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

背景：作为全面自杀预防的一部分，VA整合了精神和身体健康服务 来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，根据治疗需要进行随访。抑郁 检测和管理过程是复杂的，涉及多层次的利益相关者，并受到重大影响。 2019冠状病毒病疫情以及由此导致的旨在保护医疗服务可及性的远程医疗的扩张所带来的中断。少 大流行期间的VA访问可能意味着降低抑郁症护理质量和恶化的患者结果。 抑郁症影响五分之一的退伍军人，是自杀和残疾的主要原因。它 在很大程度上助长了目前与流行病有关的心理健康危机。抑郁症状，包括 自COVID发病以来，自杀想法/行为和相关功能障碍有所增加。合作 我们建议与初级保健、心理健康和联网保健的领导人一起研究与流行病有关的服务 这可能有助于减轻退伍军人群体的急性护理使用和死亡率。 我们将先前研究中建立的抑郁症质量指标应用于全国范围内的关键指标， 时间我们还将从VA提供者那里获得反馈，以改进当前的混合（虚拟/面对面）护理模式 以及筛查呈阳性的退伍军人，包括那些没有被检测出患有抑郁症的人。 具体目标：改善康复期间VA初级保健人群的虚拟和面对面服务， 该提案将研究大流行如何破坏抑郁症护理提供机制，包括 扩展的远程医疗和患者的治疗效果。我们的具体目标是：1）审查准则中的参与- 在大流行之前和期间，在筛查之后对抑郁症进行协调治疗（虚拟或面对面）; 2） 比较接受筛查的退伍军人之间的精神病急诊/医院就诊和自杀死亡率 阳性，临床医生检测到与未检测到抑郁; 3）了解VA患者 以及提供者目前对使用虚拟和面对面解决新的抑郁发作的看法 在大流行期间和最终恢复期间的模式。 方法：鉴于COVID-19期间假设的护理中断（降低的护理质量），目标1建议 将我们的初步VISN方法扩展到全国，以评估VA人群从新的阳性 抑郁症（和自杀风险）筛选到适当的治疗（即，药物，治疗）在FY 19 -22/23。我们将 还研究了虚拟和面对面抑郁症护理的变化组合。目标2将使用中断 时间序列分析，以探索临床医生检测急性护理使用的程度， 抑郁症全国我们还将比较检测到和未检测到的患者之间的死亡率， 患有抑郁症。子分析将揭示哪里（例如，低PC-MHI访问的诊所）以及对谁（例如， 少数民族）检测不系统地发生，和下游的负面后遗症，以指导未来 干预最后，目标3将采访（1）40名退伍军人谁被发现和未被发现有 根据目标1和2关于寻求护理的行为改变，数字鸿沟等的抑郁症和（2）40 VA初级保健 和PC-MHI提供商关于三个VA（GLA、锡拉丘兹和 达勒姆）。除了将中断的护理结果置于情境中之外，定性数据还将有助于隔离最佳实践 在患者对提供者和提供者对提供者（例如，混合抑郁症护理模式中的相互作用。 后续步骤/实施：COVID-19大流行为退伍军人事务部提供了一个改善 全系统积极应对抑郁症和自杀，一个概念化的照顾整个 退伍军人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），以及临床建议（例如，满意的虚拟供应商- 新病人转介的提供者支持），以改善虚拟和面对面的VA抑郁症服务。

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.