Implementing a Primary Care Behavioral Health Model of Care: How Do You Evaluate It?

1. Session #G2a October _17_, 2014 Implementing a Primary Care Behavioral Health Model of Care: How Do You Evaluate It? Collaborative Family Healthcare Association 16th Annual Conference October 16-18, 2014 Washington, DC U.S.A.

2. Presenters • Jennifer S. Funderburk, Ph.D.; VA Center for Integrated Healthcare, Syracuse VA Medical Center; Jennifer.Funderburk@va.gov • Robyn L. Shepardson, Ph.D. VA Center for Integrated Healthcare, Syracuse VA Medical Center; Robyn.Fielder@va.gov • Gregory P. Beehler, Ph.D. M.A. VA Center for Integrated Healthcare, Buffalo VA Medical Center; Gregory.Beehler@va.gov • Zephon Lister, Ph.D., LMFT Department of Family & Preventive Medicine University of San Diego; zlister@ucsd.edu • Gene A. Kallenberg, MD UCSD Division of Family Medicine; gkallenberg@ucsd.edu • William J. Sieber, Ph.D. UCSD Division of Family Medicine; bsieber@mail.ucsd.edu • Melissa Baker, PhD; HealthPoint Bothell; mbaker@healthpointchc.org • Tawnya Meadows,Geisinger Health System; tjmeadows@geisinger.edu

3. Faculty Disclosure We have not had any relevant financial relationships during the past 12 months. The views expressed in this presentation are those of the authors and do not reflect the official policy of the Department of Veterans Affairs, Department of Defense, or other departments of the U.S. government.

4. Learning Objectives • Summarize the definition of program evaluation • Describe one theoretical framework that can help guide program evaluation • Describe the various components of conducting a program evaluation of a PCBH model of care • Discuss the barriers that may prevent effective program evaluation

5. What is Program Evaluation? Program evaluation is a set of methods or skills used to determine if a service is meeting needs, achieving program goals, and determining if program services are being offered as planned (Posavac and Carey, 2007).

6. What Are The Goals of Program Evaluation?

7. What is a Program? A program is any organized activity used to achieve a goal.

8. It might surprise you, but you do program evaluation every day

9. Where do you start? • Best to start at the beginning when planning or designing something to implement • Determine what is the “program”? • PCBH model • Element of the PCBH model • Identify your “program’s” goals • Identify your audience

10. Use RE-AIM Framework

11. Once you have the information to answer the questions using the RE-AIM model, many times that leads to Quality Improvement efforts success

12. Example

13. VA Behavioral Telehealth Center • Program: Depression Medication Monitoring for Veterans on a new Antidepressant Medication • Basics of the Program: • EMR Case finding for new Antidepressant Medications • Health Techs called to assess symptoms and medication adherence and side effects at 2, 6, 9, 12 weeks

14. RE-AIM • Reach: How many Veterans were identified by the case finding process? How many rural? Demographic composition? • Effectiveness: What percentage reported decreases in depression symptoms at 12-week follow-up? • Adoption: What % of Veterans were identified from each clinic? • Implementation: What is the average number of contacts per patient who is enrolled? • Maintenance: What % of patients who complete sustain treatment gains?

15. Example

16. Implementing a Primary Care Behavioral Health Model of Care: How Do You Evaluate It? Zephon Lister, PhD, LMFT; Gene A. Kallenberg, MD; William J. Sieber, PhD

17. The Problem: Depression in Primary Care • Prevalence • MDD Lifetime prevalence: 13.2 %; 12-month: 5-7% • Dysthymia: 2-4% in primary care • 3rd leading cause of loss of QALYs in older adults • Screening efficacy • Healthy People 2010 reported a baseline rate of 62 percent of adults being screened for ‘mental health’ in 2000, with the goal of achieving a 68 percent screening rate by 2010; VA reported 85% of eligible patients were screened annually • Up to 40 percent of cases of depression may be missed by PCP’s if provided no assistance in screening • USPSTF estimate 12-50 % of screen positives would meet MDD criteria: majority screen positives not meet MDD yet could benefit from intervention • USPSTF/AHRQ? Did not find any studies that included adverse events of screening.

18. Goals of Universal Depression Program Within RE-AIM Framework • Reach: One-on-one provider follow-up • Effectiveness: Track rates of screening effectiveness across providers and clinics • Adoption: Implement Screening Program as part of the PCMH Implementation: Use of EHR with PDSA process • Maintenance: Solidify as part of PCMH continue to use measures used for process improvement

19. Reach and Adoption

20. Tracking Depression Screening for Effectiveness

21. Tracking and Follow-Up for Implementation

22. Example

23. Geisinger Health System PCBH Model • Three pediatric pilot sites • Behavioral health schedules • 6 billable units a day • Family, individual, group • Gaps in schedule for integrated activities (warm handoffs, consults, crisis, joint appts) • Always available

24. Program Evaluation & Outcomes IPC Key Components

25. Program Evaluation & Outcomes IPC Key Components

26. Program Evaluation & Outcomes IPC Key Components

27. Program Evaluation & Outcomes IPC Key Components

28. Program Evaluation & Outcomes IPC Key Components

29. Program Evaluation & Outcomes IPC Key Components

30. Example

31. HealthPointBothell • Network of FQHCs in greater Seattle area • BHC program since 2000 • Integrated vs co-located • Reach population • 6 Core Competencies

32. Program Evaluation • Monthly Meetings- BHC Metrics • Patients per hour -Warm handoffs • No Shows -New patients • Reassessments vs F/u -Visit Type

33. Provider Study Part 1 • Provider Survey (Part 1) • AAQ-II • PCP-SC • O’Donahue BH Satisfaction Survey *8 minute survey *57 providers 100% of providers satisfied with and recommended BHC services ; 100% of providers felt having BHC program made their job easier

34. Conclusion

35. References • Glasgow, R. E., Vogt, T. M., & Boles, S. M. (1999). Evaluating the public health impact of health promotion interventions: The RE-AIM framework. American Journal of Public Health, 89, 1322-1327. • Kahwati, Lance, Jones, & Kinsinger (2011). RE-AIM evaluation of the Veterans Health Administration’s MOVE! weight management program. Translational Behavioral Medicine, 1, 551-560. • Fitpatrick, J. L., Sanders, J. R., & Worthen, B. R. (2010). Program evaluation: Alternative approaches and practical guidelines (4th ed.). Pearson. • Mertens, D. M., & Wilson, A. T. (2012). Program evaluation theory and practice: A comprehensive guide. New York: Guilford Press. • Wholey, J. S., Hatry, H. P., & Newcomer, K. E. (2010). Handbook of practical program evaluation (3rd ed.). San Francisco, CA: Jossey Bass.

36. References • Kessler, R. C., Chiu, W. T., Demler, O., Walters, E. E. (2005). Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archies of General Psychiatry, 62(6), 617-627. • Kessler RC, Berglund P, Demler O et al. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA. 2003;289:3095-3105. • Harman JS, Veazie PJ, Lyness JM. Primary care physician office visits for depression by older Americans. J Gen Intern Med. 2006;21:926-930 • Simon GE, VonKorff M. Recognition, management, and outcomes of depression in primary care. Arch Fam Med. 1995;4:99-105. • Luber, M., Meyers, B. S., Williams-Russo, P. G., Hollenberg, J. P., DiDomenico, T. N., Charlson, M. E., & Alexopoulos, G. S. (2001). Depression and service utilization in elderly primary care patients. The American Journal Of Geriatric Psychiatry, 9(2), 169-176. • US Preventive Services Task Force. (2002). Screening for depression: recommendations and rationale. Annals of Internal Medicine, 136, 760-764. • Pignone MP, Gaynes BN, Rushton JL et al. Screening for depression in adults: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2002;136:765-776. • Wetherall et al, (2004)

37. References • Agency for Healthcare Research and Quality (2009). Screening for Depression in Adults and Older Adults in Primary Care: An Updated Systematic Review. AHRQ Publication No. 10-05143-EF-1 • Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62:617-627. • Hasin D, Goodwin RD, Stinson F, Grant B. Epidemiology of Major Depressive Disorder: Results From the National Epidemiologic Survey on Alcoholism and Related Conditions. Arch Gen Psychiatry. 2005;62:1097-1106. • Depression Guideline Panel. Depression in primary care: Detection and Diagnosis. Clinical Practice Guideline: Number 5. AHCPR Publication No. 93-0550 ed. United States Department of Health and Human Services; Public Health Service; Agency for Health Care Policy and Research; 1993. • Unutzer J, Patrick DL, Diehr P, Simon G, Grembowski D, Katon W. Quality adjusted life years in older adults with depressive symptoms and chronic medical disorders. IntPsychogeriatr. 2000;12:15-33. • Narrow WE, Rae DS, Robins LN, Regier DA. Revised prevalence estimates of mental disorders in the United States: using a clinical significance criterion to reconcile 2 surveys' estimates. Arch Gen Psychiatry. 2002;59:115-123.

38. Learning Assessment • When thinking about your PCBH program, what types of program evaluation are you already doing? • Where is there information already being collected that you could use for program evaluation? • Did any of the RE-AIM elements stand out to you as elements you would like to examine within your current program? • Other Questions?

39. Session Evaluation Please complete and return theevaluation form to the classroom monitor before leaving this session. Thank you!