Sunday, April 16, 2017
We're getting closer to starting up the first practices in the IBHPC protocol. So, it seems a good time to review the patient inclusion criteria. Who are we going to enroll and why?
The patients we are hoping to identify have at least one target chronic medical condition (arthritis, asthma, chronic obstructive lung disease (COPD), diabetes, heart failure (HF), or hypertension) and evidence of a behavioral problem or need. Such evidence may be a specific diagnosis (anxiety, chronic pain including headache, depression, fibromyalgia, insomnia, irritable bowel syndrome, problem drinking, or substance use disorder), persistent use of certain medications used for behavioral concerns (antidepressants, anxiolytics, opioids, anti-neuropathy agents, etc.), persistent failure to attain physiologic control of a medical problem (blood pressure>165 while on 3 or more medications, A1C > 9% for 6 months), or the presence of three or more of the target chronic medical conditions. (Patients with three or more of the target chronic medical problems almost always have a significant behavioral need.)
These criteria were chosen, with input from our patient advisory board, because they are commonly managed in primary care, associated with great burdens for patients, family, and the health system, have measurable outcomes, and are often associated with behavioral and lifestyle challenges such as medication non-adherence, stress, poor diet and inadequate exercise. In other words, they are the sorts of patients who most need IBH and can most benefit from it.
Our strategy for subject identification seeks to balance efficiency and representativeness while allowing us to capture the effects of each practice’s case finding and clinical management on study outcomes. We cannot sample from the entire practice panel because, in most cases, the practices will have many more patients that their BHCs can reasonably support. Nor can we allow each practice to know exactly who the study subjects are because they may tend to concentrate BH resources on those patients in a way not usual in real world practices. Therefore, we will create a “Community Panel” of about 1,000 adults per FTE BHC that the practice will be advised is the focus of integrated care (Group A). It comprises a general population of adults including those with and without BH needs. The Community Panel will be a random subset of the entire practice’s patient population of adults, regardless of diagnosis or need. Thus, the practice will need to employ whatever screening or case finding they have to find the members of the Community Panel who need BH services. The BHCs and other practice members will be told to apply their efforts in BH (including screening, case identification, management, follow-up, etc.) to those patients, but will not be told which of the patients in the panel has behavioral needs or is a research subject. (The practices will know the eligibility criteria.) The Community Panel will be substantially smaller than the number of primary care patients estimated to produce a work load for 1.0 FTE BHC. If the practice has more or less than 1.0 FTE BHC, the size of the community panel will be modified pro rata.
So, a practice with 1 full time BHC will receive a list of ~1,000 adults to focus their screening, case-finding and BH management on. That list will have a mix of folks with and without medical and behavioral issues and will include ~75 who will be research subjects and asked to report on how they are feeling (the main outcome). However, the practice will not know which of the bigger group are in the smaller group. Their job is to find them, assess them, manage them and do surveillance to make sure they stay well!
Let me know if you find this needs more clarification, or if you have any ideas for other postings. Also, feel free to post comments - you can even write your own posting, if you like!
Monday, April 3, 2017
The good folks at Kaiser Permanente Washington have started up a big effort in Behavioral Health Integration. This blog posting by Santino Telles, MAC gives an idea of how it looks from his vantage point as a Medical Assistant.
Thanks to Laurie Hassell at UW for the lead!
Thursday, March 30, 2017
A primary focus of our efforts right now are on recruiting, determining eligibility and onboarding of the 40 clinical practices needed to participate in our project. One of the requirements of a practice participating in the study is to have electronic medical records and have the ability to share them. The electronic health records will be used to create community panels at each practice, determine eligible subjects for recruitment and to measure patient health outcomes.
To accomplish this rather large task of electronic health record access, data collection and transfer, we have contracted with the DARTNet Institute. DARTNet is a non-profit 501(c)3 organization that conducts research, supports collaboration among health care providers and organizations, and hosts data sets of health information for quality improvement and research.
DARTNet’s role in the project will be to:
- Extract, transform, load and transfer electronic health records
- Work with each organization to guarantee all required data elements are included, no extraneous or hidden data elements are present, and that data relationships are maintained
- Create a community panel from each of the participating clinical practices
- Review the EHR data, identify potential subjects and obtain consent.
Study patients will be a randomly selected subset of the eligible patients. DARTNet will verbal consent our patient subjects. Potential subjects will be told the purpose of the study, that we are requesting permission to use a limited set of their health data and that we are requesting them to complete a brief web or telephone survey once a year for 2 years. Only after they have permission from the patient will any data be transferred to the research team.
Some of the DARTNet Team working on the project:
Wilson D. Pace, MD, FAAFP CMO, DARTNet Institute is a Professor Emeritus of Family Medicine at the University of Colorado, Denver, the Green-Edelman Chair Emeritus for Practice-based Research, and the past Director of the American Academy of Family Physicians National Research Network. Dr. Pace’s research has focused on patient centered health information technology, behavioral change (both patient and clinician behavior), practice reorganization and patient safety. He served on the Institute of Medicine’s committee studying the recognition and prevention of medication errors which resulted in the report entitled “Preventing Medication Errors.” His behavioral change work has involved multiple technology and clinical decision support related projects. Other projects have focused on improving care for depression in general, post-partum depression specifically, asthma and chronic kidney disease. He is the primary architect of the DARTNet Institute, a collaborative of electronic health record enabled research networks.
Deejay Zwaga and Lucy Scott. Deejay is the project manager at DARTNet for the data side of the grant in the Dallas office. Lucy Scott project manager for patient recruitment for IBH-PC. Lucy has a PhD in linguistics and speaks 6 languages but for this project she will focus on English and Spanish. Deejay and Lucy are in the DARTNet Dallas office.