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Tele-Collaborative Care for Bipolar Disorder: From Research to Practice to Sustainability and Spread

Collaborative chronic care models (CCMs) were developed in the 1990s to improve outcome for individuals with chronic medical illnesses treated in primary care. These multicomponent models were developed because single-focus programs were not efficacious.  Such CCMs consist of several or all of the following elements:

  • Work role redesign for anticipatory, continuous care,
  • Self-management support,
  • Provider decision support,
  • Information management,
  • Linkage to community resources, and
  • Leadership/organizational support.

Initially CCMs were tested for chronic medical illnesses treated in primary care, and were subsequently applied to depression treatment in primary care.  More recently they have been shown to improve outcome for severe mental health conditions treated in mental health clinics. Among serious mental health conditions, perhaps the most extensively studied CCMs are those deployed for individuals with bipolar disorder.  The National Telemental Health Center leadership in VA’s Office of Connected Care and the Office of Mental Health and Suicide Prevention were familiar with this previous research, and leadership was interested in improving outcomes for Veterans with bipolar disorder, whose numbers are growing in the VA healthcare system, and who are at high risk for suicide.

Evidence to Implementation

In late 2011, the VA National Bipolar Telehealth Program (BDTH) was established with clinical funding from the Office of Connected Care, structured as a “hub” of psychiatry and psychology expertise at VA Boston reaching out to various “spoke” sites.  Veterans are enrolled for approximately six months, receiving an initial diagnostic and psychopharmacologic evaluation by a psychiatrist followed by six modules of the Life Goals self-management skills enhancement program (Life Goals Collaborative Care) (See Figure 1).

Figure 1.

Life Goals Collaborative Care

Once a VA medical center is enrolled for BDTH participation, the program is a “turn-key” operation from the perspective of the consulting clinician: A consult request is placed via the orders tab in the provider’s home site electronic medical record, and the completed consult is entered, along with subsequent Life Goals progress notes, into that record.

All well and good: But if you build it, will they come?  And will they keep coming—given the evidence that most telehealth interventions are not sustained beyond the clinical trial or demonstration phase?

Recently, QUERI for Team-Based Behavioral Health investigators and National Telemental Health Center expert clinicians published a comprehensive mixed-methods program evaluation of the BDTH.1 To establish aspects of sustainability and spread, investigators analyzed administrative program data.  To identify barriers and facilitators to sustainability and spread, independent evaluators conducted and analyzed qualitative interviews of high- and low-utilizing. Figure 2 summarizes BDTH growth in terms of Veterans served and sites—now having served more than 1,500 Veterans across 50 enrolled sites.  In addition, more than 90% of enrolled sites have remained active, and the number of consults at enrolled sites grew significantly from the first year to subsequent years. Clearly, once the BDTH was “built” people came, and have kept coming.

Figure 2.

Growth of Bipolar Telehealth

Findings

Analyses revealed barriers and facilitators to program implementation and sustainability.  The psychopharmacologic consultations and Life Goals sessions (Life Goals Collaborative Care) were highly valued by consulting clinicians and by Veterans. Program growth was highly dependent on telehealth support at the consulter’s facility (e.g., space, telehealth support staff) and benefited from identifying a local champion clinician.  VA policy and financial support for BDTH was critical, although competing policy demands limited growth in some ways. Finally, facilitation through the National Telemental Health Center (i.e., credentialing and privileging, electronic health record linkages, scheduling) has been critical to the program’s viability.

Impact

The BDTH experience illustrates that a stepwise progression from concept to evidence to sustainability and nationwide spread is possible—even for a complex population treated with a multi-component intervention delivered over great distances. Today, the BDTH “hub” has evolved into a “neural net” of expertise, engaging experts at the VA Boston Healthcare System, VA Connecticut Healthcare System, the Edit Nourse Rogers Memorial Veterans Hospital in Bedford, MA, and the Corporal Michael J. Crescenz VAMC in Philadelphia, PA.  The program now serves Veterans at “spoke” sites ranging from Key West to rural community-based outpatient clinics (CBOCs) in northern California—providing expert care for a suicide-prone population who would not otherwise have access to such specialized care.

For more information, please contact Mark Bauer, MD, at Mark.Bauer@va.gov .

Reference

Bauer M, Krawczyk L, Tuozzo K, et al. Implementing and sustaining team-based tele-care for bipolar disorder: Lessons learned from a model-guided, mixed methods analysis. Telemedicine and eHealth. January 2018;24(1):45-53.

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