Overview of Phase I Data: Approach and Findings Gary Bess Associates April 15, 2009

Background Demonstration Sites Evaluation & Assessment

Launched in March 2006 with support from...

Background Extensive assessment process  Reviewed literature  Identified evaluative elements  Treatment approaches Meetings with key stakeholders  Primary Care Providers  Behavioral Health Professionals

Background Goals Increase patient access Reduce stigma Improve outcomes

Demonstration Sites Golden Valley Health Center, Merced Family Healthcare Network, Visalia Mendocino Community Health Clinic, Ukiah Family Health Centers of San Diego Sierra Family Medical Clinic, Nevada City SACHS-Norton Clinic, San Bernardino Open Door Community Health Centers, Arcata Primary Care Clinics

Selection Criteria Experience providing integrated services Currently operating integrated program with specific components Ability to implement quantifiable model Demonstration Sites

Data Collection Measurement Rationale IBHP Elements Local Elements Frequency Source

The DUKE Health Profile

The Duke Health Profile (DUKE) is a 17-item generic self-report instrument containing six health measures (physical, mental, social, general, perceived health, and self-esteem), and four dysfunction measures (anxiety, depression, pain, and disability).

ScalesMeasurement and Sample Items Physical Health Physical capacity for ambulation (walking and running) and physical symptoms (sleeping, fatigue, and pain). Mental Health Psychological symptoms (depressed feelings, nervousness), cognition (concentrating), and personal self- esteem (I like who I am, I give up too easily). Social Health Participation in social activities (socializing with friends or relatives, participation in group activities and social self-esteem (getting along with others, family relationships). General Health Combination of physical, mental, and social health. Perceived Health Self-assessment of overall health (I am basically a healthy person). Self-Esteem Personal self-esteem (I like who I am) and social self-esteem (getting along with others, comfortable levels around other people, family relationships). Anxiety Anxiety with social self-esteem (getting along with others, comfortable levels around other people, family relationships) and psychological symptoms (nervousness). Depression Depression with personal self-esteem (I like who I am, I give up too easily), psychological symptoms (nervousness), and cognition (concentrating). Anxiety/ Depression Psychological symptoms (nervousness), personal self-esteem (I like who I am), and somatic symptoms (sleeping and fatigue). PainHurting or aching in any part of the body. Disability Confinement to home, nursing home, or hospital because of sickness, injury, or other health problems in the preceding week.

Overview of DUKE Analysis Comparing the DUKE scores at baseline (first administration of the DUKE after commencement of grant) and most recent follow-up (most recent administration of the DUKE near the end of the grant period). The mean number of days between baseline administration and most recent administration of the DUKE was days (4.5 months), with the minimum, three (3) days, and the maximum, 284 days. Ns range between 250 and 290 based on item analyzed.

Summation of Findings Mean health scores increased (the desired clinical outcome) in each of the six health measures from baseline to most recent follow-up, changes were statistically significant for the measures of physical health, mental health, and general health. Though attaining improvement, each of the health scores at the time of the most recent assessment, however, were lower than the normative sample for the Duke.

Summation of Findings Subgroups showing the greatest increase in health scores (those subgroups with sizeable or statistically significant increases in the majority of health scores from baseline to most recent follow-up) included female patients, patients 50 to 59 years old, White patients, patients whose entry in to a behavioral health program was after the start of the study, patients with more than10 visits during the study period, and patients with at least one missed visit.

Physical Health Scores Old/New Patients p <.05 Race/Ethnicity Diabetes All p <.05 Number of Visits p < Average Below Above

Summation of Findings Mean dysfunction scores decreased (the desired clinical outcome) in each of the four health measures from baseline to most recent follow-up, and were statistically significant for the measures of anxiety and depression. Like health scores, each of the dysfunction scores at the time of the most recent health scores, however, were greater than the normative sample at statistically significant levels.

Summation of Findings Subgroups showing the greatest decrease in dysfunction scores (those subgroups with sizeable or statistically significant increases in the majority of dysfunction scores from baseline to most recent follow-up) included female patients, patients less than 40 years old, non-White patients, patients whose entry into a behavioral health program was after the start of the study, patients with more than10 visits during the study period, and patients with at least one missed visit.

Anxiety Scores All 25.4 Average Below Above p <.005 Gender p <.005 Race/EthnicityNumber of Visits p <.005

PHQ-9

The PHQ-9 is the nine item depression scale of the Patient Health Questionnaire. The PHQ-9 is a tool for assisting for diagnosing depression, as well as selecting and monitoring treatment. The PHQ-9 is based directly on the diagnostic criteria for major depressive disorder in the Diagnostic and Statistical Manual Fourth Edition (DSM-IV).

Interpretation of Scores on PHQ-9 ScoreAction ≤ 4 Suggests the patient may not need depression treatment. 5 to 14 Use clinical judgment about patient; based on patient’s duration of symptoms and functional impairment. ≥15Warrants treatment for depression.

Overview of PHQ-9 Analysis Comparing PHQ-9 scores at baseline (first administration of the PHQ-9 after commencement of grant) and most recent follow-up (most recent administration of the PHQ-9 near the end of the grant period). The mean number of days between baseline administration and most recent administration of the PHQ-9 was days, with the minimum, one (1) day, and the maximum, 284 days. N=422

Summation of Findings The mean PHQ-9 depression score for patients decreased from baseline to most recent follow-up assessment at statistically significant levels. At baseline, approximately one-third of patients had a PHQ-9 depression score that warranted treatment for depression (≥15). At the time of the most recent follow-up assessment, less than one-quarter of patients had a score that warranted treatment.

Baseline and Most Recent Follow-up (N=422)

Baseline and Most Recent Follow-up – Change (N=422)

Summation of Findings Statistically significant decreases in the PHQ-9 depression score from baseline to most recent follow-up assessment occurred for male and female patients; patients 50 years old or greater; white and non-white patients; patients whose entry into a behavioral health program was prior to study and patients whose entry into a behavioral health program was after study commencement; patients with diabetes; patients with more than one visit during the study period; patients without a missed visit during the study period; and patients with at least one missed visit during the study period.

Change in PHQ-9 Scores p <.005 Gender p <.001 Race/EthnicityAge p <.005 p <.001 p <.05

Patient Satisfaction

Patients were asked to respond to a nine (9) item general satisfaction survey assessing their satisfaction with services and the model and comfort levels with treatment and treatment setting utilizing the following scale: 1 = Strongly Disagree; 2 = Disagree; 3 = Neither Disagree Nor Agree; 4 = Agree; and 5 = Strongly Agree.

Overview of Patient Satisfaction Analyses Mean satisfaction scores generated by patients with at least two completed Patient Satisfaction Surveys, i.e., at baseline (first administration of the Patient Satisfaction Survey after commencement of grant) and most recent follow-up (most recent administration of the Patient Satisfaction Survey near the end of the grant period). Ns were at least 250 for each inquiry.

Summation of Findings Aggregate mean scores and subgroup mean scores (e.g., mean scores by gender, age, or ethnicity) for the majority of the items were above 4.50 on the five-level scale, suggesting high levels of satisfaction with services, model, treatment, and treatment setting…

Summation of Findings …However, there was an exception concerning the item, “I would follow through if I were referred outside this clinic for mental health services.” An association was found between length of engagement in counseling and the likelihood that patients would be more likely to follow through with an outside referral for mental health services.

Change in Mean Scores From Baseline to Most Recent Follow-up “I would follow through if I were referred outside this clinic for mental health services” n=64 Number of Visits n=89 n=79 p <.005 p <.001 Somewhat Agree Agree Agree Nearing Agree Undecided Undecided

Summation of Findings There were statistically significant variances in mean scores between some subgroups; however, mean scores for all subgroups suggest high levels of satisfaction.

Concerns Regarding Mental Health Treatment Plan Were Quickly Addressed *Average of mean scores from baseline administration of the Patient Satisfaction Survey to most recent follow-up administration. N=262 Race/EthnicityAge Gender n=90 n=55 n=54 n=92 n=61 n=197 n=43 n=166 p <.05