The Role of Health Services Research in a Learning Healthcare System
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The document discusses the essential role of health services research (HSR) in improving mental healthcare quality and accessibility within the Veterans Health Administration. It identifies key questions to address gaps in care and presents models such as collaborative care and tele-mental health to enhance service delivery and patient outcomes. The findings underscore that effective HSR is crucial for implementing high-value, evidence-based treatments to optimize care for veterans with mental health issues.
The Role of Health Services Research in a Learning Healthcare System
- 1. The Role of Health Services Research In a Learning Healthcare System The Path To High Value Care David Atkins, MD, MPH Acting Director, HSRD Health Services Research and Development VETERANS HEALTH ADMINISTRATION
- 2. Acknowledgements • Amy Kilbourne, PhD, MPH – Associate Director, VA National Serious Mental Illness Treatment Resource and Evaluation Center – Associate Professor of Psychiatry, University of Michigan • JoAnn Kirchner, MD – Director, VA Mental Health QUERI – Core Investigator, VA Center for Mental Healthcare and Outcomes Research – Professor, Department of Psychiatry, College of Medicine, and Associate Professor, Maternal & Child Health, College of Public Health, University of Arkansas for Medical Sciences • Lisa Rubenstein, MD, MSPH – Director, VA Center for Implementation Practice and Research Support – Professor of Medicine, VA Greater Los Angeles and UCLA – Senior Natural Scientist, RAND • Edward Post, MD, PhD – National Medical Director, Primary Care-Mental Health Integration – Assistant Professor, Department of Internal Medicine, University of Michigan School of Medicine VETERANS HEALTH ADMINISTRATION 1
- 3. Five HSR Questions to Guide National Efforts to Improve Quality and Value • Where is there room to improve quality/lower costs? • Why do gaps in quality of care exist ? • What new models of care can improve quality? • Will the new model of care provide good value ? • How can we spread effective models or interventions to more patients/more quickly ? VETERANS HEALTH ADMINISTRATION 2
- 4. 1. Where Should We Focus Efforts to Improve Quality: Mental Health Care 1990 • Serious mental illnesses, including PTSD, major depression, bipolar disorder, schizophrenia affect 1 in 4 veterans1. • Mental disorders complicate treatment of medical disorders – Cardiovascular diseases major cause of mortality in SMI2 1 (Watkins KE et al., Health Aff 2011) VETERANS HEALTH ADMINISTRATION 2 (Kilbourne AM et al., Gen Hosp Psychiatry 2009) 3
- 5. 2. Why Were There Gaps in Quality? Findings from Health Services Research in VA • Patients faced challenges accessing mental health care, adhering to treatment, and staying engaged in care – Stigma, remote location, other patient factors • Primary care clinicians lacked skills to provide optimal care and follow-up for patients with depression • Lack of coordination across medical and psychiatric providers • Lack of guidance for providers on how to integrate medical and mental health services (Oslin et al, J Gen Intern Med 2006) VETERANS HEALTH ADMINISTRATION 4
- 6. 3. What New Models Can Improve Access to and Quality of MH Care? Collaborative Chronic Care Model (CCM) • Nurse care managers link primary care to MH care • Outreach to patients, monitoring of treatment Primary Care/Mental Health Integration • Co-location of general medical clinics and mental health programs Tele-Mental Health for Rural Veterans • Provides remote access to MH specialists Outreach to Re-engage Patients Lost to Follow-up VETERANS HEALTH ADMINISTRATION 5
- 7. Outcomes of Collaborative Care at 6 Months Translating Initiatives for Depression into Effective Solutions (TIDES) • 82% of patients are able to be treated for depression in primary care • 90% of Primary Care patients had resolution of depressive symptoms • 89% remain in care, 74% remain on medication, 90% clinical appointments kept (Rubenstein et al., Fam Syst Health 2010) VETERANS HEALTH ADMINISTRATION 6
- 8. Depression Severity (PHQ-9) Following Collaborative Care Enrolment 14 12.4 12 10 7.3 8 5.8 6 4.8 4 2 0 Baseline 4-6 Wks 8-12 Wks 24 Wks (Rubenstein et al., Fam Syst Health 2010) VETERANS HEALTH ADMINISTRATION
- 9. Tele-mental Health for Veterans with PTSD • Rural patients have trouble getting psychological counseling for PTSD due to distance from VAMC • Randomized trial compared videoconference- based vs. in-person cognitive behavioral therapy for anger management in Veterans with PTSD • Patients using video-conference had slightly greater improvement in anger symptoms, similar satisfaction and equally effective relationship with therapist. (Morland et al J Clinical Psych 2010) VETERANS HEALTH ADMINISTRATION 8
- 10. Outreach Program for Veterans with Serious Mental Illness Lost to Care • 4,791 Veterans lost to care – 69% contacted • Typically male, middle-aged, unmarried • 72% of those returned to VA care by 2009 • All-cause mortality through 2009 (N=3,315): Returned for care 0.3% Did not return for care 3.9% 6-fold decreased risk of mortality among Veterans returning for care VETERANS HEALTH ADMINISTRATION (Davis CL, Kilbourne AM, et al. AJPH March 2012) Davis, Kilbourne, et al. AJPH 2012
- 11. 4. Will A New Model of Care Provide Good Value? • Collaborative Care for Mental Health • 13 studies showed improved health outcomes at comparable costs to usual care • Tele- mental health • No net increase in costs from providing MH services through videoconferencing (Woltmann et al, Am J Psych 2012) VETERANS HEALTH ADMINISTRATION
- 12. 5. How Can We Spread Effective Models More Quickly? Collaborative Care for Depression TIDES WAVES ReTIDES Bridge to Implementation COVES Implementation National Rollout Trial Evaluations Trial Leadership Planning Patient Sustain- VISN 23 Guidelines & Outcomes ability Depression Measures Collaborative VISN 10 Costs Spread Education & Care Trials VISN 16 Training Barriers Tools Decision Support Adaptation to VA, 1st-generation 2nd-generation Implementation sites sites 1995-2001 2001-2002 2002-2005 2006-2009 2009-Present VETERANS HEALTH ADMINISTRATION
- 13. A 2012 Model Of Veteran Mental Healthcare that Promotes Access, Quality and Value • Blending care service lines • Specialty Treatment (e.g., PTSD, SMI, SUD) • Homeless Program to enhance access and • Psychosocial Rehabilitation and availability to specialty Recovery Program • Inpatient Psychiatric Care care. • Evaluation and Treatment for Mild to Moderate MH Conditions • Assist with PC and Specialty MH Referrals • Integrated Care for Physical and MH • Screening for MH Conditions • Co-management of care • Begin Pharmacological Rx VETERANS HEALTH ADMINISTRATION (Post EP et al., Fam Syst Health 2010) 12
- 14. Trends in Quarterly PC-MHI Service Utilization 1st Quarter FY08 – 3rd Quarter FY12 200,000 Cumulative 180,000 encounters to 160,000 8/31/12: 2,269,641 140,000 120,000 100,000 Encounters 80,000 Unique Patients 60,000 40,000 New Patients 20,000 0 VETERANS HEALTH ADMINISTRATION
- 15. Improvements in Performance Measures FY2008-FY2011 100% 90% 80% 70% 60% FY08 50% FY09 40% FY10 30% FY11 20% 10% 0% AUDIT-C PC-PTSD MDD Following + PC- Following + Brief Alcohol Timely > + PTSD Timely > + PHQ- Screening Screening Screening PTSD Screen Annual Counseling >5 Screen 2, +PHQ-9, or Depression Misuse Screen q9 on PHQ-9 Screen Screening Measures Suicide Risk Disposition Measures Evaluation Measures VETERANS HEALTH ADMINISTRATION
- 16. Conclusions • Discovering effective treatments isn’t sufficient for providing high value healthcare • Health services research identifies ways to ensure the right treatments are delivered in a reliable, timely, and efficient manner to the right patients • Health services research is an essential component of the learning healthcare system VETERANS HEALTH ADMINISTRATION 15