Jim Fauth & George Tremblay Clinical Psychology Department

1. 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

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

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

4. PBPR Strategy

5. PBPR Learning Cycle 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

6. 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)

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

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

9. 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

11. 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 • BHMEDS Combined into BH ANY in some analyses

15. Clinic 1: 30-day Allocation by Index Severity Mild Distress Mod Distress Severe Distress No Distress

16. Clinic 2: 30-day Allocation by Index Severity

17. ICE Outcomes Informal “Test” of PBPR Planning and Pilot only No formal QI phase, ITS design • 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

18. 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

19. Input, feedback, requests for more information? Jim Fauth, Ph.D. Director, Center for Research on Psychological Practice Antioch University New England 603.283.2193 jfauth@antioch.edu Thank You!