Assessment and Management of Depression, Anxiety, and Alcohol
Problems in Primary Care:The BHL Program
VISN 4 MIRECC
VA Philadelphia
University of Pennsylvania
David Oslin, MD
MIRECC – VISN 4 / Philadelphia CESATE
Development of a Sustainable Clinical Innovation
Conceptualization and Investment Implementation
Re-engineering
Sustainable Service
Stakeholder input
Marketing/Dissemination
MIRECC – VISN 4 / Philadelphia CESATE
Development Principals
• Adaptability
• Efficiency
• Targets need
• Scalable
• Reproducible
• Ease of use
• Compassion
MIRECC – VISN 4 / Philadelphia CESATE
InceptionKey issues
• Scope: Cognition, depression, anxiety, alcohol
• Functions: Triage, decision support, monitoring
• Flexibility: ability to profile patients
• Enrollment: how to get patients to come
MIRECC – VISN 4 / Philadelphia CESATE
BHL Clinical Process
Patient IdentificationBy screening or clinical assessment
BHL Initial Assessment
Referral to MH/SA care
Provider Recommendations
Disease Management in Primary Care
No treatment / “False positive” screen
Patient Education and
Promote self-care
Watchful Waiting/ Brief Interventions
MIRECC – VISN 4 / Philadelphia CESATE
InceptionOther issues
• Scalability
• Ease of use
• Interface with CPRS
MIRECC – VISN 4 / Philadelphia CESATE
Initial Beta Version
• Small scale: self programmed in access
• Limited features: interview only, expanded to registration function
• Enrollment: partnership with primary care around screening
MIRECC – VISN 4 / Philadelphia CESATE
Contracting out
• No to CPRS integration – a big decision
• Interviewing software firms
• Developing design features for the programming: scalability, integration of change, building on
• Development of a mechanism to track, test, and deploy changes
MIRECC – VISN 4 / Philadelphia CESATE
Quality Control
• Data: range checks, limited input, limited capacity to change values (administrator)
• Input: staff training
• Acceptability: provider use, patient satisfaction, completion rates
• Algorithms: comparison to clinical interviews, randomized trials of key components, long term outcomes
• Program: EPRP measures, acceptability, management
MIRECC – VISN 4 / Philadelphia CESATE
MIRECC – VISN 4 / Philadelphia CESATE
Core Assessment Module
• During the last 12 months 3779 patients were referred (from 2 VAMCs) 81.7% had a complete assessment
PTSD (84%) Alcohol or drug problems (73%). no differences in completion rates between the
Medical Center and CBOCs.
MIRECC – VISN 4 / Philadelphia CESATE
Treatment Components
• Core Assessment – comprehensive
• Depression Module 2, 6, 9 Weeks Adherence, Depressive symptoms, Side effects
• Watchful Waiting 8 weekly calll
• Alcohol Brief intervention and followup
• Referral management
MIRECC – VISN 4 / Philadelphia CESATE
Addressing Quality Indicators
•Access – The triage and tracking mechanisms allow for seemless referral and the ability to reduce waiting times, prioritize care, and provide administrative support for monitoring.
•Screening – The BHL has been associated with greater screening rates as well as changes in the proportion that screens positive.
•Follow-up of positive screens – The BHL is directly addressing assessment of those with positive screens.
•Monitoring of new initiated treatment – The depression monitoring provides a straightforward mechanism for ongoing monitoring.
MIRECC – VISN 4 / Philadelphia CESATE
Web Resources
• http://www.va.gov/visn4mirecc/bhl/ (Behavioral Health Laboratory)