Assessment and Management of Depression, Anxiety, and Alcohol

Problems in Primary Care:The BHL Program

VISN 4 MIRECC

VA Philadelphia

University of Pennsylvania

David Oslin, MD

MIRECC – VISN 4 / Philadelphia CESATE

Development of a Sustainable Clinical Innovation

Conceptualization and Investment Implementation

Re-engineering

Sustainable Service

Stakeholder input

Marketing/Dissemination

MIRECC – VISN 4 / Philadelphia CESATE

Development Principals

• Adaptability

• Efficiency

• Targets need

• Scalable

• Reproducible

• Ease of use

• Compassion

MIRECC – VISN 4 / Philadelphia CESATE

InceptionKey issues

• Scope: Cognition, depression, anxiety, alcohol

• Functions: Triage, decision support, monitoring

• Flexibility: ability to profile patients

• Enrollment: how to get patients to come

MIRECC – VISN 4 / Philadelphia CESATE

BHL Clinical Process

Patient IdentificationBy screening or clinical assessment

BHL Initial Assessment

Referral to MH/SA care

Provider Recommendations

Disease Management in Primary Care

No treatment / “False positive” screen

Patient Education and

Promote self-care

Watchful Waiting/ Brief Interventions

MIRECC – VISN 4 / Philadelphia CESATE

InceptionOther issues

• Scalability

• Ease of use

• Interface with CPRS

MIRECC – VISN 4 / Philadelphia CESATE

Initial Beta Version

• Small scale: self programmed in access

• Limited features: interview only, expanded to registration function

• Enrollment: partnership with primary care around screening

MIRECC – VISN 4 / Philadelphia CESATE

Contracting out

• No to CPRS integration – a big decision

• Interviewing software firms

• Developing design features for the programming: scalability, integration of change, building on

• Development of a mechanism to track, test, and deploy changes

MIRECC – VISN 4 / Philadelphia CESATE

Quality Control

• Data: range checks, limited input, limited capacity to change values (administrator)

• Input: staff training

• Acceptability: provider use, patient satisfaction, completion rates

• Algorithms: comparison to clinical interviews, randomized trials of key components, long term outcomes

• Program: EPRP measures, acceptability, management

MIRECC – VISN 4 / Philadelphia CESATE

MIRECC – VISN 4 / Philadelphia CESATE

Core Assessment Module

• During the last 12 months 3779 patients were referred (from 2 VAMCs) 81.7% had a complete assessment

PTSD (84%) Alcohol or drug problems (73%). no differences in completion rates between the

Medical Center and CBOCs.

MIRECC – VISN 4 / Philadelphia CESATE

Treatment Components

• Core Assessment – comprehensive

• Depression Module 2, 6, 9 Weeks Adherence, Depressive symptoms, Side effects

• Watchful Waiting 8 weekly calll

• Alcohol Brief intervention and followup

• Referral management

MIRECC – VISN 4 / Philadelphia CESATE

Addressing Quality Indicators

•Access – The triage and tracking mechanisms allow for seemless referral and the ability to reduce waiting times, prioritize care, and provide administrative support for monitoring.

•Screening – The BHL has been associated with greater screening rates as well as changes in the proportion that screens positive.

•Follow-up of positive screens – The BHL is directly addressing assessment of those with positive screens.

•Monitoring of new initiated treatment – The depression monitoring provides a straightforward mechanism for ongoing monitoring.

MIRECC – VISN 4 / Philadelphia CESATE

Web Resources

• http://www.va.gov/visn4mirecc/bhl/ (Behavioral Health Laboratory)