Chronic care coordination by integrating care through a team-based, population-driven approach: a case study.

Here's a new article about one of the case studies that informed the IBHPC intervention. Congrats to Connie van Eeghen for this!

van Eeghen CO, Littenberg B, Kessler R. Chronic care coordination by integrating care through a team-based, population-driven approach: a case study. Translational Behavioral Medicine. 2018;8: 468-80. http://dx.doi.org/10.1093/tbm/ibx073
Patients with chronic conditions frequently experience behavioral comorbidities to which primary care cannot easily respond. This study observed a Vermont family medicine practice with integrated medical and behavioral health services that use a structured approach to implement a chronic care management system with Lean. The practice chose to pilot a population-based approach to improve outcomes for patients with poorly controlled Type 2 diabetes using a stepped-care model with an interprofessional team including a community health nurse. This case study observed the team’s use of Lean, with which it designed and piloted a clinical algorithm composed of patient self-assessment, endorsement of behavioral goals, shared documentation of goals and plans, and follow-up. The team redesigned workflows and measured reach (patients who engaged to the end of the pilot), outcomes (HbA1c results), and process (days between HbA1c tests). The researchers evaluated practice member self-reports about the use of Lean and facilitators and barriers to move from pilot to larger scale applications. Of 20 eligible patients recruited over 3 months, 10 agreed to participate and 9 engaged fully (45%); 106 patients were controls. Relative to controls, outcomes and process measures improved but lacked significance. Practice members identified barriers that prevented implementation of all changes needed but were in agreement that the pilot produced useful outcomes. A systematized, population-based, chronic care management service is feasible in a busy primary care practice. To test at scale, practice leadership will need to allocate staffing, invest in shared documentation, and standardize workflows to streamline office practice responsibilities.

- Ben Littenberg

How well integrated are the participating practices?

Now that we have enrolled the sites, it's time to think about how well they are integrated. One way to look at that is the Practice Integration Profile. The PIP is a 30-item self-report measure that can be completed by providers, managers and staff at a primary care practice. It yields a score from 0 to 100 to indicate how well Behavioral Health is integrated into the practice in each of six domains: Workflow, Clinical Services, Provider Integration, Case Identification, Patient Engagement, and Workspace. There is also an overall or Total PIP score that is the average of the six domain scores. You can read more about the PIP and even try it out yourself at the PIP homepage.

To be eligible for the IBH-PC study, a practice needed to have a Total PIP score of no more than 75. This was to avoid recruiting practices that are already so well integrated that the IBH-PC redesign intervention just doesn't make sense. Why spend a lot of time and effort to integrate when you are already well-integrated?

Of the 118 practices we considered for the study, 70 provided at least 4 PIP surveys by various clinic staff. The Total PIP scores averaged 50 and ranged from 10 to 78. The 43 randomized clinics averaged 49 and ranged from 10 to 73. (The four practices with scores above 75 were ineligible.)

Happily, the stratified randomization worked as planned: the Active and Control groups are very similar in terms of both mean (48 vs. 49) and median (50 vs. 52), with P>0.9 by both Student's t and Wilcoxon rank-sum tests.

N.B.: Some of these PIPs were collected many months before the study actually began at the sites, so all randomized sites submit another wave of PIPs to be used as the baseline in the study analysis.

-Ben Littenberg