Barriers and Facilitators to Implementing New York State - PowerPoint PPT Presentation

Barriers and Facilitators to Implementing New York State Collaborative Care Initiative for Depression in Academic Primary Care Settings: Using a Theoretical Framework to Inform Policy Nathalie Moise 1 , Ravi Shah 2 , Susan Essock 2 , Margaret Handley 3 , Amy Jones 4 , Jay Carruthers 4 , Karina Davidson 1 , Lauren Peccoralo 5 and Lloyd Sederer 4 1 Department of Medicine, Columbia University Medical Center, New York, NY 2 Department of Psychiatry, Columbia University, New York, NY 3 University of California San Francisco, San Francisco, CA 4 New York State Office of Mental Health, New York, NY 5 Icahn School of Medicine at Mount Sinai, New York, NY

Conflicts of Interest • None

Background • Numerous RCT’s have established the effectiveness of collaborative care for depression in primary care 1 • In real world settings, programs have often stumbled 2 • Suboptimal uptake/Reach (missed opportunities to discuss mental health opportunities) • Low engagement in LEP 1 Thota et al., American journal of preventive medicine, 2012; Fortney, Implementation Science, 2012.

Background 2012 2015 -NYS Hospital Medical Home Program: OMH and DOH CCI 2016 -32 Clinics (19 academic medical -55 Clinics centers, 1 million patients) -$150 per-member per- -Clinics that opted to use -Stakeholder Interviews PCMH funds for behavioral month (75% of payment is health with 19 original medical received for enrolling and -Grant funding could be used for centers treatment; 25% for staff, technical assistance, training, registry system, monitoring and QI depression improvement -Barriers and facilitators activities after ≥ 6 mo) to implementation and -Quarterly reporting to ensure -Billing code for Medicaid sustainability fidelity patients

Methods • OMH Chief Medical Officer invited the 19 original medical centers to participate in stakeholder interviews • Psychiatrist and Internist conducted site visits between December 2015-May 2016 Semi-structured interviews with PCP (implementation lead), administrator, Care • Manager (CM) and psychiatrist • Interview guide tailored to position and based on OMH clinical leadership interviews and systematic review (correlates of implementation success) • Practice size/setting, patient demographics, staffing, number/training/licensure of care managers, funding streams, registry use, warm handoffs, psychiatry consults • Collaborative care program components (e.g., day-to-day activities of CM) • What makes the program challenging? • What would make the program better? • What have been your greatest successes in this? Do you have any best practices to share? Whitebird, 2014

Analysis • NVIVO 11.1 • Hybrid thematic analysis • Data-driven inductive approach • Deductive using a theoretical framework and a priori template • 2 Coders independently coded all content for meaning ( k =0.84)

Theoretical framework: Behavioral Change Wheel Based on 19 systematic reviews and specifies that changing behavior requires increasing capability, opportunity, motivation (COM-B) 1. Categorize barriers into COM-B constructs 2. Identify intervention functions (e.g., education) 3. Identify policy categories (e.g., guidelines) 4. Identify behavioral change techniques (instruction, demonstration, rehearse, feedback) 5. Apply APEASE Criteria (affordable, practical, efficacious, acceptable, safe and equitable) Michie et al, Behavioral Change Wheel, 2011

BCW Framework Cont’d Mitchie et al., The Behavioral Change Wheel, 2011

Results 19 medical centers 2 declined 17 centers agreed to participate (9 HHC, 8 non-HHC) 2 not part of 8 site visits sustainability phase (2 HHC, 6 non-HHC) 6 psychiatrists; 8 primary 30 stakeholder interviews care physicians; 8 care (73% female) managers; 8 administrators

Results: Clinic implementation rates Sederer et al., Psychiatric Quarterly, 2014

Results: Clinic Characteristics A ¡ B ¡ C ¡ D ¡ E ¡ F ¡ G ¡ H ¡ Total Number of Patients in Clinic 1 ¡ <10K ¡ 10K-50K ¡ 10K-50K ¡ 10K-50K ¡ >50K ¡ <10K ¡ 10K-50K ¡ >50K ¡ Clinic Characteristics % Medicaid ¡ 63% ¡ 70% ¡ 35% ¡ 50% ¡ 63% ¡ 10% ¡ 48% ¡ 65% ¡ Positive Screen for Depression (%) 2 ¡ N/A ¡ 5% ¡ 12% ¡ 7% ¡ 7% ¡ N/A ¡ 29% ¡ 37% ¡ Psychiatrists (FTE) ¡ 0% ¡ 75% ¡ 50% ¡ 60% ¡ 50% ¡ 10% ¡ 10% ¡ 20% ¡ Depression Care Manager (FTE) ¡ 2 ¡ 2 ¡ 1 ¡ 2.5 ¡ 6 ¡ 0.5 ¡ 2 ¡ 2 ¡ Licensing of care manager ¡ BA ¡ LCSW ¡ Psych NP ¡ RN/LCSW ¡ LCSW ¡ LCSW ¡ LMSW ¡ LCSW ¡ Additional Para-professional roles (FTE) ¡ 0 ¡ 0.5 ¡ 1 ¡ 1 ¡ 1 ¡ 0 ¡ 0 ¡ 0 ¡ Additional Funding streams to cover extra costs ¡ Yes ¡ Yes ¡ Yes ¡ Yes ¡ Yes ¡ Yes ¡ No ¡ No ¡ Leadership committed to the program? ¡ Yes ¡ Yes ¡ Yes ¡ Yes ¡ Yes ¡ Yes ¡ Yes ¡ Yes ¡ Care manager on-site? ¡ Yes ¡ Yes ¡ No ¡ Yes ¡ Yes ¡ Yes ¡ Yes ¡ Yes ¡ Perceived financial health/security of funding ¡ Adeq ¡ InAdeq ¡ Adeq ¡ Adeq ¡ Adeq ¡ InAdeq ¡ Adeq ¡ InAdeq ¡ Psychiatrist met with care manager weekly? ¡ No ¡ Yes ¡ Yes ¡ Exceeded ¡ Yes ¡ No ¡ Yes ¡ Yes ¡ Consistency of Delivery % of Psychiatrist time providing direct patient care ¡ 0 ¡ 75% ¡ 20% ¡ 64% ¡ 50% ¡ 0% ¡ 50% ¡ 75% ¡ Strong Physician Champion(s) ¡ No ¡ Yes ¡ Yes ¡ Yes ¡ Yes ¡ No ¡ Yes ¡ Yes ¡ PCPs routinely prescribe psychiatric medications ¡ No ¡ Yes ¡ Yes ¡ yes ¡ Yes ¡ Yes ¡ Yes ¡ Yes ¡ Most PCPs support the program and refer ¡ No ¡ Yes ¡ Yes ¡ yes ¡ Yes ¡ Yes ¡ Yes ¡ Yes ¡ Care managers perceived as strong? ¡ Mixed ¡ Mixed ¡ Yes ¡ Yes ¡ Yes ¡ Yes ¡ Mixed ¡ Yes ¡ Warm handoffs to care manager (>50% of referrals) ¡ No ¡ No ¡ No ¡ Yes ¡ Yes ¡ Yes ¡ Yes ¡ No ¡ Caseload per care manager in program ¡ 30-40 ¡ 50-60 ¡ 120 ¡ 40-50 ¡ 8-44 ¡ 35-40 ¡ 65-67 ¡ 50-60 ¡ % care manager time spent in patient sessions ¡ 50% ¡ 85% ¡ 85% ¡ 50% ¡ 90% ¡ 50% ¡ 33% ¡ 60% ¡ Depression Screening (%) 3 ¡ N/A ¡ 85% ¡ 82% ¡ 95% ¡ 78% ¡ N/A ¡ 60% ¡ 75% ¡ FIDELITY % Patients Enrolled in Collaborative Care Program ¡ N/A ¡ 57% ¡ 30% ¡ 27% ¡ 21% ¡ N/A ¡ 32% ¡ 51% ¡ Enrolled patients with Psychiatric Consult (%) 5 ¡ N/A ¡ 95% ¡ 91% ¡ 96% ¡ 95% ¡ N/A ¡ 32% ¡ 67% ¡ PHQ-9 decreased below 10 in 16 weeks or greater 6 ¡ N/A ¡ 44% ¡ 36% ¡ 67% ¡ 26% ¡ N/A ¡ 31% ¡ 43% ¡

Results: Barriers COM-B Themes Construct • Training/Knowledge (20% of respondents): Lack of CC knowledge Psychological Capability • Workflow Logistics (33% of respondents): Complicated screening, referral and triaging (also physical opportunity, reflexive motivation ) Social • Outer Setting (40% of respondents) • Competing national and state policies Opportunity • Restrictive enrollment requirements • Inadequate/Complex Psychosocial Resources Physical • Funding (30% of respondents) • Complex Funding stream Opportunity • Insufficient Funding (e.g., for paraprofessionals) • Information Technology/Infrastructure (27% of respondents) • Antiquated data management/IT infrastructure • Time/Resources/Personnel (77% of respondents) • Physician Time Constraints • Competing PCP demands • Competing care management roles • Insufficient care managers • Inadequate Space • Infeasible Warm Handoffs (also motivation barrier)

Results: Barriers Cont’d COM-B Themes Construct • Team Engagement ( 50% of respondents) Reflective • Lack of primary care physician pro-activeness Motivation • Poor Continuity of care • Poor psychiatrist engagement • Lack of care manager engagement • Inadequate teamwork/communication • Patient engagement (63% of respondents) • Depression treatment stigma • Patient nonadherence • Limited Language/Literacy of patients • Infeasible warm handoffs (also opportunity barrier) • Beliefs about consequences (10% of respondents) • Inadequate Buy In

Results: Policy Categories • Communication/Marketing • Handouts/brochures/videos • Service Provision • Online service for training/education • Hire paraprofessionals to conduct quality metrics, education, billing, warm handoffs, training, and manage registry • Service to conduct quality metrics, suggestions for improvement, billing infrastructure training Paraprofessional • Environmental/social planning • Automate screening and referral (EHR) • Standardize the workflow environment • Optimize surrounding psychosocial environment • Fiscal Measures • Improve Medicaid reimbursement processes • Streamline fee-for-value process (25% retainage) • Expand enrollment requirements

Results: Clinic Level Interventions Intervention COM-B Strategy Function Barriers Training/ Psychological -Training/In-servicing residents, staff by demonstrating/ Capability Education rehearsing screening Physical -Antidepressant algorithms/Decision aids Opportunity -Quantitative feedback on screening/referral/ Reflective improvement rates motivation Social Environmental -IT: automate registry input from EHR, prompts Opportunity Restructuring -Mobile technology for screening Physical -Leverage PCMH resources Opportunity -Warm handoffs! (electronic?) -Collocation -Appointment flexibility/Walk-ins -Resident run depression clinics -Culture Change (involve MAs/staff in planning) Reflective Persuasion -Provide Data/Videos/brochures about successful Motivation stories -MI/Personalization at time of visit Reflective Incentivisation -Employee of the month/Food Motivation