Leveraging COVID-19 to modernize depression care for VA primary care populations

利用 COVID-19 实现 VA 初级保健人群的抑郁症护理现代化

基本信息

批准号：
10636681
负责人：
Lucinda B Leung
金额：
--
依托单位：
VA GREATER LOS ANGELES HEALTHCARE SYSTEM
依托单位国家：
美国
项目类别：
财政年份：
2023
资助国家：
美国
起止时间：
2023-09-01 至 2025-08-30
项目状态：
未结题

来源：
https://reporter.nih.gov/project-details/10636681
关键词：
Address Adoption Affect Behavior COVID-19 COVID-19 pandemic Caring Clinic Clinical Complex Consultations Data Detection Drops Feedback Feeling suicidal Future Guidelines Health Health Services Accessibility Hospitalization Hospitals Hybrids Interruption Intervention Interview Los Angeles Mental Depression Mental Health Mental Health Services Methodology Methods Minority Modality Modeling Modernization Morbidity - disease rate Outcome Patient-Focused Outcomes Patients Persons Pharmaceutical Preparations Population Primary Care Primary Nursing Care Process Provider Quality Indicator Quality of Care Recommendation Recovery Research Services Solid Specialist Suicide Suicide prevention System Testing Time Time Series Analysis Veterans Visit Work acute care adverse outcome behavior change care delivery care seeking collaborative care connected care coronavirus disease cost current pandemic depression prevention depressive symptoms digital disability effective therapy experience follow-up functional disability improved innovation military veteran mortality multidisciplinary pandemic disease physical conditioning physical health service population based population health preservation provider to provider psychiatric emergency response routine screening screening suicidal suicidal behavior suicidal risk suicide mortality telehealth tool virtual virtual healthcare

Address Adoption Affect Behavior COVID-19 COVID-19 pandemic Caring Clinic Clinical Complex Consultations Data Detection Drops Feedback Feeling suicidal Future Guidelines Health Health Services Accessibility Hospitalization Hospitals Hybrids Interruption Intervention Interview Los Angeles Mental Depression Mental Health Mental Health Services Methodology Methods Minority Modality Modeling Modernization Morbidity - disease rate Outcome Patient-Focused Outcomes Patients Persons Pharmaceutical Preparations Population Primary Care Primary Nursing Care Process Provider Quality Indicator Quality of Care Recommendation Recovery Research Services Solid Specialist Suicide Suicide prevention System Testing Time Time Series Analysis Veterans Visit Work acute care adverse outcome behavior change care delivery care seeking collaborative care connected care coronavirus disease cost current pandemic depression prevention depressive symptoms digital disability effective therapy experience follow-up functional disability improved innovation military veteran mortality multidisciplinary pandemic disease physical conditioning physical health service population based population health preservation provider to provider psychiatric emergency response routine screening screening suicidal suicidal behavior suicidal risk suicide mortality telehealth tool virtual virtual healthcare

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项目摘要

Background: As part of comprehensive suicide prevention, VA integrated mental and physical health services to better detect and treat depression. Primary care nurses conduct screening annually. Clinicians, including Primary Care Mental Health Integration (PC-MHI) specialists, follow up as-needed for treatment. Depression detection and management processes are complex, involve multilevel stakeholders, and subject to significant disruption from COVID-19 and from resulting expansion of telehealth aiming to preserve care access. Fewer VA visits during the pandemic may signify lowered depression care quality and worsened patient outcomes. Significance: Depression affects 1 in 5 Veterans and is a leading cause of suicidality and disability. It contributes substantially to the current pandemic-related mental health crisis. Depression symptoms, including suicidal thoughts/behaviors, and related functional impairment have increased since COVID onset. Partnering with Primary Care, Mental Health, and Connected Care leaders, we propose to study pandemic-related service disruptions for depression, which may help to mitigate acute care use and mortality in the Veteran population. We apply established depression quality indicators from our prior research to a broad national scale at a critical time. We will also obtain feedback to improve current hybrid (virtual/in-person) care models from VA providers and Veterans who screened positive, including those who were not detected to have depression. Specific Aims: To improve virtual and in-person services for the VA primary care population during recovery, this proposal will examine how the pandemic disrupted depression care delivery mechanisms, including expanded telehealth, and patient outcomes. Our Specific Aims are: 1) To examine engagement in guideline- concordant care for depression (virtual or in-person) following screening, before and during the pandemic; 2) To compare psychiatric emergency/hospital visits and mortality from suicide between Veterans who screened positive and were detected versus not detected to have depression by clinicians; 3) To understand VA patients’ and providers’ current perspectives on addressing new depressive episodes using virtual and in-person modalities during the pandemic and eventual recovery. Methodology: Given hypothesized care disruption (lowered care quality) during COVID-19, Aim 1 proposes to extend our preliminary VISN methods nationally to assess the VA population’s trajectory from a new positive depression (and suicide-risk) screen to appropriate treatment (i.e., medication, therapy) in FY19-22/23. We will also examine the changing mix of virtual and in-person depression care delivered. Aim 2 will use interrupted time series analyses to explore the extent to which acute care use may be mitigated by clinician detection of depression nationally. We will also compare mortality rates between patients detected and not detected to have depression. Sub-analyses will reveal where (e.g., clinics with low PC-MHI access) and for whom (e.g., minorities) detection does not systematically occur, and downstream negative sequelae, to guide future intervention. Finally, Aim 3 will interview (1) 40 Veterans who were detected and not detected to have depression per Aims 1 & 2 about care-seeking behavior change, digital divide, etc. and (2) 40 VA primary care and PC-MHI providers about staffing shortage, telehealth adoption, etc. across three VAs (GLA, Syracuse, and Durham). In addition to contextualizing disrupted care findings, qualitative data will help isolate best practices on patient-to-provider and provider-to-provider (e.g., handoffs) interactions in hybrid depression care models. Next Steps/Implementation: The COVID-19 pandemic provides the VA with an opportunity to improve upon a system-wide proactive response to depression and suicide, one that is conceptualized to care for the entire Veteran population. This proposed research will provide the basis for testable hypotheses (e.g., acceptable virtual depression treatments in primary care), and clinical recommendations (e.g., satisfactory virtual provider- to-provider handoffs for new patient referrals), to improve virtual and in-person VA depression services.

背景：作为全面预防自杀的一部分，VA综合身心健康服务更好地检测和治疗抑郁症。初级保健护士每年进行筛查。临床医生，包括初级保健心理健康整合（PC-MHI）专家，随后进行治疗。沮丧检测和管理过程很复杂，涉及多层利益相关者，并受到重要的影响 COVID-19的破坏以及远程医疗的扩大旨在保护护理的目的。更少大流行期间的VA访问可能表明降低抑郁症护理质量并恶化患者预后。意义：抑郁会影响5名退伍军人中的1人，是自杀性和残疾的主要原因。它为当前与大流行有关的心理健康危机做出了重大贡献。抑郁症状，包括自Covid发作以来，自杀思想/行为和相关功能障碍已增加。合作在初级保健，心理健康和互联护理领导者的情况下，我们建议研究与大流行有关的服务抑郁症的破坏，这可能有助于减轻退伍军人人口的急性护理使用和死亡率。我们将既定的抑郁质量指标应用于先前研究时间。我们还将获得反馈，以改善VA提供商的当前混合动力车（虚拟/面对面）护理模型以及筛选积极的退伍军人，包括未发现抑郁症的人。具体目的：在恢复期间为VA初级保健人群改善虚拟和面对面服务，该提议将研究大流行如何破坏抑郁症护理的交付机制，包括扩大远程医疗和患者结果。我们的具体目的是：1）检查参与指南 - 筛查后，大流行前后，对抑郁症的一致护理（虚拟或面对面）； 2）比较筛选的退伍军人之间的精神病紧急/医院访问和死亡率阳性，被发现与未发现临床医生抑郁的抑郁症； 3）了解VA患者以及提供商当前使用虚拟和面对面解决新的抑郁情节的观点大流行期间的方式和最终恢复。方法论：鉴于Covid-19期间假设的护理中断（降低护理质量），目标1提案在全国范围内扩展我们的初步VISN方法，以评估VA人口的轨迹抑郁症（和自杀风险）筛查（即在195财年）中进行适当治疗（即药物，治疗）。我们将还要检查提供的虚拟和面对面抑郁症护理的不断变化。 AIM 2将使用中断时间序列分析以探索通过临床检测可以减轻急性护理使用的程度全国抑郁。我们还将比较检测到的患者之间的死亡率有抑郁。子分析将揭示（例如，PC-MHI访问较低的诊所）以及为谁（例如，少数族裔检测不会系统地发生，并且下游负后遗症可以指导未来干涉。最后，AIM 3将采访（1）40名被发现但未发现的退伍军人抑郁症的目标1和2关于寻求护理行为的改变，数字鸿沟等。（2）40 VA初级保健以及PC-MHI提供者关于人员短缺，采用远程医疗的人员等。达勒姆）。除了将干扰的护理发现与上下文化之外，定性数据还将有助于隔离最佳实践在混合抑郁症护理模型中的患者对患者和提供者对提供者的相互作用（例如，交接）相互作用。下一步/实施：COVID-19大流行为VA提供了改进的机会对抑郁和自杀的系统范围积极反应，这是概念化的，以照顾整个资深人口。这项拟议的研究将为可检验的假设提供基础（例如，可接受初级保健中的虚拟抑郁症治疗）和临床建议（例如，令人满意的虚拟提供商 - 新患者转介的招待商交接），以改善虚拟和面对面的VA抑郁症服务。