Implementation and cost effectiveness evaluation of an integrated mental health stepped care service for adults in primary care

Abstract

Introduction: After a small successful pilot, and a revision of our implementation model, we trained and worked closely with urban and rural primary health care networks (PHNs) in Australia to implement and evaluate the acceptability, feasability, utility and cost effectiveness of an integrated online stepped care service (StepCare) for adults with anxiety and depression in general practices. Theory/Methods: Patients in a range of general practice settings were screened via a mobile tablet in their GP’s waiting room with immediate feedback to them and their doctor. Individuals were recommended the least intensive evidenced-based intervention likely to lead to health gain, and then stepped up (or down) the pathway according to changing needs and in response to treatment. A range of internet, face to face therapy and/or pharmacotherapy interventions, together with links to other care providers, were recommended based on symptom severity. Online monitoring allowed appropriate feedback to patient and GP and recommendations for follow-up. Following implementation, the acceptability, feasibility, utility and cost effectiveness of the service was examined. Results: Results from the digital screening and 10 week follow-up of over 1000 patients in more than 20 general practices revealed high levels of acceptability and feasibility as rated by GPs, practice staff and patients. In addition GPs rated the service as effective in the early detection of hitherto undiagnosed anxiety and depression and helpful in the development and implementation of mental health treatment plans. Initial results of cost effectiveness evaluation suggest that the StepCare service is cost-saving over a 12 month period. A detailed final cost evaluation will be presented. Discussion: This study examined the acceptability, feasibility and effectiveness of an integrated stepped mental health care service (StepCare) in Australian primary care. Results showed that it could be implemented via a Train the Trainer model involving PHN staff (and is therefore capable of being implemented at scale), it integrates smoothly into general practices (thus normalising into routine practice) and it produces clinical changes (it is effective). Conclusions: StepCare is the first fully integrated and digitally enabled stepped mental health care service to be implemented and evaluated in Australian primary care. Lessons learned: Despite the effort expended by the StepCare team to integrate the Service seamlessly into the workflow of general practices, some fine-tuning needs to be considered. For example, alternatives that allow for electronic screening to take place without impacting practice staff workflow may be required, such as self-service kiosks and an app available on patients’ personal smartphones. Limitations: Our study suffered from low participant response rates, common in primary care research, but reducing generalizability of results. Our research design had strengths including mixed method and multi-stakeholder approach but lacked a control group. Improvements in patients symptoms over time may therefore have been due to spontaneous symptom remission, the effects of fortnightly review or factors other than recommended clinical care. Suggestions for future research: Improvements are already being addressed in the StepCare Service through a structured program of upgrade prior to wider implementation across Australia, together with further evaluation of the service.

Keywords

• stepped-care
• digital
• mental health