Telemedicine-Based Collaborative Care to Reduce Rural Health Disparities

描述（由申请人提供）：农村抑郁症患者在护理方面面临巨大障碍，很少接受循证治疗，并且结果不佳。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提出了一个独特的挑战，因为聘请现场多学科护理团队致力于抑郁症治疗是不可行的。没有发表的研究证明协作护理在小型农村PC诊所的有效性。事实上，最近在农村和城市实践中进行的一项合作护理有效性研究发现，城市诊所的结果得到了显著改善，而农村诊所则没有。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。以远程医疗为基础的协作护理由一个非现场抑郁症护理小组通过电话、电子邮件、互动视频和共享电子医疗记录向农村诊所提供。该领域的一个关键问题是，小型农村诊所是否更有效地提供现场协作护理服务（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，该团队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）。我们建议比较阿肯色州农村地区六个社区卫生中心（CHC）系统中基于远程医疗的协作护理与基于实践的协作护理的有效性/成本效益。2003年，890个联邦资助的健康中心为生活在医疗服务不足地区的1200多万贫困、不同种族的患者提供服务。保健中心正在对诊所进行重新设计，以提供基于实践的协作护理，作为健康差异协作的一部分。拟议的研究有可能对公共卫生产生重大影响，因为研究结果应该可以推广到全国数百个农村CHCs。CHCs代表了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大量的提供者和患者。此外，保健中心主要服务于生活在医疗服务不足地区的低收入少数民族人口。这一人群面临面临健康差异的高风险，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.