A Safety Net Collaboratory to Improve the Use of Patient-Reported Outcome Measures of Health Behaviors and Psychological Status

Beth Glenn, PhD, Hector Rodriguez, PhD, Roshan Bastani, PhD.

Community Partner: Bridget Hogan Cole, MPH, Building Clinic Capacity for Quality (BCCQ), a program of Community Partners®

CERP Meeting

9/20/2012

Background • Health behaviors and psychological status (e.g., tobacco use, poor

diet, depression) are infrequently and inconsistently assessed in primary care despite their negative effects on health outcomes

• Standardized collection of patient-reported data on these health topics is an important first step

• Establishment of clinic protocols to also systematically address behavioral factors in primary care are critically needed

▫ Methods that maximize use of EHR hold the greatest promise for routinization, institutionalization and sustainability

• Inclusion of safety net clinics and the vulnerable patients they serve in these efforts is vital to reduce widening health disparities

NIH-Funded Pilot Study (10/11-9/12)

• Implemented a brief questionnaire to assess patient reported data for 10 domains in 4 Federally Qualified Health Clinics in Southern California

• Paper-and-pencil administration of “Patient Health Update” in English, Spanish, and Chinese

Patient-Reported Behavioral Health Domains Domain Final Measure (Source)

1.Demographics 9 items: Sex, date of birth, race, ethnicity, English fluency, occupation, household

income, marital status, education, address, insurance status, veteran’s status.

Multiple sources including: Census Bureau, IOM, and National Health Interview

Survey (NHIS)

2. Overall Health Status 1 item: BRFSS Questionnaire

3. Eating Patterns 3 items: Modified from Starting the Conversation (STC).

(Adapted from Paxton, AE et al. Am J Prev Med, 2011; 40(1):67-71.)

4. Physical Activity 2 items: The Exercise Vital Sign (Sallis, R. Br J Sports Med 2011; 45(6):473–474)

5. Stress** 1 item: Distress Thermometer (Roth AJ, et al. Cancer 1998; 15(82):1904-1908.)

6. Anxiety and

Depression

4 items: Patient Health Questionnaire - Depression & Anxiety (PHQ-4)

(Kroenke K, et al. Psychosomatics 2009; 50(6):613-621.)

7. Sleep 2 items: a. Adapted from BRFSS

b. Neuro-QOL (Item PQSLP04)

8. Smoking/ Tobacco

Use**

2 items: Tobacco Use Screener (Adapted from YRBSS Questionnaire)

9. Risky Drinking** 1 item: Alcohol Use Screener (Smith PC, et al. J Gen Intern Med 2009; 24(7):783-788)

10. Substance Use ** 1 item: NIDA Quick Screen (Smith PC, et al. Arch Intern Med 2010, 170(13): 1155-

1160.)

176, 62%

75, 26%

33, 12%

Q2a. How many days did you get moderate to strenuous exercise? Q2b. On those days, how many minutes, on average, do you exercise at

this level?

Positive: Less than 150 min/week

Negative: More than 150 min/week

Missing

Physical Activity Level

70, 25%

209, 73%

5, 2%

Q7. How many times in the past year have you had X or more drinks in a day? (Where X is 5 for men, and 4 for women)

Positive: 1 or more times

Negative: Never

Missing

Alcohol Use: Risky Drinking

56, 20%

211, 74%

17, 6%

Q4a. Feeling nervous, anxious, or on edge Q4b. Not being able to stop or control worrying

Positive: Total score of 4 or more

Negative: Total score of less than 4

Missing

Anxiety

85.56%

61.97%

58.10%

54.58%

30.28%

24.65%

19.72%

13.38%

9.51% 8.80%

4.58% 3.87% 1.06%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

FRTS

VG

EXER

CIS

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HEA

LTH

STR

ESS

SOD

A

ALC

AN

X/W

OR

PH

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SNO

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SLEE

P

DEP

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HQ

SMO

KE1

FSTF

OO

D

DR

UG

USE

SMO

KE2

Q1b Q2 Q9 Q3 Q1c Q7 Q4a&b Q5 Q4c&d Q6a Q1a Q8 Q6b

Percentage of Positive-Screens by Measure Fr

uit

& V

eg S

vgs

Ph

ysic

al A

ctiv

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Stre

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Ove

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Hea

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An

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De

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ssio

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Sno

re/S

lee

p

Fast

Fo

od

Dru

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se

Smo

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ss T

ob

.

4/1%

22/8%

48/17%

57/20%

63/22%

42/15%

29/10%

12/4%

5/2%

1/<1% 1/<1% 0

0

10

20

30

40

50

60

70

0 PositiveScreenings

1 PositiveScreenings

2 PositiveScreenings

3 PositiveScreenings

4 PositiveScreenings

5 PositiveScreenings

6 PositiveScreenings

7 PositiveScreenings

8 PositiveScreenings

9 PositiveScreenings

10 PositiveScreenings

11-13Positive

Screenings

Fre

qu

en

cie

s

Distribution of Sample for Number of Positive Screenings

CERP Pilot Project Aims

• Project Aim 1: In collaboration with Building Community Capacity for Quality (BCCQ) convene a learning community comprised of 3-4 safety-net clinic organizations to understand current practices with regard to the assessment of patient-reported measures of behavioral risk factors and protocols to address these risk factors in primary care settings. (Relevant to CERP Aim 1)

• Project Aim 2: Through a collaborative stakeholder engagement

process, select a set of patient-reported measures that can be commonly collected across clinics participating in the learning community. (Relevant to CERP Aim 2)

• Project Aim 3: Use data collected to inform development of a prototype of an electronic patient-reported outcome data collection and feedback system. (Relevant to CERP Aim 4)

Methods • Convene a Learning Collaborative to Facilitate Sharing of Best Practices:

▫ Half day event scheduled for November 2012

▫ Working with BCCQ to select invitees-plan to include high level administrators or medical director and information technology staff

▫ Plan to involve 3-6 organizations to keep group small and interactive

▫ Goal of event: provide opportunity for sites to share “best practices” for electronic capture of behavioral risk factor data and using EHR and registry systems

• Organizational Assessment: Collection of data from each clinic participating in the learning community with regard to current collection of patient-reported data for the behavioral domains (i.e., method of collection, frequency of collection, target population for assessment) and protocols in place for addressing these issues

• Key Informant Interviews with Clinic Administrators and Staff: Conduct key informant interviews (2-3 informants per clinic) to understand stakeholder experiences of PRO data collection, challenges & facilitators, interoperability between EHR and other data systems, use of PRO data for reports and feedback

Methods

• Develop PRO Data Collection and Feedback Prototype: Use data to develop a prototype that can be used to electronically capture data and facilitate providers in addressing “out of range” patient values

▫ Prototype to produce easy-to-use views of patient data to allow for tracking assessment over time and generating flags for “positive” results

▫ Goal to develop system that will be interoperable with many EHR systems

▫ Collaborating with technical team led by NIH’s Office of Behavioral and Social Sciences Research

CERP aims addressed

• CERP Aim 1. Promote and sustain bidirectional knowledge sharing between community and academia.

• CERP Aim 2. Strengthen community infrastructure for sustainable partnered research.

• CERP Aim 4. Build health services research (HSR) methods into partnerships to accelerate design, production, and wide adoption of evidence-based practice and behavior.

August-October, 2012 November 2012-February 2013

Organizational assessments of

community clinic structural capabilities

(current use of electronic data and

feedback systems)

Finalize the collaboratory

participants

Develop a clinician

resource guide for use in

next phase

Develop a prototype for

electronic PRO data

collection and feedback

(for later testing) Key informant interviews

of community clinic

stakeholders

(clinicians and staff)

Finalize the set of

PRO measures for

inclusion in prototype

Complete key

informant interview

findings report

Convene learning

collaborative

(November, 2012)

Formal Testing

Timeline

Added-Value from CTSI Funding • Recently completed pilot allowed us to collect data from 4

Federally Qualified Health Center using paper-based methods

• CTSI funding allows us to take project to the next step:

▫ Focus on electronic capture of data

▫ Continued partnership with BCCQ will ensure involvement of clinics with more HIT experience to share

▫ Comprehensive assessment of current practice and solicitation of “best practices” in safety net will provide valuable foundation for future work

▫ Development of a prototype will greatly facilitate ability to address behavioral risk factors

Next Steps

• Dissemination of “lessons learned” to safety net clinics

• Use pilot to apply for external funding to evaluate the effect of prototype system more formally