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Telemedicine-Based Collaborative Care

Telemedicine-Based Collaborative Care is designed to improve patient depression outcomes (response and remission) in rural primary care practices that lack on-site mental health specialists. The intervention is an adaptation of the collaborative care model for rural Department of Veterans Affairs (VA) primary care practices using telemedicine technologies including telephone, interactive video, Internet, and electronic medical records. In the collaborative care approach to depression treatment, primary care providers work in conjunction with a depression care team that consists of nonphysicians (e.g., nurses, pharmacists) and mental health specialists (e.g., psychologists, psychiatrists).

Three types of providers are required to implement the intervention: on-site primary care providers, off-site telephone nurse care managers (CMs), and off-site telepsychiatrists. The on-site primary care providers screen all patients for depression, make diagnoses, and prescribe antidepressants, which are supplied to patients through the VA pharmacy. The CMs conduct biweekly telephone discussions with patients diagnosed with depression. During the discussions, the CMs are guided by a Web-based decision support system (NetDSS) that includes evidence-based instruments and scripts. The CMs provide patient education; assess barriers, preferences, and comorbidities; assist with patient self-management; and monitor symptoms, adherence, and side effects. The off-site telepsychiatrists provide clinical supervision for CMs during weekly meetings to discuss new patients and patients failing treatment. The telepsychiatrists also make treatment recommendations to primary care providers and conduct consultations with patients via interactive video. Telepharmacists and telepsychologists also may be involved in care. Telepharmacists conduct medication histories, address side effects of medications and nonadherence to protocols, and assess issues when patients do not respond to antidepressant therapy. Telepsychologists provide evidence-based psychotherapy via interactive video.

Intervention duration ranges from 8 months (2 months acute phase and 6 months continuation phase) to 12 months (for patients not responding in the acute phase or relapsing in the continuation phase). The intervention uses a stepped-care model in which treatment intensity is increased for patients failing to respond to lower levels of care by involving a greater number of intervention personnel with increasing mental health expertise. The sequence is as follows: (1) the patient and provider choose either watchful waiting or antidepressant therapy; (2) if the patient does not respond to antidepressant therapy, the telepharmacist conducts a medication history and provides pharmacotherapy recommendations to the primary care provider; and (3) if the patient still does not respond to antidepressant therapy, a telepsychiatrist provides a patient consultation followed by additional treatment recommendations to the primary care provider.

Descriptive Information

Areas of Interest	Mental health treatment
Outcomes	Review Date: January 2010 1: Medication adherence 2: Treatment response 3: Remission 4: Health-related quality of life 5: Cost effectiveness
Outcome Categories	Cost Mental health Quality of life Treatment/recovery
Ages	26-55 (Adult) 55+ (Older adult)
Genders	Male Female
Races/Ethnicities	American Indian or Alaska Native Black or African American White Race/ethnicity unspecified
Settings	Outpatient
Geographic Locations	Rural and/or frontier
Implementation History	Telemedicine-Based Collaborative Care was first implemented in 2003 in seven small VA community-based outpatient clinics. To date, it has been implemented in 28 clinics (20 VA community-based outpatient clinics and 8 federally qualified health centers). A total of 1,716 patients have participated in the program.
NIH Funding/CER Studies	Partially/fully funded by National Institutes of Health: Yes Evaluated in comparative effectiveness research studies: Yes
Adaptations	No population- or culture-specific adaptations of the intervention were identified by the developer.
Adverse Effects	No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories	IOM prevention categories are not applicable.

Quality of Research

Review Date: January 2010

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Fortney, J. C., Pyne, J. M., Edlund, M. J., Williams, D. K., Robinson, D. E., Mittal, D., & Henderson, K. L. (2007). A randomized trial of Telemedicine-Based Collaborative Care for Depression. Journal of General Internal Medicine, 22(8), 1086-1093.

Pyne, J. M., Fortney, J. C., Tripathi, S., Maciejewski, M. L., Edlund, M. J., & Williams, D. K. (2009). Cost effectiveness analysis of a rural telemedicine collaborative care intervention for depression. Manuscript submitted for publication.

Supplementary Materials

Fortney, J., & Pyne, J. (2009, June). Telemedicine-Based Collaborative Care models for rural primary care practices [PowerPoint slides]. Presented at the Future of Telehealth Workshop, National Institutes of Health, Bethesda, MD.

Fortney, J. C., Pyne, J. M., Edlund, M. J., Robinson, D. E., Mittal, D., & Henderson, K. L. (2006). Design and implementation of the Telemedicine-Enhanced Antidepressant Management Study. General Hospital Psychiatry, 28(1), 18-26.

Fortney, J., Pyne, J., Mittal, D., & Hudson, T. (2009, July). Comparative effectiveness study of rural collaborative care models: The Outreach Study [PowerPoint slides]. Presented at the National Institute of Mental Health (NIMH) Mental Health Research Conference on Increasing the Efficacy of Research and Mental Health Services Delivery, Washington, DC.

Williams, J. W., Jr., Stellato, C. P., Cornell, J., & Barrett, J. E. (2004). The 13- and 20-item Hopkins Symptom Checklist Depression Scale: Psychometric properties in primary care patients with minor depression or dysthymia. International Journal of Psychiatry in Medicine, 34(1), 37-50.

Outcomes

Outcome 1: Medication adherence
Description of Measures	Medication adherence was measured by self-report and pharmacy/electronic medical records. Prior to the 6- and 12-month follow-up surveys, a study psychiatrist examined each patient's electronic medical record to determine what antidepressants had been prescribed or refilled during the past 6 months. In the surveys, blinded telephone interviewers asked patients who had an active prescription about their most recently prescribed/refilled antidepressant medication, referring to the antidepressant explicitly by name. Patients were asked if they were currently taking the medication, and if so, how frequently they took the medication in the past month and if they took the dosage prescribed. Patients were categorized as adherent if their responses indicated they took the full dosage on 80% or more of days in the past month. Patients without an active prescription or who reported stopping antidepressants following their primary care provider's instruction were excluded from the adherence analysis.
Key Findings	Matched clinics participating in the study were randomized to an intervention group that implemented Telemedicine-Based Collaborative Care or to a comparison group that provided usual care. Usual care involved the use of a two-stage clinical reminder system to facilitate depression screening and follow-up assessment, an in-clinic VA pharmacy, and interactive video equipment for telepsychiatry consultations at those sites lacking on-site psychiatrists. Patients in the intervention group had significantly greater odds of being adherent to their medication protocol than those receiving usual care at both 6-month (p = .04) and 12-month follow-up (p = .01). The effect size for these findings was small (odds ratios = 2.1 and 2.7, respectively).
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	3.2 (0.0-4.0 scale)

Outcome 2: Treatment response
Description of Measures	Treatment response was defined as a 50% or greater improvement in depression severity between baseline and follow-up. Depression severity was measured using the Hopkins Symptom Checklist 20-item scale (SCL-20), a widely used instrument for measuring symptoms of depression. The SCL-20 was administered via blinded telephone interview at baseline and at 6- and 12-month follow-up.
Key Findings	Matched clinics participating in the study were randomized to an intervention group that implemented Telemedicine-Based Collaborative Care or to a comparison group that provided usual care. Usual care involved the use of a two-stage clinical reminder system to facilitate depression screening and follow-up assessment, an in-clinic VA pharmacy, and interactive video equipment for telepsychiatry consultations at those sites lacking on-site psychiatrists. At 6-month follow-up, patients in the intervention group were significantly more likely to respond than those receiving usual care (p = .02), with a large effect size (odds ratio = 1.94). There were no significant findings for this outcome at 12 months.
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	3.5 (0.0-4.0 scale)

Outcome 3: Remission
Description of Measures	Remission was defined as a depression severity score of less than 0.5 on the SCL-20. The SCL-20 was administered via blinded telephone interview at baseline and at 6- and 12-month follow-ups.
Key Findings	Matched clinics participating in the study were randomized to an intervention group that implemented Telemedicine-Based Collaborative Care or to a comparison group that provided usual care. Usual care involved the use of a two-stage clinical reminder system to facilitate depression screening and follow-up assessment, an in-clinic VA pharmacy, and interactive video equipment for telepsychiatry consultations at those sites lacking on-site psychiatrists. At 12-month follow-up, patients in the intervention group had significantly greater odds of achieving remission from depression compared with those receiving usual care (p = .02). This finding was associated with a small effect size (odds ratio = 2.4). There were no significant findings for this outcome at 6 months.
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	3.6 (0.0-4.0 scale)

Outcome 4: Health-related quality of life
Description of Measures	Improvement in health-related quality of life was measured by the change in patient's score on the Quality of Well-Being scale (QWB) between baseline and follow-up. The QWB is an interviewer-administered tool that assesses four domains: mobility, physical activity, social activity, and symptomatic complaints that might inhibit function. Data were collected via blinded telephone interview at baseline and at 6- and 12-month follow-ups.
Key Findings	Matched clinics participating in the study were randomized to an intervention group that implemented Telemedicine-Based Collaborative Care or to a comparison group that provided usual care. Usual care involved the use of a two-stage clinical reminder system to facilitate depression screening and follow-up assessment, an in-clinic VA pharmacy, and interactive video equipment for telepsychiatry consultations at those sites lacking on-site psychiatrists. Patients' QWB scores improved significantly more in the intervention group than in the usual care group by 6-month follow-up (p < .01). There were no significant findings for this outcome at 12 months.
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	3.3 (0.0-4.0 scale)

Outcome 5: Cost effectiveness
Description of Measures	Cost effectiveness was measured by calculating the ratio of total expenditures to quality-adjusted life years (QALYs). For each patient, two predicted expenditures were calculated: one prediction as if the patient had been randomized to the intervention, and the second as if the patient had been randomized to usual care. The difference between these two expenditures predictions represented the incremental effect of the intervention on expenditures for the particular patient. The difference between the two predicted values for each participant was then averaged across all patients to determine the incremental effect for the entire sample. Expenditures and QALYs were measured for the entire 12-month study period. Expenditure data were derived from administrative records. QALYs were calculated using formulas developed by Brazier that convert data from the Short-Form Health Survey 12 (SF-12) using preference-weighted methods. The formulas are based on standard gamble methods and produce an overall preference-weighted index score that ranges from 0 (death) to 1.0 (perfect health). QALY data were collected via blinded telephone interview at baseline and at 6- and 12-month follow-ups.
Key Findings	Matched clinics participating in the study were randomized to an intervention group that implemented Telemedicine-Based Collaborative Care or to a comparison group that provided usual care. Usual care involved the use of a two-stage clinical reminder system to facilitate depression screening and follow-up assessment, an in-clinic VA pharmacy, and interactive video equipment for telepsychiatry consultations at those sites lacking on-site psychiatrists. In a sensitivity analysis that included all inpatient expenditures and base case analysis expenditures, the incremental effect of the intervention on expenditures was significant (p = .002).
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	3.3 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study	Age	Gender	Race/Ethnicity
Study 1	26-55 (Adult) 55+ (Older adult)	91.7% Male 8.3% Female	74.7% White 18.2% Black or African American 4.1% Race/ethnicity unspecified 3% American Indian or Alaska Native

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

1. Reliability of measures	4. Missing data and attrition
2. Validity of measures	5. Potential confounding variables
3. Intervention fidelity	6. Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome	Reliability of Measures	Validity of Measures	Fidelity	Missing Data/Attrition	Confounding Variables	Data Analysis	Overall Rating
1: Medication adherence	3.0	3.0	3.3	3.5	2.8	3.5	3.2
2: Treatment response	4.0	4.0	3.3	3.5	2.8	3.5	3.5
3: Remission	4.0	4.0	3.3	3.5	3.3	3.5	3.6
4: Health-related quality of life	3.5	3.0	3.3	3.5	3.3	3.5	3.3
5: Cost effectiveness	3.0	3.0	3.3	3.0	3.3	4.0	3.3

Study Strengths

The study's methodological strengths include clearly specified eligibility criteria, a good acceptance rate among eligible participants, the use of outcomes appropriate to the intervention and measures appropriate to quantifying those outcomes, and the use of blinded telephone interviews to collect patient data. Most of the measures used in the study have strong psychometric properties and have been used with a variety of study populations, and the analysis was appropriate to the intervention. Attrition and missing data were addressed using statistical procedures. Evidence for intervention fidelity is strong based on the use of intervention scripts, branching of scripts, and techniques to measure fidelity.

Study Weaknesses

It is unclear whether the measures have been tested with people of color. Some discussion of this segment of the population should have been included considering that more than one fifth of the participants were people of color and given the well-documented differential experiences of this population within mental health systems. The fact that many of the participants were already receiving treatment for depression may have affected study findings. Randomization was used with matched clinics but not at the patient or provider level.

Readiness for Dissemination

Review Date: January 2010

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Fortney, J. C., Pyne, J. M., Smith, J. L., Curran, G. M., Otero, J. M., Enderle, M. A., & McDougall, S. (2009). Steps for implementing collaborative care programs for depression. Population Health Management, 12(2), 69-79.

NetDSS Web site, Version 2.5, https://www.netdss.net

Telemedicine-Based Collaborative Care implementation tools:

Implementation Tool (Steps, Decisions, and Actions Items)
NetDSS brochure and summary
NetDSS Users Manual (Version 2.5). (2009). Available online at https://www.netdss.net/UManual.pdf
Telephone Care Manager job posting

Telemedicine-Based Collaborative Care quality assurance tools:

Fidelity Checklist and Score Sheet
NetDSS Telephone Care Manager Date Range Report Summary
NetDSS Telephone Care Manager Date Range Report Template

Telemedicine-Based Collaborative Care training and support tools:

Depression Care Management Part I: Diagnosis and Treatment [PowerPoint slides]
Depression Care Management Part II: Trial Management & Assessments [PowerPoint slides]
Fortney, J., Davis, A., Pyne, J., Raney, W., & Ackerman, S. (2007). Depression Care Manager training manual (Version 1.1). Available online at https://www.netdss.net/CMManual.pdf
Major Depressive Disorder: Recognition and Management in Primary Care [PowerPoint slides]

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

Availability of implementation materials
Availability of training and support resources
Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation Materials	Training and Support Resources	Quality Assurance Procedures	Overall Rating
2.8	2.8	3.3	2.9

Dissemination Strengths

The Web-based NetDSS decision support system supports implementation by providing a centralized repository of information related to patient assessment and treatment. The system includes a wealth of evidence-based instruments and scripts to guide treatment decisions, is intuitive to use, and comes with supplemental materials that include a user's guide and the Depression Care Manager training manual. The materials provided for training clinical and care management staff are high quality, detailed, and comprehensive. The quality assurance materials, resources, and procedures that are available to support implementation are well developed and easy to use. The NetDSS's automation of work flow and processes maximizes the use of evidence-based tools and resources, in turn enhancing fidelity.

Dissemination Weaknesses

While the Web-based system and other implementation tools provide an abundance of information, potential implementers may find them difficult to access or sort through at first. No concise description of the program components, implementation steps, and contact information is offered to orient newcomers to the program. The program does not provide any hard-copy materials to give to patients to explain the care they will receive, including the role of follow-up telephone calls. There does not appear to be any systematic orientation, training, consultation, or ongoing technical assistance offered aside from the Web-based tools. No resources or guidelines for evaluating program outcomes are provided.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description	Cost	Required by Developer
All implementation materials (electronic format)	Free	Yes
NetDSS Web-based decision support tool (for primary care practice)	Free	Yes
1-day, off-site training	$3,000 per site	No
1-day, on-site training	$5,000 per site plus travel expenses	No
Consultation	$125 per hour	No
Fidelity checklist	Free	No

Replications

No replications were identified by the developer.

Contact Information

To learn more about implementation or research, contact:
John Fortney, Ph.D.
(501) 257-1726
fortneyjohnc@uams.edu, john.fortney@va.gov

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.

Web Site(s):

https://www.netdss.net