Sunday, April 16, 2017

Inclusion Criteria

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.
Subjects will be identified by review of electronic records in patients in each practice. First, the records will be searched for community panel patients who meet the eligibility criteria by virtue of the data in their problem lists, medication lists and billing codes on at least two different dates in the previous year (Group B). A random subset of eligible Group B patients will be invited to participate in the study. Those consenting will comprise the Study Subjects Panel (Group C).

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!


Ben Littenberg

Monday, April 3, 2017

Behavioral health integration: Empowered MAs are at the forefront

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!

-Ben Littenberg

Thursday, March 30, 2017

Our DARTNet partners

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.

Friday, March 17, 2017

Understanding the Issues Regarding Misuse of the Term "Behavioral Health"

by Anne Donahue
IBH-PC Stakeholder Advisory Group

What is the accurate definition of “behavioral health”?

“The chronic diseases that drive the majority of mortality, morbidity and cost in America and around the globe are largely behavioral in origin or management. Tobacco, diet, physical inactivity, alcohol, substance abuse, non-adherence to treatment, insomnia, anxiety, depression, and stress are major causes of morbidity, mortality and expense, especially when chronic medical problems such as heart disease, lung disease, diabetes, or kidney disease are also present. Behavioral problems can often be effectively managed with improved outcomes for patients, their families and the health care system, but the current health care system is often unable to provide such care. Behavioral health includes mental health care, substance abuse care, health behavior change, and attention to family and other psychosocial factors.” (From the study protocol for Integrating Behavioral Health and Primary Care for Comorbid Behavioral and Medical Problems)
In other words, “behavioral health care” is about health behavior, whether in relation to medical or psychological issues that are barriers to health. Behavioral health care that addresses change in behavior includes examples such as motivation to quit smoking, to exercise, to follow a diet, or to follow physical therapy routines; learning new ways to respond to stress; or addressing how to cope with past trauma. 
  • Mental health and substance abuse conditions are often addressed through health behavior change, and thus many MH/SA conditions come within behavioral health care, just as many other health conditions do. 
  • On the other hand, many mental health and substance abuse conditions have significant medical components and some may be mostly medical in nature, just as many other health conditions are mostly medical in nature. 

Thus behavioral health is an umbrella that includes MH/SA, but is not only MH/SA. The opposite is also true: biological and genetic health factors are an umbrella that also include MH/SA. If we recognized all of health as a holistic spectrum, we would recognize that most illnesses have biopsychosocial components, and treatment needs to align with each of those aspects, in relationship to the role each is playing in the specific person’s condition. It’s not an all or none, in any category. 

What are the problems when the terms behavioral health is (mis)used as synonymous with or as an alternative term for MH/SA?  

  • Inaccuracy: The problem is not with recognizing the benefits of behavioral intervention for MH/SA; it is about failing to recognize the need for behavioral intervention for a person with heart disease. Likewise, both MH and heart disease may benefit from pharmacological or other medical interventions. In the one, if we focus only on treating the behavior we may miss an underlying illness; in the other, if we fail to address behavioral health, we might preclude medical recovery. It is a barrier to understanding the inter-relationship between behavior and all of health, and thus a barrier to fully integrated, holistic health care.
  • Stigma: It is stigmatizing and hurtful to people with MH/SA conditions because the message is that the cause of the condition is a behavior (e.g., you drink too much; you are lazy; you are weak; thus you are to blame) OR that it is being called “behavioral” because the symptoms take the form of behavior that you are failing to control (e.g., you act out; you are violent; in other words, you are the problem.) It exacerbates the false separation between “mental” and “physical” health by re-categorizing them into “behavioral-fault” and “medical-not-your-fault.” 

It is a product of the inherent marginalization of persons within a stigmatized minority that the plea to avoid this hurtful language is so broadly ignored. 

Why is addressing stigma so important? 

The consequence of this historic stigma and discrimination in public attitudes is loss of successful health intervention, because:
  1. It diminishes the perceived importance of access to MH/SA health care (parity)
  2. It remains the single largest barrier to people seeking and accepting care

As long as people believe that if they seek help or acknowledge having an emotional crisis, they will be labelled and stigmatized in this way, we will face deep challenges in supporting individuals with these health conditions.

Wednesday, March 15, 2017

New Report: Behavioral Health Integration in Pediatric Primary Care

Thanks to Stakeholder Advisory Group member Jim Hester for bringing this to our attention:

New Report  

Behavioral Health Integration in Pediatric Primary Care: 

Considerations and Opportunities for Policymakers, Planners, and Providers
Much of the research on behavioral health integration (BHI) has focused on adults. But children are affected by mental disorders too. Estimates consistently indicate that 13% to 20% of US children have been diagnosed with a mental disorder. Yet not a single state in the country has an adequate supply of child psychiatrists, and 43 states are considered to have a severe shortage.

Models exist, however, for treating many of these children effectively in primary care settings that offer integrated, family-centered care. In this Milbank-sponsored report, Elizabeth Tobin Tyler, JD, MA, of Brown University, and Rachel L. Hulkower, JD, MSPH, and Jennifer W. Kaminski, PhD, of the Centers for Disease Control and Prevention, explore the prevalence of childhood behavioral health problems; describe the need for, barriers to, and models of BHI in pediatrics; and offer BHI policy and implementation considerations for policymakers, planners, and providers.

The report aims to help policymakers and providers who are looking for research-supported models of care that will improve the health of children with mental disorders. 

Sunday, March 12, 2017

Does ACT mean we don't need IBH-PC?

A recent article by IBH-PC consultants Deborah CohenFrank DeGruy and others reports a study of integration with many of the same goals as ours. It is based on a sub-analysis of the ACT study from Colorado. The key findings were improvement in depression (measured by interviews and by PHQ-9 depression score). These results are more good news for the idea of Integrating Behavioral Health and Primary Care.

Does this study (and other results of ACT) mean that the IBH-PC study is not needed? No - important as ACT is, there are a lot of limitations and unanswered questions that we will address in IBH-PC.

This analysis did not have a control group. IBH-PC has randomized concurrent controls.

Because it studied only patients with high scores on the PHQ-9 at baseline, it is subject to regression to the mean. IBH-PC will not select for high scores at baseline.

It had 475 patients from five practices, all in one state. IBH-PC will enroll 3,000 patients from 40 practices all over the country.

It addressed only depression.  IBH-PC will study a broad range of overlapping medical and behavioral conditions.

All of these issues weaken the conclusions that can be drawn and limit the ability of policy- and decision-makers to get fully behind integration. So, we soldier on!


- Ben Littenberg

Outcomes of Integrated Behavioral Health with Primary Care
Bijal A. Balasubramanian, Deborah J. Cohen, Katelyn K. Jetelina, L. Miriam Dickinson, Melinda Davis, Rose Gunn, Kris Gowen, Frank V. deGruy III, Benjamin F. Miller, and Larry A. Green
J Am Board Fam Med March-April 2017; 30:130-139; doi:10.3122/jabfm.2017.02.160234

Background: Integrating behavioral health and primary care is beneficial to patients and health systems. However, for integration to be widely adopted, studies demonstrating its benefits in community practices are needed. The objective of this study was to evaluate effect of integrated care, adapted to local contexts, on depression severity and patients' experience of care.
Methods: This study used a convergent mixed-methods design, merging findings from a quasi-experimental study with patient interviews conducted as part of Advancing Care Together, a community demonstration project that created an innovation incubator for practices implementing evidence-based integration strategies. The study included 475 patients with a 9-item Patient Health Questionnaire (PHQ-9) score ≥10 at baseline, from 5 practices.
Results: Statistically significant reductions in mean PHQ-9 scores were observed in all practices, ranging from 2.72 to 6.46 points. Clinically, 50% of patients had a ≥5-point reduction in PHQ-9 score and 32% had a ≥50% reduction. This finding was corroborated by patient interviews that demonstrated positive experiences with behavioral health clinicians and acquiring new skills to cope with adverse situations at work and home.
Conclusions: Integrating behavioral health and primary care, when adapted to fit into community practices, reduced depression severity and enhanced patients' experience of care. Integration is a worthwhile investment; clinical leaders, policymakers, and payers should support integration in their communities.