News and comments for investigators, staff, advisors, collaborators and colleagues of "Integrating Behavioral Health and Primary Care for Comorbid Behavioral and Medical Problems", a large pragmatic clinical trial funded by the Patient Centered Outcomes Research Institute (PCORI).
“The best thing for being sad," replied Merlin, beginning to puff and blow, "is to learn something. That's the only thing that never fails. You may grow old and trembling in your anatomies, you may lie awake at night listening to the disorder of your veins, you may miss your only love, you may see the world about you devastated by evil lunatics, or know your honour trampled in the sewers of baser minds. There is only one thing for it then — to learn. Learn why the world wags and what wags it. That is the only thing which the mind can never exhaust, never alienate, never be tortured by, never fear or distrust, and never dream of regretting. Learning is the only thing for you. Look what a lot of things there are to learn.”
Learning is never so sweet as when that education comes from people who care. I want to tell you just how important our SAG (Stakeholder Advisory Group) is to our PCORI IBH-PC learning community. Our advisory group is made up of 22 members who represent the “end users” of healthcare,namely, patients, family caregivers, community leaders, providers, payers and policy makers. For some reason when I was thinking about each member and who/what they represent I got an image of one of those mix and match puzzles that children play with where you can switch heads and feet and torsos around. It dawned on me the more I listen to our advisers the more I hear that the common thread in our SAG puzzle is the compassion for patients. Even though each person represents a different community within our healthcare system, everyone on the SAG seems bonded by the magnitude of caring for others. All patients want a system that can serve effectively and efficiently but primarily we want a system that can invite all human beings to thrive (not just survive) within the boundaries of each of our unique health conditions.
By the way, that definition of good health actually comes from members of our SAG.
So how does the SAG work?
Long before the project got funded, members of the SAG, experts and leaders in their communities, were meeting, emailing and conversing with the research team in order to help design the study and write the grant proposal. Now that funding has happened, they will continue to help us keep things rigorous and meaningful as the study is conducted. Eventually when the project ends, they will also help disseminate the findings of the study to their communities.
Our SAG will be meeting at least 4 times a year over the life of the project. (*and possibly a few “extra miles” if needed!) Meetings are held at UVM for those who can attend in person but members are also able to attend via webinar. During these 2 hour sessions the research team is there to provide information about current activities going as planned but also share news about what we are learning or thinking hard about. The real heart of these meetings is the moment when we ask our members to help us figure something out that might be missing from that knowledge base.
So what has the SAG been up to lately you may ask?
Recently, the Education team asked the patient co-investigators for some help. They wanted a comprehensive “checklist” of what is essential for patient-centered integration. The Ed team is constructing the body of knowledge that will be used to educate the sites who get randomized into the active arm of the study. At least 80 topics are being covered and currently are under development. This list would help assure that all topics are seen through a lens of what is most important to patients.
Defining what patient-centered means is no easy task. We all want so much from our healthcare system. We all need so much depending on where we find ourselves as the “end user”. But thank you for asking Ed team!! So glad you did. And who better to ask than patients?
The 3 Patient Co-investigators on the research team have been working on this list for many months. Through hours of really deep, honest conversations and documenting our experiences that involved getting really good care or experiences when we had to resort to finding our own resources, we have been getting to the heart of what it means to actually live well with a chronic illness. By now we could write a book on what matters most. But we know we can’t answer that question for everyone. There are no two patients alike. We needed confirmation and help to determine what we were possibly missing and we needed to transform all of that “data” into checklist form.
So we reached out to the SAG and asked for an “extra mile”. We invited members to attend two focus group sessions and give us the patient perspective. Not surprisingly, despite very short notice, we had several members step up and offer to help.
During these sessions, using a very effective method called an Affinity diagram and expertly lead by Connie van Eeghen, Project Director, our advisers were able to generate a lot of content in a short amount of time. We asked these questions: What matters most to Patients? and What do Patients want the Learners (your integrated care team) to remember? This tenacious and courageous group, with much insight and thoughtful consideration, gave us a comprehensive list. During our 2nd session our advisers took it another step further and applied this checklist to a matrix of patient concerns that will be important topics covered in the educational materials.
1st session-affinity diagram-What matters most to patients?
2nd session-creating the matrix
When our 3rd quarterly meeting convened on Dec 5th, we asked our SAG members to take it one step further. I felt we might be"testing the Camel’s back",but I also know just how important it is to get it right for patients, so we asked for actual lived examples of what successful experiences look and sound like. The question we asked: "During healthcare interactions, what was actually said that worked well? What was actually done that made it successful for the patient? " And once again, our members stepped up to the plate and delivered what was needed.
We have all heard that expression: “Give a man a fish, he eats for a day. Teach a man to fish, he eats for a lifetime.” I get it, very nice idea- but in the interest of deeper learning, I would take it a few steps backwards...Who wants him to eat fish everyday for a lifetime and why? It makes sense to me to ask the person who needs food what he really wants to eat before you start giving him, or teaching him anything.
So as all of you caring and compassionate learners out there go about doing the tough work of transforming healthcare, if you find yourself wondering if what you are doing will work best for patients, I invite you to give me a call. I just might be able to get you on the short list to ask our Stakeholders to help answer your questions. Jen Lavoie
The first clinical sites have passed their initial qualifications and are beginning the contracting phase. Three sites from The University of Buffalo have each completed 4 PIP surveys and the Research Management Survey and demonstrated that they meet the inclusion criteria for the study. So, today, Sylvie Frisbie (Research Associate) sent out their "Commitment Packages" which contain all the contracting forms and legal boilerplate.
Still to come: IRB approvals, Data Use Agreements, test data transfer and so on.
Kudos to Kim Griswold (Cluster Leader) and Chloe Hurley (Cluster Administrator) for being first past the gate!
Juvena Hitt (Project Manager), Jennifer Lavoie (Patient co-investigator), and Ben Littenberg (Principal Investigator) attended the 2016 PCORI Annual Meeting in National Harbor, MD near Washington, DC last week.
The crowd was even bigger than last year, it seemed, and the gigantic Gaylord Resort venue was swarming with PCORIans from all over the country. There were dozens of presentations on various aspects of PCOR with a special emphasis on stories from the many patient participants who attended.
Jen was part of a panel at a Pre-Conference Session for Patient Scholarship Recipients and Ambassadors and got great reviews. Ben and Jen presented at a panel discussion on "Novel Delivery of Evidence-Based Behavioral Interventions for Anxiety and Depressive Disorders" where we featured all of your great work!
On Thursday August 25th and Friday August 26th the
IBH-PC team convened the first Annual Meeting in Burlington, Vermont at the
Hilton Garden Inn. The meeting brought together members of the Executive Team,
Co-Investigators, Consultants, Cluster Site Leaders, Patient Partners, and staff
from PCORI (our funders).
This was a chance for those involved with the project to meet face to face and
exchange ideas, concerns, and tips as we enter the beginning stages of
onboarding the clinical sites. The meeting was also an opportunity to bring the
participants to the Green Mountain State to see a glorious New England summer
and take inspiration from the natural beauty of Vermont.
After opening remarks from Rodger Kessler, we heard progress reports
from Ben Littenberg, Connie van Eeghen, Rodger Kessler, and Elias Brandt. There
were many questions, comments and suggestions that will shape the project going
forward. After the presentations and a delicious lunch, the hard work began as
the large group broke into teams to discuss the following issues:
With a diverse mix of all the represented participants, the groups took
the rest of the day to both pose, and answer the questions in each section on
what is still needed to help the transition from onboarding to research run as
smoothly as possible.
The Site Management team worked on how best to recruit
and on-board eligible clinical practices, including a number of thorny issues
The Practice Change team reviewed and revised the
Practice Redesign Toolkit, one of the three key elements of the intervention.
The Patient Engagement team developed an enhanced a theoretical model of
patient engagement and looked for ways to apply it at the clinical level to
support patients in the Redesign Teams.
Day 2 opened with a continuation of the small group work. The Site
Management team practiced dealing with clinical site leadership with role playing
exercises about potential site issues and how a Cluster Site Leader could address
them. The Patient Engagement group focused on making the patients involved less
“subjects” and more “advisors and partners” in their care. The Practice Change
group tackled redesign issues with implementing the Toolkit in diverse
Then the small groups reported back on their findings to the larger
group for input and comment. The general consensus was that though there were
still issues needing resolution, the project was on the right track. The PCORI
Representatives mentioned how excited they were to see where the project was
leading and could not wait for onboarding to begin. Then, just like the local
children seen outside the venue’s windows, the participants scampered out into
the sun to enjoy one of the last sunny days of summer. A productive meeting
that left all involved energized and inspired to kick this project into drive!
Faculty: C.R. Macchi, Daniel Mullin, Richard Pinckney, Connie van Eeghen, and many
names look familiar… they are. Those mentioned above are also involved in the
Transforming Primary Care will provide strategies for prioritizing and
measuring behavioral integration into medicine.
Leadership in the National Committee for Quality Assurance (NCQA),
OneCare, and Community Physicians and Behavioral Health practitioners involved
in integration activities will discuss specific strategies to help your
practice improve medical care, moving Vermont healthcare forward clinically and
financially. Participants will review practice assessment, recognize
facilitators and barriers to integration, consider the need for a Vermont
interprofessional training model for those in practice and in Vermont academic
institutions. An optional workshop day
will facilitate practice-specific integration improvement. Additionally
we are offering an optional two-part workshop: Staying Ahead of Integration:
It’s the Process Not the Provider
- From an NCQA Perspective: Integrated
Primary Care as Part of the Patient-Centered Medical Home - Sarah Scholle, DrPH, MPH ·An
Integrated Treatment Model of Medication Assisted Treatment of Narcotics - James Anderson, PhD, Daniel Mullin, PsyD,
Discussion: The Integration Metrics
Project: Results of a National Expert Panel -
Rodger Kessler, PhD, ABPP, Daniel
Mullin, PsyD, MPH, Sarah Scholle, DrPH, MPH ·Education
for Teams That are Integrating Behavioral Care:
What’s Needed and How to Get It – C.R.
Macchi, PhD ·Panel: Future of Behavioral Health
in New Healthcare Funding Models: What Would it Look Like and What Would it
Take? - Claude Deschamps, MD, Vicki
Loner, MHCDS, RN, CCM, CMCN, PAHM, Sarah Scholle, DrPH, MPH ·Behavioral Management of Chronic
Pain: Tools We Can All Use to Transform Care - Richard Pinckney, MD, MPH
·The Relationship of Care Processes
to Care Outcomes - Rodger Kessler, PhD,
ABPP, Sarah Scholle, DrPH, MPH
We're looking forward to this November 12-16 in Colorado Springs to the 2016 North American Primary Care Research Group Annual Meeting. Here are some abstracts from the IBH-PC team that have been accepted for presentation. Please let us know if you will be there.
Development and Validation
of a Measure of Primary Care Behavioral Health Integration
Rodger Kessler Ph.D. ABPP, Andrea Auxier Ph.D., Juvena Hitt
B.S., Benjamin Littenberg M.D., C.R. Macchi Ph.D., Daniel Mullin Psy.D. MPH,
Connie van Eeghen Dr.P.H., Jon van Luling B.A.,
There are a large number of initiatives co-locating,
behavioral clinicians within primary care practices. These take a variety of
formats and models, from embedded specialty mental health and substance
providers to integrated systems of care. While many are identified as
collaborative or integrated care, there is no method to validly identify
elements or levels of collaboration or integration, and thus an inability to
systematically contrast elements and levels to clinical, operational and
We will report on the development and validation of the
Practice Integration Profile (PIP), a thirty item electronic survey completed
by primary care medical and behavioral practitioners and practice
administrators. The PIP is based on the AHRQ Lexicon of Collaborative Care, and
evaluates and provides scores on six domains as well as generates a total
169 surveys were returned. mean total score was 55 (0-100).
There was high internal consistency, and the measure discriminates between
exemplar practices, primary care practices with behavioral health, primary care
without behavioral health, and community mental health centers. Test retest
differences averaged 1.5 points.
The Practice Integration Profile is a rapidly administered
measure of integration level, acceptable to primary care practices, that can be
used to assist practices to make decisions about clinical care and assist
researchers to identify factors and levels of integration activities that may
be associated with outcomes of care.
Variability in the Implementation of Integrated Behavioral Health
Rodger S. Kessler PhD ABPP, Andrea Auxier PhD, Juvena Hitt BS, Benjamin Littenberg MD, CR Macchi PhD, Daniel Mullin PsyD, Connie van Eeghen DrPH, Jonathan van Luling BA
Context: Behavioral Health (BH) includes mental health care, substance use disorder care, health behavior change, and attention to family and other psychosocial factors including management of depression, anxiety, stress, chronic pain, and other common conditions. Most patients with BH needs present to primary care, but traditional models of referral to specialty BH services often fail. Therefore, many practices have attempted to integrate BH and primary care. The most basic form of Integrated Behavioral Health (IBH) is simple co-location of BH and medical services at the same address. More advanced integration addresses shared infrastructure and care planning and practice-wide systems to identify, engage, treat and follow patients with BH needs. It not clear how much practices vary in their approach to implementing IBH.
Objective: Determine the variability of IBH across practices.
Design: On-line survey comparing “integrated practices” (defined as at least physical co-location of BH and medical services) to non-integrated practices.
Setting: 237 outpatient practices in 36 US states delivering adult primary care, BH, or both.
Participants: 336 medical and BH providers, practice managers and other practice staff.
Measures: The Practice Integration Profile (PIP), a novel 30-item online survey completed by BH providers, medical providers, managers, and staff about their own practice. It assesses six domains and a total score derived from the AHRQ Lexicon for Behavioral Health and Primary Care Integration.
Results: Wide variability was seen in all measures of integration even among apparently “integrated” practices. For instance, the PIP Total Score ranged from 0 to 100 among all practices and 23-100 among “integrated” practices.
Conclusions: Practices vary widely in the degree of integration they have achieved. Even practices with apparently high levels of integration show very large variation in the implementation of integration. Co-location of behavioral and medical providers is not enough to achieve high levels of Integrated Behavioral Health.
So what is this “IRB”, what do they do and why
is it important?
Institutional Review Boards (IRBs), (in Vermont, aka "the Committees on Human Research"), review and approve human
subject research. IRBs have one paramount responsibility:
To protect the rights
and welfare of human research subjects
The committee review process is designed to
protect the rights and welfare of participants who participate in research by
·risks are minimized,
·subject selection is
·informed consent is
confidentiality are preserved.
In addition to approving our research study
protocol, IRBs require that all research staff involved in the project
complete education and training.
IRB approval is taken very seriously. Before we
could begin work on this project, well before human subjects are even involved,
we needed to obtain approval from the University of Vermont’s IRB to
conduct the study. Done J……
And now for the easy part - getting IRB approval from all 40 of the individual
practice sites' IRBs to participate in the study.
This morning, the Cluster Leaders were provided
materials to assist them in getting this project approved by their institution’s
IRB. Every IRB office is
different with unique forms and documentation needs specific to each
organization. Outlined below are the steps we will be using to work through securing
IRB approvals at all practice sites.
Process for Cluster Leaders:
over the documents we sent you.
the forms needed from your institution’s IRB office
out your institution’s forms using the information found in the documents
your completed institution’s forms to Juvena Hitt at UVM to review.
review, Juvena will send the forms back to you for submission to your IRB
us know of any feedback our questions from your IRB office and provide us with
the approval letter once approved.
Please ask any questions along the way. If you need assistance in filling out the forms from your institution -we can help with that as well
Health Affairs recently published an article by a team including Sarah H. Scholle, DrPH. In addition to serving as Vice President of the National Committee for Quality Assurance, in Washington, D.C., Sarah is a co-investigator on IBH-PC.
Following up on its Crossing the Quality Chasm report, in 2006 the Institute of Medicine issued a report that included sweeping recommendations to improve the quality of behavioral health care in the United States. To date, few of those recommendations have been implemented, and there is little evidence that behavioral health care quality has improved significantly over the past ten years. However, the advent of health care reform, parity of insurance coverage, and growing recognition of the impact of behavioral health disorders on population health and health care costs have created new demands and opportunities for expanded and innovative strategies to assess the quality of care for this patient population. We provide an overview of the current state of quality measurement in behavioral health, identify key priorities for measure development, and describe the most important challenges. We recommend a coordinated plan that would boost investment in developing, evaluating, and implementing behavioral health quality measures; conduct research to develop the evidence necessary to support a more robust set of measures; overcome barriers to the improvement and linking of data sources; and expand efforts to build the capacity of the clinical workforce, in partnership with consumers, to improve quality.
When she is not a patient co-investigator managing the stakeholder engagement activities of IBH-PC, Jen Lavoie is a highly-regarded fiber artist. In fact, many in the special field of hooked-rug art consider her the best practitioner working today! One of her latest rugs is mentioned here and is part of a show of hand-hooked rugs depicting the Tarot.
Brief interventions for unhealthy drinking in primary care settings are efficacious, but underutilized. Efforts to improve rates of brief intervention though provider education and office systems redesign have had limited impact. Our novel brief intervention uses interactive voice response (IVR) to provide information and advice directly to unhealthy drinkers before a physician office visit, with the goals of stimulating in-office dialogue about drinking and decreasing unhealthy drinking. This automated approach is potentially scalable for wide application.
We aimed to examine the effect of a pre-visit IVR-delivered brief alcohol intervention (IVR-BI) on patient-provider discussions of alcohol during the visit.
This was a parallel group randomized controlled trial with two treatment arms: 1) IVR-BI or 2) usual care (no IVR-BI).
In all, 1,567 patients were recruited from eight university medical center-affiliated internal medicine and family medicine clinics.
IVR-BI is a brief alcohol intervention delivered by automated telephone. It has four components, based on the intervention steps outlined in the National Institute of Alcohol Abuse and Alcoholism guidelines for clinicians: 1) ask about alcohol use, 2) assess for alcohol use disorders, 3) advise patient to cut down or quit drinking, and 4) follow up at subsequent visits.
Outcomes were patient reported: patient-provider discussion of alcohol during the visit; patient initiation of the discussion; and provider's recommendation about the patient's alcohol use.
Patients randomized to IVR-BI were more likely to have reported discussing alcohol with their provider (52 % vs. 44 %, p = 0.003), bringing up the topic themselves (20 % vs. 12 %, p < 0.001), and receiving a recommendation (20 % vs. 14 %, p < 0.001). Other predictors of outcome included baseline consumption, education, age, and alcohol use disorder diagnosis.
Providing automated brief interventions to patients prior to a primary care visit promotes discussion about unhealthy drinking and increases specific professional advice regarding changing drinking behavior.