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

Discover how the Hogg Foundation's initiative addressed barriers to implementing collaborative care in Texas, with insights, lessons learned, and successful solutions. Learn about the core components of collaborative care, training, evaluation plans, and outcomes.

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

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

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

  3. 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

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

  5. 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

  6. 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

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

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

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

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

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

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

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

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

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

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

  17. Sample screen: Patient tracking

  18. Sample screen: A PCP’s patients

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

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

  21. 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

  22. 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)

  23. 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

  24. 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

  25. 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

  26. 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

  27. 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

  28. 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

  29. 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

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

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

  32. 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

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

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