Stacy Ogbeide, PsyD, MS David Bauman, PsyD Bridget Beachy, PsyD Session #G5b Saturday, October 18, 2014 Repaving the Road: Addressing the Challenges of Conducting Outcome Research in Primary Care Stacy Ogbeide, PsyD, MS David Bauman, PsyD Bridget Beachy, PsyD Please insert the assigned session number (letter and number), i.e., A2a Please insert the assigned DAY and DATE of your presentation, i.e., Friday, October 17, 2014 Collaborative Family Healthcare Association 16th Annual Conference October 16-18, 2014 Washington, DC U.S.A. Collaborative Family Healthcare Association 12th Annual Conference

Faculty Disclosure We have not had any relevant financial relationships during the past 12 months. CFHA requires that your presentation be FREE FROM COMMERCIAL BIAS. Educational materials that are a part of a continuing education activity such as slides, abstracts and handouts CANNOT contain any advertising or product‐group message. The content or format of a continuing education activity or its related materials must promote improvements or quality in health care and not a specific propriety business interest of a commercial interest. Presentations must give a balanced view of therapeutic options. Use of generic names will contribute to this impartiality. If the educational material or content includes trade names, where available trade names for products of multiple commercial entities should be used, not just trade names from a single commercial entity. Faculty must be responsible for the scientific integrity of their presentations. Any information regarding commercial products/services must be based on scientific (evidence‐based) methods generally accepted by the medical community. Collaborative Family Healthcare Association 12th Annual Conference

Learning Objectives 1) At the end of the presentation, participants will understand the importance to conducting and disseminating research in primary care settings; 2) At the end of the presentation, participants will understand the challenges that occur with conducting research in primary care as well as ways to address the barriers associated with the research process; and 3) At the end of the presentation, participants will gain knowledge in the types of research designs that can be appropriate for primary care Include the behavioral learning objectives for this session Collaborative Family Healthcare Association 12th Annual Conference

References Davis, M., Balasubramanian, B. A., Waller, E., Miller, B. F., Green, L. A., & Coben, D. J. (2013). Integrating behavioral and physical health care in the real world: Early lessons from advancing care together. Journal of the American Board of Family Medicine, 26(5), 588-602. Goodie, J. L., Kanzler, K. E., Hunter, C. L., Glotfelter, M. A., & Bodart, J. J. (2013). Ethical and effectiveness considerations with primary care behavioral health research in the medical home. Families, Systems, & Health, 31(1), 86-95. doi: 10.1037/a0031852 Peek, C. J., Cohen, D. J., deGruy, F. V. (2014). Research and evaluation in the transformation of primary care. American Psychologist, 69(4), 430-442. doi: 10.1037/a0036223 Ray-Sannerud, B. N., Dolan, D. C., Morrow, C. E., Corso, K. E., Kanzler, K. E., Corso, M. L. ... Bryan, C. J., (2012). Longitudinal outcomes after brief behavioral health intervention in an integrated primary care clinic. Families, Systems, & Health, 30(1), 60-71. doi: 10.1037/a0027029 Sarris, J., Glick, R., Hoenders, R., Duffy, J., & Lake, J. (2013). Integrative mental healthcare White Paper: Establishing a new paradigm through research, education, and clinical guidelines. Advances in Integrative Medicine, 1-8. Collaborative Family Healthcare Association 12th Annual Conference

Learning Assessment A question and answer period will be conducted at the end of this presentation. Please incorporate audience interaction through a brief Question & Answer period during or at the conclusion of your presentation. This component MUST be done in lieu of a written pre- or post-test based on your learning objectives to satisfy accreditation requirements. Collaborative Family Healthcare Association 12th Annual Conference

Presentation Objectives Introduction Barriers and challenges Current strategies and recommendations Creating flexible research protocols Disseminating research Collaborative Family Healthcare Association 12th Annual Conference

Introduction Cartoon from www.stus.com Collaborative Family Healthcare Association 12th Annual Conference

Introduction Data on integrated primary care behavioral health (PCBH) models There is research! Clinical Indicators E.g., UDS High acuity patients One important aspect of BHC in PCBH model – impact on patient’s overall functioning Ray-Sannerud et al., 2012 Collaborative Family Healthcare Association 12th Annual Conference

Introduction Time! Who will help? Manpower? Buy-in? What research needs to be done? Goodie, Kanzler, Hunter, Glotfelter, & Bodart, 2013 Collaborative Family Healthcare Association 12th Annual Conference

Our experience in integrated research Outcome research Anxiety Weight management HTN Protocols for integrating BHCs Integration is intuitive. That alone does not equate with improved patient outcomes Unique Obstacles

Barriers and Challenges Confounds Use of medications concurrently with behavioral strategies Comorbid pathologies – mental and physical External vs internal validity Real world settings Recruitment Organizational buy-in Number of visits Protocol 1-3 visits, mode patient visit is 1 What about the participants coming to 1 visit? Short term vs long term outcomes How to randomize while still staying true to model? Rigidity vs flexibility If rigid, how it is feasible? If flexible, fidelity? Comorbid pathologies – mental and physical - we are working w/htn, but pt has depression, thus they do not “do” behavioral strategies. How do we know if behavioral strategies then work? Working on depression, but has medical conditions – back surgery, this is a huge confound External vs internal validity Generalizable in real world settings; Do these interventions have a direct impact on presenting concern? Messy Real world application Recruitment Organization buy-in Patient referrals Different PCPs referred, PCPs also referred difficult patients, relying on other team members for their end, if we assign participants who are interested – there is bias there too; Organic referral process – PCP determines whether they want a “warm hand off” – BHC is seeing both follow-ups; even if every pt was asked – what if comorbidities agreed, while those with simpler said “no” and were not included in study. Of course it is harder ot get movement on measures when there is co-morbidities. Davis et al., 2013

An impossible task? Biomedical approach vs contextual approach “Cause and effect” in physical world vs psychological “Broken, needs fixed” vs learning to be aware and accepting of pain that comes in life while engaging in value-congruent behavior Measures, how to quantify? Weight loss, less anxiety, more energy = success? AAQ? Robinson, Gould, & Strosahl, 2010; Sarris et al., 2013 Collaborative Family Healthcare Association 12th Annual Conference

“Trident” Approach to Integrated Research Clinical Interventions Training/Teaching Holistic Health Assisting PCPs “Trident” approach Assessing brief clinical interventions Training and teaching medical providers on mind-body connection (ACT philosophy, ACEs study, panic attacks, etc.) Assisting overworked PCPs to reduce burden

Recommended strategies Have EMRs? USE IT! Standardizing quality of life measure and tracking in EMR Ability to measure long-term impact Measures Brief Concern specific AND quality of life Process measures (may be most important) Need buy in from organization Takes a tribe to complete research in PC Clear workflow for PCPs, MAs, office administration, etc. As close to regular workflow as possible All three prongs of the Trident Collaborative Family Healthcare Association 12th Annual Conference

Flexible research protocols Uniqueness of operating in integrated context Focus on specific concern (e.g., HTN) with goal of improving overall functioning Psychoeducation important Components vs. standard procedures Adapting SMH evidence based protocols Flexible in approach while maintaining philosophy Need for process measures Transdiagnostic MI, ACT, 5 A’s If we cannot apply the protocol to other concerns, what is the point? 15 – 30 minute visits Keep track of time spent, GREAT DATA Change the way we evaluate success Collaborative Family Healthcare Association 12th Annual Conference

Disseminating Your Work Sustainability! Organizations outside of psychology American Academy of Family Physicians Society of Teachers of Family Medicine State/County Organizations Practice-Based Research Network (PBRN) Collaborative Care Research Network (CCRN) Regional Networks as well Peek, Cohen, & deGruy, 2014 Collaborative Family Healthcare Association 12th Annual Conference

Disseminating Your Work http://pbrn.ahrq.gov/funding-opportunities/ahrq-pbrn-centers-primary-care-practice-based-research-and-learning Collaborative Family Healthcare Association 12th Annual Conference

Questions? Contact: Stacy Ogbeide: stacy.ogbeide@gmail.com David Bauman: davidbauman4@gmail.com Bridget Beachy: bridget.beachy@gmail.com Collaborative Family Healthcare Association 12th Annual Conference

Thank you! Session Evaluation Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you! This should be the last slide of your presentation Collaborative Family Healthcare Association 12th Annual Conference