1. Roshan Bastani, PhD, Beth Glenn, PhD, Russ Glasgow, PhD CPCRN Spring Virtual Meeting April 15, 2013 My Own Health Report (MOHR) Project (Previously PRO Project) Goal: Integrate Patient Reported Behavioral Health Domains into Routine Primary Care Practice

2. Patient-Reported Behavioral Health Domains DomainFinal Measure (Source) 1.Demographics 9 items: Sex, date of birth, race, ethnicity, English fluency, occupation, household income, marital status, education, address, insurance status, veteran’s status. Multiple sources including: Census Bureau, IOM, and National Health Interview Survey (NHIS) 2. Overall Health Status1 item: BRFSS Questionnaire 3. Eating Patterns 3 items: Modified from Starting the Conversation (STC). (Adapted from Paxton, AE et al. Am J Prev Med, 2011; 40(1):67-71.) 4. Physical Activity2 items: The Exercise Vital Sign (Sallis, R. Br J Sports Med 2011; 45(6):473–474) 5. Stress1 item: Distress Thermometer (Roth AJ, et al. Cancer 1998; 15(82):1904-1908.) 6. Anxiety and Depression 4 items: Patient Health Questionnaire - Depression & Anxiety (PHQ-4) (Kroenke K, et al. Psychosomatics 2009; 50(6):613-621.) 7. Sleep 2 items: a. Adapted from BRFSS b. Neuro-QOL (Item PQSLP04) 8. Smoking/ Tobacco Use 2 items: Tobacco Use Screener (Adapted from YRBSS Questionnaire) 9. Risky Drinking1 item: Alcohol Use Screener (Smith PC, et al. J Gen Intern Med 2009; 24(7):783-788) 10. Substance Use1 item: NIDA Quick Screen (Smith PC, et al. Arch Intern Med 2010, 170(13): 1155- 1160.)

3. Background Round 1 of Funding to UCLA Step 1: Key Informant Interviews Solicited input from clinic leaders/staff regarding implementation of PRO measure within workflow Participants represented 4 FQHCs in CA and partner clinics in Virginia, Vermont, and Massachusetts Results suggested high interest among providers but concerns about duplication of data collection and added time and cost burden Step 2: Paper and Pencil Implementation of PRO Measure Participating clinics implemented measure with N = ≥ 50 patients plus post-implementation key informant interviews and brief patient survey Majority of patients “screened positive” for multiple domains Clinic follow-up of identified concerns varied widely Patients had few difficulties or complaints about measure itself

4. Round 2 of Funding: Nine Sites Funded (5 PBRN; 4 FQHC) Name change: My Own Health Report (MOHR) Pragmatic Trial –Cluster randomized trial of 9 pairs of clinics (5 PBRN; 4 FQHC) –Study was designed to maximize flexibility and adoption (e.g., clinics with different levels of HIT use, experience with QI) –Standard delivery of automated assessment tool, feedback, goal setting materials, and suggestions for follow-up –Delivery of these components is customized to each setting –Study goal: sustainable, routine implementation of MOHR assessment and intervention CA 1 PBRN 1 FQHC TX 2 FQHCs NC 1 FQHC VA 3 PBRNs VT 1 PBRN

5. Pragmatic Features Relevant Diverse, real-world primary care settings; and staff who do all the intervention Rigorous Cluster randomized, delayed intervention design Rapid One year from concept, planning, and Execution Low Cost and Cost informative Transparent Report on adaptations, failures, lessons learned

6. Design of Pragmatic Trial MOHR Assessment (all non-acute adult visits for 3-4 months, n = ~300) Months0 1 2 3 4 5 6 7 8 9 10 11 12 Early Implementation Sites (4 FQHC, 5 PBRN) Delayed Implementation Sites (4 FQHC, 5 PBRN) Intervention (Provider & Patient Feedback Reports + F. U) Intervention (Provider & Patient Feedback Reports + F. U) Patient Experiences Survey (n = 300) Optional: 2 nd MOHR Assessment (only for those who completed MOHR) Arrow = between group comparison Implementation of MOHR Tool Patient Experiences Survey (n = 300)

7. MOHR Online Assessment Tool: Developed by Alex Krist (VCU) (Transfer of “co-ordinating center” from UCLA to VCU) Features: Health Risk Assessment (13 domains) Solicitation of Patient Priorities –e.g., ready to change; want to discuss with doctor Patient Health Summary Report –e.g., things they are doing well; areas for improvement Online Access to Patient Summaries –Can look up specific patients Online Tracking of Implementation Progress across Sites –e.g., number of patients that were screened, % screened + for specific domains

8. Screenshots from MOHR Online Assessment Tool

9. Health Risk Assessment

10. Soliciting Patient Priorities

12. Patient Health Summary Report

13. Access to Patient Summaries

14. Online Tracking of Implementation Progress

15. Design of Pragmatic Trial MOHR Assessment (all non-acute adult visits for 3-4 months, n = ~300) Months0 1 2 3 4 5 6 7 8 9 10 11 12 Early Implementation Sites (4 FQHC, 5 PBRN) Delayed Implementation Sites (4 FQHC, 5 PBRN) Intervention (Provider & Patient Feedback Reports + F. U) Intervention (Provider & Patient Feedback Reports + F. U) Patient Experiences Survey (n = 300) Optional: 2 nd MOHR Assessment (only for those who completed MOHR) Arrow = between group comparison Implementation of MOHR Tool Patient Experiences Survey (n = 300)

16. Patient Experience Survey (PES) 20 item survey to be administered 2-8 weeks post-visit Eligibility for PES: all patients reporting for non-acute care visits during implementation period for both clinics within each pair (regardless of MOHR use) The PES assesses patient perceptions regarding: – Assessment of the specific health behavior and psychological domains related to recent clinic visit – Collaborative goal-setting within each domain – Clinic/provider follow-up for each domain – Quality of clinic/provider communication – Patient-centeredness of care provided by their clinic

17. Context & Cost Assessments Goals of Contextual Assessment To identify and describe contextual phenomena that may impact MOHR implementation To provide information on external validity and factors important for transferring MOHR to other settings Goals of Cost Assessment To assess clinic resources & time needed to implement MOHR To provide information to practices considering MOHR implementation as well as to funding agencies and payers

18. Study Outcomes Summary Between group comparison – Patient Experiences Survey Within group implementation outcomes: – REACH: % eligible patients completing the health assessment – Follow-up health assessment: only for patients who complete online and provide email address – Contextual assessment – Cost assessment