Session # F4 Implementation and Dissemination of a Large ......Therapy, 2013;51(9):597- 606....

Implementation and Dissemination of a Large-Scale Psychotherapy Tracking Database in Primary Care

Craig N. Sawchuk, PhD, ABPP

Mark Williams, MD

Sarah Trane, PhD

Michelle LeRoy, PhD, ABPP

Session # F4

CFHA 20th Annual ConferenceOctober 18-20, 2018 • Rochester, New York

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Please insert the assigned session number (track letter, period number), i.e., A2a Please insert the TITLE of your presentation. List EACH PRESENTER who will ATTEND the CFHA Conference to make this presentation. You may acknowledge other authors who are not attending the Conference in subsequent slides.

Faculty DisclosureThe presenters of this session have NOT had any relevant financial relationships during the past 12 months.

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You must include ONE of the statements above for this session. CFHA requires that your presentation be FREE FROM COMMERCIAL BIAS. Educational materials that are a part of a continuing education activity such as slides, abstracts and handouts CANNOT contain any advertising or product‐group message. The content or format of a continuing education activity or its related materials must promote improvements or quality in health care and not a specific propriety business interest of a commercial interest. Presentations must give a balanced view of therapeutic options. Use of generic names will contribute to this impartiality. If the educational material or content includes trade names, where available trade names for products of multiple commercial entities should be used, not just trade names from a single commercial entity. Faculty must be responsible for the scientific integrity of their presentations. Any information regarding commercial products/services must be based on scientific (evidence‐based) methods generally accepted by the medical community.

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Slides and handouts are also available on the mobile app.

Learning ObjectivesAt the conclusion of this session, the participant will be able to:

1. Identify at least one benefit and challenge of using registries to track outcomes in primary care.

2. Describe how psychotherapy outcomes can be utilized in program development.

3. Identify at least one challenge and solution to implementing and disseminating a psychotherapy tracking database for pediatric populations.

4. Identify at least one challenge and solution to implementing and disseminating a psychotherapy tracking database in rural clinics.

Presenter

Presentation Notes

Include the behavioral learning objectives you identified for this session

Craner JR, Sawchuk CN, Mack J, LeRoy M. Development and implementation of a psychotherapy tracking database in primary care. Families, Systems, and Health, 2017;35(2):207-216.

Gyani A, Shafran R, Layard R, Clark DM. Enhancing recovery rates: lessons learned from year one of IAPT. Behaviour Research and Therapy, 2013;51(9):597-606.

Salomonsson S, et al. Stepped care in primary care - guided self-help and face-to-face cognitive behavioural therapy for common mental disorders: a randomized controlled trial. Psychological Med, 2017;2:1-11.

Shepardson RL, et al. Psychological interventions for anxiety in adult primary care patients: a review and recommendations for future research. J Anx Disord, 2018; 54:71-86.

Sawchuk CN, Craner JR, Berg SL, Smyth K, Mack J, et al. Initial outcomes of a real-world multi-site primary care psychotherapy program. General Hospital Psychiatry, 2018;54:5-11.

Williams MD, Sawchuk CN, Shippee ND, Somers KJ, Berg SL, Mitchell JD, et al. A quality improvement project aimed at adapting primary care to ensure the delivery of evidence-based psychotherapy for adult anxiety. BMJ Open Qual, 2018;9:7(1).

Bibliography / Reference

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Continuing education approval now requires that each presentation include five references within the last 5 years. Please list at least FIVE (5) references for this presentation that are no older than 5 years. Without these references, your session may NOT be approved for CE credit.

Learning AssessmentA learning assessment is required for CE credit.

A question and answer period will be conducted at the end of this presentation.

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Please incorporate audience interaction through a brief Question & Answer period during or at the conclusion of your presentation. This component MUST be done in lieu of a written pre- or post-test based on your learning objectives to satisfy accreditation requirements.

©2012 MFMER | slide-7

Registries and Measurement-Based CareMark Williams, MD

Associate ProfessorDivision of Integrated Behavioral Health & Department of Family MedicineMayo Clinic, Rochester, MN


Different CulturesPrimary Care and Behavioral Health

SimilarDeal with a lot of chronic conditionsAcute episodes and relapse

DifferentPrimary care routinely measures outcomesBlood pressure, Hemoglobin A1c, etc.

Psych – tend to measure for diagnosis onlyBut what if measuring impacts outcomes?


• Psychiatric Services. 2017 Feb 1;68(2):179-188.

Virtually all randomized controlled trials with frequent and timely feedback of patient-reported symptoms to the provider during the medication management and psychotherapy encounters significantly improved outcomes.


Measuring DOES improves outcome, but

Screening alone is not effective (Cochrane) Measures must be linked to encounters Patient-report measures are as good as clinician rated

measures To identify response/remission

Symptom severity feedback MUST BE CLINICALLY ACTIONABLE Current/interpretable/reliable/sensitive to change/etc.


Why does MBC improve outcomes?Provider behavior: Helps overcome clinical inertia Triggers a change in the treatment plan Prompts for a consultation or referral

Facilitates the use of algorithms Data can be operationalized at decision points

Facilitates the detection of residual symptoms Intensify treatment if necessary Treatment to target

Focuses collaboration/coordination across providers


Why does MBC improve outcomes?Patient perspective: More knowledgeable about their disorders A more informed and activated patient Easier to participate in shared decision making Aware of symptom fluctuation over time Cognizant of the warning signs of relapse or reoccurrence

Mitigates the self-blame that patients sometimes experience

Empowers patients – addresses inertia at a patient level More likely to advocate for themselves Enhanced therapeutic relationship


Population Health is different:

When you start to try to manage a population of patients you have a new denominator to consider… Not just those in your treatment program Not just those who come to your appointments

You MUST have data Patients are at different levels of health/illness There are too many patients to manage in a typical

fee-for-service approach Data needed to create registries Allows for management of patients AND to help

with other priorities


Data for Research versus Data for PracticeResearch EnvironmentResearch staff job to collect data

Highly structured data collection

Data entered into a registry

Set inclusion/exclusion

Fidelity to a model

Track dropouts

Data regularly reviewed for whole population for accuracy and completeness

Practice EnvironmentClinical staff job to treat patients

Data collected based on clinical need

Data in individual charts

Flexible incl./exc. criteria

Model of care in constant flux

Focus on those patients who show up

Minimal peer review unless data needed for billing or quality reporting


The Balancing Act of Data CollectionAmount of DataWhat are you collecting, where is it coming from, and how is it being collected?

Utility of DataHow will this data be used?What is the benefit to the patient, the provider, the practice, etc.?

Consider the Load and who will do what?Desk and rooming staffPatientProviderAnalyst


Registry Building BlocksInstitutional SupportKnow your stakeholders and programmers

Relevant “Columns”Will the variables you collect help answer the questions you need?Flexible and sortable

UsabilityInvolve the users early and often in the buildDeveloping a shared language

Real-Time AccessLag = drag

Use the data – for practice improvement and include stakeholders on publications


Summary: Benefits and Challenges of a Registry Benefits: Patients, providers, and systems do better with feedback Provides aggregate data to improve the quality and safety of care Compare effectiveness of different treatments for the same disease or

condition Support health care education, accreditation and certifications

Challenges: Accurate and complete data Staying focused on registry’s key purpose(s); navigate competing

demands User drift Taking the time to monitor data, provide feedback, use data


Initial Development and Implementation – How Did We Do It?

Craig N. Sawchuk, PhD, ABPP

ProfessorCo-Chair, Division of Integrated Behavioral HealthMayo Clinic, Rochester, MN


It has to Start Somewhere... Existing culture of assessment and

measurement-based care The “Beg, Borrow, and Steal” approach Participatory buy-in Letting the programmers program Riding the continuous cycle of quality

improvement


Evolution of the Primary Care Psychotherapy Data Tracking System

On-line; partially linked to EMR

Continuously populating, expanding scope

June 2014: Rochester pilot (1 clinic)

November 2014: Rochester roll out (4 clinics)

October 2015: MCHS roll out – MN, WI, AZ, FL (5 clinics)

May 2015: Pediatrics roll out (5 clinics)

May 2018: Transition to a new medical record system


Primary Care Psychotherapy Tracking System Variables (Adults) Demographics, diagnoses Mental health service utilization Psychotherapy principles Exposure (situational, imaginal, interoceptive) Cognitive (reframing, mindfulness) Behavioral activation Motivational engagement Skill-building (sleep, pain, communication) Relaxation

Symptom measures (GAD-7 and PHQ-9)


Mental Health Service Utilization


Psychotherapy Principles


Patient-Level Outcomes


Practice-Level Outcomes


Results – Anxiety (N = 928)Consultation Only (N = 366); CBT (N = 562)Mean completed sessions (weeks) = 4.7* (13.7)GAD-7RC = 54%Resp = 43%Remiss = 23%

PHQ-9RC = 51%Resp = 35%Remiss = 21%

0

2

4

6

8

10

12

GAD-7 PHQ-9

InitialFinal

p < .001; d’ = .59

p < .001; d’ = .50


Results – Depression (N = 682) Consultation Only (N = 297); CBT (N = 385) Mean completed sessions (weeks) = 4.2* (13.5) GAD-7 RC = 48% Resp = 35% Remiss = 22%

PHQ-9 RC = 54% Resp = 40% Remiss = 23%

0

2

4

6

8

10

12

GAD-7 PHQ-9

InitialFinal

p < .001; d’ = .48

p < .001; d’ = .62


Results – CBT Principles (N = 6,960)

Anxiety Disorders Cognitive strategies = 84%* Exposure therapy = 67%*

Depressive Disorders Cognitive strategies = 87% Behavioral activation = 64%


Where Do We Go From Here? Patient and provider feedback Program development and expansion Support educational and research missions Keep riding the continuous cycle of quality

improvement


Implementation and Dissemination for Pediatric Populations

Sarah Trane, PhD

Assistant ProfessorDivision of Integrated Behavioral HealthMayo Clinic Health System, LaCrosse, WI


Implementation

Mission/Goals

• What are the needs• How we can help

Presenter

Presentation Notes

Recognize how things fit within the workflow already established.


Behavioral and Developmental ScreeningPeds Prevention Measures in EHR

Which to choose?PEDSAges & StagesSWYKPSC-17PPSCBPSCPOSI

PHQ9M / CRAFFT


Primary Care Psychotherapy Tracking System Variables(Pediatrics/Family Medicine)

Demographics, diagnoses Mental health service utilization Psychotherapy principles

Exposure Cognitive Defusion

Behavioral activation Motivational engagement Skill-building – VALUES identification Relaxation

Symptom Behavioral measures (PSC-17, PHQ9M, VPRS/VTRS)

Parent/Family SkillsBehavior ModificationDevelopmental EducationFamily dynamicsFamily-based therapyParent-child interaction

skills

TF-CBT


Parenting Skills Elements


20% GOAL Track outcomes

Schedule if appropriate.

If not available in clinic for WHO/RN phone triage

PCP, RN or rooming staffWARM HAND OFF

TELEPHONE FOLLOW UP

BHC APPOINTMENT

DOCUMENTATION ON REGISTRY


Using IBH Registry


IBH Psychotherapy Registry – PEDIATRICS Provider Number Active Number of

Sessions% Consult Only Avg PSC 17

Time 1

AB 9 0 100 9.5

MG 23 0-2 39 13.7

ML 4 0-4 25 10.25

SM 11 0-5 18 9.0

DM 13 0-2 46 10.9

HM 51 0-4 20 12.4

NR 59 0-4 46 10.3

JS 46 0-2 89 12.3

ST 33 0-5 44 13.5

MW 8 0-4 50 14.0

Presenter

Presentation Notes

Beginning stats to compare practice. Tracking since April 2018.


Implementation and Dissemination in Rural Primary Care Clinics

Michelle LeRoy, PhD, ABPP

Assistant ProfessorDivision of Integrated Behavioral HealthMayo Clinic Health System, Red Wing, MN


Behavioral Health Challenges in Rural Communities

➢The 4 A’s of behavioral health services○ Availability○ Accessibility○ Affordability○ Acceptability

National Rural Health Assocation (2015). The Future of Rural Behavioral Health


Site-specific Challenges

➢General practice challenges:○ Physical office space○ Newly developing relationships between

Behavioral Health and Primary Care○ Behavioral Health provider transitions and split

positions


Site-specific Challenges

➢Database-specific challenges:○ Multiple, partially linked Electronic Medical

Records (EMRs)○ Lower rate of research consent○ Scheduling/Registration workflow


What we did...

Provider Time➢Initial training in the use of the database➢Ongoing training/education○ Weekly case consultation meetings ○ Monitoring of database utilization by supervisors○ Workflow problem-solving


How we did it...

Provider Time ➢Redesign of provider scheduling templates➢Protected non-visit care time - THIS IS KEY➢Manage competing demands, especially for clinical

social workers


What we did…

Questionnaire Administration

➢A) Provider gives paper questionnaires➢B) Provider gives questionnaires via flowsheet in EMR ➢C) Front desk staff distribute paper questionnaires at check-in➢D) Front desk staff distribute questionnaires via tablet ➢E) Electronic completion of auto triggered questionnaires via

patient portal


How we did it…

Questionnaire Administration

➢Collaboration with clinic administrators➢Problem-solving with scheduling supervisors

○ Table with questionnaires by patient age and visit type to post at registration desk

➢Ongoing monitoring and feedback to scheduling supervisors➢Build relationships with scheduling team➢ Set expectations with patients


Practice-Level Outcomes


Thank You!Questions & Discussion

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Session # F4 Implementation and Dissemination of a Large ......Therapy, 2013;51(9):597- 606....

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