Part artic icip ipato atory ry S Syst ystem em D Dyna ynami mics cs: Tri riang ngul ulat ating ng Ele lectr tron onic ic He Heal alth th Reco ecord rds, s, St Stak akeh ehold older er E Expe xpert rtis ise a e and nd Sim imula lati tion on Mo Mode deli ling g to to E Expa pand nd E Evid iden ence ce- Bas ased d Pr Prac actic ices es F rac of veterans who Initial tx wait screen positive for list PTSD depression or anxiety Veterans Veterans Pending @LZPhD Pending Tx Second Appt Veterans second therapy Screen Veterans first therapy appt completion rate positive rate appt completion rate Second appt December 15, 2016 F irst appt tx Screening appts Average time to Average time tx capacity capacity per day first therapy ratio to second ratio appt therapy appt Lindsey Zimmerman, PhD Effect of tx capacity on time Effect of tx F irst appt capacity on time to first therapy tx capacity to second therapy Second appt tx appt appt capacity Standard Clinical & Community Psychologist, therapy appt <Standard wait time therapy appt Implementation Science wait time> Proportion allocated to first tx appt Average time to National Center for PTSD, complete EBT Total appt capacity Dissemination & Training Division Affiliate Instructor, University of David Lounsbury, PhD, Craig Rosen, PhD Washington School of Medicine Rachel Kimerling, PhD, Jodie Trafton, PhD Lindsey.zimmerman@va.gov & Steve Lindley MD, PhD 1
These views are my own. The views and opinions expressed herein do not necessarily state or reflect those of the United States Government. 2
The aim of our research: • …is to develop a systems understanding of mental health service delays and how they contribute to limited reach of evidence-based mental health care. • …and empower mental health stakeholders to make optimized quality improvement decisions with ex ante assessments of their proposed redesign solutions. 3
Future of Implementation Science “The next generation of studies…will address the sustainable integration of interventions within dynamic health care delivery systems and the implementation of evidence-based systems of care rather than the individual intervention.” - David Chambers (2012) Brownson, Colditz & Proctor, 2012
Setting - time, place, and circumstances in which something occurs or develops Organization - act or process of organizing or of being organized Context - interrelated conditions in which something exists or occurs Merriam Webster, 2016 5
Adoption as a situated individual and collective behavior: The interrelated time, place, and circumstances in which providers commit to and are organized to initiate an EBP. 6
System – A set of elements interconnected in such a way that they produce their own internal dynamics. The system, to a large extent, causes its own behavior. Meadows, 2008 7
Structure determines behavior. Structure determines behavior. 8
We define EBP reach as the proportion of patients with a PTSD, depression or SUD diagnosis who a) initiate b) timely EBP session c) complete an adequate, therapeutic EBP dose 9
Reach as a system behavior: the whole set of mechanisms by which the needs of the patient population are or are not addressed by their health care system. 10
There is strong evidence for EBPsy and EBPharm as the best approaches to meet patient demand in VA. • Evidence-based Psychotherapy (EBPsy) – Depression, PTSD, Substance Use Disorder (SUD) • Evidence-based Pharmacotherapy (EBPharm) – Depression, Alcohol Use Disorder (AUD) and Opioid Use Disorder (OUD) • EBPsy and EBPharm reduce PTSD and depression symptoms, reduce alcohol or opiate use and thereby, reduce risk of chronic impairment, relapse, suicide and overdose. 11
Palo Alto VA Health Care System Main facility • and nine outpatient clinics +85K patients • served >17,000 patients • receive MH care each year 12
Exi xisti ting ng S Stat ate: e: I Inad adeq equa uate e pr prop oport rtio ion n of f pat atien ents ts g gett ttin ing g tim imel ely, y, hi high gh-qu qual alit ity y car are 80 70 Wait Time 1 Goal Days from intake to first 60 appointment 50 40 30 20 10 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 New OEF/OIF PTSD Intakes 13
Tar arget et S Sta tate: e: Lea ean SMA MART RT Go Goal al By April 2015, 40% of patients newly seen in outpatient mental health at Menlo Park for depression, PTSD, or anxiety disorders will have two psychotherapy visits completed within 28 days from time of intake assessment. 14
Local improvement, but wide variability & goal not achieved. 100.00% Implemented changes % of new patients with 2nd appointment within 2 weeks 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% 29-Sep 29-Oct 29-Nov 29-Dec 29-Jan 29-Feb 31-Mar 30-Apr 31-May 30-Jun 31-Jul 31-Aug 15
Gap between scheduling and completing psychotherapy remained. 40.0% Two Psychotherapy Visits within one month of Intake 35.0% 30.0% % of New Intake patients 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% 16
Tar arget et S Sta tate: e: Lea ean SMA MART RT Go Goal al By April 2015, 40% of patients newly seen in outpatient mental health at Menlo Park for depression, PTSD, or anxiety disorders will have two psychotherapy visits completed within 28 days from time of intake assessment. Specific. Measurable. Attainable : if never achieved morale may suffer. Realistic : with the available resources. Time frame : A due date.
System dynamics makes complexity more manageable. We look at Everyone will have interdependence among multiple opportunities for clinic components. input. We partner with frontline staff and leadership to learn together. Everyone has relevant expertise. Hard for any single person to grasp the interrelated whole system. 18
PSD em embeds a a susta tainable le QI proces ess and d tool tool in in the e local l settin ing Drawn from Hovmand (2014) Description of why Scientific Problem quality problems persist. Model Stakeholders cannot or Learning do not learn and adapt to their situation. Subjective Conflict or lack of Coordination stakeholder consensus. Policies are inconsistent Analysis with the real system constraints. Objective The underlying structure Restructuring of the system prevents workable solutions. 19
Modeling saves time and effort. We use simulation to Average Time to Tx see impacts of 20 proposed changes 15 on the whole system Days 10 in real time before we actually try to 5 implement anything. 0 0 10 20 30 40 50 60 70 80 90 100 Time ( Day) Average time to case manage appt : Demo calibration Average time to med manage appt : Demo calibration We also determine Average time to first therapy appt : Demo calibration Average time to complete E BT : Demo calibration when we should achieve our goal. 20
Systems have properties of self- organization, emergence & adaptation. Chambers, Stange, & Glasgow, 2013 – Dynamic Sustainablity Framework 21
Systems have properties of self-organization, emergence & adaptation. “It is not yet clear how best to tailor interventions and therefore not clear what the effect of an optimally tailored intervention would be .” Baker et al., 2015 – Cochrane Database of Systematic Reviews 22
PSD: Addresses Multifinality and Equifinality Menlo Park Stockton 3548 unique patients/year 2043 unique patients/year Lower caseload per provider Higher caseload per provider Rare wait for initial appointment Occasional waitlist to get into clinic 5.2 psychiatrists per 9 EBPsy providers 3.0 psychiatrists per 4 EBPsy providers Higher EBPsy providers/MD ratio Lower EBPsy provider/MD ratio Higher EBPsy base rate Higher EBPharm base rate Providers often self refer for EBPs Referrals to other providers by necessity Multiple on-site specialty programs Only telehealth specialty care Training program site multiple disciplines No trainees providing care Most groups "open" (ongoing Most groups "closed" (infrequent enrollment) opening) Shorter time to next available Longer time to next available appointment appointment 23
Reach as a system behavior: the purposes of subunits in a system may add up to an overall behavior no one wants; changing elements usually has the least effect on the system. Meadows, 2008 24
Systems have properties of self- organization, emergence & adaptation. Plan Plan Act Do Act Study Study Do Damschroder et al., 2009 – Process domain: Engage, Plan, Execute, Evaluate 25 Consolidated Framework for Implementation Research
System Dynamics provided the original conceptualization of a learning organization. 26
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