could be implemented in Veterans Affairs (VA) primary care. Method: Based on feedback from a content expert panel, clinical stakeholders, and a pilot study conducted in a postdeployment clinic, the original depression collaborative care protocol was modified to include PTSD assessment and support for PTSD medication adherence, self-management, and engagement in evidence-based PTSD care. Results: The modified program was implemented from November 2012 to March 2017, and 239 patients with PTSD were referred. Nearly two thirds (n = 185) enrolled, and they participated in the program for an average of 4 to 5 months and completed calls approximately once per month. Among patients with more than one assessment of clinical outcomes, 53.4% (n = 94) reported clinically significant improvement in depression on the Patient Health Questionnaire-9 (≥ 5-point decrease), and 42.2% (n = 35) reported clinically significant improvement on the PTSD Checklist (≥ 10-point decrease). Veterans and clinical staff described the modified collaborative care program positively in qualitative interviews. Discussion: Our findings suggest that a depression collaborative care program can be modified to support treatment of PTSD in primary care. The modified program was acceptable to both veterans and clinical staff and showed potential for positive clinical change in an uncontrolled quality improvement study. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Implementation of a Telemental Health Training Program Across a Mental Health Department.

Introduction: Telemental health (TMH) has increased substantially. However, health care systems have found it challenging to implement TMH ubiquitously. A quality improvement project guided by implementation science methodology was used to design and implement a TMH training program. Materials and Methods: Implementation science methodology (Promoting Access to Research Implementation in Health Services, Reach-Effectiveness-Adoption-Implementation-Maintenance, Implementation/Facilitation) provided the framework to design and implement the training program. A total of 100 interdisciplinary mental health providers from outpatient mental health clinics participated. Results: Providers reported satisfaction with the training program. Results indicated that the training increased providers' TMH knowledge and competence. The number of providers using TMH and patients who received TMH nearly doubled. Conclusions: Implementation science methodology was important in creating an organizational framework at this facility to design, evaluate, and implement an innovative TMH training program.

Telemental health training in the Veterans Administration Puget Sound Health Care System.

As a pioneer of training in the field of psychology, the Veterans Affairs (VA) HealthCare System serves as a leader in the training in and provision of Telemental Health (TMH) services in the United States. To meet goals toward continued expansion of these services, the VA TMH training program includes both web-based didactic courses and a skills competency test at a basic level with supervision and consultation in TMH for more advanced training and is available to staff psychologists and psychologist trainees. Despite these efforts, barriers for training in and implementation of TMH occur at the provider, system, and patient level. At the national level, the VA is actively working to resolve these barriers and we share site-specific examples implemented by the VA Puget Sound Health Care System promoting access through TMH team to further address barriers to training and implementation.

Recommendations for Using Clinical Video Telehealth with Patients at High Risk for Suicide.

There is increasing evidence that the delivery of mental health services via clinical video telehealth (CVT) is an effective means of providing services to individuals with access barriers, such as rurality. However, many providers have concerns about working with individuals at risk for suicide via this modality, and many clinical trials have excluded individuals with suicide risk factors. The present article reviews the literature, professional guidelines, and laws that pertain to the provision of mental health services via CVT with high-risk patients and provides suggestions for adapting existing best-practice recommendations for assessing and managing suicide risk to CVT delivery.

Practical and Regulatory Considerations of Teleprescribing via CVT.

PURPOSE OF REVIEW: Clinical video teleconferencing (CVT) represents a robust mechanism for more accessible medical care. Providers who practice medicine via CVT, including teleprescribing, should understand a number of core practical and regulatory factors. This paper aims to review these core factors, such that providers new to CVT may offer teleprescribing services in a manner consistent with current clinical standards and regulatory requirements. RECENT FINDINGS: A number of practical factors relate to the setup and delivery of teleprescribing services that are contextually influenced by federal and state law. This review will elucidate the practical and regulatory factors relevant to teleprescribing and encourage the use of CVT for patient care. Through consideration of these factors, providers may better implement teleprescribing and prepare for future technology and policy changes relevant to practice.

A pilot trial of telephone-based collaborative care management for PTSD among Iraq/Afghanistan war veterans.

BACKGROUND: Collaborative care and care management are cornerstones of Primary Care-Mental Health Integration (PC-MHI) and have been shown to reduce depressive symptoms. Historically, the standard of Veterans Affairs (VA) collaborative care was referring patients with posttraumatic stress disorder (PTSD) to specialty care. Although referral to evidence-based specialty care is ideal, many veterans with PTSD do not receive such care. To address this issue and reduce barriers to care, VA currently recommends veterans with PTSD be offered treatment within PC-MHI as an alternative. The current project outlines a pilot implementation of an established telephone-based collaborative care model-Translating Initiatives for Depression into Effective Solutions (TIDES)-adapted for Iraq/Afghanistan War veterans with PTSD symptoms (TIDES/PTSD) seen in a postdeployment primary care clinic. MATERIALS AND METHODS: Structured medical record extraction and qualitative data collection procedures were used to evaluate acceptability, feasibility, and outcomes. RESULTS: Most participants (n=17) were male (94.1%) and white (70.6%). Average age was 31.2 (standard deviation=6.4) years. TIDES/PTSD was successfully implemented within PC-MHI and was acceptable to patients and staff. Additionally, the total number of care manager calls was positively correlated with number of psychiatry visits (r=0.63, p<0.05) and amount of reduction in PTSD symptoms (r=0.66, p<0.05). Overall, participants in the pilot reported a significant reduction in PTSD symptoms over the course of the treatment (t=2.87, p=0.01). CONCLUSIONS: TIDES can be successfully adapted and implemented for use among Iraq/Afghanistan veterans with PTSD. Further work is needed to test the effectiveness and implementation of this model in other sites and among veterans of other eras.

VA Puget Sound Telemental Health Service to rural veterans: a growing program.

The VA Puget Sound Health Care System Telemental Health program connects veterans with psychologists, psychiatrists, and social workers via live clinical video teleconferencing. Providers deliver care to veterans in rural Veteran Affairs medical centers, community-based outpatient clinics and residences, and thus, increase access to specialty mental health care for rural and medically underserved veteran communities.

Suicide risk management: development and analysis of a telephone-based approach to patient safety.

Research-based queries about patients' experiences often uncover suicidal thoughts. Human subjects review requires suicide risk management (SRM) protocols to protect patients, yet minimal information exists to guide researchers' protocol development and implementation efforts. The purpose of this study was to examine the development and implementation of an SRM protocol employed during telephone-based screening and data collection interviews of depressed primary care patients. We describe an SRM protocol development process and employ qualitative analysis of de-identified documentation to characterize protocol-driven interactions between research clinicians and patients. Protocol development required advance planning, training, and team building. Three percent of screened patients evidenced suicidal ideation; 12% of these met protocol standards for study clinician assessment/intervention. Risk reduction activities required teamwork and extensive collaboration. Research-based SRM protocols can facilitate patient safety by (1) identifying and verifying local clinical site approaches and resources and (2) integrating these features into prevention protocols and training for research teams.

Prevalence of depression-PTSD comorbidity: implications for clinical practice guidelines and primary care-based interventions.

BACKGROUND: Compared to those with depression alone, depressed patients with posttraumatic stress disorder (PTSD) experience more severe psychiatric symptomatology and factors that complicate treatment. OBJECTIVE: To estimate PTSD prevalence among depressed military veteran primary care patients and compare demographic/illness characteristics of PTSD screen-positive depressed patients (MDD-PTSD+) to those with depression alone (MDD). DESIGN: Cross-sectional comparison of MDD patients versus MDD-PTSD+ patients. PARTICIPANTS: Six hundred seventy-seven randomly sampled depressed patients with at least 1 primary care visit in the previous 12 months. Participants composed the baseline sample of a group randomized trial of collaborative care for depression in 10 VA primary care practices in 5 states. MEASUREMENTS: The Patient Health Questionnaire-9 assessed MDD. Probable PTSD was defined as a Primary Care PTSD Screen > or = 3. Regression-based techniques compared MDD and MDD-PTSD+ patients on demographic/illness characteristics. RESULTS: Thirty-six percent of depressed patients screened positive for PTSD. Adjusting for sociodemographic differences and physical illness comorbidity, MDD-PTSD+ patients reported more severe depression (P < .001), lower social support (P < .001), more frequent outpatient health care visits (P < .001), and were more likely to report suicidal ideation (P < .001) than MDD patients. No differences were observed in alcohol consumption, self-reported general health, and physical illness comorbidity. CONCLUSIONS: PTSD is more common among depressed primary care patients than previously thought. Comorbid PTSD among depressed patients is associated with increased illness burden, poorer prognosis, and delayed response to depression treatment. Providers should consider recommending psychotherapeutic interventions for depressed patients with PTSD.

Developing effective collaboration between primary care and mental health providers.

OBJECTIVE: Improving care for depressed primary care (PC) patients requires system-level interventions based on chronic illness management with collaboration among primary care providers (PCPs) and mental health providers (MHPs). We describe the development of an effective collaboration system for an ongoing multisite Department of Veterans Affairs (VA) study evaluating a multifaceted program to improve management of major depression in PC practices. METHOD: Translating Initiatives for Depression into Effective Solutions (TIDES) is a research project that helps VA facilities adopt depression care improvements for PC patients with depression. A regional telephone-based depression care management program used Depression Case Managers (DCMs) supervised by MHPs to assist PCPs with patient management. The Collaborative Care Workgroup (CWG) was created to facilitate collaboration between PCPs, MHPs, and DCMs. The CWG used a 3-phase process: (1) identify barriers to better depression treatment, (2) identify target problems and solutions, and (3) institutionalize ongoing problem detection and solution through new policies and procedures. RESULTS: The CWG overcame barriers that exist between PCPs and MHPs, leading to high rates of the following: patients with depression being followed by PCPs (82%), referred PC patients with depression keeping their appointments with MHPs (88%), and PC patients with depression receiving antidepressants (76%). The CWG helped sites implement site-specific protocols for addressing patients with suicidal ideation. CONCLUSION: By applying these steps in PC practices, collaboration between PCPs and MHPs has been improved and maintained. These steps offer a guide to improving collaborative care to manage depression or other chronic disorders within PC clinics.

The influence of patient preference on depression treatment in primary care.

BACKGROUND: The chronic illness model encourages consideration of patients' treatment preferences. Moreover, research suggests that matching treatment to preference might affect outcomes for patients with depression. PURPOSE: This investigation explored factors associated with treatment preference matching and the effects of matching on depression treatment outcomes. METHODS: Treatment preferences were assessed among primary care patients with depression participating in a large randomized trial of depression management. Patients were offered antidepressant medication and/or counseling based on preference and several other factors. Depression was assessed at 3 and 9 months. RESULTS: Participants who preferred medication were older, were in worse physical health, and were more likely to already be taking antidepressants. Participants who preferred both medication and counseling evidenced greater agreement with the statement that depression is a medical illness. Overall, 72% of participants were matched with their preferred treatment; matched participants demonstrated more rapid improvement in depression symptomatology than unmatched participants. CONCLUSIONS: Obtaining preferred treatment appears to contribute to improved treatment outcome. Continued attempts to assess for and accommodate treatment preferences might result in better response to depression treatment.

Preliminary outcomes from an integrated mental health primary care team.

The effects of establishing a multidisciplinary mental health primary care team in a Veterans Affairs internal medicine primary care clinic were evaluated. The multidisciplinary team worked in collaboration with primary care providers to evaluate and treat their patients, who had a wide variety of psychiatric disorders, in the primary care clinic. In the first year of operation preliminary outcomes indicated that the rate of referrals to specialty mental health care dropped from 38 percent to 14 percent. The mean number of appointments with the team for evaluation and stabilization was 2.5. These outcomes suggest that a multidisciplinary mental health primary care team can rapidly evaluate and stabilize patients with a wide range of psychiatric disorders, reduce the number of referrals to specialty mental health care, and improve collaborative care.