During the period between January and June 2004, 17,543 patients were screened using the depression clinical reminder, representing 63.8% of the unique veterans seen in primary care. Of those screened, 3,008 (17.1%) were marked as already receiving MH/SA care, while 1,232 (7.0%) screened positively. During the comparable period in 2002, 11,826 veterans were screened, representing 52.0% of the unique patients seen during that time frame. Thus, there was an 11.8% increase in the number of veterans screened from 2002 to 2004. In addition, there was a significantly greater proportion of patients who screened positive in 2004 (7.0%) compared with 2002 (2.8%) (χ2=895.8, 1 df, P<.001).
During the 6 months in 2004, 740 referrals were made to the BHL (approximately 60% of those screening positively). Of those referred, 78.4% completed the assessment, with an additional 7.6% refusing assessment and 14.1% being UTC. Older veterans were more likely to refuse assessment, and a greater proportion of younger veterans could not be contacted (F=6.40, 1 df, P<.001). describes the flow of patients from screening to referral.
Patient flow from screening in the primary care clinic to assessment and referral by the Behavioral Health Laboratory.
outlines the demographic and clinical characteristics of assessed patients. Complex cases accounted for 44% of all assessed patients. Severe cognitive impairment accounted for 5.2% of those assessed. Minor depression or distress was present in 40.5% of the cases. A self-reported past history of depression (59.5% overall) as well as significant suicidal ideation (12.9% overall) was common. Overall, only 19.7% of patients were in MH/SA care, with the majority being complex cases. However, only 23.9% of the complex group was in MH/SA care. Altogether, 261 patients had significant symptoms warranting specialty MH/SA care either because of significant suicidal ideation or presence of complex symptoms. In terms of the complex cases, 67 met criteria for alcohol dependence (11.6% of the total assessed sample), 44 used illicit drugs other than marijuana (7.6%), 128 met criteria for PTSD (22.1%), 51 had manic symptoms (8.8%), 86 had possible psychotic symptoms (14.8%), and 26 met criteria for current panic disorder (4.5%).
Characteristics of Patients Interviewed by the BHL
The depression monitoring program identified 13 patients with newly prescribed antidepressants. Of these patients, 12 completed at least 2 follow-up assessments. Reports were given to the clinician indicating change in depressive symptoms, adverse events, and adherence.
Clinician acceptance was measured using a series of focus groups with each primary care practice, except one which was unavailable to meet. Feedback was invited with discussion for improving the services. In all instances, providers commented on the rapid turnaround in assessment time, the identification of symptoms other than depression, positive comments from patients about the BHL staff, and improved access to behavioral health. Providers have been particularly positive about the depression-monitoring program. Negative comments focused mostly on the formatting of reports, desire for a face-to-face component, and desire to refer more patients to the MH/SA clinic. The success of the program led to the use of the BHL as the single point of entry for outpatient MH/SA care.
Cost estimates were calculated first for bachelor's level HTs. The core baseline assessment takes an average of 30 minutes for the interview, with an additional 30 minutes of scheduling appointments, filing, sending a letter to patients, and sending the report to the provider. Additional depression monitoring assessments take 30 minutes of the HT's time. Time for administrative and quality management activities, including training and supervision, is estimated at 60 minutes/day or 5 hours/week. Vacation/holiday/break time is 7.2 hours/weeks. Thus, there is approximately 27 hours (40 hours −(5+7.2)) available to conduct interviews. An HT salary is $36,092 with benefits or $695/week. Thus, the cost per unit for initial evaluations is $695/27 or $25.74. The cost per unit for depression monitoring assessments is $695/54 or $12.87.
Ongoing staffing for laboratory operations includes 0.20 FTE for the Medical Director, 0.30 FTE for the Behavioral Health Specialist, 0.3 FTE for the HT Coordinator, and 0.1 Full Time Eqivalent (FTE) for IT support. These costs represent the fixed costs for maintaining the laboratory as an entity and are estimated based on the amount of administrative support required for every 5 HTs. Other expenses include computer upgrades, software license, supplies, and a toll free number. These are estimated at $6,250/year or $120/week/HT. In total, the administrative costs translate into $527/week/HT. This corresponds to approximately $19.52/initial assessment or $12.26/follow-up assessment. Thus, the total costs are approximately $45.26/initial assessment and $25.13/follow-up assessment.