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

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

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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

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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 Moise1, Ravi Shah2, Susan Essock2, Margaret Handley3, Amy Jones4, Jay Carruthers4, Karina Davidson1, Lauren Peccoralo5 and Lloyd Sederer4

1Department of Medicine, Columbia University Medical Center, New York, NY 2Department of Psychiatry, Columbia University, New York, NY 3University of California San Francisco, San Francisco, CA 4 New York State Office of Mental Health, New York, NY 5Icahn School of Medicine at Mount Sinai, New York, NY

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Conflicts of Interest

  • None
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SLIDE 3

Background

  • Numerous RCT’s have established the

effectiveness of collaborative care for depression in primary care1

  • In real world settings, programs have
  • ften stumbled2
  • Suboptimal uptake/Reach (missed
  • pportunities to discuss mental health
  • pportunities)
  • Low engagement in LEP

1 Thota et al., American journal of preventive medicine, 2012; Fortney, Implementation Science, 2012.

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Background

2012

  • NYS Hospital Medical Home

Program: OMH and DOH CCI

  • 32 Clinics (19 academic medical

centers, 1 million patients)

  • Clinics that opted to use

PCMH funds for behavioral health

  • Grant funding could be used for

staff, technical assistance, training, registry system, monitoring and QI activities

  • Quarterly reporting to ensure

fidelity

2015

  • 55 Clinics
  • $150 per-member per-

month (75% of payment is received for enrolling and treatment; 25% for depression improvement after ≥6 mo)

  • Billing code for Medicaid

patients

2016

  • Stakeholder Interviews

with 19 original medical centers

  • Barriers and facilitators

to implementation and sustainability

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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

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SLIDE 6

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)

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Theoretical framework: Behavioral Change Wheel

Michie et al, Behavioral Change Wheel, 2011

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)

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BCW Framework Cont’d

Mitchie et al., The Behavioral Change Wheel, 2011

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Results

19 medical centers 17 centers agreed to participate

(9 HHC, 8 non-HHC)

8 site visits

(2 HHC, 6 non-HHC)

30 stakeholder interviews (73% female) 2 declined

2 not part of sustainability phase 6 psychiatrists; 8 primary care physicians; 8 care managers; 8 administrators

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Results: Clinic implementation rates

Sederer et al., Psychiatric Quarterly, 2014

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Results: Clinic Characteristics

A ¡ B ¡ C ¡ D ¡ E ¡ F ¡ G ¡ H ¡

Clinic Characteristics

Total Number of Patients in Clinic1 ¡

<10K ¡ 10K-50K ¡ 10K-50K ¡ 10K-50K ¡ >50K ¡ <10K ¡ 10K-50K ¡ >50K ¡

% 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 ¡

Consistency of Delivery

Psychiatrist met with care manager weekly? ¡

No ¡ Yes ¡ Yes ¡ Exceeded ¡ Yes ¡ No ¡ Yes ¡ Yes ¡

% 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% ¡

FIDELITY

Depression Screening (%)3 ¡

N/A ¡ 85% ¡ 82% ¡ 95% ¡ 78% ¡ N/A ¡ 60% ¡ 75% ¡

% 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 greater6 ¡

N/A ¡ 44% ¡ 36% ¡ 67% ¡ 26% ¡ N/A ¡ 31% ¡ 43% ¡

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Results: Barriers

COM-B Construct Themes Psychological Capability

  • Training/Knowledge (20% of respondents): Lack of CC knowledge
  • Workflow Logistics (33% of respondents): Complicated screening,

referral and triaging (also physical opportunity, reflexive motivation)

Social Opportunity

  • Outer Setting (40% of respondents)
  • Competing national and state policies
  • Restrictive enrollment requirements
  • Inadequate/Complex Psychosocial Resources

Physical Opportunity

  • Funding (30% of respondents)
  • Complex Funding stream
  • 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)
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Results: Barriers Cont’d

COM-B Construct Themes Reflective Motivation

  • Team Engagement (50% of respondents)
  • Lack of primary care physician pro-activeness
  • 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
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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

  • 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

Paraprofessional

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Results: Clinic Level Interventions

Intervention Function COM-B Barriers Strategy Training/ Education

Psychological Capability Physical Opportunity Reflective motivation

  • Training/In-servicing residents, staff by demonstrating/

rehearsing screening

  • Antidepressant algorithms/Decision aids
  • Quantitative feedback on screening/referral/

improvement rates Environmental Restructuring

Social Opportunity Physical Opportunity

  • IT: automate registry input from EHR, prompts
  • Mobile technology for screening
  • Leverage PCMH resources
  • Warm handoffs! (electronic?)
  • Collocation
  • Appointment flexibility/Walk-ins
  • Resident run depression clinics
  • Culture Change (involve MAs/staff in planning)

Persuasion

Reflective Motivation

  • Provide Data/Videos/brochures about successful

stories

  • MI/Personalization at time of visit

Incentivisation

Reflective Motivation

  • Employee of the month/Food
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Limitations

  • Small sample size
  • Hypothesis generating study
  • Breadth of barriers at a healthcare system level may not have been

reflected during clinic visits

  • Limited generalizability to non-academic institutions
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Conclusions

  • One of the largest state-wide efforts to implement CC using blended

measurement based reimbursement

  • High fidelity/Integrity of CC (variations in how to implement)
  • Fiscal measures/training àresources/engagement still barriers
  • Using theoretical behavioral change framework, we propose several

intervention strategies to improve implementation/sustainability

  • Policy Level Strategies
  • Simplifying reporting metrics/billing infrastructure
  • Clinic Level Strategies
  • Ongoing Training (e.g., resident run depression clinic)
  • Centralization and audit/feedback to providers/staff on key metrics
  • Multi-level strategies
  • Automate registry/IT
  • Paraprofessionals may improve care manager time spent in patient care, depression

screening, and psychiatry consultation rates

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Next Steps

  • Economic evaluation of 55 clinics
  • Surveys: paraprofessionals and outcomes
  • Test multi-component interventions strategy

Barriers to patient engagement in collaborative care (CC) Selected Intervention Function Selected Behavior Change Technique Selected Mode of Delivery

CAPABILITY

OPPORTUNITY MOTIVATION Language Memory to go to appointment Knowledge Time for warm handoffs Time to discuss treatment Stigma Limited resources/Technology Resident continuity Self-efficacy Automatic refusal (emotion) Belief about pos/neg consequences eSDM Tool, Training and Referral/Appointment System Education/ Persuasion/ enablement Information about consequence eSDM Tool (tool in lieu

  • f physician/CC,

tailored video, decision aid) Training Modeling Regular Resident/ Physician SDM/CC Training sessions Enablement Prompts/Cues Paraprofessional for scheduling/reminders Restructure environment Prompts/Cues EHR orderset for referral/pt preference

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Thank You

Lloyd Sederer, MD Ravi Shah, MD, MBA Susan Essock, PhD Amy Jones Margaret Handley, PhD Karina Davidson, PhD Ian Kronish, MD, MPH Office of Mental Health Policy Scholar Program

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Questions?