USING PRACTICE-BASED EVIDENCE TO ASSESS AND IMPROVE INTEGRATED CARE: THE INTEGRATED CARE EVALUATION PROJECT Jim Fauth & George Tremblay Clinical Psychology Department Center for Research on Psychological Practice

Traditional practice change strategies don’t work 2 Science Dissemination, Diffusion of RCTs Guidelines, Demonstration Projects Practice “We know best, do as we say”

A Way Forward: Practice Based Participatory Research (PBPR) 3 Science Translation, Facilitation, Formative Evaluation, Implementation Practice-Based Participatory Research Practice What do you need, and how can we help?

PBPR Strategy 4 EXTERNAL FACILITATION Problem solving and support Dialectic negotiation of needs Translation of evidence base FEEDBACK OF FORMATIVE EVIDENCE Continuous feedback loops Utilization of high leverage formative evidence IMPLEMENTATION TEAMS Internal change agents Key Practice stakeholders, Clinical Champion, Key decision makers

PBPR Learning Cycle 5 PLANNING PHASE Goal 1: Create Learning Context Identify practice contexts Engage practices/stakeholders Goal 2: Identify Information Gaps Perform diagnostic analysis Identify high leverage information gaps Goal 3: Develop pilot evaluation plan Develop evaluation options, scenarios Iteratively negotiate final evaluation plan PILOT PHASE Goal 4: Assess feasibility Implement pilot Track pilot fidelity, feasibility Analyze pilot findings Goal 5: Improve discovery plan Facilitate utilization of pilot finding Finalize discovery plan QUALITY IMPROVEMENT PHASE Goal 8: Address QI opportunities Implement QI plan Track fidelity & feasibility Goal 9: Evaluate QI intervention Complete process evaluation Complete summative evaluation Complete interpretive evaluation DISCOVERY PHASE Goal 6: Address Information Gaps Implement discovery plan Track discovery plan fidelity Analyze discovery plan results Goal 7: Identify QI opportunities Facilitate utilization of discovery findings Identify, prioritize, and adapt QI targets Identify, prioritize, adapt QI strategies Finalize QI implementation plan

Integrated Care Evaluation Project (ICE) What the RCTs tell us Scientific Gap: “Real world” Practice Context Four NH IC pioneers Moderate to high need Low to low moderate capacity Financial Resources: Private - NH Endowment for Health ($250K ~ 3 years) 6

Diagnostic Analysis 7 Evidence-based Models Target specific patients Systematic, formulaic Formal treatment models; Implemented by BH specialists; Supervised by tx developer Formally track outcomes; Adjust using algorithms Practice-based Models “Target” all patients Flexible, clinical judgment Flexible consultation & treatment models; Implemented by BH specialists Variably track outcomes; Adjust using judgment Patient presents to primary care BH assessment & allocation to care PCP BH PCP MED PCP BH-C BH MED SMH C Track Response & Adjust Treatment Integrated Care Task Model

ICE Pilot Evaluation Design 8 Key. IC=Integrated Care; ED=Emotional Distress; PCP=Primary Care Provider only; MED= psychotropic medication; BH ANY=ANY Behavioral Health Specialist Intervention.

Feasibility: Framing & Measures Primary purpose of pilot = feasibility Can we implement the evaluation plan? Metric = “capture rates” # target patients during study period # approached to consent # consented # filled out 1+ EDMs 9

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Allocation Data Does allocation vary as a function of patients’ emotional distress? (Compare with EBP benchmarks) Measures Emotional Distress Measure (EDM) Severity (items 1-15: PHQ-8+GAD-7) Functional Impairment (item 16) Chronicity (item 17) Care Type Variables PCP ONLY PCP Meds BH ONLY BH MEDS 11 Combined into BH ANY in some analyses

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Clinic 1: 30-day Allocation by Index Severity 15 No Distress Mild DistressMod DistressSevere Distress

Clinic 2: 30-day Allocation by Index Severity 16

ICE Outcomes 17 Findings Diffusion accompanied by dilution Variability within constraints Elephants outside the room Utilization Clinic 1: Immediate action Clinic 2: blocked by MD Clinic 3: QI team Clinic 4: Nothing Informal “Test” of PBPR Planning and Pilot only No formal QI phase, ITS design

ICE Implications from Your Perspective? Allocation (and outcomes) in your practices What do you know? How can you find out? What do to improve? Strategies for working with more chronically and severely distressed in primary care Real-time monitoring of treatment response Enhanced referral to specialty mental health Supportive treatment Groups Peer support Self-management Research we need 18

Input, feedback, requests for more information? 19 Jim Fauth, Ph.D. Director, Center for Research on Psychological Practice Antioch University New England Thank You!