Collaborative Care for Indigent Populations: Barriers, Solutions, Outcomes, & Lessons Learned

Collaborative Care for Indigent Populations: Barriers, Solutions, Outcomes, & Lessons Learned Laurie Alexander, Ph.D. Program Officer

Today’s presentation • Barriers & solutions • Data & lessons learned • Resources

The Hogg Foundation • Since 1940, the foundation has worked to promote improved mental health for all Texans through grants & programs • Part of The University of Texas at Austin, Division of Diversity & Community Engagement • $4.5 M in grants per year

Addressing barriers • Hogg Foundation’s IHC Initiative • GOAL: Identify solutions for barriers to implementing collaborative care in Texas

Grant program Grants began ending in April 2009 ■ Parkland ■ Project Vida ■ People’s ■ TCPA TCPA = TX Children’s Pediatric Assocs (Houston) SCF = Su Clinica Familiar (Harlingen) NCDV = Nuestra Clinica del Valle (San Juan) BCHC = Brownsville CHC ■ SCF ■ NCDV ■ BCHC

Grantees • Grantees = 7 PC organizations (4 FQHCs) • Behavioral health partnerships include: • Contracts for psychiatric consultation w/: • CMHCs (2), academic depts (3), and/or psychiatrists in private practice (2) • Contracts for psychotherapy with private nonprofits (2) • 1 site already had psychiatrists & psychotherapists on staff

Training and consultation • Training and consultation: Jürgen Unützer, Wayne Katon, et al. (University of Washington) • Loose implementation of IMPACT model • Distilling the core components

Collaborative care • Core components • Care manager • Clinical assessment tool • Psychiatric consultation • Patient registry

Care manager • Professional or paraprofessional • In person or by phone • Caseload = ~80 active patients (200-300 pts / yr) • Cover 6-7 FTE PCPs

Clinical assessment tool • Objective measure of treatment response • Administered at every care mgmt contact • Examples • PHQ-9, OASIS, & Vanderbilt

Psychiatric consultation Weekly meetings with care manager (1-2 hrs / wk per care manager) Flexible implementation By phone or in person

Patient registry • Track large patient panels • Different formats, different features

Sample screen: Patient tracking

Sample screen: A PCP’s patients

Evaluation • Evaluation team: • Richard Frank (Harvard) • Howard Goldman (Univ of MD) • Brenda Coleman-Beattie (Texas health care consultant) • Targets • Implementation factors • Outcomes • Costs

Evaluation plan • Formative quantitative and qualitative evaluation with mixed design • Qualitative • 2 site visits per grantee • Standardized protocol

Qualitative evaluation domains • Leadership and program level preparation • Clinical planning and the clinical management practices • Training for team members and new hires • Fidelity to the collaborative care model • Financing considerations • Technology services/information systems • Implementation considerations including barriers and facilitators

Evaluation plan - Quantitative • Web-based registry data • PHQ, OASIS (anxiety), CAGE-AID, prescribed treatment (psychotx and/or meds), service contacts, psych consultations • Gender, age, Spanish language preference, insurance status • ADHD registry being re-vamped • Data collected will include Vanderbilt and others • EMR data • Utilization and billing data (starting pre-grant)

Evaluation plan - Quantitative • Comparison data • Dallas site has control site • Screening with PHQ • With (+) screen, do initial assessment & 4-month follow-up • 3 Valley sites have comparison sites constructed from Texas Medicaid data • Drugs and claim data for Valley sites and similarly located comparison sites • All 7 sites’ outcomes are being compared against data from effectiveness trials

Patients served • 2,500 patients seen between 7/06 – 9/08 • Primarily adults • Delays in child sites – ADHD pilot • Primary dxs = depression, anxiety, & ADHD • Across all sites, largely uninsured & predominantly Latino • Medicaid & Medicare represent small % of patients served (TX Medicaid is small) R. Frank, 2008

Preliminary data - Demographics N cases (3 sites) 975 Average ages 39-47 years % Female 78%-84% Prefer Spanish 26%-58% Uninsured 81%-88% Baseline PHQ-9 16.0-16.7 Baseline OASIS 11.3-11.7 R. Frank, 2008

Preliminary data - Service contacts • Range in % of patients who had any follow-up contacts: 61% to 95% • Range in average # of follow-up contacts for patients with any follow-ups: 2.0 to 6.2 contacts • Most clinical trials show averages of 3-7 visits • % of contacts by phone:56% to 68% R. Frank, 2008

Preliminary data - Outcomes • PHQ - 50% improvement at 10 weeks • Outcomes range from: • 28% (~“usual care” in effectiveness trials) • 54% (~”active treatment” findings) • People with single diagnosis had larger improvements • People with Spanish language preference had smaller improvements • All sites improved over 18-month period R. Frank, 2008

Lessons learned • When core components are implemented, the program works • Co-location is not sufficient • Initial treatment is rarely sufficient Program appears to be low cost R. Frank, 2008

Success factors • Core components in place • Successful engagement of patients • Most patient contacts by phone • Close tracking of medications • Active adjustment of treatment J. Unutzer, 2008

Challenges • Organizational readiness & leadership • Engaging PCPs • BH providers’ transition to new roles • Workforce issues • Team-work orientation • Shortages • Lack of referral options • Sustainability issues

Policy work • Engaging state and local leaders • IHC Leadership Team • IHC policy workgroup • Engaging private sector • Supporting implementation • Statewide learning community

Policy work (cont.) • Framing the issues & serving as information resource • Connecting Body and Mind: A Resource Guide to Integrated Health Care in Texas & the U.S. (Sept. 2008) • Online at: www.hogg.utexas.edu

More information at:www.hogg.utexas.eduLaurie Alexander, Ph.D.Program Officerlaurie.alexander@austin.utexas.edu

Collaborative Care for Indigent Populations: Barriers, Solutions, Outcomes, & Lessons Learned