Scale-Up, Spread, and Sustainment of Tele-Collaborative Care: - - PowerPoint PPT Presentation

Scale-Up, Spread, and Sustainment of Tele-Collaborative Care: Lessons Learned from a Model-Guided, Mixed Methods Analysis Mark S. Bauer, MD

VA Center for Healthcare Organization & Implementation Research (CHOIR) & the VA QUERI for Team-Based Behavioral Health

“Telecare is characterized frequently by experimental developments that seem seldom to last beyond the trial

• stage. Some do not even get that far.”

— May et al, JAMIA 2003

“Telemedicine implementations often remain in the pilot phase and do not succeed in scaling-up to robust products that are used in daily practice.”

—Broens et al, J Telemed & Telecare 2007

Public health impact for telehealth?

(tele)Collaborative Chronic Care Models (CCMs)

• CCMs first described by Wagner and colleagues for

medical illnesses. Clinical components:

• Work role redesign for anticipatory care
• Patient self-management enhancement
• Facilitated access to expertise
• Information management
• Substantial evidence also shows effects in serious

mental health conditions like bipolar disorder

• VA health system leadership requested adaption of our

bipolar CCM for clinical video teleconference delivery

Bipolar Disorder: a growing clinical concern

• Almost 90,000 Veterans

treated annually in VA. The number is growing steadily.

• #1 cause of completed

suicide in Veterans.

• Suicide attempts in 1 of 50

patients treated each year.

• Treatment adherence

adequate in < 50% of patients.

• 24% of patients

hospitalized per year.

Bipolar Telehealth program elements

• Based on Life Goals CCM for bipolar disorder (Bauer et al)
• www.lifegoalscc.com
• Funded by VACO Office of Telehealth Services 2011
• Current staffing: 2.6 MD, 2.6 psychologist virtually

collaborating:

• VA Boston
• VA Connecticut
• Bedford (MA) VAMC
• VA National TeleMental Health Center at VA Connecticut

provides administrative infrastructure

Bipolar Telehealth program elements

• Clinical components:
• Comprehensive diagnostic assessment
• Psychopharmacologic consultation
• Life Goals Self-Management Skills Program: Six

manual-based modules covering: goals and values, mania and depression profiles and coping responses, provider visit preparation

• Consult request and response via inter-facility consult in

electronic health record at patient’s site

• CCM delivered via videoconference from expert hub to

patient’s VAMC

Bipolar Telehealth program flow

INTAKE Weekly Life Goals Sessions One-month Life Goals Booster Session to reinforce skills and update status Booster Typical enrollment: 4-6 months Comprehensive Diagnostic Assessment & Psychopharm Consultation

Program evaluation aims & methods

Implementation & sustainability (quantitative)

• RE-AIM framework: Reach, Effectiveness, Adoption,

Implementation, Maintenance → Successful implementation →Review of prospectively collected program utilization data (2011-2016) Barriers & facilitators (qualitative)

• iPARIHS model: Innovation, Recipients, Context (inner &
• uter), Facilitation → Successful implementation

→Qualitative interviews of high/low-use consulting providers (n=16)

Quantitative results: Reach

Quantitative results: Efficacy (1)

(first 129 program completers)

Quantitative results: Efficacy (2)

Quality measure Baseline Termination p-value

Lithium use 106 (35.8%) 154 (52.0%) <0.001 Lithium level obtained (if receiving lithium prescription) 81 (76.4%) 114 (75.5%) 0.88 Antidepressant use 143 (48.3%) 103 (34.8%) <0.001 Prazosin use (if comorbid PTSD diagnosis) 30 (21.9%) 48 (35.0%) 0.02

(first 400 patients)

Quantitative results: Adoption

Quantitative results: Implementation

73.8% of consults completed via CVT 70.6% of those referred for Life Goals completed 10.4 + 3.6 Life Goals sessions for completers 3.8 + 2.6 Life Goals sessions for non- completers

Quantitative results: Maintenance

• 33 of 35 sites (94.3%) still active.
• For sites with 2+ years since start, consults/site

increased after Year 1: median 1730 (p<0.001).

Qualitative results (iPARIHS)

• Innovation
• Consult viewed as valuable clinically
• Recipients
• Alignment with assumed mental models of care

(medications, self-management program)

• Context, inner (at the sites)
• Space, telehealth staff support
• Champion helps
• Context, outer
• Nationwide emphasis on telehealth… and $.
• Facilitation
• National infrastructure  “turnkey” operation for

providers

Summary & conclusions

• Linear growth of sites & patients
• 1+ consult per business day since 2011
• ↑ clinical outcome & quality of care
• Variable penetration across sites
• Participation rates ≈ those for face-to-face Life

Goals clinical trials

• Program maintained in >90% of sites
• Barriers and facilitators not surprising
• How generalizable?
• Lessons learned…

Acknowledgements

Citation:

• Bauer MS et al. Implementing and sustaining team-based tele-

care for bipolar disorder: lessons learned from a model- guided, mixed methods analysis. Telemed & eHealth 2017; epub: PMID 28665773.

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Lois Krawczyk, PhD Aleda Franz, PhD Kathy Tuozzo, MSN Cynthia Brandt, MD Cara Frigand, MPH Meghan Rooney, PsyD Sally Holmes, MBA Jerry Flemming, MS Chris Miller, PhD Eric Smith, MD Erica Abel, PhD Linda Godleski, MD David Osser, MD

Co-authors: