collaborative care for indigent populations: barriers, solutions, outcomes, & lessons learned
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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. - PowerPoint PPT PresentationTRANSCRIPT
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