Time allocation and caseload capacity in telephone depression care management

VA Puget Sound Health Care System, Health Services Research & Development, 1100 Olive Way, Ste 1400, Seattle WA 98101, USA.
The American journal of managed care (Impact Factor: 2.26). 01/2008; 13(12):652-60.
Source: PubMed


To document time allocated to care management activities and care manager workload capacity using data collected for studies of telephone care management of depression.
Cross-sectional, descriptive analysis of depression care manager (DCM) activities and workload in 2 collaborative depression care interventions (1 implementation study and 1 effectiveness study) at Department of Veterans Affairs primary care facilities.
Each intervention tracked specific care management activities for 4 weeks, recording the number of events for each activity type and length of time for each activity. Patient workload data were obtained from the patient tracking systems for the 2 projects. We calculated the average time for each activity type, the average total time required to complete an initial assessment call and follow-up call, and the maximum patient panel for both projects.
The total time per successful initial assessment was 75 to 95 minutes, and the total time per successful follow-up call was 51 to 60 minutes, with more time spent on ancillary activities (precall preparation, postcall documentation, and provider communication) than on direct patient contact. A significant amount of time was spent in unsuccessful call attempts, requiring 9 to 11 minutes for each attempt. The maximum panel size per care manager per quarter was in the range of 143 to 165 patients.
The study found similar DCM time allocations and panel sizes across 2 studies and 3 regions with full-time DCMs. Reductions in DCM time spent on ancillary activities may be achievable through improved informatics and other support for panel management.

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    • "As originally envisioned, the randomized evaluation would have begun after EBQI-CCM practices had completed a small number of PDSA cycles of the CCM intervention involving as few as ten and no more than fifty total patients. Under this scenario, care managers could have covered both naturalistic referrals and randomized evaluation referrals, given typical care manger caseloads [52]. In reality, the requirements of eight separate IRBs, faced with an unfamiliar implementation research model and with the introduction of HIPAA [53], led to a prolonged period between start of naturalistic PDSA intervention development and start of the randomized evaluation (a gap per intervention practice of between 111 and 334 days with a mean of 263 days). "
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    ABSTRACT: Meta-analyses show collaborative care models (CCMs) with nurse care management are effective for improving primary care for depression. This study aimed to develop CCM approaches that could be sustained and spread within Veterans Affairs (VA). Evidence-based quality improvement (EBQI) uses QI approaches within a research/clinical partnership to redesign care. The study used EBQI methods for CCM redesign, tested the effectiveness of the locally adapted model as implemented, and assessed the contextual factors shaping intervention effectiveness. The study intervention is EBQI as applied to CCM implementation. The study uses a cluster randomized design as a formative evaluation tool to test and improve the effectiveness of the redesign process, with seven intervention and three non-intervention VA primary care practices in five different states. The primary study outcome is patient antidepressant use. The context evaluation is descriptive and uses subgroup analysis. The primary context evaluation measure is naturalistic primary care clinician (PCC) predilection to adopt CCM.For the randomized evaluation, trained telephone research interviewers enrolled consecutive primary care patients with major depression in the evaluation, referred enrolled patients in intervention practices to the implemented CCM, and re-surveyed at seven months. Interviewers enrolled 288 CCM site and 258 non-CCM site patients. Enrolled intervention site patients were more likely to receive appropriate antidepressant care (66% versus 43%, p = 0.01), but showed no significant difference in symptom improvement compared to usual care. In terms of context, only 40% of enrolled patients received complete care management per protocol. PCC predilection to adopt CCM had substantial effects on patient participation, with patients belonging to early adopter clinicians completing adequate care manager follow-up significantly more often than patients of clinicians with low predilection to adopt CCM (74% versus 48%%, p = 0.003). Depression CCM designed and implemented by primary care practices using EBQI improved antidepressant initiation. Combining QI methods with a randomized evaluation proved challenging, but enabled new insights into the process of translating research-based CCM into practice. Future research on the effects of PCC attitudes and skills on CCM results, as well as on enhancing the link between improved antidepressant use and symptom outcomes, is needed. NCT00105820.
    Implementation Science 10/2011; 6(1):121. DOI:10.1186/1748-5908-6-121 · 4.12 Impact Factor
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    • "We collected the data presented here as part of the Cost and Value of Evidence-Based Solutions for Depression Study (COVES) [21,22]. COVES evaluated the VA TIDES [23,24] (Translating Initiatives for Depression into Effective Solutions) depression care initiative, a clinic-level quality improvement (QI) intervention to enhance depression treatment in primary care. The VA is a national healthcare system, divided into 21 distinct geographic regions or VISNs (VA Integrated Service Networks). "
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    ABSTRACT: The Veterans Health Administration (VA) has invested significant resources in designing and implementing a comprehensive electronic health record (EHR) that supports clinical priorities. EHRs in general have been difficult to implement, with unclear cost-effectiveness. We describe VA clinical personnel interactions with and evaluations of the EHR. As part of an evaluation of a quality improvement initiative, we interviewed 72 VA clinicians and managers using a semi-structured interview format. We conducted a qualitative analysis of interview transcripts, examining themes relating to participants' interactions with and evaluations of the VA EHR. Participants described their perceptions of the positive and negative effects of the EHR on their clinical workflow. Although they appreciated the speed and ease of documentation that the EHR afforded, they were concerned about the time cost of using the technology and the technology's potential for detracting from interpersonal interactions. VA personnel value EHRs' contributions to supporting communication, education, and documentation. However, participants are concerned about EHRs' potential interference with other important aspects of healthcare, such as time for clinical care and interpersonal communication with patients and colleagues. We propose that initial implementation of an EHR is one step in an iterative process of ongoing quality improvement.
    Implementation Science 08/2010; 5(1):63. DOI:10.1186/1748-5908-5-63 · 4.12 Impact Factor
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    • "; Williams et al . 2007 ) . For example , among patients referred to DCMs , 82 percent were treated for de - pression in primary care and 74 percent stayed on medication ; 90 percent of primary care patients and 50 percent of mental health patients had clinically significant reductions in depressive symptomatology ( PHQ9 scores o10 ) at 6 months ( Liu et al . 2007 ) . The EBQI process , and the costs it entailed , also achieved intended results in terms of sustainability and spread . TIDES care models endured at all original sites ( continuously cared for patients ) for over 2 years , and remain active in five of the seven sites in 2008 ( sustained over 5 years ) . In terms of spread goals , by 2"
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    ABSTRACT: We documented organizational costs for depression care quality improvement (QI) to develop an evidence-based, Veterans Health Administration (VA) adapted depression care model for primary care practices that performed well for patients, was sustained over time, and could be spread nationally in VA. Project records and surveys from three multistate VA administrative regions and seven of their primary care practices. Descriptive analysis. We documented project time commitments and expenses for 86 clinical QI and 42 technical expert support team participants for 4 years from initial contact through care model design, Plan-Do-Study-Act cycles, and achievement of stable workloads in which models functioned as routine care. We assessed time, salary costs, and costs for conference calls, meetings, e-mails, and other activities. Over an average of 27 months, all clinics began referring patients to care managers. Clinical participants spent 1,086 hours at a cost of $84,438. Technical experts spent 2,147 hours costing $197,787. Eighty-five percent of costs derived from initial regional engagement activities and care model design. Organizational costs of the QI process for depression care in a large health care system were significant, and should be accounted for when planning for implementation of evidence-based depression care.
    Health Services Research 03/2009; 44(1):225-44. DOI:10.1111/j.1475-6773.2008.00911.x · 2.78 Impact Factor
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