Background: Providing mental health care to rural Veterans in geographically accessible Community Based Outpatient Clinics (CBOCs) is a major priority of the Office of Rural Health. Likewise, integrating mental health into primary care is one of the highest priorities of the Offic of Mental Health Services and the Office of Mental Health Operations. The Uniform Mental Health Services Handbook mandates the blending of the two predominant, evidence-based models of integrated care (the Care Management model and the Co-Located model) at VAMCs, very large CBOCs, and large CBOCs. Because there is no scientific evidence to support its implementation, the Blended model is not mandated at medium CBOCs or small CBOCs that serve rural Veterans. At most smaller CBOCs, on-site mid-level providers and/or off-site tele-psychiatrists and tele-psychologists deliver traditional referral-based specialty treatment (Referral model) rather than integrated care. Objective: This project contributes to Specific Aim 3 (Test clinical interventions to improve quality and outcomes of mental health care at CBOCs) of the Little Rock CREATE application. The goal of this proposed Hybrid Type 2 pragmatic effectiveness-implementation trial is to generate the scientific evidence needed to justify the national dissemination of the Blended model adapted using telemedicine technologies to accommodate the clinical context of smaller CBOCs that lack on-site psychiatrists and PhD psychologists. The resulting Telemedicine Blended model will be compared to usual care (Referral model) in a pragmatic trial, where the intervention will be delivered by clinical staff available in routine care settings and fidelity will be monitored but not controlled.
Specific Aim : Use Evidence Based Quality Improvement (EBQI) techniques to adapt the Blended model for CBOCs lacking on-site PhD psychologists and psychiatrists using telemedicine technology and refine the adapted Telemedicine Blended model during a four month pilot test.
Specific Aim 2 : Conduct a Hybrid Type 2 pragmatic effectiveness-implementation trial of the adapted Telemedicine Blended model by assessing RE-AIM outcomes including: provider Reach into the patient population, Effectiveness at improving clinical outcomes, Adoption by providers and Implementation Fidelity. Methods: In conjunction with national, regional and local partners, the Blended model will be adapted for smaller CBOCs using telemedicine technologies and pilot tested to generate a standardized treatment protocol. Using a Zelen study design, days of the week will be randomized to intervention or control conditions and CBOC patients will be consented to participate in the Hybrid Type 2 pragmatic effectiveness-implementation trial. Data about Reach and Adoption will be obtained from the Austin Automation Center. Data about Implementation Fidelity will be obtained from chart review. Data about clinical Effectiveness will be obtained from telephone survey. Impact: If the Telemedicine Blended model improves clinical outcomes compared to usual care, results will be used to justify and facilitate the implementation of the Telemedicine Blended model at smaller CBOCs.

Public Health Relevance

Integrating mental health treatments into the primary care delivered at Community Based Outpatient Clinics (CBOCs) that are geographically accessible to rural Veterans is a major priority for the Department of Veterans Affairs. However, there is no scientific evidence that integrating mental health and primary care is clinically effective at smaller CBOCs that have limited mental health staffing. The goal of this proposed project is to generate the scientific evidence needed to justify the dissemination of integrated care models that have been adapted for smaller CBOCs using telemedicine technologies. The acceptability and effectiveness of the telemedicine integrate care model will be tested using data from administrative records, chart review and patient self-report. If clinical outcomes are improved compared to usual care, findings will be used to justify and facilitate the implementation of this telemedicine integrated care model at smaller CBOCs in order to increase rural Veterans' access to effective mental health treatments.

National Institute of Health (NIH)
Veterans Affairs (VA)
Non-HHS Research Projects (I01)
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HCR 8 - CREATE Safety HIT (HCR8)
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Central Arkansas Veterans Hlthcare Sys
North Little Rock
United States
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