USING PRACTICE-BASED EVIDENCE TO ASSESS AND IMPROVE INTEGRATED

CARE: THE INTEGRATED CARE EVALUATION PROJECT

Jim Fauth & George TremblayClinical Psychology Department

Center for Research on Psychological Practice

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Traditional practice change strategiesdon’t work

ScienceDissemination, Diffusion of RCTs

Guidelines, Demonstration ProjectsPractice

“We know best, do as we say”

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A Way Forward: Practice Based Participatory Research (PBPR)

Science

Translation, Facilitation, Formative Evaluation, Implementation

Practice-Based Participatory Research

Practice

What do you need, and how can we help?

PBPR Strategy4

EXTERNAL FACILITATION

Problem solving and support

Dialectic negotiation of needs

Translation of evidence base

FEEDBACK OF FORMATIVE EVIDENCE

Continuous feedback loops

Utilization of high leverage formative evidence

IMPLEMENTATION TEAMSInternal change agents

Key Practice stakeholders, Clinical Champion, Key decision makers

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PBPR Learning CyclePLANNING PHASE

Goal 1: Create Learning ContextIdentify practice contexts

Engage practices/stakeholdersGoal 2: Identify Information Gaps

Perform diagnostic analysisIdentify high leverage information gapsGoal 3: Develop pilot evaluation plan Develop evaluation options, scenarios

Iteratively negotiate final evaluation plan

PILOT PHASEGoal 4: Assess feasibility

Implement pilotTrack pilot fidelity, feasibility

Analyze pilot findingsGoal 5: Improve discovery planFacilitate utilization of pilot finding

Finalize discovery plan

QUALITY IMPROVEMENT PHASEGoal 8: Address QI opportunities

Implement QI planTrack fidelity & feasibility

Goal 9: Evaluate QI interventionComplete process evaluation

Complete summative evaluationComplete interpretive evaluation

DISCOVERY PHASEGoal 6: Address Information Gaps

Implement discovery planTrack discovery plan fidelity

Analyze discovery plan resultsGoal 7: Identify QI opportunities

Facilitate utilization of discovery findingsIdentify, prioritize, and adapt QI targetsIdentify, prioritize, adapt QI strategies

Finalize QI implementation plan

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Integrated Care Evaluation Project (ICE)

• What the RCTs tell us

• Scientific Gap: “Real world”

• Practice Context• Four NH IC pioneers

• Moderate to high need

• Low to low moderate capacity

• Financial Resources: Private - NH Endowment

for Health ($250K ~ 3 years)

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Diagnostic AnalysisEvidence-based Models

Target specific patients

Systematic, formulaic

Formal treatment models;Implemented by BH

specialists; Supervised by tx

developer

Formally track outcomes; Adjust using algorithms

Practice-based Models

“Target” all patients

Flexible, clinical judgment

Flexible consultation & treatment models;

Implemented by BH specialists

Variably track outcomes; Adjust using judgment

Patient presents to primary care

BH assessment & allocation to care

PCP

BH

PCP MED

PCP BH-C

BH MED

SMHC

Track Response & Adjust Treatment

Integrated Care Task Model

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ICE Pilot Evaluation Design

Key. IC=Integrated Care; ED=Emotional Distress; PCP=Primary Care Provider only; MED= psychotropic medication; BH ANY=ANY Behavioral Health Specialist Intervention.

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Feasibility: Framing & Measures

• Primary purpose of pilot = feasibility

• Can we implement the evaluation plan?

• Metric = “capture rates”• # target patients during study period• # approached to consent• # consented• # filled out 1+ EDMs

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1/1/

2010

2/1/

2010

3/1/

2010

4/1/

2010

5/1/

2010

6/1/

2010

7/1/

2010

8/1/

2010

9/1/

2010

10/1

/201

00

200

400

600

800

1000

1200

1400

1600

1800

2000

1800

940

674

ICE Cross Site Capture Rate

# of Consented Patient Encounters # of EDMs Collected Total # Consented Patients

To

tal

Nu

mb

er

First Capture rate data re-ported

Problem solving meetings begin

Data Collection Begins

Problem solving meetings end

Data Collection Ends

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Allocation Data• Does allocation vary as a function of patients’ emotional distress? (Compare with EBP benchmarks)

• Measures• Emotional Distress Measure (EDM)

• Severity (items 1-15: PHQ-8+GAD-7)• Functional Impairment (item 16)• Chronicity (item 17)

• Care Type Variables• PCP ONLY• PCP Meds• BH ONLY• BH MEDS Combined into BH ANY in some

analyses

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Clinic 1 Clinic 2 Clinic 3 Clinic 40%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

61.5

27.4

56.266.2

20.5

26.6

20.5

20.3

10.9

21

12.66.8

7.1

2510.7 6.8

Patient EDM Severity by Site

Not distressed Mildly DistressedModerately Distressed Severely Distressed

Per

cen

t o

f P

atie

nts

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Clinic 1 Clinic 2 Clinic 3 Clinic 40%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

325

125

210 60

235

48

208 50

140

5 8 11

14 4 6 0

Allocation of Care by Site

PCP ONLY PCP MED BH MED BH ONLY

Per

cen

t C

are

Typ

e

14

Clinic 1 Clinic 2 Clinic 1 Clinic 2 Clinic 1 Clinic 2 Clinic 1 Clinic 2PCP ONLY PCP MED BH ONLY BH MED

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

274

37235

9

11

2

25

0

20

41

169

6

2

1

47

2

17

33 90

10

1

1

26

0

14 143

27

0

142

2

Care Allocation by Severity by Site

Not Distressed Mildly DistressedModerately Distressed Severely Distressed

Per

cen

t C

are

Typ

e

15

0 0.5 1 1.5 2 2.5 30%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pro

b.

of

Car

e T

ype

wit

hin

30

day

s

PCP ONLY

PCP MED

BH ANY

BH Bench-mark

Clinic 1: 30-day Allocation by Index Severity

No Distress Mild Distress Mod Distress Severe Distress

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0 0.5 1 1.5 2 2.5 30%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pro

b.

of

Ca

re T

yp

e w

ith

in 3

0 d

ay

s

PCP ONLY

PCP MED

BH ANY

BH Bench-mark

No Distress Mild Distress Mod Distress Severe Distress

Clinic 2: 30-day Allocation by Index Severity

ICE Outcomes

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Findings• Diffusion accompanied

by dilution• Variability within

constraints• Elephants outside the

room

Utilization• Clinic 1: Immediate

action• Clinic 2: blocked by

MD• Clinic 3: QI team• Clinic 4: Nothing

Informal “Test” of PBPRPlanning and Pilot only

No formal QI phase, ITS design

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ICE Implications from Your Perspective?

• Allocation (and outcomes) in your practices• What do you know?• How can you find out?• What do to improve?

• Strategies for working with more chronically and severely distressed in primary care• Real-time monitoring of treatment response• Enhanced referral to specialty mental health• Supportive treatment• Groups• Peer support• Self-management

• Research we need

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Input, feedback, requests for more information?

Jim Fauth, Ph.D.Director, Center for Research on Psychological Practice

Antioch University New England603.283.2193

jfauth@antioch.edu

Thank You!