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Price-Haywood EG, Burton J, Harden-Barrios J, Bazzano A, Lefante J, Shi L, Jamison RN. Depression, anxiety, pain and chronic opioid management in primary care: Type II effectiveness-implementation hybrid stepped wedge cluster randomized trial. Contemp Clin Trials 2020; 101:106250. [PMID: 33326877 DOI: 10.1016/j.cct.2020.106250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 11/14/2020] [Accepted: 12/08/2020] [Indexed: 11/17/2022]
Abstract
Even though current prescribing trends reveal that high-dose opioid prescribing and opioid prescribing in general has decreased, sustained efforts are needed to help providers adopt and maintain safe prescribing behaviors. The purpose of this four-year type 2 effectiveness-implementation hybrid stepped wedge cluster randomized trial is to: (1) compare the clinical and cost effectiveness of electronic medical record-based clinical decision support [EMR-CDS] versus additional integrated, collaborative behavioral health [EMR-CDS + BHI-CCM] for opioid management of patients with co-morbid chronic non-cancer pain with depression or anxiety; and (2) examine facilitators and barriers to implementing these interventions within 35 primary care clinics in a integrated delivery health system. The EMR-CDS alerts providers to employ opioid risk mitigation and safe prescribing practices at the point of care. The BHI-CCM consists of primary care embedded community health workers for case management; licensed clinical social workers for cognitive behavioral therapy, and a clinical pharmacist for medication management who provide care management via telemedicine (virtual video or audio only visits) under the guidance of a consulting psychiatrist. The primary outcome is reduction in the percentage of patients with average daily opioid dose ≥50 mg morphine equivalent. Secondary outcomes include changes in service utilization, patient reported outcomes and processes of care. The investigators anticipate that study results will elucidate the role of technology versus care team optimization in changing opioid prescribing behaviors. The investigators further anticipate that integrated mental/behavioral health care will increase value-based care and the efficiency with which guideline concordant care is delivered.
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Affiliation(s)
- Eboni G Price-Haywood
- Ochsner Center for Outcomes and Health Services Research, 1514 Jefferson Highway, New Orleans, LA 70121, USA; Ochsner Clinical School, University of Queensland, 1514 Jefferson Highway, New Orleans, LA 70121, USA.
| | - Jeffrey Burton
- Ochsner Center for Outcomes and Health Services Research, 1514 Jefferson Highway, New Orleans, LA 70121, USA
| | - Jewel Harden-Barrios
- Ochsner Center for Outcomes and Health Services Research, 1514 Jefferson Highway, New Orleans, LA 70121, USA
| | - Alessandra Bazzano
- Tulane University School of Public Health and Tropical Medicine, 1440 Canal Street, New Orleans, LA 70112, USA
| | - John Lefante
- Tulane University School of Public Health and Tropical Medicine, 1440 Canal Street, New Orleans, LA 70112, USA
| | - Lizheng Shi
- Tulane University School of Public Health and Tropical Medicine, 1440 Canal Street, New Orleans, LA 70112, USA
| | - Robert N Jamison
- Brigham and Women's Hospital, Pain Management Center, 850 Boylston Street, Chestnut Hill, MA 02467, USA; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
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Abstract
PURPOSE OF REVIEW This review discusses the role of the patient-centered medical home (PCMH) in treating depression, focusing on findings from primary care-based studies and their implications for the PCMH. RECENT FINDINGS Pharmacotherapy, psychotherapy, and collaborative care are evidence-based treatments for depression that can be delivered in primary care and extended to diverse populations. Recent research aligns with the core components of the PCMH model. The core components of the PCMH are critical elements of depression treatment. Comprehensive care within the PCMH addresses medical and behavioral health concerns, including depression. Psychiatric and psychological care must be flexibly delivered so services remain accessible yet patient-centered. To ensure the quality and safety of treatment, depression symptoms must be consistently monitored. Coordination within and occasionally outside of the PCMH is needed to ensure patients receive the appropriate level of care. More research is needed to empirically evaluate depression treatment within the PCMH.
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Arriola-Vigo JA, Stovall JG, Moon TD, Audet CM, Diez-Canseco F. Perceptions of Community Involvement in the Peruvian Mental Health Reform Process Among Clinicians and Policy-Makers: A Qualitative Study. Int J Health Policy Manag 2019; 8:711-722. [PMID: 31779299 PMCID: PMC6885866 DOI: 10.15171/ijhpm.2019.68] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 08/03/2019] [Indexed: 11/25/2022] Open
Abstract
Background: The global burden of mental health conditions has led to the implementation of new models of care for persons with mental illness. Recent mental health reforms in Peru include the implementation of a community mental health model (CMHM) that, among its core objectives, aims to provide care in the community through specialized facilities, the community mental health centers (CMHCs). Community involvement is a key component of this model. This study aims to describe perceptions of community engagement activities in the current model of care in three CMHCs and identify barriers and potential solutions to implementation. Methods: A qualitative research study using in-depth semi-structured interviews with clinicians from three CMHCs and with policy-makers involved in the implementation of the mental health reforms was conducted in two regions of Peru. The interviews, conducted in Spanish, were digitally recorded with consent, transcribed and analyzed using principles of grounded theory applying a framework approach. Community engagement activities are described at different stages of patient care. Results: Twenty-five full-time employees (17 women, 8 men) were interviewed, of which 21 were clinicians (diverse health professions) from CMHCs, and 4 were policy-makers. Interviews elucidated community engagement activities currently being utilized including: (1) employing community mental health workers (CMHWs); (2) home visits; (3) psychosocial clubs; (4) mental health workshops and campaigns; and (5) peer support groups. Inadequate infrastructure and financial resources, lack of knowledge about the CMHM, poorly defined catchment areas, stigma, and inadequate productivity approach were identified as barriers to program implementation. Solutions suggested by participants included increasing knowledge and awareness about mental health and the new model, implementation of peer-training, and improving productivity evaluation and research initiatives. Conclusion: Community engagement activities are being conducted in Peru as part of a new model of care. However, their structure, frequency, and content are perceived by clinicians and policy-makers as highly variable due to a lack of consistent training and resources across CMHCs. Barriers to implementation should be quickly addressed and potential solutions executed, so that scale-up best optimizes the utilization of resources in the implementation process.
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Affiliation(s)
- Jose A Arriola-Vigo
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jeffrey G Stovall
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Troy D Moon
- Department of Pediatrics, Division of Infectious Diseases, and Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Carolyn M Audet
- Department of Health Policy, and Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Francisco Diez-Canseco
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
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Henry TL, Schmidt S, Lund MB, Haynes T, Ford D, Egwuogu H, Schmitz S, McGregor B, Toomer L, Bussey-Jones J. Improving Depression Screening in Underserved Populations in a Large Urban Academic Primary Care Center: A Provider-Centered Analysis and Approach. Am J Med Qual 2019; 35:315-322. [PMID: 31701768 DOI: 10.1177/1062860619884639] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Screening for depression is paramount to identify patients with depression and link them to care, yet only 29% of patients in the primary care center (PCC) were screened for depression in 2016. A baseline survey identified provider barriers to depression screening, including lack of time, support staff, and referral resources. The purpose of this project was to increase depression screening in the PCC using the Patient Health Questionnaire (PHQ-2/9). The authors created an educational program for staff and providers that included referral resources, treatment guidelines, and a decision-support tool in the electronic medical record. A retrospective chart review was performed, from January 2016 to June 2017, to determine the percentage of patients who received annual depression screening. During the program, the PCC saw an increase in depression screening rates. Thus, it is possible to overcome barriers to depression screening in a primary care setting by providing resources and education to clinicians.
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Thompson H, Faig W, Gupta N, Lahey R, Golden R, Pollack M, Karnik N. Collaborative Care for Depression of Adults and Adolescents: Measuring the Effectiveness of Screening and Treatment Uptake. Psychiatr Serv 2019; 70:604-607. [PMID: 31023189 PMCID: PMC6602801 DOI: 10.1176/appi.ps.201800257] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study analyzed effectiveness of screening, referrals, and treatment uptake of a collaborative care for depression intervention across 10 primary care clinics in Chicago. METHODS Between November 2016 and December 2017, patients (N=25,369) were screened with the Patient Health Questionnaire-2 and the Patient Health Questionnaire-9 on the basis of an eligibility algorithm. Electronic health record data were analyzed for sample characteristics, screening rates, referrals, and treatment pathways. To identify disparities, a test of proportions was conducted between eligible and screened patients as well as referred and treated patients. RESULTS Screenings, referrals, and uptake occurred proportionately across subgroups except for patients ages 12-17. Adolescent age was associated with disproportionate Patient Health Questionnaire-9 screenings and with treatment disengagement. CONCLUSIONS The intervention shows promise in expanding access to care and reducing disparities. Greater access to psychotherapies and innovative treatment modalities, particularly for adolescents, may improve overall treatment uptake.
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Affiliation(s)
- Hale Thompson
- Department of Psychiatry & Behavioral Sciences, Rush Medical College, Rush University, Chicago, IL USA
| | - Walter Faig
- Department of Psychiatry & Behavioral Sciences, Rush Medical College, Rush University, Chicago, IL USA
| | - Neha Gupta
- Department of Psychiatry & Behavioral Sciences, Rush Medical College, Rush University, Chicago, IL USA
| | - Rebecca Lahey
- Department of Social Work & Community Health, Rush University Medical Center, Chicago, IL USA
| | - Robyn Golden
- Department of Social Work & Community Health, Rush University Medical Center, Chicago, IL USA
| | - Mark Pollack
- Department of Psychiatry & Behavioral Sciences, Rush Medical College, Rush University, Chicago, IL USA
| | - Niranjan Karnik
- Department of Psychiatry & Behavioral Sciences, Rush Medical College, Rush University, Chicago, IL USA
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Fuller SM, Koester KA, Erguera XA, Wilde Botta E, von Beetzen F, Steward WT, Avery A. The collaborative care model for HIV and depression: Patient perspectives and experiences from a safety-net clinic in the United States. SAGE Open Med 2019; 7:2050312119842249. [PMID: 31044076 PMCID: PMC6446432 DOI: 10.1177/2050312119842249] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 03/14/2019] [Indexed: 12/22/2022] Open
Abstract
Objectives: Collaborative care models may improve outcomes for both HIV and depression. The model includes routine screening and re-assessment of depressive symptoms as well as care coordination services delivered by an ancillary provider focused on mental health. We sought to explore patient experiences and attitudes about the services received through the collaborative care model, including measurement-based care using the Patient Health Questionnaire-9. Methods: We conducted 17 qualitative interviews with patients in a collaborative care model implemented at an HIV primary care clinic in a safety-net hospital in the United States. Interviews were analyzed using Framework Analysis. Results: Our findings illustrate the ways in which the collaborative care model for depression may be meaningful to patients in HIV care settings. Participants appreciated the support offered through the collaborative care model. Most participants perceived measurement-based care as useful to their providers, and an additional subset used the Patient Health Questionnaire-9 for their own self-management and awareness of depression. Over time, the collaborative care model appeared to motivate some patients to address depressive symptoms. Conclusion: The collaborative care model may be particularly helpful to patients in the way that it reinforces how depressive symptoms can be measured and managed. Furthermore, routine screening and re-measurement for depressive symptoms using the Patient Health Questionnaire-9 hold promise as an additional self-management tool to complement other clinical and supportive services.
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Affiliation(s)
- Shannon M Fuller
- Division of Prevention Sciences, Center for AIDS Prevention Studies, The University of California, San Francisco, San Francisco, CA, USA
| | - Kimberly A Koester
- Division of Prevention Sciences, Center for AIDS Prevention Studies, The University of California, San Francisco, San Francisco, CA, USA
| | - Xavier A Erguera
- Division of Prevention Sciences, Center for AIDS Prevention Studies, The University of California, San Francisco, San Francisco, CA, USA
| | - Emma Wilde Botta
- Division of Prevention Sciences, Center for AIDS Prevention Studies, The University of California, San Francisco, San Francisco, CA, USA
| | - Fredrik von Beetzen
- Division of Prevention Sciences, Center for AIDS Prevention Studies, The University of California, San Francisco, San Francisco, CA, USA
| | - Wayne T Steward
- Division of Prevention Sciences, Center for AIDS Prevention Studies, The University of California, San Francisco, San Francisco, CA, USA
| | - Ann Avery
- MetroHealth Medical Center, Cleveland, OH, USA.,Case Western Reserve University, School of Medicine, Cleveland, OH, USA
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Nieuwboer MS, van der Sande R, van der Marck MA, Olde Rikkert MGM, Perry M. Clinical leadership and integrated primary care: A systematic literature review. Eur J Gen Pract 2019; 25:7-18. [PMID: 30474447 PMCID: PMC6394325 DOI: 10.1080/13814788.2018.1515907] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 07/18/2018] [Accepted: 08/15/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Leaders are needed to address healthcare changes essential for implementation of integrated primary care. What kind of leadership this needs, which professionals should fulfil this role and how these leaders can be supported remains unclear. OBJECTIVES To review the literature on the effectiveness of programmes to support leadership, the relationship between clinical leadership and integrated primary care, and important leadership skills for integrated primary care practice. METHODS We systematically searched PubMed, CINAHL, Embase, PsycINFO until June 2018 for empirical studies situated in an integrated primarycare setting, regarding clinical leadership, leadership skills, support programmes and integrated-care models. Two researchers independently selected relevant studies and critically appraised studies on methodological quality, summarized data and mapped qualitative data on leadership skills. RESULTS Of the 3207 articles identified, 56 were selected based on abstract and title, from which 20 met the inclusion criteria. Selected papers were of mediocre quality. Two non-controlled studies suggested that leadership support programmes helped prepare and guide leaders and positively contributed to implementation of integrated primary care. There was little support that leaders positively influence implementation of integrated care. Leaders' relational and organizational skills as well as process-management and change-management skills were considered important to improve care integration. Physicians seemed to be the most adequate leaders. CONCLUSION Good quality research on clinical leadership in integrated primary care is scarce. More profound knowledge is needed about leadership skills, required for integrated-care implementation, and leadership support aimed at developing these skills.
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Affiliation(s)
- Minke S. Nieuwboer
- Department of Geriatric Medicine, Radboud University Medical Center, Radboud UMC Alzheimer Centre, Nijmegen, The Netherlands
| | - Rob van der Sande
- Department of Primary and Community Care, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
- Faculty of Health, Behaviour and Society, HAN University of Applied Sciences, Nijmegen, The Netherlands
| | - Marjolein A. van der Marck
- Department of Geriatric Medicine, Radboud University Medical Center, Radboud UMC Alzheimer Centre, Nijmegen, The Netherlands
- Radboud University Medical Center, Department of Geriatric Medicine, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Marcel G. M. Olde Rikkert
- Department of Geriatric Medicine, Radboud University Medical Center, Donders Institute for Brain Cognition and Behaviour, Nijmegen, The Netherlands
- Radboud University Medical Center, Department of Geriatric Medicine, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Marieke Perry
- Department of Geriatric Medicine, Radboud University Medical Center, Radboud UMC Alzheimer Centre, Nijmegen, The Netherlands
- Department of Primary and Community Care, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
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Improving Culture, One Quality Improvement Project at a Time. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2018; 24:57-62. [PMID: 28383343 DOI: 10.1097/phh.0000000000000554] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
CONTEXT A culture of quality improvement (QI) values collaboration, transparency, and staff empowerment. Organizations exhibiting a culture of QI are more likely to engage in QI. OBJECTIVE We examined whether local health departments' (LHDs') participation in a longitudinal, experiential QI training program changes QI culture. DESIGN Prior to and following participation in a QI training program, all employees of participating LHDs were asked to complete an 8-item survey assessing components of QI culture on a 5-point scale. INTERVENTION From 2010 to 2015, multidisciplinary teams from North Carolina LHDs participated in sequential cohorts of a 6-month QI training program, during which the teams completed a QI project. MAIN OUTCOME MEASURE We dichotomized culture survey responses, with 4 or 5 being "Supportive." We compared adjusted proportions, using linear regression, clustering at LHD, and controlling for cohort. RESULTS Data from 42 LHDs were included. At baseline, 7.8% responded that their LHD had a supportive culture for all 8 components, compared with 12% at follow-up (P < .001), adjusted for cohort and clustering by LHD. At follow-up, the percentage of employees responding that their LHDs had supportive cultures increased for all components of culture including communication by 4.1% (95% CI: 2.0%-6.2%), problem solving by 2.9% (95% CI: 1.6%-5.5%), team work by 5.2% (95% CI: 2.5%-7.8%), vision by 4.3% (95% CI: 1.1%-7.5%), performance measures by 5.6% (95% CI: 1.6%-9.6%), recognition by 4.7% (95% CI: 1.4%-8.0%), for conflict by 5.5% (95% CI: 1.7%-9.4%), and alignment by 5.8% (95% CI: 2.3%-9.2%). CONCLUSIONS Engagement with structured QI training programs-and perhaps simply completing QI projects-can cause small, but important changes in organizations' cultures, thus increasing engagement in future QI and improving overall care and services. The article demonstrates that when LHDs participate in a longitudinal, experiential QI training program, their cultures of QI improve. Local health departments participating in similar training programs might experience similar improvements in culture, increasing subsequent participation in QI projects and improving related health outcomes.
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