Telemedicine-Based Collaborative Care to Reduce Rural Health Disparities

描述(申请人提供)：农村抑郁症患者面临巨大的护理障碍，很少接受循证治疗，结果很差。协作护理已被证明可以改善大型城市初级保健(PC)诊所的结果。在小型农村实践中实施协作护理是一个独特的挑战，因为雇用致力于抑郁症治疗的现场多学科护理团队是不可行的。没有发表的研究记录了小型农村个人电脑诊所协作护理的有效性。事实上，最近在农村和城市进行的一项协作护理有效性研究发现，城市诊所的结果有显著改善，但农村诊所没有。我们目前的VA研究结果表明，基于远程医疗的协作护理在小型农村PC诊所是有效的。异地抑郁症护理团队使用电话、电子邮件、互动视频和共享的电子病历向农村诊所提供基于远程医疗的协作护理。该领域的一个关键问题是，小型农村诊所在现场提供协作护理服务(基于实践的协作护理模式)还是与一个非现场护理团队签订合同更有效，后者专门使用远程医疗技术从一个集中地点向多个诊所提供协作护理(基于远程医疗的模式)。我们建议在阿肯色州农村的六个社区卫生中心(CHC)系统中比较基于远程医疗的协作护理和基于实践的协作护理的效果/成本效益。2003年，890家由联邦政府资助的社区卫生保健中心为生活在医疗服务不足地区的1200多万名不同种族的贫困患者提供了服务。儿童保健中心正在重新设计诊所，以提供以实践为基础的协作护理，作为健康差距协作的一部分。这项拟议的研究有可能对公共卫生产生重大影响，因为其结果应该可以推广到全国数百家农村社区卫生保健机构。CHC代表着全国最大和快速增长的PC系统之一，因此结果应该适用于全国各地的大量提供者和患者。此外，社区保健中心主要为生活在医疗服务不足地区的低收入少数群体提供服务。这一人群经历健康差距的风险很高，因此，针对这一人群的干预措施有可能产生重大影响。

DESCRIPTION (provided by applicant): Rural individuals with depression face substantial barriers to care, seldom receive evidence-based treatment, and experience poor outcomes. Collaborative care has been documented to improve outcomes in large urban Primary Care (PC) clinics. Implementing collaborative care in small rural practices presents a unique challenge because it is not feasible to employ on-site multidisciplinary care teams dedicated to depression treatment. No published studies have documented the effectiveness of collaborative care in small rural PC clinics. In fact, one recent collaborative care effectiveness study conducted in both rural and urban practices found that outcomes were significantly improved in urban clinics, but not rural clinics. Results from our current VA study demonstrate that telemedicine-based collaborative care is effective in small rural PC clinics. Telemedicine-based collaborative care was provided to rural clinics by an off-site depression care team using telephones, emails, interactive video, and a shared electronic medical record. A critical question for the field is whether it is more effective for small rural clinics to provide collaborative care services on-site (practice-based collaborative care model) or to contract with an off-site care team that specializes in providing collaborative care to multiple clinics from a centralized location using telemedicine technologies (telemedicine-based model). We propose to compare the effectiveness/cost-effectiveness of telemedicine-based collaborative care to practice-based collaborative care in six Community Health Center (CHC) systems in rural Arkansas. In 2003, 890 federally-funded CHCs served over 12 million poor, ethnically diverse patients living in medically underserved areas. CHCs are in the process of re-engineering clinics to provide practice-based collaborative care as a part of the Health Disparities Collaboratives. The proposed research has the potential to have a major public health impact because the results should be generalizable to the hundreds of rural CHCs across the country. CHCs represent one of the largest and fasting growing PC systems in the nation, and thus results should be applicable to a large number of providers and patients across the nation. In addition, CHCs serve predominantly low income minority populations living in medically underserved areas. This population is at high risk for experiencing health disparities and thus, interventions targeting this population have the potential to have a major impact.