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Team-Based Telecare for Bipolar Disorder

The QUERI for Team-Based Behavioral Health program, led by JoAnn Kirchner, MD, and Mark Bauer, MD, works to enhance and inform team-based care for Veterans with behavioral health conditions. More specifically, investigators conduct research to advance VA’s knowledge of how team-based behavioral healthcare can be improved through the use of implementation facilitation strategies, with anticipated improvements in Veteran outcomes. Toward this goal, Team-Based Behavioral Health QUERI has added a new project to their portfolio that will work to implement and sustain team-based telecare for Veterans with bipolar disorder, which can greatly increase the risk of suicide. A new VA study shows that nearly 82% of Veterans with bipolar disorder have documented suicidal behavior or ideation.

Telemental health interventions, including clinical video teleconferencing (CVT), have empirical support from clinical trials and structured demonstration projects. However, their implementation and sustainability under less structured clinical conditions are not well demonstrated. Dr. Bauer and colleagues analyzed the implementation and sustainability of a clinical video teleconference-based collaborative care model (Bipolar Disorders Telehealth Program) for Veterans with bipolar disorder who were treated at the  35 VA healthcare facilities in which it was established over five years (2011-2016).¹ Bipolar Telehealth is a CVT-based program staffed by 1.1 full-time equivalent (FTE) psychiatrists and 2.6 FTE psychologists located across three sites, with administrative support from the VA National TeleMental Health Center. Psychologists conduct Life Goals Collaborative Care training, while psychiatrists make medication and monitoring recommendations to the primary mental health provider. Veterans are enrolled for ~6 months. Results of the evaluation show that the Bipolar Telehealth Program experienced linear and continuing growth and good sustainability over almost five years of operation. The program significantly improved quality of care and Veteran health status.  Key facilitators included:

• Valued recommendations from the consultants;
• Ease of use and integration into ongoing workflow via electronic health record for consulting providers; and
• Extensive infrastructure at the national level to support implementation.

Notable barriers included:

• Labor-intensive nature of scheduling;
• Variable availability of telehealth space, equipment, and staff at certain sites; and
• Disjunction of opinions of consulting provider and consultant, on occasion.

Thus clinical video teleconference-based interventions, even multicomponent collaborative care interventions for individuals with complex mental health conditions, can grow vigorously under appropriate conditions. Studies such as this – and the work being conducted by Team-Based QUERI – will help VA provide increased access to optimal care for Veterans with mental illness.

1. Bauer M, Tuozzo K, Holmes S, et al. Implementing and sustaining team-based telecare for bipolar disorder: Lessons learned from a model-guided, mixed methods analysis. Telemedicine and e-Health. June 2017; Epub ahead of print.

For more information, please contact Mark Bauer, MD, at Mark.Bauer@va.gov .