December 14th, 2012

Behavioral Health Integration

Potential Agenda

•Who and what we are•Description of Web Based CCBT•Programs and Data•Platform•Workflow examples

Web address: www.cobalttx.com

Broad Suite of Programs

• Anxiety, phobias, panic attackso FearFighter

• Insomnia and sleep problemso RESTORE

• Alcohol, substance use and depressiono SHADE

• Obsessive Compulsive Disorder (OCD)o OCFighter

• Depressiono MoodCalmer and COPE

These disorders affect:

• >25% of all primary care patients

• >85% of all behavioral outpatients

• Majority of Rx costs

Program Commonalities• Efficacy

o Developed in academic institutionso Computerized and on the webo Proven efficacy in randomized, controlled trialso Published in peer reviewed journals

• Clinician guidedo Lower level of expertise neededo Few minutes needed per sessiono Can use telemedicine

• Securityo HIPAAo Patient data transferable to EMR

• Platformo Client administrationo Clinician administration

CBT and CCBT

• Cognitive Behavioral Therapy (CBT)o Breaks harmful cycle of thoughts and behaviors o Can improve outcomes in co-morbiditieso First line for insomnia, panic, phobias, OCD (APA)

• Computerized CBT (CCBT)o Puts 70-95% of therapy (repetitive elements and homework) into

interactive moduleso Allows for broad geographic accesso Increases efficiency: clinician time lowered by 70-100% depending on

diagnosis and treatment o Allows lower level of clinician/coach: peers, otherso In UK NHS for several years for Panic, Phobias, etc. (NICE)

CCBT Experience

• Techniques: efficient communication - video narration, vignettes, voiceover

• Examples of each: o Video narration: RESTORE Narration o Efficient: FearFighter Program Explanationo Use of Multimedia: Fight or Flighto Interactivity: MoodCalmer Pleasurable Activities Plannero Vignettes: SHADE, MoodCalmer, FearFighter

• Weekly sessions replicate traditional therapy structures

Efficiencies• Direct Cost Savings: Cost per unit improvement varies based on software costs and level

of training of “guide” (e.g. at $200 per patient, administered by PhD or MD FearFighter demonstrates 63% savings; Savings increase quickly with lower price and lower training level).

• Helping Mental Health Clinicians: One clinician can see many more patients (e.g. with Restore one PhD has gone from managing 145 patients a year to approx. 650 without sacrificing outcomes). Non-CBT trained clinicians, including peer counselors and those in primary care, can support validated CBT programs where appropriate.

• Decreasing “Step ups” in Care: Patients can receive a medication free option and often avoid long term medications or face-to-face therapy (e.g. referrals for face-to-face specialty care in a clinic decreased by 66% for insomnia when patients were offered online program).

• Rural and “Clinically Isolated” Access: No geographic or specialty boundaries – can work with Tele-Medicine, CBOCs or call-center “guides”.

• Available Immediately: Veterans can access validated options as an alternative or while they wait for appointments.

Data – Brief Overview • Depression – 52% reduction in symptoms for completers

and 41% ITT.• Anxiety – 63% reduction in symptoms, works for panic

disorders and phobias including social anxiety and includes exposure therapy.

• OCD – 3.4 hour reduction in symptoms/week – full Exposure and Response Prevention (ERP) program.

• Insomnia – 4/5 patients improve – reduces specialty care by 2/3. Improves workplace performance.

• Alcohol/Drugs – large reductions in drinking and drug use: hazardous use declines 72% in 12 months.

Possible Workflows?• Immediate Access: Immediately after evaluation, appropriate

patients can have brief visits (5-10 min) and begin with programs. o Can combine with telepsycho May work well for primary care siteso Can have computers on site [or at home]

• Clinic Sign Up: Signed up in clinic and followed/monitored in clinic.

• Anonymous: Option for those who are reluctant to access behavioral health care in-clinic to contact # anonymously.o Insomnia may be a good fit to engage those who may not view it as a

“mental illness” and therefore may not view the engagement as “therapy”.

Workflows?

• Immediate access via phone number: Those who may benefit from assistance are given # they call. Are signed up and “coached” by clinicians. Allows for immediate access and minimal impact on current clinic workflow.

o May work well for primary care sites.o May work well for families who are now going off site to TriCare vendors.

Patient is identified with insomnia, depression, anxiety, etc.

Given # to call• Can begin program

immediately• Call center can also

monitor for crisis

Phone clinician signs up and follow up• Can follow up in

clinic per traditional SOP

• Progress can be viewed by Clinic

Workflows?• Clinic Sign Up: Signed up in clinic and followed /

monitored in clinic.o Primary careo Behavioral

Patient is identified with insomnia, depression, anxiety, etc.

Clinician in clinic logs in, assigns username and password• Can put computers

in clinics

Primary or specialty clinician signs up and follow up• Can follow up in

clinic per traditional SOP

• Progress can be viewed by clinic

Workflows?• Anonymous: Option for those who are reluctant to access

behavioral health care in-clinic to contact # anonymously.o Insomnia may be a good fit to engage those who may not view it

as a “mental illness” and therefore may not view the engagement as “therapy”.

Advertisements in primary care, newsletters, etc.• Can have specific

campaigns for each disorder

Call # and engage with clinician operator• May engage the

reluctant• Allows for those in

crisis to have another reason to reach out

Immediately available

Insomnia• 30%-40% say they suffer each year (NIH)• 10%-15% say they suffer chronically (NIH)• Increases direct medical costs by $924-$1,143 over a six month period1 • Insomnia causes 2x missed work days and 2.5x errors at work compared to those without

insomnia2

• Treating insomnia improves outcomes in a variety of conditions including depression and heart disease3

• Relative risk for MDD: 4.04

• Medication for insomnia linked to 1.36 OR for mortality when hypnotic or anxiolytic used in previous month5

• CBT for sleep, combined with medication, improves remission for MDD from 33.3% to 61.5%6

• Sleep problems facilitate alcohol relapse7

1. Cost Burden of Untreated Insomnia—Ozminkowski et al SLEEP, Vol. 30, No. 3, 20072. Insomnia, Who Pays the Costs?—Godet-Cayré et al SLEEP, Vol. 29, No. 2, 20063. Clinical Correlates of Insomnia in Patients with Chronic Illness - Arch Intern

Med. 1998;158:1099-11074. Breslau, Biol Psy 19945. Belleville, C Jour Psy 20106. Manber et al SLEEP 20087. Brower et al 1998, Alcoholism

RESTORETM for Insomnia• 81% improve

o 43% “Significantly improved”o 30% receive >1hour additional sleep

• Improvement in fatigue indexes• Improvement in sleep efficiency

RESTORE with Psychiatric and Medical Comorbidity:

Anxiety: Panic and Phobia

FearFighter• Approximate 50% reduction on panic and phobia scales

o No outcome difference from face-to-face• Cost per patient (with same outcome) approximately

45% lower• Cost per unit of improvement 63% lower vs. face-to-face

(when software is $200/pp and by PhD and MD– drops as price drops and pay grade drops and therefore can go far lower)

• Clinician time reduced by 73%• 9 week program plus ability to access ongoing “booster”Source: NHS Economic Evaluation Database

SHADE

Details• Components• Data• What SHADE looks like

SHADE: Components• Suicide Screening

o Symptom questionnaireo Automated notifications

• Educationo Alcoholo Drugso Depressiono CBT

• Activities o Worksheetso Relaxation exerciseso Mindfulness exerciseso Monitoring of use and moodo Planning for the future

• Homeworko Log and analyze activitieso Monitor and analyze thoughts, feelings and behaviorso Relaxation exerciseso Mindfulness activities

Cognitive Behavior

Identify distortions

Learn balanced

view

Create new thought patterns

Vignettes

Feedback

Automatic ThoughtsRelaxation

MindfulnessCravingsPlanningActions

Motivation

SHADE: Data – Heavy use, 18-34 y.o.

Focus on Binge Drinking, Age 18-34:• Binge Drinking All Ages (n=342):

o Computer better than all arms(Focused, PCT, BI); No difference from F2F

o Binge rates decrease: 24% at 6 mos; 30% at 12 mos.• P values range from 0.001 to 0.032

• Binge Drinking Age 18-34 (n=74)o Computer: 20% reduction at 6 mos.; 32% reduction at 12 mos. o Computer better that any focused or brief therapy - no difference from

F2F (p values range from .001-.03)

• Significant finding: Many prefer computer to F2F

Sources: Addiction, 104, 378-388; Unpublished data

SHADE: Data - CannabisFocus on Cannabis and Hazardous use:

• Hazardous alcohol and/or drug “use days”: o F2F and Computer no difference (both better than control)o 6 mos: reduction of 44%; 12 mos: 50%o P<0.001 at 12 months

• Cannabis use generally:o F2F and Computer besto 6 mos: reduction of 58%; 12 mos: 72%o P<0.001 at 12 months

Sources: Addiction, 104, 378-388; Unpublished data

Enterprise Clinician “Back End”

Enterprise Organizational Structure

Operational Admin: Adding Users

Clinician: Overview

Clinician: Clinical Tracking

CCBT Workflow

• Patient presents with complaint (insomnia, anxiety, etc.)

• Treatment options discussed

Clinician Logs In to “Back End”

•Clinician creates new account for patient/client(≈2min)

Clinician gives “program” Log In details to patient •Patient access program

online (home or clinic)•Follow ups as prescribed (PRN, telephonic, in-person, weekly, biweekly, etc.

Clinician “guides” patient as needed

•Patient/client completes program

•Clinician logs in to monitor compliance and progress PRN

Clinician refers for “Step Up” care, if

necessary