1. Degree of Integration of Behavioral Health: Does it Impact Patient Outcomes? Rachel Valleley, PhD, Associate Professor Jennifer Burt, PhD, Assistant Professor Blake Lancaster, PhD, Assistant Professor Tawnya Meadows, PhD Shelley Hosterman, PhD, Monika Parikh, PhD Jessica Sevecke, PhD Collaborative Family Healthcare Association 17 th Annual Conference October 15-17, 2015 Portland, Oregon U.S.A. Session # F2b, 58090000 October 16th, 2015

2. Faculty Disclosure The presenters of this session have NOT had any relevant financial relationships during the past 12 months.

3. Learning Objectives At the conclusion of this session, the participant will be able to: Identify simple data collection procedures to measure patient outcomes. Compare patient outcomes based upon degree of integration. Discuss implications of degree of integration on patient outcomes.

4. Bibliography / Reference McDaniel, S., & deGruy, F. (2014). An introduction to primary care and psychology. American Psychologist, 69, 325-331. Merikangas, K., He, J., Burstein, M., Swanson, S., Avenevoli, S., Cui, L., Benjet, C., Georgiades, K., & Swendsen, J. (2010). Lifetime prevalence of mental disorders in US adolescents: Results from the National Comorbidity Study-Adolescent Supplement (NCS-A). Journal of American Academy of Child and Adolescent Psychiatry, 49, 980-989. Miller BF, Kessler R, Peek CJ., Kallenberg, GC. Establishing the research agenda for collaborative care. AHRQ Publication No. 11-0067. Rockville, MD: Agency for Healthcare Research and Quality. June 2011. Stancin, T., & Perrin, E. (2014). Psychologists and pediatricians: Opportunities for collaboration in primary care. American Psychologist, 69, 332-343. Asarnow, J.R., Rozenman, M., Wiblin, J., & Zeltzer, L. (2015). Integrated medical- behavioral care compared with usual primary care for child and adolescent behavioral health: A meta-analysis. JAMA Pediatrics, doi:10.1001/jamapediatrics.2015.1141.

5. Learning Assessment A learning assessment is required for CE credit. A question and answer period will be conducted at the end of this presentation.

6. Acknowledgements Munroe-Meyer Institute, UNMC: Katy Menousek, Becky Gathje, Kristen Carson, Kenya Makhiawala, Haley York, Jonathon Ortega, Heather Unrue, Jennifer Kennedy, Kenneth Shamlian, Brandon Rennie, Gail Robertson University of Michigan Health System: Rachel Knight, Andrew Cook, Jessica Sevecke, Hannah Ham Geisinger Health System: Vanessa Pressimone, Laura Cook, Jessica Sevecke, Laura Kise

7. Background and Significance Behavioral health services are a vital resource to help meet a significant public health need Primary care physicians are the de facto first line mental health providers in the pediatric population Primary care physicians have little training, short time, and are not reimbursed for BH Few with BH concerns receive BH care

8. Solution: Integrated Care Referring patients off-site has many pitfalls – Poor treatment initiation rates – Lack of communication/coordination between providers Models of care range from – Traditional: PCP and mental health professional located at different sites – Co-located: Behavioral health providers and PCPs located in the same practice – Collaborative: Greater degree of coordinated patient care – Integrated Care: Tightly integrated, on-site teamwork between behavioral health providers and PCPs resulting in a unified treatment plan, BH available to all (Blount, 2003; Stancin & Perrin, 2014)

9. Establishing Effective and Efficient Practice

10. Triple Aim

11. Degree of Integration? Integration of BH into PC works, HOWEVER, cannot determine what model for what population for what condition works best (Butler, Kane, McAlpin, et al., 2008) Call specifically for research to determine if there are differential effects of the level of integration on the triple aim clinical, operational and financial outcomes (Miller, Kessler, Peek, & Kallenberg 2011) The goal for this study is to determine whether the level of integration of behavioral health services in a primary care setting impact patient outcomes

12. Specific Objectives Differences in the following variables based upon the level of integration: – Treatment initiation – Number of sessions attended – Adherence to recommendations – Improvement in symptoms Determine if differences exist dependent on the following variables: – Age of patient – Gender – Diagnosis – Symptom severity – Insurance (i.e., private vs. public) – Rural/urban – Number of years BH provider on site

13. Geisinger’s Pediatric Integrated Model First clinics established in 2011 4 clinics (family practice, pediatrics, pediatric residency clinic) Significant expansions planned over the next year 4 adult primary care clinics Each clinic has BH coverage 5 days a week with on-site staff Shared EPIC EMR Verbal Consults WHO Centralized authorization and billing Schedule templates 6-7 billable units a day (Family, individual, group) Limited session model Gaps in schedule for integrated activities

15. Michigan’s Integrated Model 1 st clinic established in 2012 Currently have 2 integrated clinics within the 9 General Pediatric Clinics in the University of Michigan Health System. Services offered 3-4 days a week at PC settings Share EPIC electronic medical records system Verbal consults with pediatricians as needed Centralized authorization and billing

17. Nebraska’s Integrated Model 1 st clinic established in 1997 Currently have 33 integrated clinics across Nebraska Services offered 2-3 days a week at PC settings Provide copies of all contact notes Verbal consults as needed Warm Hand-Offs Fee for service, handled by MMI

19. Methods Eligibility Any child or adolescent referred from on site PCP for initial appointment between November 2014 and April 2015 Any previously seen child or adolescent returning for services after a year or longer Between November 2014 and May 2015

20. Clinic Demographics Clinic 1 NE Clinic 2 NE Clinic 3 NE Clinic 4 NE Clinic 5 MI Clinic 6 MI Clinic 7 PA Clinic 8 PA Clinic 9 PA BH Days per week 22.53434555 BH Years8717731444 # of PCPs FT/PT 6/25/02/011/04/16/35/0 2/3 PCP TypePeds Both Peds FP Peds LocationSuburbanUrbanRural Suburban Rural Site Self Assess. Score 8011993879899135 109

21. Patient Demographics Total Clinic 1 NE Clinic 2 NE Clinic 3 NE Clinic 4 NE Clinic 5 MI Clinic 6 MI Clinic 7 PA Clinic 8 PA Clinic 9 PA N74656857752131129557982 Mean Age9.28.349.018.775.49.99.7610.029.549.9 Male Number % 424 56.8% 31 55.4% 35 41.2% 53 68.8% 39 75% 74 56.5% 82 63.6% 27 49.1% 39 49.4% 44 53.7% Insurance %Private %Public %Both % None 66.6% 31.2% 1.1%.7% 80% 18.2% 1.8% 0% 56.5% 43.5% 0% 50.6% 49.4% 0% 42.3% 51.9% 0% 5.8% 55.7% 38.2% 5.3%.8% 76% 23.3% 0% 96.4% 3.6% 0% 74.7% 25.3% 0% 76.3% 23.8% 0%

22. Independent Variable Site Self Assessment Evaluation Tool 18-item site self-assessment looking at the site’s currently available integrated services for patient/family centered care and the organizational supports for practice change toward integrated services 1-10 Likert Scale

23. Sample item 1. Co-location of treatment for primary care and mental/behavioral health care – 1= does not exist, consumers go to separate sites for services – 5= is partially provided; multiple services are available at same site; some coordination of appointments and services – 10= exists, with one reception area; appointments jointly scheduled; one visit can address multiple needs

24. Dependent Measures Treatment initiation Number of sessions attended Number of sessions cancelled/ no showed Adherence with treatment recommendations – Homework completion, clinician rating of adherence Clinical Global Impression - Improvement scale (CGI-I) Clinician Parent And/or youth rating

25. Homework returned Completed for at least 75% of days/opportunities Completed for at least 50% of days/opportunities Completed for at least 25% of days/opportunities Completed less than 25% of days/opportunities Not completed at all Not applicable

26. Report of homework completion Every day/opportunity Most days/opportunities Half of the time A couple times Not at all

27. Adherence with recommendations Excellent (70% or greater of recommendations followed as intended either determined by verbal description of following recommendations and/or demonstration in session of skills) Moderate (31-69% of recommendations followed as intended either determined by verbal description of following recommendations and/or demonstration in session of skills) Poor (30% or less, Tried to follow recommendations but inaccurate in delivery, not following procedures as intended, didn’t implement recommendations)

28. The Clinical Global Impression - Improvement scale 1= very much improved (nearly all better; good level of functioning; minimal symptoms; represents a very substantial change) 2 = much improved (notably better with significant reduction of symptoms; increase in the level of functioning but some symptoms remain) 3= minimally improved (slightly better with little or no clinically meaningful reduction of symptoms. Represents very little change in basic clinical status, level of care, or functional capacity) 4= no change (symptoms remain essentially unchanged) 5= minimally worse (slightly worse but may not be clinically meaningful; may represent very little change in basic clinical status or functional capacity) 6= much worse (clinically significant increase in symptoms and diminished functioning) 7= very much worse (severe exacerbation of symptoms and loss of functioning)

29. Procedure Research team met prior to study initiation to operationally define adherence to recommendations and CGI-I ratings Site Self Assessment completed in research meeting in November 2014 Clinicians across clinics inputted variables into EHRs Data extracted from EHRs

30. Treatment Brief, problem-focused treatment Behavior problems Anxiety Depression ADHD Adjustment

31. Reliability Percentage of agreement between two independent raters was calculated for the following variables: Data returned: 87.2% Parent report of homework completed: 75.2% Clinical impression of adherence: 79.5% Clinician impression of improvement in symptoms (CGI): 79.5% Note: Due to limitations (e.g., only one provider present at visit), reliability data was only calculated for patients at 4 (clinics 1-4) of the 9 participating clinics.

32. Service Use Total Clinic 1 NE Clinic 2 NE Clinic 3 NE Clinic 4 NE Clinic 5 MI Clinic 6 MI Clinic 7 PA Clinic 8 PA Clinic 9 PA % at 1 st appt. 85.5%89.3%89.4%94.8%88.5%64.9%82.2%87.3%93.7%97.6% % of 1 st BH users 82.7%90%78.6%66.7%75%96.5%99.1%74.5%73.4%70.7% Sessions Mean Range 2.9 1-12 3.5 1-8 3.0 1-11 2.2 1-8 3.6 1-8 2.7 1-8 2.6 1-11 4.4 1-10 2.7 1-12 2.6 1-11 *Failed Appt Mean Range 1.6 0-13 1.2 0-4 1.0 0-8.7 0-4 1.7 0-5 1.7 0-6 1.5 0-6 2.9 0-9 2.0 0-13 2.0 0-9 Most Common Problem BX 33.8% BX 40% BX 42.1% BX 59.5% BX 78.3% Adj 55.3% Adj 51.9% BX 30.9% BX 29.1% Adj 36.6% * Significant differences found for failed appointments between states PA sites had significantly more failed appointments than NE (p<.001) and MI (p=.02). MI had significantly more failed appointments than NE (p<.001)

33. Descriptive Results

34. CBCL T-scores: 1 1/5-5 yrs.

35. CBCL T-scores: 6-18 yrs.

36. Descriptive Results

39. Data Analysis and Results Logistic Regression – Does the degree of integration in IPC predict treatment initiation? Yes: For every 1 unit increase in integration, patients were 1.014 times more likely to attend their initial BH appointment (p=.03) – Does age predict treatment initiation? Yes: Patients were 1.05 times more likely to attend their initial BH appointment for every.05 years younger the patient (p=.03) – Does number of years patient has seen their PCP predict treatment initiation? No (p=.24)

40. Data Analysis and Results Multiple regression analyses: Does the degree of integration in IPC predict: Number of sessions attended? No (p=.19) Adherence to treatment recommendations? Yes: For report of HW completed and clinician rating of adherence For every 1 unit increase in integration, patient report of completing recommendations reduced by.012 units, F(1,362) = 13.06, p<.001, R 2 =.04 For every 1 unit increase in integration, clinician rating of patient adherence reduced by.004 units, F(1,385) = 4.48, p=.04, R 2 =.01 No: For patient return of data (p =.91) Improvement in symptoms? No: For clinician (p=.68), parent (p=.91), or patient (p=.93)

41. Data Analysis and Results Analysis of variance: Does diagnostic category predict: Adherence to treatment recommendations? –Yes: Families of children with behavior disorders were significantly more likely to return data than families of children with adjustment disorders (p=.02) or ADHD (p=.03), F(1,5)=3.54, p=.004, ƞ 2 =.06 –Families of children with behavior disorders were significantly more likely to report completing homework than families of children with ADHD (p=.01), F(1,5)=3.18, p=.008, ƞ 2 =.04

42. Data Analysis and Results Improvement in symptoms? Yes: For clinicians and parents (not for patient) Clinicians: CGI [F(5,375)=6.38, p<.001, ƞ 2 =.08] Anxiety, adjustment, and other disorders were rated to be more improved than conduct disorders Parent [F(5,324)=7.38, p<..001, ƞ 2 =.10] Anxiety, depression, adjustment disorders, and other disorders were rated to be more improved than conduct disorders Anxiety also rated to be more improved than ADHD Chi Square analysis: Does diagnostic category predict treatment initiation? –No [Χ 2 (5, N=653)=5.67, p=.33]

43. Discussion Increased integration improves treatment initiation but decreased adherence Clinics with higher integration do more warm hand offs Less effort on patient to get in May not be as motivated for services (higher no show rates) More likely to come in when children younger Adolescents may refuse to come in Adolescents could be more severe and go to more specialized care

44. Discussion Most patients experienced symptom improvement according to all raters regardless of level of integration Families with children with behavior problems more likely to do homework but had lower ratings for improvement Diagnostic category did not predict treatment initiation

45. Limitations Reliability data limited CAUTION: These were preliminary analyses. Data needs to be transformed to adjust for normality

46. Conclusion The more integrated BH is in primary care, the more likely a child or adolescent is going to receive services However, access to BH treatment is higher than traditional models for all degrees of integration Most patients have improvement in symptoms when accessing integrated BH regardless of the degree of integration

47. Session Evaluation Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you!