Dr. David Atkins, U.S. Department of Veterans Affairs, presented at AcademyHealth's 2012 Capitol Hill briefing entitled "Health and the Deficit: Using Health Services Research to Reduce Costs and Improve Quality."

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