Wisdom in Numbers: Using Stakeholder Feedback To Shape a Research Agenda for Integrating Mental Health and Primary Care

1. Wisdom in Numbers: Using Stakeholder Feedback To Shape a Research Agenda for Integrating Mental Health and Primary Care Charlotte Mullican Benjamin F. Miller C.J. Peek Rodger Kessler

2. First there was the AHRQ EPC Report Finding the gapssetting and agendachanging healthcare

3. The Collaborative Care Research Network (CCRN), a sub-network of the AAFP’s National Research Network (NRN), was created so that clinicians from across the country can ask questions and investigate how to make integrating mental health and primary care work more effectively.

4. The purpose of the Collaborative Care Research Network Research Conference was to respond to the questions raised by the Agency for Healthcare Research and Quality (AHRQ) Evidence Practice Committee (EPC) report: Integration of Mental Health/Substance Abuse and Primary Care. There were four specific aims for the conference: • to establish and prioritize a set of research questions to evaluate collaboration between behavioral health and primary care; • 2) to respond to the set of questions identified in the 2008 AHRQ systematic review and other publications concerning the effectiveness of collaborative care; • 3) to inform AHRQ about the identified research goals to assist the development of future contract task orders; • 4) to inform investigators outside of the existing PBRN community about areas to serve as the focus for investigator initiated research.

5. Wisdom of Crowds Using stakeholder opinion to set a prioritized research agenda

6. Language is important CJ Peek

7. “Is there a lexicon in the house?”Normal confusion in a new field Imagine being on a planning committee conference call………. • “Are you saying integrated care and collaborative care are the same thing?” • “Is integrated behavioral health the same as co-located mental health or primary behavioral healthcare?” • “What functions have to be on the collaborative care team if it is to be real collaborative care?” • “What has to be in place in practice to count as the genuine article—and what can be different from practice to practice?” Do you think your clarity (or lack of it) is shared by the person next to you?

8. We needed a common ‘lexicon’ for Collaborative Care Shared terms for the essence that unites the many local variations as the “genuine article” • But with a vocabulary for acceptable differences • Enough resolution of definitional confusion to allow consistently understood research / evaluation questions • Enough clarity of essence to point to business model • Developing a common language with which to represent this field to ourselves and others

9. Lesson from history: Emerging fields require conceptual systems adequate to the work Before 1881: 12 different units of electromotive force, 10 units of current, 15 units of resistance“The International Electrical Congress of 1881 has borne good fruit. . . a rapprochement between electricians of all countries. . . and the adoption of an international system of measurement which will be in universal use”. Nature 30, 26-27; 8 May 1884. After 1881: Volt, Ohm, and Ampere all defined as one conceptual system--as in a mature field

10. To ask research and practice development questions-- deal with both the empiricaland thepre-empirical

11. Pre-empirical

12. Requirements for “lexicon” development method: • Consensual but analytic (a disciplined process--not a political campaign) • Involving “native speakers” (implementers and users) • Focused on what functionalities look like in practice (not just principles, values, abstractions) • Amenable to gathering an expanding circle of “owners” and contributors (not just an elite group coming with a declaration)

13. Method: Paradigm Case Formulation & Parametric Analysis(Ossorio 2006; The Behavior of Persons) A. Describe an incontrovertible case of collaborative care practice (“if that’s not collaborative care, I don’t know what is!”) B. List how that indubitable case could be changed and still be collaborative care (“yes you can change X or delete Y and it’s still genuine collaborative care”) C. Name the dimensions or parameters along which collaborative care practices can legitimately differ from one another. (“our vocabulary for describing and evaluating acceptable variations among practice components”)

14. Paradigm case: Collaborative care is. . . 1. A team • physician, psychologist, care manager • Working in same space • Having formal or informal job training for their roles • Working in one practice culture, eager to address biopsychosocial • Transformations (acceptable differences) • T1. Change “family physician” to any other physician discipline • T2. Change “psychologist” to any other MH discipline • T3. Delete “care manager” • T4. Change “in one clinic” to multiple clinics and clinical partners • T5. Change “working in same space” to “set of working relationships…..” • T6. Change “single culture” to “commitment to building shared culture…” 2. With a shared population & mission E. Same panel of clinic pts, same mission of PC, assessment, tx, F/U F. With BH clinician working under same mission and boundaries of PC • Transformations (acceptable differences) • T7. Change “mission of PC” to any other area of medicine • T8. Change “identified w same panel of pts” to “any subset of pts. . . “

15. Paradigm case: Collaborative care is. . . 3. Using a clinical system G. Employing population level screening to identify who needs this collab H. Working form an explicit, unified care plan document w goals & roles I. With care plans that pay attention to family, culture, lang., school etc J. Contained in shared med record, with ongoing communic & SDM • Transformations • T9. Change “population level screening” to “other form of ident. syst” • T10. Change “unified care plan doc” to info in separate record wcomm” • T11. Delete “patient-clinician decision-making” (SDM) 4. Supported by an office practice & financial system K. Clinic ops systems & mgmt that supports communic, collab, care mgmt L. Sustainable package of financing e.g., single pool, bundled + FFS, PPF, etc • Transformations • T12. Delete “office processes clear, effective & efficient as can be found” • T13. Delete / add any mode of financ. support as long as supports collab • T14. Substitute “working toward sustainability” for “sustainable fin support”

16. Paradigm case: Collaborative care is. . . 5. And continuous QI and effectiveness measurement M. Routine collection of use of practice data for local decision-making to improve your performance and for research. • Transformation • T15. Substitute “commitment & proposal for practice data collection. . .”

17. Parameters of collaborative care practice (1) The team Blount; Doherty, McDaniel & Baird

18. Parameters of collaborative care practice (2) With a shared population and mission Stage of life Kessler & Miller; Peek & Baird Blount

19. Parameters of collaborative care practice (3) Using a clinical system Davis (2001)

20. Parameters of collaborative care practice (4) Supported by an office practice and financial system Reliability science & Lean concepts

21. Into the research Rodger Kessler

22. “You cannot solve problems by continuing to use the same solutions that created the problem in the first place.” -Albert Einstein

23. Conceptual Model of the CCRN Broad implementation of research findings into practice. Practice guidelines; public health and professional society recommendations. Specificity Generalizability The Domains of the CCRN Efficacy Comparative EffectivenessTranslationPolicy Disease specific interventions within an organized care framework (e.g., Katon & Unutzer, 2006; Unutzer et al., 2002). What are the critical elements required in general practice to accomplish the desired outcomes?

24. If we had a moratorium we could do things including but not limited to… • Real world EMR data on millions patients in real world settings under real world conditions • Study of contextual factors critical to translation • Natural experiments-eg: tobacco progress • Simulation models- including economic • Multiple baseline across settings; replication designs, regression discontinuity • The ultimate 'efficacy’ RCT- except with complex patients- N of 1 research • PRAGMATIC studies of stakeholders questions

25. We Need new RCT’s Relevant Contextual Timely Intervention studies

26. The Two Generations of Questions Descriptive (Generation A): • What is currently occuring in collaborative care? • What are the elements, frequencies and variations in practice models, target populations and other dimensions? • Evaluative (Generation B): • What collaborative care arrangements work best for whom? • What are the outcomes and the relationship of varaitions to outcomes?

27. Because what you told me is absolutely correct but completely useless Where am I? Yes, how did you know? You must be a researcher Because you don’t know where you are, you don’t know where you’re going, and now you’re blaming me The problem Yes. How did you know? You’re 30 yards above the ground in a balloon You must be a policy maker

28. Finale The End

29. References • Peek, C.J. (2009). Toward a conceptual system for the field of collaborative care: A starter lexicon for the Collaborative Care Research Network (conference white paper) • Ossorio P.G. (2006). Conceptual-Notational Devices. Chapter in The Behavior of Persons, The Collected Works of Peter. G. Ossorio, Vol V. Descriptive Psychology Press, Ann Arbor, MI • The 1881 Electrical Congress of Paris. Nature 30, 26-27; 8 May 1884.