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Session # B5b October 29, 2011 1:30 PM. Strategies for Obtaining Stakeholder Feedback on Integrated Care. David Johnson, MSW, ACSW Lori Lackman-Zeman, PhD. Collaborative Family Healthcare Association 13 th Annual Conference October 27-29, 2011 Philadelphia, Pennsylvania U.S.A.

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strategies for obtaining stakeholder feedback on integrated care

Session # B5b

October 29, 20111:30 PM

Strategies for Obtaining Stakeholder Feedback on Integrated Care

David Johnson, MSW, ACSW

Lori Lackman-Zeman, PhD

Collaborative Family Healthcare Association 13th Annual Conference

October 27-29, 2011 Philadelphia, Pennsylvania U.S.A.

faculty disclosure
Faculty Disclosure

We have not had any relevant financial relationships during the past 12 months.

CFHA 13th Annual Conference, October 29, 2011

need practice gap supporting resources
Need/Practice Gap & Supporting Resources
  • The ultimate success of integrated care programs is dependent upon the people involved. Yet few tools have been developed and presented that facilitate the capture of data from major stakeholders:
    • Behavioral health staff
    • Medical staff—physicians, nurses
    • Consumers (patients)
  • Establishing mechanisms/tools to obtain these data facilitate program evaluation as well as inform ongoing program design.

CFHA 13th Annual Conference, October 29, 2011

objectives
Objectives
  • Identify the importance of obtaining input and feedback from major stakeholders in the development and continuous quality improvement of integrated care.
  • Describe variables included in surveys of staff and consumers relevant to integrated care.
  • Provide example tools for three major stakeholder groups.
  • Define the role of consumer advisory boards.

CFHA 13th Annual Conference, October 29, 2011

expected outcome
Expected Outcome
  • Participants are able to identify methods and strategies to solicit data from stakeholders related to integrated care.
  • Participants are able to identify relevant factors/variables to evaluate when seeking information from stakeholders.

CFHA 13th Annual Conference, October 29, 2011

learning assessment
Learning Assessment

We encourage you participation and interaction during our presentation to facilitate a better understanding of our presentation materials.

CFHA 13th Annual Conference, October 29, 2011

clinic settings
Clinic Settings
  • Wayne State University Physician Group operates a number of specialty and general medicine clinics.
  • Over the past five years, the Department of Psychiatry has implemented integrated care programs in conjunction with Internal Medicine’s HIV Clinic; two “safety net” General Medicine Clinics, and an OB/GYN clinic
  • These Clinics are all centrally located in Detroit

CFHA 13th Annual Conference, October 29, 2011

population served
Population Served
  • Black/African Americans, ~80%;
  • Low income, 82% earn less than $20,000 per year;
  • Most individuals are uninsured or underinsured
  • Detroit is a City that has been in decline over the past ten years losing over 25% of its population from 2000 to 2010. This is attendant with numerous psychosocial stressors and problems—housing, transportation.

CFHA 13th Annual Conference, October 29, 2011

program design
Program Design
  • Each site has is its own unique features and operational structures, but they a number of program components in common:
    • Co-location of behavioral health professionals in the health clinic
    • Collaboration between behavioral and physical health staff
    • Screening for behavioral health conditions (instruments and process vary by clinic)
    • Interventions focus on promoting overall health while addressing psychosocial stressors
    • Follow-up and case management

CFHA 13th Annual Conference, October 29, 2011

stakeholders a blending of cultures
Stakeholders, a blending of cultures
  • Physicians, nurses and physical medicine staff
  • Behavioral health professionals, psychiatrists, psychologists, social workers, peer advocates
  • Consumers/patients

CFHA 13th Annual Conference, October 29, 2011

knowledge and skills domains
Knowledge and Skills Domains
  • Physicians and physical health professionals
    • Conditions and diseases that impact health from acute episodic illness to chronic disease such as diabetes, cancer, HIV
    • Prevention, immunizations, blood pressure checks, cancer screening
  • Behavioral health
    • Psychosocial stressors and psychiatric conditions related to mood, anxiety, thought disorders, and behavioral interactions and interpersonal relations
  • Consumers
    • Values, beliefs, attitudes, preferences regarding health and well-being

CFHA 13th Annual Conference, October 29, 2011

strategies to obtain stakeholder feedback
Strategies to Obtain Stakeholder Feedback
  • Physician and Nurse Surveys
  • Behavioral Health Surveys
  • Consumer/Patient Surveys
    • Satisfaction Survey
    • Service preference/needs and Stigma
    • Social Media
    • Consumer Advisory Board

CFHA 13th Annual Conference, October 29, 2011

physicians and medical staff
Physicians and Medical Staff
  • What is the perceived need for integrated care?
  • What is the perceived degree of expertise to address behavioral health issues?
  • What are values and attitudes regarding integrated care?
  • What are the perceived barriers—system and patient—to integrated care?

CFHA 13th Annual Conference, October 29, 2011

physicians and nursing staff
Physicians and Nursing Staff
  • Experience and expectations in managing patients with psychiatric conditions
  • Knowledge—theoretical and experiential learning
  • Skills—applying knowledge to address psychiatric conditions
  • Comfort—level of ease to assess and intervene with patients experiencing a psychiatric condition

CFHA 13th Annual Conference, October 29, 2011

physician and nurse survey
Physician and Nurse Survey
  • 35-item, self-administered questionnaire
  • Completed by 85 physicians, residents, and nurse practitioners in a general medicine clinic
  • 43 individuals completed a baseline and a follow-up questionnaire after working in the clinic for at least 6 months
  • Items grouped into 5 factors:
    • Expertise Value/Attitude
    • System/Patient Barriers Need
    • Confidence in BH Services

CFHA 13th Annual Conference, October 29, 2011

barriers
Barriers
  • It takes too long to obtain an appointment for
    • Psychiatric Services
    • Substance Abuse Services
  • Too many logistics to make a referral for
    • Psychiatric Services
    • Substance Abuse Services
  • Too little time to make a referral for:
    • Psychiatric Services
    • Substance Abuse Services
  • I have little confidence in the value of
    • Psychiatric Services
    • Substance Abuse Services

CFHA 13th Annual Conference, October 29, 2011

expertise
Expertise
  • I have knowledge to address a patients co-occurring psychiatric condition such as:
    • Depression, anxiety, or relationship issues
    • Bipolar disorders, psychosis, or personality disorders
    • Alcohol or substance use disorders
  • I am skilled….
  • I am comfortable…

CFHA 13th Annual Conference, October 29, 2011

value attitude regarding integrated care
Value/Attitude Regarding Integrated Care
  • It is important in the evaluation and treatment of health conditions to address any co-occurring
    • Psychiatric Conditions
    • Substance Use Disorders
  • I actively seek out mental health specialists in addressing patient’s psychiatric needs
  • I actively coordinate a patient’s care with psychiatric service providers
  • I believe it is important to have a mental health professional co-located in the clinic

CFHA 13th Annual Conference, October 29, 2011

slide19
Need
  • Number of patients believed to have a psychiatric condition
  • Number of patients believed to have a substance use disorder
  • How often during medical exam inquire about psychiatric condition
  • How often during medical exam inquire about substance use disorder
  • How much time during a medical exam spend on psychiatric or substance use disorder

CFHA Annual Conference, October 29, 2011

confidence in behavioral health specialists
Confidence in Behavioral Health specialists
  • Confidence in the value of specialty mental health services
  • Confidence in the value of specialty substance abuse treatment/services.

CFHA Annual Conference, October 29, 2011

survey response data
Survey Response Data

CFHA Annual Conference, October 29, 2011

physician baseline and follow up mean ratings n 43 pairs
Physician Baseline and Follow-up Mean Ratings (N=43 Pairs)

CFHA 13th Annual Conference, October 29, 2011

using physician survey results
Using Physician Survey Results
  • In one clinic when we learned from physician feedback that they could not identify BH staff we took actions to increase the presence of BH staff in the hall way of the exam rooms.
  • Launched a pre-clinic meeting for all staff on duty for that clinic.
  • Structured time for BH staff to be available for Resident/Attending Physician briefing on patients.
  • Developed written materials and handouts.

CFHA 13th Annual Conference, October 29, 2011

behavioral health professionals
Behavioral Health Professionals
  • Understanding the nature of practice in outpatient medical settings
  • Knowledge and skills to practice in a co-located, integrated care setting
  • Comfort and confidence for working in primary care
  • Nature of interactions between physical and behavioral health conditions

CFHA Annual Conference, October 29, 2011

questionnaire
Questionnaire
  • A 23-item questionnaire
  • Likert type responses of Strongly agree to Strongly Disagree, ranging from 1 to 5
    • 6 items addressed perceptions of work in primary care clinics
    • 4 items related to issues of comfort and confidence in working in primary care
    • 4 items addressed understanding and knowledge about interactions with primary care physicians
    • 9 items related to knowledge and skills for practice in a primary care clinic

CFHA Annual Conference, October 29, 2011

bh professionals survey
BH Professionals Survey
  • 28 individuals involved in integrated care programs
  • Questionnaire administered at the start of a structured training program conducted for BH professionals who were working in various program sites.
  • Follow-up approximately 5 months later, reflecting continued work experience and training.

CFHA Annual Conference, October 29, 2011

perceptions of work in primary care
Perceptions of Work in Primary Care

CFHA Annual Conference, October 29, 2011

comfort and confidence
Comfort and Confidence

CFHA 13th Annual Conference, October 29, 2011

interactions with primary care physicians
Interactions with Primary Care Physicians

CFHA 13th Annual Conference, October 29, 2011

knowledge and skills
Knowledge and Skills

CFHA 13th Annual Conference, October 29, 2011

using behavioral health staff feedback
Using Behavioral Health Staff Feedback
  • Scheduling BH staff for “Clinic Duty” no scheduled appointments during assigned clinic time; to be present in the exam room area
  • Pre-clinic meetings
  • Flags on exam doors to denote which profession in exam room with patient
  • Issues white board—identify scheduled patients and any special needs/concerns
  • All staff meetings

CFHA 13th Annual Conference, October 29, 2011

consumer perceptions and preferences related to co located care
Consumer Perceptions and Preferences Related to Co-located Care
  • Standardized questions asked by research assistant
  • Rating likelihood of service use by type of service
  • Preference for service location
  • Interest in timing, type, and frequency of services
  • A convenience sample of 58 clinic consumers

CFHA 13th Annual Conference October 29, 2011

accessing bh services
Accessing BH Services

CFHA 13th Annual Conference, October 29, 2011

importance of bh service features n 58
Importance of BH service features (N=58)

CFHA 13th Annual Conference, October 29, 2011

rate how you would prefer to set up bh visits n 55
Rate how you would prefer to set up BH visits(N=55)

CFHA 13th Annual Conference, October 29, 2011

preference of frequency of bh service
Preference of Frequency of BH Service

CFHA 13th Annual Conference, October 29, 2011

comfort with type of bh service
Comfort with Type of BH Service

CFHA 13th Annual Conference, October 29, 2011

patient satisfaction survey
Patient Satisfaction Survey
  • A review of the literature did not turn up any patient satisfaction surveys that were reflective of co-located, integrated care programs
  • Personal inquiries to co-located, integrated care programs did not result in the identification of an instrument
  • 23-item questionnaire developed that included items on psychosocial and mental health issues

CFHA 13th Annual Conference, October 29, 2011

patient ratings from a general medicine clinic
Patient Ratings from a General Medicine Clinic

CFHA 13th Annual Conference, October 29, 2011

patient s receiving bh service ratings
Patient’s Receiving BH Service-- Ratings

CFHA 13th Annual Conference, October 29, 2011

community advisory board cab
Community Advisory Board (CAB)
  • Consumers identified by program staff and CAB members to serve on an advisory board
  • CAB selects officers, schedules meetings, and sets agenda
  • CAB selects a person to attend program operations meetings that addresses daily operations, quality improvement, program evaluation and program development

CFHA 13th Annual Conference , October 29, 2011

cab cont
CAB cont.
  • Utilization data presented to CAB for review and suggestions regarding engagement
  • Set up a suggestion box
  • Suggested topics to be investigated for program enhancement—access to technology
  • Identifying topics for support groups
  • Promoting community involvement—World AIDS Day, Testing Day
  • Promoted development of peer advocate program

CFHA 13th Annual Conference, October 29, 2011

cab raised issue of using internet to support clinic programs
CAB Raised Issue of using Internet to Support Clinic Programs
  • Resulted in a survey of a convenience sample of consumers in the client
    • Do individual receiving health care services in an HIV Clinic have access to cell phones and the Internet?
    • Do these individuals want to receive information related to their health via text messages or email?
  • Reported results to CAB
  • Promoted discussion about social networking and program applications

CFHA 13th Annual Conference, October 29, 2011

regarding technology
Regarding technology…
  • A significant number of individuals receiving services in the health clinic have access to cell phones and the Internet.
  • However:
    • A large number of these individuals do not want to receive text messages about their health.
    • Likewise, a large number do not want to exchange emails with heath providers related to their health.

CFHA 13th Annual Conference, October 29, 2011

summary
Summary
  • Using structured surveys and questionnaires has provided an efficient way to obtain data from three major groups of stakeholders
  • A consumer advisory board provides a ready “focus group” to test out ideas and receive feedback on program issues and concerns

CFHA 13th Annual Conference, October 29, 2011

summary cont
Summary Cont.
  • Taken together, data supports that co-location and integration increases access for consumers and provides greater opportunity to connect with consumers over time in promoting and assisting consumers to achieve health goals. Consumers like co-located services.

CFHA 13th Annual Conference, October 29, 2011

summary cont1
Summary Cont.
  • The physician and behavioral health survey suggests that in a brief period of time there is little movement in beliefs and perceived abilities to work in co-located, integrated care programs.
  • Nonetheless, feedback lead to a number of operational and structural changes to increase collaboration and integration.

CFHA 13th Annual Conference, October 29, 2011

presenters
Presenters

David Johnson, MSW, ACSW

Wayne State University School of Medicine, Department of Psychiatry and Behavioral Neurosciences

[email protected]

Lori Lackman Zeman, PhD

Wayne State University School of Medicine, Department of Psychiatry and Behavioral Neurosciences

[email protected]

CFHA 13th Annual Conference, October 29, 2011

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