RESPECT-Mil: Early Intervention & Outcomes of PTSD ... · system 8 weeks or more, and have a...

Charles C. Engel, MD, MPH

Associate Chair (Research), Department of PsychiatryUniformed Services University School of Medicine

Director, Deployment Health Clinical Center at Walter ReedSenior Scientist, Center for the Study of Traumatic Stress

cengel@usuhs.mil

RESPECT-Mil: Early Intervention & Outcomes of PTSD

& Depression in Primary Care

Report Documentation Page Form ApprovedOMB No. 0704-0188

Public reporting burden for the collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering andmaintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,including suggestions for reducing this burden, to Washington Headquarters Services, Directorate for Information Operations and Reports, 1215 Jefferson Davis Highway, Suite 1204, ArlingtonVA 22202-4302. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to a penalty for failing to comply with a collection of information if itdoes not display a currently valid OMB control number.

1. REPORT DATE 2011 2. REPORT TYPE

3. DATES COVERED 00-00-2011 to 00-00-2011

4. TITLE AND SUBTITLE RESPECT-Mil: Early Intervention & Outcomes Of PTSD & DepressionIn Primary Care

5a. CONTRACT NUMBER

5b. GRANT NUMBER

5c. PROGRAM ELEMENT NUMBER

6. AUTHOR(S) 5d. PROJECT NUMBER

5e. TASK NUMBER

5f. WORK UNIT NUMBER

7. PERFORMING ORGANIZATION NAME(S) AND ADDRESS(ES) Uniformed Services University School of Medicine,Department ofPsychiatry,4301 Jones Bridge Rd,Bethesda,MD,20814

8. PERFORMING ORGANIZATIONREPORT NUMBER

9. SPONSORING/MONITORING AGENCY NAME(S) AND ADDRESS(ES) 10. SPONSOR/MONITOR’S ACRONYM(S)

11. SPONSOR/MONITOR’S REPORT NUMBER(S)

12. DISTRIBUTION/AVAILABILITY STATEMENT Approved for public release; distribution unlimited

13. SUPPLEMENTARY NOTES Presented Mar 21 at the 1st Annual Armed Forces Public Health Conference 2011

14. ABSTRACT

15. SUBJECT TERMS

16. SECURITY CLASSIFICATION OF: 17. LIMITATION OF ABSTRACT Same as

Report (SAR)

18. NUMBEROF PAGES

52

19a. NAME OFRESPONSIBLE PERSON

a. REPORT unclassified

b. ABSTRACT unclassified

c. THIS PAGE unclassified

Standard Form 298 (Rev. 8-98) Prescribed by ANSI Std Z39-18

Why Primary Care?A Gap Between Needs & Services

Among the 20% of Soldiers with moderate to severe disorder after OIF deployment…

Hoge CW, et al. N Engl J Med. 2004;351:13-22.

Want help

Mental health

professional

Acknowledge

a problem

Got help (past 12 months)

Any

professional

13-27%38-45%

78-86%

23-40%

Potential for Offset: Service Use & Missed Work

0

10

20

30

40

50

60

15+ on PHQ-

15

limb pain back pain 2+ sick call

visits/mo

2+ missed

work

days/mo

PTSD

No PTSD

Hoge et al, Am J Psychiatr, 2007

2,863 Iraq War returnees one-year post-deployment

Twice as many

sick call visits &

missed work days

Percen

t o

f S

old

iers

4

Primary Care…Where Soldiers Get Their Care

Mean primary care use is 3.4 visits per year

88-94% have one or more visits per year

Primary care approach to mental health is an opportunity to…

Reduce stigma & barriers

Intervene early

Reduce unmet needs

Reduce unnecessary service use

4

5

Primary Care Intervention is Evidence-Based

Randomized trials offer sound evidence that systems-level approaches benefit…

Depression (e.g., IMPACT Trial BMJ 2006)

Suicidal ideation & depression (Bruce et al, JAMA 2004)

Depression and physical illness (e.g., Lin et al, JAMA, 2003)

PTSD and physical injury (Zatzick, AGP, 2004)

Panic disorder (e.g., Roy-Byrne et al, AGP 2005)

Somatic symptoms (e.g., Smith et al, AGP 1995)

Health anxiety (e.g., Barsky et al, JAMA 2004)

Substance dependence (e.g., O‟Connor et al. Am J Med. 1998)

Dementia (e.g., Callahan et al, JAMA 2006)

5

Defense Centers of Excellence for Psychological Health & TBI

Office of The Surgeon General, Army

Deployment Health Clinical Center

Uniformed Services University

3CM®

COLORADO SPRINGS, CO 5-7 OCTOBER 2010

RESPECT-MilRe-Engineering Systems of Primary Care Treatment in the Military

6

3 Component Model

systems-based carePREPARED PRACTICE

BH SPECIALIST

PATIENTCARE MANAGER

an extra resourcethat links patient,

provider & specialist

Oxman et al, Psychosomatics, 2002;43:441-450

8

Encourage AdherenceProblem Solve Barriers

Measure Treatment Response

Monitor Remission

RESPECT-Mil

Care Facilitator Functions

9

RESPECT-Mil Worldwide Sites

Levels of Implementation

Micro: Clinic level implementation

Meso: Site level implementation (R-SIT)

Macro: Program level implementation (R-MIT)

10

11

RESPECT-Mil ImplementationMicro- or Clinic-level

Brief PTSD & depression screening (all visits)

Pre-clinician diagnostic aid

Patient education materials

Psychosocial options

Care Facilitator assisted follow-up option

Aggressive facilitator outreach & monitoring

Web-based care facilitation system

“Just-in-time” treatment adjustment

Weekly BH Champion review of facilitator caseload

1

12

RESPECT-Mil ImplementationMicro- or Clinic-level

Brief PTSD & depression screening (all visits)

Pre-clinician diagnostic aid

Patient education materials

Psychosocial options

Care Facilitator assisted follow-up option

Aggressive facilitator outreach & monitoring

Web-based care facilitation system

“Just-in-time” treatment adjustment

Weekly BH Champion review of facilitator caseload

1

13

14

RESPECT-Mil ImplementationMicro- or Clinic-level

Brief PTSD & depression screening (all visits)

Pre-clinician diagnostic aid

Patient education materials

Psychosocial options

Care Facilitator assisted follow-up option

Aggressive facilitator outreach & monitoring

Web-based care facilitation system

“Just-in-time” treatment adjustment

Weekly BH Champion review of facilitator caseload

1

PT

SD

In

stru

men

t (P

CL

-C)

15

16

RESPECT-Mil ImplementationMicro- or Clinic-level

Brief PTSD & depression screening (all visits)

Pre-clinician diagnostic aid

Patient education materials

Psychosocial options

Care Facilitator assisted follow-up option

Aggressive facilitator outreach & monitoring

Web-based care facilitation system

“Just-in-time” treatment adjustment

Weekly BH Champion review of facilitator caseload

1

Provider “Fast Facts”

Participant Education &Self-Management Materials

Goals & Self-Management Worksheet

Participant Brochure

18

RESPECT-Mil ImplementationMicro- or Clinic-level

Brief PTSD & depression screening (all visits)

Pre-clinician diagnostic aid

Patient education materials

Psychosocial options

Care Facilitator assisted follow-up option

Aggressive facilitator outreach & monitoring

Web-based care facilitation system

“Just-in-time” treatment adjustment

Weekly BH Champion review of facilitator caseload

1

DESTRESS-PC - Web-based,

nurse assisted, PTSD self-training

DElivery of

Self-

TRaining &

Education for

Stressful

Situations –

Primary Care version

20

RESPECT-Mil ImplementationMicro- or Clinic-level

Brief PTSD & depression screening (all visits)

Pre-clinician diagnostic aid

Patient education materials

Psychosocial options

Care Facilitator assisted follow-up option

Aggressive facilitator outreach & monitoring

Web-based care facilitation system

“Just-in-time” treatment adjustment

Weekly BH Champion review of facilitator caseload

1

FIRST-STEPS – Web-based Care-

Manager Support & Reporting System

21

22

RESPECT-Mil ImplementationMicro- or Clinic-level

Brief PTSD & depression screening (all visits)

Pre-clinician diagnostic aid

Patient education materials

Psychosocial options

Care Facilitator assisted follow-up option

Aggressive facilitator outreach & monitoring

Web-based care facilitation system

“Just-in-time” treatment adjustment

Weekly BH Champion review of facilitator caseload

1

FIRST-STEPS – Improves Efficiency,

Accountability & Effectiveness of Staffing

23

RESPECT-Mil ImplementationMacro- or Program-level

RESPECT-Mil Implementation Team (R-MIT):

Monitors program implementation, fidelity, outcomes

Trains & consults with R-SiTs

Develops & disseminates education modules and tools

Pilots & evaluates new components

Performs site visits & site calls

24

RESPECT-Mil ImplementationMeso- or Site-level

RESPECT-Mil Site Team (R-SIT)

Primary Care ChampionMonitors local program & process

Behavioral Health ChampionMonitors facilitator caseloads

FacilitatorRN, 1 per 6K in eligible population

Administrative assistant1 per 10K in eligible population

25

Web-Based PTSD &

Depression Training for

Primary Care Providers*

26

* Includes suicide assessment training

27

RESPECT-MilProvider Manuals

3 Component Model

systems-based carePREPARED PRACTICE

BH SPECIALIST

PATIENTCARE MANAGER

an extra resourcethat links patient,

provider & specialist

Oxman et al, Psychosomatics, 2002;43:441-450

RESPECT-Mil

Implementation Results

61 of 95 primary care clinics at 34 sites are implementing, with the remainder expected on line by July 2011.

86% of visits at implementing clinics screened in last 12 months (75% since January 2007; 2-5% at non-RESPECT-Mil clinics)

13% of all screened visits are positive (PTS or depression)

48% of positive screens result in a primary care diagnosis of „depression‟ or „possible PTSD‟

26% of positive screens receive other BH diagnoses (e.g., adjustment disorder)

29* Data through November 2010

RESPECT-Mil Screening Visits*Steadily Rising Rate of Routine Screening*

30Data through November 2010

Referrals for Enhanced BH Services*Referrals for Facilitation Nearly as High as to Specialist*

31* Data through November 2010

Care Facilitation & PTSD Severity (PCL-C)*Number of facilitator visits associated with improvement*

32

1 2 3 4 5 6 7+

Number of care facilitator contacts

* Data from RESPECT-Mil enrolled cases from 01 Feb 2007 to 31 Aug 2009 (N = 2,548)

Care Facilitation & Depression Severity (PHQ-9) *Number of facilitator visits associated with improvement*

33

1 2 3 4 5 6 7+

Number of care facilitation sessions used

* Data from RESPECT-Mil enrolled cases from 01 Feb 2007 to 31 Aug 2009 (N = 2,548)

RESPECT-Mil

Safety & Risk Management

Visits associated with any suicidal ideation

1% of screened visits (8.6% of screen positive

visits)

25% of visits involving suicidal ideation are rated

by provider as intermediate or high risk (“non-low risk”)

8,771 visits involved suicidal ideation

Frequent “save” anecdotes

* Data through November 2010

RESPECT-Mil

Safety & Risk Management

Visits associated with any suicidal ideation

Appropriate risk assessment - 99.4% of

screened positive visits

Appropriate risk assessment - 99.9% of

screened visits

* Data through May2010

RESPECT-Mil

Dispositions

66% assistance rateaccept/[accept + decline]

4% of all visitsinvolve recognition & assistance for previously

unrecognized mental health needs

36* Data through November 2010

Real-time Aggregate Data ReportsPTSD Remission Trend – Region #1

**Remission is defined as the count of individuals who have an open episode in FIRST STEPS, have been in the system 8 weeks or more, and have a PCL score of 27 or less.

Real-time Aggregate Data ReportsPTSD Remission Trend – Region #2

**Remission is defined as the count of individuals who have an open episode in FIRST STEPS, have been in the system 8 weeks or more, and have a PCL score of 27 or less.

Real-time Aggregate Data Reports

PTSD Remission Trends by Region

Quarterly Progress Report: Fort Alpha

Example of a High Performance Site

40

41

RESPECT-Mil

Findings to Date

Often concerns about getting started

Once started, approach is acceptable and feasible for both Soldiers and providers

Enrolled soldiers show clinical improvement

Identifying & referring Soldiers with previously unrecognized and unmet needs

Enhanced safety and risk assessment capabilities

42

RESPECT-Mil

Challenges & Road Ahead

Provider training and retraining

Expansion site training

Web-based training ongoinghttp://www.pdhealth.mil/respect-mil.asp

FIRST-STEPS performance reporting

Alcohol SBIRT demonstration in preparation

REHIP: triservice demonstration of a “blended” model

Intercalation with Patient Centered Medical Home

STEPS-UP: 5-year, 18-clinic controlled trial – intervention is blended + centralized care management + stepped psychosocial modalities

RESPECT-Mil Central

Implementation Team

COL Charles Engel, MCDirector

Tim McCarthyDeputy Director

Sheila Barry, BAAssociate Director, Program Development & Training

Mark Weis, MDPrimary Care Health Proponent

David Dobson, MDBehavioral Health Proponent

Kelly Williams, RNNurse Proponent & Educator

Lee BalitonProgram Evaluation/IT Specialist

James HarrisProgram Manager

Justin Curry, PhDAssociate Director, Program Evaluation

Barbara CharlesAdministrative Assistant

Phyllis HardyAdministrative Assistant

Consultant TeamAllen Dietrich, MD

Professor of Family Medicine, Dartmouth Medical School

Thomas Oxman, MDEmeritus Professor of Psychiatry, Dartmouth Medical School

John Williams, MD, MSPHProfessor of Medicine, Duke University & Durham VA

Kurt Kroenke, MDProfessor of Medicine, Indiana University & Regenstrief Institute

Advances in Psychosomatic Medicine 2004;25:102-22

RESPECT-Mil

Patient Flow & Clinic Process

45

Already in BH /RESPECT-Mil 63%

New referral to BH care 16%

New referral to RESPECT-Mil 15%

New referral out to BH care 7%

BH care enhanced7.6% of visits

negative

episode complete86.6% of visits

negative

episode complete4.4% of visits

Negative PHQ & PCL 72%

No PCC Diagnosis 28%

PCC visit10.2% of visits

screenall visits

diagnostic aid13.4% of visits

positive

positive

enhanced BH care declined1.4% of visits

no diagnosis

“Possible PTSD”

and / or “Depression”

RESPECT-MilTime & Workload

component % visits

All clinic patients 100.0%

Screen positive 13.4%

Diagnosis 10.2%

Suicidality 0.7%

estimated time / visit

2 minutes medic time

3 minutes medic time

10 minutes clinician time

25 minutes clinician time

46

Total Estimated Time Per VisitMedic = 2 + (0.134 x 3) = 2.4 min

Provider = (0.102 x 10) + (0.007 x 25) = 1.2 min

47

RESPECT-Mil Creating Efficiencies

screen -~ 2 min medic time

NO provider time

screen+, dx+, suicide-~ 5 min medic~10 min provider time

screen+, dx+, suicide+~5 min medic~25 min provider time

~0.7%

~9.5%

~86.6%

~3.2% screen+, dx-~ 5 min medic time

NO provider time

~ 90% of visits require NO added provider time

~ 84% of added clinician time is for the 0.7% of visits at highest risk

RESPECT-Mil Facilitator Use*Only 20.6% have four or more facilitator contacts*

48* Data from RESPECT-Mil enrolled cases from 01 Feb 2007 to 31 Aug 2009 (N = 2,548)

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

1 2 3 4 5 6 7 8 9 10 or

more

42.0%

17.4%

11.6%

8.8%6.2%

4.4%3.5%

1.6%2.0% 2.6%

Number of care facilitation sessions used

Quarterly Progress Report: Fort Bravo

Example of an Average Performance Site

49

Quarterly Progress Report: Fort Charlie

Example of a Low Performance Site

50

DoD STEPS-UP

A 6-site (18 clinic) RCT

comparing 12-months of

collaborative PTSD &

depression care vs usual

primary care.

Intensified intervention…

• aggressive case management (behavioral activation, motivation enhancement,

centralized tracking)

• stepped psychosocial care

Stepped

Treatment

Enhanced

PTSD

Services

Using

Primary Care

Supported by a DoD grant (DR080409) from the Congressionally-

Directed Medical Research Program (CDMRP)

STEPS-UP Investigators

CoinvestigatorsDouglas Zatzick, MD (UW, Seattle)

Brett Litz, PhD, MA (Boston Univ & VA)

Terri Tanielian, MA (RAND)

Christine Eibner, PhD (RAND)

Jürgen Unützer, MD, MPH (UW, Seattle)

Wayne Katon, MD (UW, Seattle)

Donald Brambilla, PhD (RTI)

Michael C. Freed, PhD (DHCC/USUHS)

Kristie L. Gore, PhD (DHCC/USUHS)

Laurel L. Hourani, PhD, MPH (RTI)

Becky Lane, PhD (RTI)

Site InvestigatorsChris Warner, MD (Ft Stewart, GA)

Kris Peterson, MD (Ft Lewis, WA)

Melissa Molina, MD (Ft Bliss, TX)

Mark Reeves, MD (Ft Carson, CO)

Anthony Noya, MD (Ft Polk, LA)

Pascale Guirand, FNP (Ft Bragg, NC)

Scientific AdvisorsAllen Dietrich, MD (Dartmouth)

John Williams, MD (Duke & Durham VA)

Kurt Kroenke, MD (Regenstrief Institute)

Kathryn Magruder, PhD (MUSC)

Charles Hoge, MD (Walter Reed Army Institute of Research)

Principal InvestigatorsInitiating: Charles Engel, MD MPH (USU / DHCC)

Partnering: Robert Bray, PhD (RTI International)

Partnering: Lisa Jaycox, PhD (RAND Corporation)