Collaborative Care for Indigent Populations: Barriers, Solutions, Outcomes, & Lessons Learned

Laurie Alexander, Ph.D.Program Officer

Today’s presentation

Barriers & solutions

Data & lessons learned

Resources

The Hogg Foundation Since 1940, the foundation has worked to

promote improved mental health for all Texans through grants & programs

Part of The University of Texas at Austin, Division of Diversity & Community Engagement

$4.5 M in grants per year

Addressing barriers Hogg Foundation’s IHC Initiative

GOAL: Identify solutions for barriers to implementing collaborative care in Texas

Grant program

■ People’s

■ Project Vida

■ Parkland

■ TCPA

■ BCHC■ NCDV

■ SCF

TCPA = TX Children’s Pediatric Assocs (Houston)

SCF = Su Clinica Familiar (Harlingen)

NCDV = Nuestra Clinica del Valle (San Juan)

BCHC = Brownsville CHC

Grants began ending in April 2009

Grants began ending in April 2009

Grantees Grantees = 7 PC organizations (4 FQHCs)

Behavioral health partnerships include:

Contracts for psychiatric consultation w/: CMHCs (2), academic depts (3), and/or

psychiatrists in private practice (2)

Contracts for psychotherapy with private nonprofits (2)

1 site already had psychiatrists & psychotherapists on staff

Training and consultation Training and consultation:

Jürgen Unützer, Wayne Katon, et al. (University of Washington)

Loose implementation of IMPACT model Distilling the core components

Collaborative care Core components

Care manager

Clinical assessment tool

Psychiatric consultation

Patient registry

Collaborative care Core components

Care manager

Clinical assessment tool

Psychiatric consultation

Patient registry

Care manager Professional or paraprofessional

In person or by phone

Caseload = ~80 active patients(200-300 pts / yr)

Cover 6-7 FTE PCPs

Collaborative care Core components

Care manager

Clinical assessment tool

Psychiatric consultation

Patient registry

Clinical assessment tool Objective measure of treatment

response

Administered at every care mgmtcontact

Examples PHQ-9, OASIS, &

Vanderbilt

Collaborative care Core components

Care manager

Clinical assessment tool

Psychiatric consultation

Patient registry

Psychiatric consultation

PSYCHIATRIST

CARE MANAGER

PCP PCP PCP PCP PCP PCP PCP

Weekly meetings with care manager

(1-2 hrs / wk per care manager)

Flexible implementation

By phone or in person

Collaborative care Core components

Care manager

Clinical assessment tool

Psychiatric consultation

Patient registry

Patient registry Track large patient panels

Different formats, different features

Sample screen: Patient tracking

Sample screen: A PCP’s patients

Evaluation Evaluation team:

Richard Frank (Harvard)Howard Goldman (Univ of MD)Brenda Coleman-Beattie

(Texas health care consultant)

TargetsImplementation factorsOutcomesCosts

Evaluation plan Formative quantitative and qualitative

evaluation with mixed design

Qualitative 2 site visits per grantee Standardized protocol

21

Qualitative evaluation domains1. Leadership and program level preparation

2. Clinical planning and the clinical management practices

3. Training for team members and new hires

4. Fidelity to the collaborative care model

5. Financing considerations

6. Technology services/information systems

7. Implementation considerations including barriers and facilitators

Evaluation plan - Quantitative Web-based registry data

PHQ, OASIS (anxiety), CAGE-AID, prescribed treatment (psychotx and/or meds), service contacts, psych consultations

Gender, age, Spanish language preference, insurance status

ADHD registry being re-vamped Data collected will include Vanderbilt and

others

EMR data Utilization and billing data (starting pre-grant)

Evaluation plan - Quantitative

Comparison data Dallas site has control site

Screening with PHQ With (+) screen, do initial assessment & 4-

month follow-up

3 Valley sites have comparison sites constructed from Texas Medicaid data

Drugs and claim data for Valley sites and similarly located comparison sites

All 7 sites’ outcomes are being compared against data from effectiveness trials

Patients served 2,500 patients seen between 7/06 – 9/08

Primarily adultsDelays in child sites – ADHD pilot

Primary dxs = depression, anxiety, & ADHD

Across all sites, largely uninsured & predominantly Latino

Medicaid & Medicare represent small % of patients served (TX Medicaid is small)

R. Frank, 2008

Preliminary data - Demographics

N cases (3 sites) 975

Average ages 39-47 years

% Female 78%-84%

Prefer Spanish 26%-58%

Uninsured 81%-88%

Baseline PHQ-9 16.0-16.7

Baseline OASIS 11.3-11.7

R. Frank, 2008

Preliminary data - Service contacts Range in % of patients who had any

follow-up contacts: 61% to 95%

Range in average # of follow-up contacts for patients with any follow-ups: 2.0 to 6.2 contacts Most clinical trials show averages of 3-7 visits

% of contacts by phone:56% to 68%

R. Frank, 2008

Preliminary data - Outcomes PHQ - 50% improvement at 10 weeks

Outcomes range from: 28% (~“usual care” in effectiveness trials) 54% (~”active treatment” findings)

People with single diagnosis had larger improvements

People with Spanish language preference had smaller improvements

All sites improved over 18-month periodR. Frank, 2008

Lessons learned When core components are

implemented, the program works

Co-location is not sufficient

Initial treatment is rarely sufficient

Program appears to be low cost

R. Frank, 2008

Success factors Core components in place

Successful engagement of patients

Most patient contacts by phone

Close tracking of medications

Active adjustment of treatment

J. Unutzer, 2008

Challenges Organizational readiness & leadership

Engaging PCPs

BH providers’ transition to new roles

Workforce issues Team-work orientation Shortages

Lack of referral options

Sustainability issues

Policy work Engaging state and local leaders

IHC Leadership Team IHC policy workgroup

Engaging private sector

Supporting implementation

Statewide learning community

Policy work (cont.) Framing the issues & serving

as information resource Connecting Body and Mind:

A Resource Guide to Integrated Health Care in Texas & the U.S. (Sept. 2008)

Online at:www.hogg.utexas.edu

More information at:www.hogg.utexas.edu

Laurie Alexander, Ph.D.Program Officer

laurie.alexander@austin.utexas.edu