Lipschitz Jessica M, Benzer Justin K, Miller Christopher, Easley Siena R, Leyson Jenniffer, Post Edward P, Burgess James F
Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 South Huntington Ave, Jamaica Plain,, Boston, MA, 02130, USA.
Harvard Medical School, Department of Psychiatry, Boston, USA.
BMC Health Serv Res. 2017 Oct 10;17(1):691. doi: 10.1186/s12913-017-2601-9.
The collaborative care model is an evidence-based practice for treatment of depression in which designated care managers provide clinical services, often by telephone. However, the collaborative care model is infrequently adopted in the Department of Veterans Affairs (VA). Almost all VA medical centers have adopted a co-located or embedded approach to integrating mental health care for primary care patients. Some VA medical centers have also adopted a telephone-based collaborative care model where depression care managers support patient education, patient activation, and monitoring of adherence and progress over time. This study evaluated two research questions: (1) What does a dedicated care manager offer in addition to an embedded-only model? (2) What are the barriers to implementing a dedicated depression care manager?
This study involved 15 qualitative, multi-disciplinary, key informant interviews at two VA medical centers where reimbursement options were the same- both with embedded mental health staff, but one with a depression care manager. Participant interviews were recorded and transcribed. Thematic analysis was used to identify descriptive and analytical themes.
Findings suggested that some of the core functions of depression care management are provided as part of embedded-only mental health care. However, formal structural attention to care management may improve the reliability of care management functions, in particular monitoring of progress over time. Barriers to optimal implementation were identified at both sites. Themes from the care management site included finding assertive care managers to hire, cross-discipline integration and collaboration, and primary care provider burden. Themes from interviews at the embedded site included difficulty getting care management on leaders' agendas amidst competing priorities and logistics (staffing and space).
Providers and administrators see depression care management as a valuable healthcare service that improves patient care. Barriers to implementation may be addressed by team-building interventions to improve cross-discipline integration and communication. Findings from this study are limited in scope to the VA healthcare system. Future investigation of whether alternative barriers exist in implementation of depression care management programs in non-VA hospital systems, where reimbursement rates may be a more prominent concern, would be valuable.
协作护理模式是一种基于证据的抑郁症治疗方法，其中指定的护理经理通常通过电话提供临床服务。然而，退伍军人事务部（VA）很少采用协作护理模式。几乎所有VA医疗中心都采用了共址或嵌入式方法，为初级保健患者整合心理健康护理。一些VA医疗中心还采用了基于电话的协作护理模式，抑郁症护理经理在此模式下支持患者教育、患者激活以及对依从性和进展的长期监测。本研究评估了两个研究问题：（1）除了仅嵌入式模式外，专职护理经理还能提供什么？（2）实施专职抑郁症护理经理的障碍有哪些？
本研究在两个VA医疗中心进行了15次定性、多学科、关键信息人访谈，这两个医疗中心的报销选项相同，都有嵌入式心理健康工作人员，但其中一个有抑郁症护理经理。对参与者的访谈进行了录音和转录。采用主题分析法来识别描述性和分析性主题。
研究结果表明，抑郁症护理管理的一些核心功能是仅嵌入式心理健康护理的一部分。然而，对护理管理的正式结构性关注可能会提高护理管理功能的可靠性，特别是对进展的长期监测。两个地点都发现了最佳实施的障碍。护理管理地点的主题包括寻找自信的护理经理来聘用、跨学科整合与协作以及初级保健提供者的负担。嵌入式地点访谈的主题包括在相互竞争的优先事项和后勤问题（人员配备和空间）中，难以将护理管理纳入领导议程。
提供者和管理人员将抑郁症护理管理视为一项有价值的医疗服务，可改善患者护理。实施障碍可通过团队建设干预措施来解决，以改善跨学科整合与沟通。本研究结果的范围仅限于VA医疗系统。未来研究在非VA医院系统中实施抑郁症护理管理项目时是否存在其他障碍将很有价值，在这些系统中报销率可能是更突出的问题。
