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Collaborative Care for Indigent Populations: Barriers, Solutions, Outcomes, & Lessons Learned Laurie Alexander, Ph.D. Program Officer Today’s presentation Barriers Data & solutions & 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 Grants began ending in April 2009 ■ Parkland ■ Project Vida ■ People’s ■ TCPA TCPA = TX Children’s Pediatric Assocs (Houston) SCF = Su Clinica Familiar (Harlingen) NCDV = Nuestra Clinica del Valle (San Juan) BCHC = Brownsville CHC ■ SCF ■ NCDV ■ BCHC 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 Patient consultation registry Collaborative care Core components Care manager Clinical assessment tool Psychiatric Patient consultation registry Care manager Professional In or paraprofessional 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 Patient consultation registry Clinical assessment tool Objective response measure of treatment Administered at every care mgmt contact Examples PHQ-9, OASIS, & Vanderbilt Collaborative care Core components Care manager Clinical assessment tool Psychiatric Patient consultation registry Psychiatric consultation Weekly meetings with care manager By phone or in person (1-2 hrs / wk per care manager) PCP PCP Flexible implementation PSYCHIATRIST CARE MANAGER PCP PCP PCP PCP PCP Collaborative care Core components Care manager Clinical assessment tool Psychiatric Patient consultation 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) Targets Implementation factors Outcomes Costs Evaluation plan Formative quantitative and qualitative evaluation with mixed design Qualitative 2 site visits per grantee Standardized protocol Qualitative evaluation domains 1. 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 21 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 & 4month 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 adults Delays 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 R. Frank, 2008 N cases (3 sites) Average ages % Female Prefer Spanish 975 39-47 years 78%-84% 26%-58% Uninsured Baseline PHQ-9 Baseline OASIS 81%-88% 16.0-16.7 11.3-11.7 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 period R. Frank, 2008 Lessons learned When core components are implemented, the program works Co-location Initial is not sufficient treatment is rarely sufficient Program appears to be low cost R. Frank, 2008 Success factors Core components in place Successful Most engagement of patients patient contacts by phone Close tracking of medications Active J. Unutzer, 2008 adjustment of treatment 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 More information at: www.hogg.utexas.edu Laurie Alexander, Ph.D. Program Officer [email protected]