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Wisdom in Numbers: Using Stakeholder Feedback To Shape a Research Agenda for Integrating Mental Health and Primary Care. Charlotte Mullican Benjamin F. Miller C.J. Peek Rodger Kessler. First there was the AHRQ EPC Report. Finding the gaps setting and agenda changing healthcare. - PowerPoint PPT Presentation
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Wisdom in Numbers: Using Stakeholder Feedback To Shape a Research Agenda for
Integrating Mental Health and Primary Care
Charlotte MullicanBenjamin F. Miller
C.J. PeekRodger Kessler
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The Collaborative Care Research Network (CCRN), a sub-network of the AAFP’s National Research Network (NRN), was created so that clinicians from across the country can ask questions and investigate how to make integrating mental health and primary care work more effectively.
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The purpose of the Collaborative Care Research Network Research Conference was to respond to the questions raised by the Agency for Healthcare Research and Quality (AHRQ) Evidence Practice Committee (EPC) report: Integration of Mental Health/Substance Abuse and Primary Care.
There were four specific aims for the conference:
1) to establish and prioritize a set of research questions to evaluate collaboration between behavioral health and primary care;
• 2) to respond to the set of questions identified in the 2008 AHRQ systematic review and other publications concerning the effectiveness of collaborative care;
• 3) to inform AHRQ about the identified research goals to assist the development of future contract task orders;
• 4) to inform investigators outside of the existing PBRN community about areas to serve as the focus for investigator initiated research.
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“Is there a lexicon in the house?”Normal confusion in a new field
Imagine being on a planning committee conference call……….
• “Are you saying integrated care and collaborative care are the same thing?”
• “Is integrated behavioral health the same as co-located mental health or primary behavioral healthcare?”
• “What functions have to be on the collaborative care team if it is to be real collaborative care?”
• “What has to be in place in practice to count as the genuine article—and what can be different from practice to practice?”
Do you think your clarity (or lack of it) is shared by the person next to you?
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We needed a common ‘lexicon’ for Collaborative Care
Shared terms for the essence that unites the many local variations as the “genuine article”
• But with a vocabulary for acceptable differences
• Enough resolution of definitional confusion to allow consistently understood research / evaluation questions
• Enough clarity of essence to point to business model
• Developing a common language with which to represent this field to ourselves and others
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Lesson from history: Emerging fields require conceptual systems adequate to the work
Before 1881: 12 different units of electromotive force, 10 units of current, 15 units of resistance“The International Electrical Congress of 1881 has borne good fruit. . . a rapprochement between electricians of all countries. . . and the adoption of an international system of measurement which will be in universal use”.
Nature 30, 26-27; 8 May 1884.
After 1881: Volt, Ohm, and Ampere all defined as one conceptual system--as in a mature field
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To ask research and practice development questions-- deal with both the empirical and the pre-empirical
Empirical Pre-empiricalThe cat is on the mat--
Is it in fact the case?Do we agree enough about:• What counts as a cat?
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Pre-empirical
Do we agree enough about: What counts as “is on”?
Do we agree enough about: What counts as a mat?
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Requirements for “lexicon” development method:
A. Consensual but analytic(a disciplined process--not a political campaign)
B. Involving “native speakers” (implementers and users)
C. Focused on what functionalities look like in practice
(not just principles, values, abstractions)
D. Amenable to gathering an expanding circle of “owners” and contributors
(not just an elite group coming with a declaration)
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Method: Paradigm Case Formulation & Parametric Analysis
(Ossorio 2006; The Behavior of Persons)
A. Describe an incontrovertible case of collaborative care practice
(“if that’s not collaborative care, I don’t know what is!”)
B. List how that indubitable case could be changed and still be collaborative care
(“yes you can change X or delete Y and it’s still genuine collaborative care”)
C. Name the dimensions or parameters along which collaborative care practices can legitimately differ from one another.
(“our vocabulary for describing and evaluating acceptable variations among practice components”)
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Paradigm case: Collaborative care is. . .
1. A teamA. physician, psychologist, care managerB. Working in same spaceC. Having formal or informal job training for their rolesD. Working in one practice culture, eager to address biopsychosocial
– Transformations (acceptable differences)– T1. Change “family physician” to any other physician discipline– T2. Change “psychologist” to any other MH discipline– T3. Delete “care manager”– T4. Change “in one clinic” to multiple clinics and clinical partners– T5. Change “working in same space” to “set of working relationships…..”– T6. Change “single culture” to “commitment to building shared culture…”
2. With a shared population & missionE. Same panel of clinic pts, same mission of PC, assessment, tx, F/U
F. With BH clinician working under same mission and boundaries of PC
– Transformations (acceptable differences)– T7. Change “mission of PC” to any other area of medicine– T8. Change “identified w same panel of pts” to “any subset of pts. . . “
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Paradigm case: Collaborative care is. . .
3. Using a clinical systemG. Employing population level screening to identify who needs this collabH. Working form an explicit, unified care plan document w goals & rolesI. With care plans that pay attention to family, culture, lang., school etcJ. Contained in shared med record, with ongoing communic & SDM
– Transformations– T9. Change “population level screening” to “other form of ident. syst”– T10. Change “unified care plan doc” to info in separate record w comm”
– T11. Delete “patient-clinician decision-making” (SDM)
4. Supported by an office practice & financial systemK. Clinic ops systems & mgmt that supports communic, collab, care mgmtL. Sustainable package of financing e.g., single pool, bundled + FFS, PPF, etc
– Transformations– T12. Delete “office processes clear, effective & efficient as can be found”– T13. Delete / add any mode of financ. support as long as supports collab
– T14. Substitute “working toward sustainability” for “sustainable fin support”
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Paradigm case: Collaborative care is. . .
5. And continuous QI and effectiveness measurementM. Routine collection of use of practice data for local decision-making to improve your performance and
for research.
– Transformation– T15. Substitute “commitment & proposal for practice data collection. . .”
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Parameters of collaborative care practice (1)
2. Level of collaboration or integration
Coordinated--basic collaboration at a
distance
Co-located--basic collaboration on-site
Integrated--in partially or fully
integrated system
The team
Blount; Doherty, McDaniel & Baird
1. Team composition
PCP+ nurse/MA+ Care mgr
PCP+ nurse/MA+ care mgr+ consulting BH
PCP+ nurse/MA+ care mgr+ Integr BH
PCP+ nurse/MA+ care mgr+ integr BH+ other
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Parameters of collaborative care practice (2)
3. Target population
Primary medical care
Specialty medical care
Specialty MH care
With a shared population and mission
Children Adults Geriatrics End of life
Targetedspecific diseases, populations
Non-targetedAll comers
Mental health conditions
Psycho-physiological
symptoms
Medical / chronic
conditions
Complex cases of any kind
Stage of life
Kessler & Miller; Peek & Baird
Blount
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Parameters of collaborative care practice (3)
5. Program scale /maturity
Pilot: demo or test of change
Projectpilots rolled together
Mainstreamfull scale way of life
6. Level of pt centeredness / engagement
Little or nonechance--up to
individuals
Limitedsome systematic effort
By protocolbuilt into clinical
system
Using a clinical system
Davis (2001)
4. Method of population identification
Patient or clinician Patient or clinician+ system indicators
Patient or clinician+ universal screening
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Parameters of collaborative care practice (4)
9. Ability to collect and use practice data
Little or no routine data collected or
used
Commitment to building a system to collect & use data
Mature data collection and use in decision-making
Supported by an office practice and financial system
Reliability science & Lean concepts
7. Level of office practice design & reliability
Informalnon-standard processes vary by individual & day
Partially routinizedsome standards set for
some processes
Standard workWhole system
operates in standard expected way
8. Business model / financing
FFS only FFS + small bundled
care mgmt fee
Large bundled care mgmt fee +
small FFS
Separate MH and medical fund pools
One pool of funds for all medical or MH care
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“You cannot solve problems by continuing to use the same solutions that
created the problem in the first place.” -Albert Einstein
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What are the critical elements required in general practice to accomplish the desired outcomes?
Disease specific interventions within an organized care framework (e.g., Katon & Unutzer, 2006; Unutzer et al., 2002).
Practice guidelines; public health and professional society recommendations.
Broad implementation of research findings into practice.
Specificity Generalizability
Efficacy Comparative Effectiveness Translation Policy
Conceptual Model of the CCRN
The Domains of the CCRN
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If we had a moratorium we could do things including but not limited to…
• Real world EMR data on millions patients in real world settings under real world conditions
• Study of contextual factors critical to translation• Natural experiments-eg: tobacco progress• Simulation models- including economic• Multiple baseline across settings; replication designs,
regression discontinuity• The ultimate 'efficacy’ RCT- except with complex patients- N
of 1 research
• PRAGMATIC studies of stakeholders questions
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The Two Generations of Questions
Descriptive (Generation A): • What is currently occuring in collaborative care?• What are the elements, frequencies and
variations in practice models, target populations and other dimensions?
• Evaluative (Generation B): • What collaborative care arrangements work best
for whom?• What are the outcomes and the relationship of
varaitions to outcomes?
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Where am I?
You’re 30 yards above the ground
in a balloon
You must be a researcher
Yes. How did you know?
Because what you told me is absolutely
correct but completely useless
You must be a policy maker
Yes, how did you know?
Because you don’t know where you are, you don’t know where you’re going,
and now you’re blaming me
The problem
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References
• Peek, C.J. (2009). Toward a conceptual system for the field of collaborative care: A starter lexicon for the Collaborative Care Research Network (conference white paper)
• Ossorio P.G. (2006). Conceptual-Notational Devices. Chapter in The Behavior of Persons, The Collected Works of Peter. G. Ossorio, Vol V. Descriptive Psychology Press, Ann Arbor, MI
• The 1881 Electrical Congress of Paris. Nature 30, 26-27; 8 May 1884.