USING PRACTICE-BASED EVIDENCE TO ASSESS AND IMPROVE INTEGRATED CARE: THE INTEGRATED CARE EVALUATION...
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Transcript of USING PRACTICE-BASED EVIDENCE TO ASSESS AND IMPROVE INTEGRATED CARE: THE INTEGRATED CARE EVALUATION...
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
2
Traditional practice change strategiesdon’t work
ScienceDissemination, Diffusion of RCTs
Guidelines, Demonstration ProjectsPractice
“We know best, do as we say”
3
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
5
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
6
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)
7
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
8
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.
9
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
10
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
11
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
13
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
16
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
18
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
19
Input, feedback, requests for more information?
Jim Fauth, Ph.D.Director, Center for Research on Psychological Practice
Antioch University New England603.283.2193
Thank You!