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Introduction to QUERI Implementation Research for VHA Operations Staff: What It is and Why Introduction to QUERI Implementation Research for VHA Operations Staff: What It is and Why It is Helpful Richard R. Owen, MD Director, Mental Health QUERI Jeffrey L. Smith, Ph. D(c) Implementation Research Coordinator, Mental Health QUERI April 28, 2009 Quality Enhancement Research Initiative

Overview • Clinical Research Translation Roadblocks and the Quality Chasm • Introduction to QUERI Overview • Clinical Research Translation Roadblocks and the Quality Chasm • Introduction to QUERI and Implementation Science • Examples of QUERI Projects • Barriers to and Opportunities for Greater Involvement of Policymakers and Managers • Discussion

The problem • Clinical research translational roadblocks Significant barriers impede timely progression of innovations The problem • Clinical research translational roadblocks Significant barriers impede timely progression of innovations from basic science to clinical application to routine use and population benefit • The healthcare quality chasm Pervasive gaps exist in the quality, safety, equity, efficiency, timeliness and patient-centeredness of healthcare

Translational roadblocks: Io. M Clinical Research Roundtable Sung NS, Crowley WF et al. , Translational roadblocks: Io. M Clinical Research Roundtable Sung NS, Crowley WF et al. , Central challenges facing the national clinical research enterprise, JAMA 2003.

Implementation gaps and the quality chasm Most healthcare quality gaps result from insufficient implementation Implementation gaps and the quality chasm Most healthcare quality gaps result from insufficient implementation of evidence-based practices Strategies and programs to accelerate implementation and to improve quality are similar and generally involve organizational and professional behavior change

Possible Solutions • “Push” research into practice – researchers get involved in implementation of Possible Solutions • “Push” research into practice – researchers get involved in implementation of research findings • “Pull” research into practice – policymakers, managers get involved in prioritization and planning of research

VHA Example ORD HSR&D PCS Gap OMHS Prog Eval Centers OQP EES 10 N VHA Example ORD HSR&D PCS Gap OMHS Prog Eval Centers OQP EES 10 N …

OMHS Policy Initiative: MIRECCs ORD PCS HSR&D OMHS MIRECCs, COEs OQP Prog Eval Centers OMHS Policy Initiative: MIRECCs ORD PCS HSR&D OMHS MIRECCs, COEs OQP Prog Eval Centers EES 10 N …

ORD/HSR&D Policy Initiative: QUERI R&M ORD HSR&D OQP PCS MHQ EC OMHS QUERI MH ORD/HSR&D Policy Initiative: QUERI R&M ORD HSR&D OQP PCS MHQ EC OMHS QUERI MH QUERI MIRECCs, COEs Prog Eval Centers EES 10 N …

US Department of Veterans Affairs Quality Enhancement Research Initiative (QUERI) QUERI Mission To enhance US Department of Veterans Affairs Quality Enhancement Research Initiative (QUERI) QUERI Mission To enhance the quality, outcomes and efficiency of VA health care by systematically implementing evidencebased clinical guidelines and innovations into routine clinical practice

Nine QUERI coordinating centers • Chronic Heart Failure • Diabetes • HIV/AIDS • Ischemic Nine QUERI coordinating centers • Chronic Heart Failure • Diabetes • HIV/AIDS • Ischemic Heart Disease • Mental Health • Polytrauma/Blast-Related Injuries • Spinal Cord Injury • Stroke • Substance Use Disorders

“Implementation research in health” Implementation research is the scientific study of methods to promote “Implementation research in health” Implementation research is the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice, and, hence, to improve the quality and effectiveness of health services. It includes the study of influences on healthcare professional and organizational behavior. -- Eccles and Mittman, Implementation Science 2006

Implementation research policy/practice goals • Develop effective strategies for improving health-related processes and outcomes Implementation research policy/practice goals • Develop effective strategies for improving health-related processes and outcomes • Improve health-related processes and outcomes within participating study sites • Facilitate widespread adoption (or ‘spread’) of these strategies

Implementation research science goals • Generate new insights and generalizable knowledge regarding implementation processes, Implementation research science goals • Generate new insights and generalizable knowledge regarding implementation processes, barriers, facilitators, strategies • Develop, test and refine implementation theories, hypotheses, models and principles • Develop improved approaches and methods for studying implementation

The Classic Six-Step QUERI Process 1. Identify high risk/high burden conditions 2. Identify best The Classic Six-Step QUERI Process 1. Identify high risk/high burden conditions 2. Identify best practices 3. Define existing practice patterns in VA and variations from best practices 4. Identify (or develop) and implement programs to promote best practices 5. Document outcome and system improvements 6. Document improvements in health related quality of life

Expanded QUERI Six-Step Process Step 1: Select Diseases/Conditions/Patient Populations 1 A. identify and prioritize Expanded QUERI Six-Step Process Step 1: Select Diseases/Conditions/Patient Populations 1 A. identify and prioritize high risk/high burden clinical conditions 1 B. identify high priority outcomes and areas of practice within a selected condition Step 2: Identify Evidence-Based Guidelines, Practices 2 A. identify evidence-based clinical practice guidelines and recommendations 2 B. identify evidence-based clinical practices, care models Prioritize recommendations for implementation (based on gap, importance for outcomes, feasibility of improvement)

Expanded QUERI Six-Step Process Step 3: Measure and Diagnose Quality/Performance Gaps 3 A. measure Expanded QUERI Six-Step Process Step 3: Measure and Diagnose Quality/Performance Gaps 3 A. measure existing practice patterns and outcomes and identify variations from evidence-based practices and benchmark outcomes (quality, outcome and performance gaps) 3 B. identify determinants of current practices 3 C. diagnose quality gaps 3 D. identify barriers and facilitators to improvement

Expanded QUERI Six-Step Process Step 4: Implement Improvement Programs 4 A. identify implementation/quality improvement Expanded QUERI Six-Step Process Step 4: Implement Improvement Programs 4 A. identify implementation/quality improvement strategies, programs and program components or tools (e. g. , via literature reviews, formative evaluation techniques) 4 B. develop implementation/quality improvement strategies, program components or tools 4 C. implement quality improvement strategies and programs Step 5/6: Evaluate Improvement Programs 5. assess improvement program feasibility, implementation and impacts on patient, family and system outcomes 6. assess improvement program impacts on health-related quality of life (HRQOL)

Implementing evidence-based depression treatment model in VA primary care (Example of Clinical-Research Partnerships at Implementing evidence-based depression treatment model in VA primary care (Example of Clinical-Research Partnerships at VISN- / National-Level)

Depression Care in VA § 7% of patients have depression diagnosis; 44% receive all Depression Care in VA § 7% of patients have depression diagnosis; 44% receive all or most treatment in primary care § Patients treated exclusively in primary care have fewer visits than those seen in mental health specialty care § Less than half (45%) of patients started on antidepressants receive adequate dose for guideline-recommended duration

Collaborative Care for Depression § Integrated package of intervention tools / strategies, including… – Collaborative Care for Depression § Integrated package of intervention tools / strategies, including… – Clinician education and decision support – Care management – Active collaboration between primary care and mental health specialists – Patient education and self-management support § Consistent with Chronic Care Model (Wagner)

Collaborative Care for Depression Primary Care Clinician Nurse Care Manager Psychiatrist Patien t Collaborative Care for Depression Primary Care Clinician Nurse Care Manager Psychiatrist Patien t

Collaborative Care for Depression § Improves depression treatment, symptoms, functioning, work-related outcomes, qualityof-life, and Collaborative Care for Depression § Improves depression treatment, symptoms, functioning, work-related outcomes, qualityof-life, and is cost-effective § Achieving the Promise: Transforming Mental Health Care in VA – “Develop… a VA-adapted collaborative care model dissemination package as the basis for national rollout”

Translating Initiatives for Depression into Effective Solutions (TIDES) § PI’s: Lisa Rubenstein, Ed Chaney Translating Initiatives for Depression into Effective Solutions (TIDES) § PI’s: Lisa Rubenstein, Ed Chaney § Implement collaborative care for depression in VAMCs from 3 VISNs (VISNs 10, 16 & 23) § Use evidence-based quality improvement (EBQI) processes for tailored implementation § Findings – Patients kept 90% of follow-up appointments – Twice as many patients receiving collaborative care were treatment adherent – Depression symptoms significantly improved at 8 -12 weeks – Improved work/social functioning at 6 months

Regional TIDES Spread (Re. TIDES) § PI’s: Rubenstein, Chaney § Sustainability in 1 st Regional TIDES Spread (Re. TIDES) § PI’s: Rubenstein, Chaney § Sustainability in 1 st generation TIDES sites (VISNs 10, 16, 23) § Spread collaborative care to new sites (VISN 22) § Evaluate impact of implementation on patient care, clinical outcomes, and costs § Build and leverage system support for further spread

Implementing and Spreading Collaborative Care for Depression Clinical / Research Partnerships Leadership Support ■ Implementing and Spreading Collaborative Care for Depression Clinical / Research Partnerships Leadership Support ■ Input on ‘TIDES National Dissemination Plan’ ■ OMHS Primary Care / Mental Health A i ptat Ada o. V on t VISN 23 Depression Collaborative Care Model Efficacy / effectiveness studies (VA and other) VISN 10 VISN 1 Imp 6 lem enta tion TIDES Black Hills Twin Ports Sioux Falls Akron Canton Youngstown Beaumont Pensacola Lufkin 1 st-generation sites Re. TIDES Sustainability in st-generation sites 1 (VISNs 10, 16, 23) Spread to 2 nd-generation sites (VISNs 10, 16, 22, 23) Integration Initiative Guidelines & Performance Indicators ■ Updated depression guidelines (release pending internal VA review) ■ ‘Guidance for Program Integrity’ developed, identifying key features of TIDES and related QI models (with performance targets) Training & Education ■ TIDES Depression Care Manager Manual ■ TIDES resources accessible to all VA facilities via Sharepoint website ■ EES-sponsored TIDES trainings Informatics Tools ■ IT Expert Panel conference hosted by Re. TIDES team resulted in plans to integrate TIDES software into VA ‘Mental Health Assistant’ tool

Improving metabolic side effect monitoring for veterans taking antipsychotic medications (Example of Clinical-Research Partnership Improving metabolic side effect monitoring for veterans taking antipsychotic medications (Example of Clinical-Research Partnership at VISN- / Facility-Level)

Background • Psychotic disorders highly disabling and burdensome in VA – 1. 3% prevalence Background • Psychotic disorders highly disabling and burdensome in VA – 1. 3% prevalence of schizophrenia; over 90, 000 vets treated annually – Vets w/ schizophrenia account for 12% of annual VA healthcare costs • Second-generation antipsychotics (SGAs) are a key component of treatment – Prescribed to over 80% of veterans with psychosis • SGAs can cause adverse metabolic side effects – Weight gain – Diabetes – Dyslipidemia • VA guidelines and ADA/APA consensus statement recommend monitoring and management of metabolic side effects for patients started on new antipsychotic

A Study of Strategies to Improve Schizophrenia Treatment (ASSIST) § Objectives: Develop and test A Study of Strategies to Improve Schizophrenia Treatment (ASSIST) § Objectives: Develop and test intervention strategies/tools to improve metabolic side effect monitoring for patients taking APs • Increase baseline monitoring for weight gain, diabetes onset, dyslipidemia § ASSIST Tools / Strategies • Educational tools (for clinicians and patients) • Clinical support tools • Pocket-sized booklet with AP side effect monitoring recommendations • CPRS clinical reminder for side effect monitoring • Performance monitoring tools • Monthly site-level performance reports • Weekly provider-specific feedback on side effect monitoring • Facilitated Team QI and Opinion Leader strategies

External Facilitation in ASSIST • Facilitator – Maintained regular contact w/ local QI team External Facilitation in ASSIST • Facilitator – Maintained regular contact w/ local QI team • Email communication • Participate in monthly ASSIST Team meetings – Monitored implementation of project tools/strategies; performance on AP side effect monitoring and dosing – Identified and problem-solved barriers to implementation – Assisted in adapting tools/strategies as needed or suggested by local QI team to meet project goals

External Facilitation ‘Products’ (Facility A) • Collaborative research-clinical partnership • Placement of recommendations for External Facilitation ‘Products’ (Facility A) • Collaborative research-clinical partnership • Placement of recommendations for antipsychotic side effect monitoring on medication order screens • Enhanced monthly performance reports, tailored to clinician preferences and specifications • Development of weekly reporting system identifying patients in need of metabolic side effect monitoring – Provider name, patient identifier, AP fill date, medication name, info on monitoring parameters – Now fully automated

AP Side Effect Monitoring at Facility A Weekly reports implemented % AP Side Effect Monitoring at Facility A Weekly reports implemented %

VISN 16 Performance Measures – FY 06 VISN 16 Performance Measures – FY 06

Clinical-Research Partnerships: Barriers and Opportunities Clinical-Research Partnerships: Barriers and Opportunities

Barriers to “Clinical-Research Partnerships” • As part of the Re. TIDES project, we interviewed Barriers to “Clinical-Research Partnerships” • As part of the Re. TIDES project, we interviewed 26 VHA leaders and key staff about perspectives on EBP implementation. • Barriers: – Research takes too long – Research isn’t practical • Researchers’ pursue their own career goals • Research tends to focus on single diseases – Managers have to balance available evidence with clinical needs

Opportunities for Enhanced Collaboration and Partnerships • QUERI centers and other initiatives to bridge Opportunities for Enhanced Collaboration and Partnerships • QUERI centers and other initiatives to bridge the gap, while being recognized for their impact, haven’t solved the problem • Clinical-research partnership should include early and active involvement of managers in research prioritization and design • Clinical-research partnership should include capacity for rapid research response to high priority needs of managers

QUESTIONS? Contact: Rick Owen (Richard. Owen 2@va. gov) Jeff Smith (Jeffrey. Smith 6@va. gov) QUESTIONS? Contact: Rick Owen (Richard. Owen [email protected] gov) Jeff Smith (Jeffrey. Smith [email protected] gov) VA Mental Health QUERI http: //www. queri. research. va. gov/mh/default. cfm