Transcript WRNMMC Directorate of Behavioral Health Grand Rounds

2016 AMSUS Annual Meeting
Effect of Centralized Care Coordination on
Treatment Continuity and Quality: Findings and
Case Series Presentation
Brad Belsher, PhD
Chief of Research Translation and Integration
Deployment Health Clinical Center, Defense Center of Excellence for PH and TBI
Research Assistant Professor, Department of Psychiatry,
Uniformed Services University of the Health Sciences
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Disclaimer
The views expressed are those of the authors and do not
represent the views of the U.S. Government, Department of
Defense, USUHS, RAND Corporation, RTI International,
University of Washington, BVARI, the Boston VA Healthcare
system or any other agency either public or private. The
presenter/s have no relevant financial relationships. The
presenters do not intend to discuss the off-label /
investigative (unapproved) use of commercial
products/devices.
Presentation Outline
Part I. Background: System Level Approaches
Part II. STEPS UP: Design and Implementation
Part III. STEPS UP: Main Findings
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Part I.
Background: System Level Approaches
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The Military Health System (MHS)
The Military Health System as America’s undiscovered
laboratory for health research.
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Primarily serves active duty and retired service members
Over 9 million beneficiaries
$50 billion budget
57 Hospitals
400+ clinics
Gimbel, R. W., Pangaro, L., & Barbour, G. (2010). America's “undiscovered” laboratory for health services
research. Medical care, 48(8), 751-756
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Background
 1/10 military personnel have mental health diagnosis
 1/5 returning from combat receive diagnosis of PTSD
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MHS Mental Health Care:
Access, Continuity, and Adequacy Challenges
High dropouts and low recovery even in highly resourced clinical trials for
PTSD. Peterson 2011; Steenkamp & Litz 2013; Hoge 2011
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Only a subset of the target population
will receive and benefit from an EBT
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CPT/PE
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MHS
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Barriers to care
Adequate Screening and Referral
Resource Barriers
Provider Attitudes
Logistical Constraints
Patient Perceptions
Stigma
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Gap in Mental Health Care in the
Military Health System
DOD's PTSD treatment programs appear to be local, ad hoc, incremental, and
crisis-driven, with little planning devoted to the development of a long-range
approach to obtaining desired outcomes.
The IoM recommends that DOD develop, coordinate, and implement a
measurement-based PTSD management system that documents patients'
progress over the course of treatment, regardless of where they receive
treatment, and does long-term follow-up using standardized and validated
instruments.
Institute of Medicine. (2014). Treatment for posttraumatic stress disorder in military and
veteran populations: final assessment. Washington, DC.
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Systems Interventions Improve Care
 Randomized trials offer sound evidence
(Gilbody et al., 2006; Katon & Guico-Pabia, 2011; Katon 2012;
Archer et al. 2012; Fortney et al. 2014)
•
•
•
•
depression
PTSD
Other anxiety, mental health problems, and suicidality
Co-morbid medical conditions
 Infrastructure exists within the MHS
•
•
•
Developed Programs: RESPECT-Mil; PCMH-BH; PCBH
Demonstrated (Engel et al., 2008) and evaluated (RAND, 2015)
Not trialed until now: STEPS UP (Engel et al., 2014; Engel et al., under review)
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[A]n integrated, coordinated, and comprehensive
PTSD management strategy is needed
Primary Care
∎ Primary care is de facto mental health system
∎ MHS primary care is ideally suited for integrated care strategy to capture
the target population: mandatory primary care appointments; stigma
concerns highly relevant
∎ Service members go 3.5 times per year (Engel, 2005)
Institute of Medicine. (2014). Treatment for posttraumatic stress disorder in military and veteran populations: final assessment.
Washington, DC
.
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Part II.
STEPS UP: Design and Implementation
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STEPS-UP Trial
Team
Research and
Support Staff
Brad Belsher, PhD (DHCC/USUHS)
Donald Brambilla, PhD (RTI)
Robert Bray, PhD (RTI)
Charles Engel, MD, MPH (USUHS/RAND)
Daniel Evatt, PhD (DHCC/USUHS)
Lisa Jaycox, PhD (RAND)
Wayne Katon, MD (UW, Seattle)
Becky Lane, PhD (RTI)
Tara Lavelle, PhD (RAND)
Brett Litz, PhD, MA (Boston Univ & VA)
Jessica Nelson (RTI)
Laura Novak, BS (DHCC)
Kristine Rae Olmsted, MSPH (RTI)
Russ Peeler, MA (RTI)
Terri Tanielian, MA (RAND)
Jürgen Unützer, MD, MPH (UW, Seattle)
Douglas Zatzick, MD (UW, Seattle)
Site Investigators
Burton Kerr, PhD (Joint Base Lewis-McChord, WA)
Melissa Molina, MD / Stanley Harmon FNP (Ft Bliss, TX)
CPT Vlatka Plymale/ MAJ Jason Dailey (Ft Campbell, KY)
LTC Robert Price (Ft Carson, CO)
MAJ Thurman Saunders (Ft Bragg, NC)
Allen Swan, MD (Ft Stewart, GA)
Nurse Care Managers
Donna Buckmore, RN (JBLM, WA)
Jodi Buford, RN (Fort Campbell, KY)
John Dempsey, RN (Fort Bragg, NC)
Mary Hull, RN, MSN (Fort Stewart, GA
Lori Peterson, RN (Fort Carson, CO)
Koby Ritter, RN (DHCC)
Debbie Rosales, RN (Fort Bliss, TX)
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Primary Aim & Objective
∎ Objective: To evaluate whether an enhanced, centralized
collaborative care (CCC) approach significantly improves PTSD
& depression symptoms among Army soldiers screening
positive for PTSD or depression in the primary care setting,
relative to care as usual
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Key Design Features
∎ Randomized trial: Offers compelling evidence of cause and effect.
∎ Effectiveness trial: Uses broad inclusion for maximum generalizability.
∎ Multiple installations: Yield real world estimate of impact.
∎ Cost effectiveness study: Facilitates data driven policy-making.
∎ Qualitative study: Is it credible in the view of patients and clinicians?
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Control Arm:
Usual Collaborative Care (UCC)
BH Support
Prepared
Primary
Care
Nurse
Care
Manager
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Treatment Arm:
Centralized Collaborative Care (CCC)
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CENTRAL
TEAM
BH Support
Web-based Treatment
Telephonic CBT
Medication Consultation
Specialty Care Advocacy
Prepared
Primary
Care
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Nurse
Care
Manager
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JBLM
CENTRAL
TEAM
Carson
Campbell
Bragg
Bliss
Stewart
Centralized Team
Multidisciplinary team:
∎ Program Director
∎ Psychiatrists
∎ Psychologists
∎ Nurse
∎ Data Managements Specialists
Specific Functions
∎ Clinical
Centralized Staffing
Training, monitoring, and mentoring of nurses
Telephonic therapy
Centralized nurse care manager
∎ Programmatic
Monitor implementation fidelity and treatment outcomes
Rapid identification and remediation of program
challenges
Information Technology
∎ FIRST-STEPS:
Care management support tool that enhances:
 On the ground clinician performance
 Centralized case staffing
 Program evaluation and improvement
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Panel Level Staffing
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Part III.
STEPS UP: Main Findings
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666 Participants Enrolled
∎ 80% male
∎ Mean age of 29
∎ 90% were E1-E6
∎ 50% Caucasian
∎ 80% at least 1 deployment
∎ High combat exposure
∎ High comorbidity prevalence
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Primary Outcomes:
Self-Reported PTSD and Depression Severity
(Engel et al., 2016)
0
PTSD (PDS)
-1
Depression (HSCL-20)
-0.1
-2
-3
Intervention
-4
Usual Care
* P<0.01
-5
*
-6
Change Scores (SE)
Change Scores (SE)
0
-0.2
-0.3
*
-0.4
*
-0.5
-0.6
-0.7
-7
0
3
6
12
0
3
6
12
Month
Month
PTSD (PDS) Severity
Difference of Difference (95% CI)
Depression (HSCL-20)
Difference of Difference (95% CI)
0-3 Months
-0.23 (-1.72,1.26)
0-3 Months
-0.08 (-0.19, 0.03)
0-6 Months
-1.43 (-3.11, 0.25)
0-6 Months
-0.19 (-0.32, -0.06)
0-12 Months
-2.53 (-4.47,-0.59)
0-12 Months
-0.26 (-0.41, -0.11)
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Mental Health Utilization Patterns:
Probability of MH Care
(Belsher et al., 2016)
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Mental Health Utilization Patterns:
Number of MH Encounters
(Belsher et al., 2016)
A. Primary Care
B. Specialty Care
C. Total Encounters
Mental Health Encounters
30
25
20
15
10
5
0
STEPS UP
Control
Clinical Complexity
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Qualitative Results
(Batka et al., 2016)
• Stakeholders recognized value of collaborative care
to overcome barriers to care
• The use of phone for care management and
psychotherapy was generally acceptable.
• Additional training for primary care providers to
improve comfort/abilities to treat PTSD and
depression in primary care
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Discussion and Next Steps
∎ First randomized, effectiveness trial on an integrated mental health treatment in
the MHS.
∎ Effects are modest, but…
 Compared against active control group
 System challenges in the military exist limiting access, continuity, and quality
of care
 The right collaborative care components are needed to treat and manage
PTSD (e.g, Schnurr et al. 2012 versus Fortney et al., 2014)
 Highly generalizable sample to include patients who left the military during
treatment
∎ STEPS UP enhancements are feasible and implementable
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Questions
Bradley E. Belsher, Ph.D.
Chief of Research Translation and Integration,
Deployment Health Clinical Center, Defense
Center of Excellence for PH and TBI
Research Assistant Professor, Department of
Psychiatry Uniformed Services University of
the Health Sciences
Email: [email protected]
Phone: (301) 295-7153
Blackberry: (240) 485-7481
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References
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Archer, J., Bower, P., Gilbody, S., Lovell, K., Richards, D., Gask, L., . . . Coventry, P. (2012). Collaborative care for
depression and anxiety problems. Cochrane Database of Systematic Reviews, 10, CD006525. doi:
10.1002/14651858.CD006525.pub2.
Batka C, Tanielian T, Woldetsadik MA, Farmer C, Jaycox LH. Stakeholder experiences in a stepped collaborative care
study within U.S. Army clinics. Psychosomatics. In press.
Belsher, B. E., Jaycox, L. H., Freed, M. C., Evatt, D. P., Liu, X., Novak, L. A., Zatzick, D., Bray, R. M., & Engel, C. C.
(2016). Mental health utilization patterns during a stepped, collaborative care effectiveness trial for PTSD and
depression in the military health system. Medical Care, 54(7), 706-713. doi: 10.1097/MLR.0000000000000545.
Engel, C. C., Bray, R. M., Jaycox, L., Freed, M. C., Zatzick, D., Lane, M. E., Brambilla, D., Rae Olmsted, K. L.,
Vandermaas-Peeler, R., Litz, B., Tanielian, T., Belsher, B. E., Evatt, D. P., Novak, L. A., Unützer, J., & Katon, W.J. (2014).
Implementing collaborative primary care for depression and posttraumatic stress disorder: Design and sample for a
randomized trial in the U.S. military health system. Contemporary Clinical Trials, 39(2), 310-319. doi:
10.1016/j.cct.2014.10.002
Engel, C. C., Jaycox, L. H., Freed, M. C., Bray, R. M., Brambilla, D., Zatzick, D., Litz, B., Tanielian, T., Novak, L. A., Lane,
M. E., Belsher, B. E., Rae Olmsted, K. L., Evatt, D. P., Vandermaas-Peeler, R., Unutzer, J., & Katon, W. J. (2016).
Centrally assisted collaborative telecare for posttraumatic stress disorder and depression among military personnel
attending primary care: A randomized controlled trial. JAMA Internal Medicine, Epub ahead of print. doi:
10.1001/jamainternmed.2016.2402
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References
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Engel CC, Oxman T, Yamamoto C, et al. (2008). RESPECT-Mil: Feasibility of a systems-level collaborative
care approach to depression and post-traumatic stress disorder in military primary care. Military Medicine,
173(10), 935-940.
Fortney, J. C., Pyne, J. M., Kimbrell, T. A., Hudson, T. J., Robinson, D. E., Schneider, R., . . . Schnurr, P. P.
(2015). Telemedicine-based collaborative care for posttraumatic stress disorder: a randomized clinical trial.
JAMA Psychiatry, 72(1), 58–67. doi: 10.1001/jamapsychiatry.2014.1575.
Gilbody, S., Bower, P., Fletcher, J., Richards, D., & Sutton, A. J. (2006). Collaborative care for depression: A
cumulative meta-analysis and review of longer-term outcomes. Archives of Internal Medicine, 166(21)
2314-2321.
Hoge, C. W., Grossman, S. H., Auchterlonie, J. L., Riviere, L. A., Milliken, C. S., & Wilk, J. E. (2014). PTSD
treatment for soldiers after combat deployment: low utilization of mental health care and reasons for
dropout. Psychiatric Services, 65(8), 997-1004. doi: 1010.1176/appi.ps.201300307.
Institute of Medicine (IOM). (2014). Treatment for posttraumatic stress disorder in military and veteran
populations: final assessment. Washington, DC: The National Academies Press.
Tanielian TL, Woldetsadik M, Jaycox LH, Batka C, Moen S, Farmer C, Engel C. (2016). Barriers to engaging
service members in mental health care within the U.S. military health system. Psychiatric Services, 67(7),
718-727. doi: 10.1176/appi.ps.201500237
Wong EC, Jaycox LH, Ayer LA, et al. (2015). Evaluating the Implementation of Re-Engineering Systems of
Primary Care Treatment in the Military (RESPECT-Mil). Santa Monica, CA: RAND Corporation.
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Effect of Centralized Care Coordination on Treatment
Continuity and Quality: Findings and Case Series
Presentation
Daniel P. Evatt, Ph.D.,
Chief, Research Production & Investigation
Deployment Health Clinical Center
Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury
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Disclaimer
The views expressed in this presentation are those of
the authors and do not necessarily represent the
official policy or position of the Deployment Health
Clinical Center, Walter Reed National Military Medical
Center, USUHS, DCoE, Department of Defense, the
United States Government, RAND Corporation, RTI
International, University of Washington, BVARI, or the
Boston VA Healthcare system.
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Centralized Care Coordination
Designed to Maintain Contact
 Centralized team was not limited by geographical borders
 Care continued regardless of referral status
 Centralized team was not limited by career events
 PCS
 ETS
 Deployment
 Centralized team used multiple methods to maintain
contact
 Telephone
 Email
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Advantages of Centralized Clinical
Components


Clinical Components: Care management, telephone therapy,
web-based interventions
Service members are busy
 During their lunch break
 Before or after work
 Time zone differences can work in favor

Flexibility

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
Sessions/contacts while on vacation
Sessions/contacts with spouse
10/20/30/40/50 minute sessions/contacts
A call to schedule a session becomes a session!
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Event: Referral to Specialty Care
Care As Usual
Centralized Care Management
Typically care management ends
Attempt to continue monthly contact
Possible re-initiation of care
management following new primary
care episode
Attempt to continue symptom tracking
Possible engagement with specialty care
provider
If drop-out from specialty care –
engagement on additional care options
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Event: Inpatient Care / Hospitalization
Care As Usual
Typically care management ends,
facilitated by a referral to specialty care
Centralized Care Management
Attempt to continue monthly contact
Attempt to continue symptom tracking
Possible engagement with inpatient care
providers
Attempt to facilitate additional care
following inpatient stay
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Event: Training Exercise
Care As Usual
Centralized Care Management
Depending on situation, care may
continue
Care manager engages patient on
possible ways to maintain contact (e.g.,
email)
Likely interruption of care management
Attempt routine contact and symptom
tracking
Possible referral to centralized care
manager for improved follow-up
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Event: Permanent Change of Station
Care As Usual
Centralized Care Management
Typically care management ends
Attempt to continue monthly contact
Possible re-initiation of care
management if facilitated by care
manager
Attempt to continue symptom
tracking
Possible re-initiation of care
management following new primary
care episode
Possible referral to centralized care
manager for easier follow-up
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Event: Deployment
Care As Usual
Centralized Care Management
Care management ends
Care manager engages patient on
possible ways to maintain contact
(e.g., email)
Possible re-initiation of care
management following new primary
care episode
Attempt to continue routine contact
and symptom tracking
Possible referral to centralized care
manager for improved follow-up
Facilitation of continued care during
deployment if appropriate (e.g.,
continued access to medication)
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Event: End of Time in Service /
Separation / Retirement
Care As Usual
Care management ends
Centralized Care Management
Attempt to continue monthly contact
Attempt to continue symptom tracking
Facilitate engagement with transition
programs
Facilitate engagement with VA and
engage VA or external providers when
appropriate
 Continued management following ETS was facilitated by research protocol; may
not be feasible in practice
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Patient Contact
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Patient Staffing
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Patient Assessment
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Differences in Services Received
Probability of Receiving Essential Collaborative Care
Elements Across Trial Period (N=666):
Care Manager Contact & Assessment & BH Staffing
90%
80%
70%
Probability
60%
50%
SU
40%
Rmil
30%
20%
10%
0%
1-2
3-4
5-6
7-8
9-10
11-12
Months
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STEPS UP Case Example



32 year old divorced female SPC
Reason for Referral: Positive PHQ-9 screen
On initial assessment, current treatments included:


Behavioral Health counseling
Citalopram 10 mg QD
Care Manager Initial Assessment

Depressed Mood



No SI/HI
Pt did not enjoy Behavioral Health visit; will not go back
Introduced treatment options



Agreed to continue Citalopram
Rejected telephone therapy
Agreed to try web based therapy for depression
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Staffing #1


Presents case
Staffing Recommendations


Continue Citalopram 10 mg QD
Start Pt on web based therapy for depression
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Staffing #2

Status


Some symptom improvement; completing computer based therapy
Staffing Recommendations

Continue to follow up
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Staffing #3

Status


Quit computer based therapy; stopped taking medication; refused other referrals
Staffing Recommendations

Engagement supervision
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Staffing #4

Status


Mother passed away; increased symptoms, continues to refuse referrals; no SI/HI
Staffing Recommendations

Engagement supervision
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Staffing #5

Status


Two months lost contact; discharge from military; reduced symptoms
Staffing Recommendations

Continue to follow up
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Staffing #6

Status


“Hard transition;” SI – no plan or intent; refuses all referrals
Staffing Recommendations

Motivational interviewing supervision; increase engagement; frequent assessment
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Staffing #7

Status


“Living in hotel;” SI – no plan or intent; refuses all referrals
Staffing Recommendations

Motivational interviewing supervision; increase engagement; frequent assessment
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Staffing #8

Status


Accepted Telephone Therapy referral; Pt prescribed Bupropion by new civilian
PCM, but will not fill prescription
Staffing Recommendations

Begin telephone therapy; MI for medication
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Benefits of Centralized Telephone
Therapy and Medication Management

Telephone Therapy can overcome barriers to care
 Referral problems, hard-to-reach locations, stigma, duty hours (IOM
2012; IOM 2013; Hoge et al., 2004).

Centralized Telephone Therapy
 Can be effective at more than one location
 Highly trained therapists at one location

Medication Management
 Centralized team makes recommendations to on the ground providers
 Care manager engages in motivational interviewing skills and behavioral
activation
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Staffing #9

Status


Symptom improvement – remains elevated; Pt taking medications
Staffing Recommendations

Continue telephone therapy; medication management
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Staffing #10

Status


Symptom improvement; Pt completed 8 sessions of telephone therapy; Pt continues
to take medication; Pt now has completed transition to VA and has a therapist
Staffing Recommendations

Discharge from study
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Complex Presentations

This Pt endorsed symptoms of PTSD; likely indicative of overall distress
“Medically Ready Force…Ready Medical Force”
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One Patient Among Many
60
50
40
30
20
10
0
1
2
3
4
5
6
7
“Medically Ready Force…Ready Medical Force”
8
60
Conclusions

Centralized care improves engagement
 Numerous barriers that end management in traditional model

Flexible treatment choice and delivery
 Meeting the patient where they are
 Stepped care considering patient preferences and motivation

Overcome barriers to maintain contact
 Military specific barriers
 Geographical barriers
 Motivational barriers
LIFE HAPPENS
“Medically Ready Force…Ready Medical Force”
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