Transcript Partnered Comparative Effectiveness Trial to Improve Depression

Community Partners in Care: Partnered
Comparative Effectiveness Trial to Improve
Depression Care in Los Angeles
Ken Wells, Felica Jones, Jim Gilmore, 1-2011
Healthy African American Families Developed
Community Partnered Participatory Research
Circle of Influence: A Model for Collaborative
Research
© 2002 Jones, Martin, Pardo, Baker, and Norris
Community
Resident Experts
Partners
Resident Experts
Community
Key Features of CPPR
• Core Principles
– Equal power sharing and respect
– Find the win-win
– Support community capacity
• Structure
– Partnered Council frames and guides initiative
– Community Forum provides broad input
– Partnered Work Groups
• Develop action plans for community approval
• Implement and evaluate approved plans
• Disseminate programs and findings
• Stages: Vision, Valley and Victory
• Jones and Wells, 2007; Wells and Jones 2009;
www.communitytrials.org; Jones et al., 2009
Clinical Background
• Depression is the largest cause of disability in the
world among adults.
• Evidence-based treatments work – therapy and
medications
• Primary and specialty care are major care settings for
depression—larger known quality gap in primary care
• Other community agencies provide services to people
with depression, especially in vulnerable communities
Collaborative Care for Depression for
Depression is Effective in Primary Care
• Components of Collaborative Care
• Care management: Screening; Education, Follow•
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up support; Patient Activation; Coordination
Cognitive Behavioral Therapy
Psychotropic Medication Management
Team-based Quality Review
Provider Education and Support
System Changes
• Gilbody et al. (2007) reviewed 27 randomized trials;
effective QI includes care management
Supported by
the National Institute of Mental Health and the
Agency for Healthcare Research and Quality
Outcome Disparities Reduced at
5-Year Follow-up
African
American
QI programs
Usual care
Latino
White
0
10
20
30
40
50
60
70
80
% recovered from depression at 5 years
90
PIC Gets Engaged to CPPR
Getting Engaged
• Developing Equal Partnerships:
– Share power, listen, respect differences
– Develop and honor agreements
• Embrace Community:
– Not as "subject" but partner
– Honor community strength while building capacity
• Align Funding and other Resources to Join CPPR and PIC
• Jones and Wells, 2007; Wells and Jones 2009; Jones et al., 2009,
special issue of Ethnicity and Disease
Working together in an equal partnership
To learn how to improve depression care
DEPARTMENT OF
MENTAL HEALTH
And build community strength
CPIC Framework: How Can We Beat Depression in Our Community?
Community Capacity
Partnered Planning (Vision)
Partnered Trial (Valley)
Resources for
Services
(Agency support)
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Community
Engagement &
Planning
(Network support)
Outcomes
Partnered Dissemination (Victory)
Academic Capacity
CPIC Structure
• CPIC Partnered Council: Responsible for all major
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decisions; Executive Committee expedites
Partnered Committees: Design; Measures;
Intervention Development; Study and Intervention
Implementation Evaluation; Operations and
Recruitment; Dissemination and Products
Intervention Structure: CEP Councils, each SPA;
RS (combined leadership across SPAs).
Community Forums
Policy Advisory Board
National Scientific and Policy Advisors/Funders
Vision: Community Expanded Sampling Plan
• Community Definition (Council)
– County service regions
• Agencies (Community Meetings)
– Proposed: Mental health, medical, substance
abuse, public health, social services
– Added: “Community-trusted”(Parks & senior
centers, faith-based, businesses; public health)
• Providers (Council)
• Proposed: Service providers and case workers
• Added: Lay staff with client contact
• Clients (Community Meetings)
– Add the most vulnerable—homeless, HIV, prison
parolees/probation
Vision: Expanded Intervention Design
• Resources for Services
– Proposed: Kick-off conference & web-based TA
– Added :3-4 webinars per CC component; site visit
to primary care; community consultant
• Community Engagement and Planning
– Proposed: Kick-off conference, CEP Council, 2day conference with 4- month supervision
– Added: 4 conferences, webinars, individual site
trainings, quality review, Council budget (CPIC
Village Clinic)
Modified study goal: How to best serve community
Community Input Into Recruitment
• Policy Advisory Board: Slowed down planning
Study added engagement specialist to academic
team
• Community leaders nominated agencies
• Academic and community partners recruited
providers
• Client recruitment led by academic survey group
that recruited local community members co-trained
by academic and community staff
– Community leaders support staff resiliency
Vision: Community Input Expanded Measures
• Add employment, housing as outcomes
– Required a supplemental grant
• Track depression services in all locations
– Developed network approach to services use
Increased time and budget for surveys
• Prioritize suicidality and comorbidity
– Maintain suicide assessment items
– Study clinicians conduct 1-7 suicide calls/day
– Expand diagnostic assessment
Vision: Community Input Shaped
Randomization Design
• Two-way exchange
– Randomization/equipoise
– Community trust/Tuskegee
• Community & academics matched agencies for
randomization
• Community leaders selected seed numbers to
initiate randomization
• Academic & community co-presented design
– Kick-off community conferences
– American Statistical Association 2010
Valley: Implementing Interventions
Results: Sampling
• 2 Communities Engaged: > 2 million underserved
• Agency sampling
– 177 names through lists and nomination
– 65 ineligible (22) or not located (43)
– 50 refused and 62 agreed
• 93 programs in 50 agencies agreed (5 refusals)
• Randomization: Council clustered programs into
“units” and matched units
• RS: 45 programs (27 units)
• CEP 48 programs (25 units)
CPIC Programs by Intervention Status/SPA
Intervention
Condition
Program Type
# Sites
CEP
SPA
RS
4
6
Community trusted locations
10
6
4
1
9
10
5
5
7
3
Mental health services
18
8
10
11
7
Primary care
17
9
8
13
4
Social services
18
11
7
8
10
Substance abuse
20
9
11
3
17
93
48
45
43
50
Homeless services
Total
CPIC Providers
• For 93 programs participating in CPIC, 21 have only
a program director (no provider)
• For 72 programs with staff, 395 providers enrolled
and 277 completed the provider baseline survey
CPIC Providers (N=277 with surveys)
Provider Occupation
N
%
Missing
5
1.81
1:Religious clergy
5
1.81
2:Primary care physician
7
2.53
3:Psychiatrist
2
0.72
5:Nurse (RN) or Nurse Practitioner
7
2.53
6:Nurse (Licensed Vocational Nurse)
2
0.72
8:Psychologist (licensed, waivered, or intern)
5
1.81
9:Social worker (licensed, waivered, or intern)
44
15.88
10:Marriage & family therapist (licensed, waivered, or intern)
18
6.50
12:Substance abuse specialist (licensed, certified, or intern)
53
19.13
14:Lay health educator
8
2.89
15:Lay mental health counselor
1
0.36
17:Case management provider
54
19.49
18:Community outreach provider
22
7.94
4
1.44
40
14.44
20:Medical Assistant
21:Other
CPIC Client Enrollment
4,645 Clients Approached for Screening
209 Refused Screening
4436 Completed Screening
2965 Ineligible (PHQ-9 score<10)
1471 Initially Eligible And
Asked for Contact Information
149 No Contact Information
1322 Eligible Were Invited to Participate
76 Refused
1246 Consented and Baseline Survey Was Attempted
347 Inaccessible at Baseline
899 Enrolled Participants
Complete Baseline Survey
RS (45 programs) has 446 Participants
CEP (48 programs) has 453 Baseline Participants
Prevalence of Depression (PHQ => 10)
by Sector
Overall
(N=4436)
PHQ-9>=10
(N=1471)
Community/Public/Religious
356 (8.03%)
58 (16.29%)
Homeless services
654 (14.74%)
255 (38.99%)
Mental health services
457 (10.30%)
236 (51.64%)
Primary care
1399 (31.54%)
493 (35.24%)
Social services
771 (17.38%)
150 (19.46%)
Substance abuse
799 (18.01%)
279 (34.92%)
Service sector
Enrolled Client Characteristics (N=899)
• Mean age 45 (range 18-83)
• 57% Female
• 24% married/living with partner; 27% divorced; 46%
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single
43% < high school education
Ethnicity: 39% Latino; 48% African American; 9%
non-Hispanic white; 4% other
28% unemployed in work force; 59% unemployed
not in work force; 13% working full or part time
26% uninsured; 36% Medicaid/state; 10% Medicare;
51% any other (VA, private)
74% family income <$10K
37% 1 or more children at home
Client SES and Health Status (N=899)
• 57% Poor or fair general health; only 3.5% excellent
“My community knows how to support people with
mental health or emotional problems”
– 46% agree; 26.5% unsure; 27.5% disagree
Victory: The Win-Win (Cont.)
• Community Benefit:
– All screened receive Resources Guide
– Suicidal patients on baseline have telephone
intervention (160 so far)—all appreciate it
• Products: partnered papers, presentations:
– Health reform and MHSA, Academy Health
– Partnered Design at ASA
– Participatory Research at APHA
– Partnered Intervention, APA
• Reputation: locally and nationally
• Paradigm shift for community & academic partners
Other Community Benefits
• Trainings: Multiple 1-2 day trainings; 20+ smaller
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trainings; 16+ webinars
Leader Development: 24 in CBT alone
CME, CEUs, certificates of appreciation
Agency $-matching requirements
Letters of support
Research opportunities
Data for programs and policy makers
Sustainable website with toolkits and flashdrives
Hope: We can improve outcomes, save lives, and
inform policy debates locally and across America
Summary:
How We Build Capacity
• Build relationships and trust, invite people to the
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table, & stay involved
Knowledge-exchange activities:
Develop and use a common, simple language
Support working groups of stakeholders as equals
Develop action plans & programs to support
understanding and implementation
Disseminate information & products
Social activities
Food and fun at meetings and outside of work
New Orleans Partners
Onward….
In Partnership!