EVIDENCE BASED? PROVE IT! REAL WORLD STRATEGIES FOR SHOWING YOUR WORK…

WORKS!

Collaborative Family Healthcare Association 16th Annual ConferenceOctober 16-18, 2014 Washington, DC U.S.A.

Session G2bOctober 17, 2014

Jodi Polaha, Ph.D. Jennifer S. Funderburk, Ph.D.

Jeffrey L. Goodie, Ph.D., ABPP

Associate ProfessorDepartment of Psychology

East Tennessee State University

Center for Integrated Healthcare

Syracuse VA Medical Center

Department of Psychology, Syracuse University;

Department of Psychiatry, University of Rochester

CDR, USPHSAssociate ProfessorMedical & Clinical

Psychology Family Medicine

Uniformed Services University

Faculty Disclosure

We have not had any relevant financial relationships during the past 12 months.

Disclaimer: The views expressed in this presentation are solely those of the authors and do not reflect an endorsement by, or the official policy of, the U.S. Public Health Service, the Department of Health and Human Services, Department of Defense, the Veterans Affairs Administration, or the U.S. Government.

Learning Objectives

At the conclusion of this session, the participant will be able to:

• Identify factors to consider when developing and implementing research in primary care settings.

• Describe a framework for guiding implementation science.

• Implement lessons learned to their own research in collaborative care environments.

Why we need to show that our work ….works

• Buy In

• Build Up

• Back Translation

Proving it at the end point

Overview:

• Dr. Jeffrey Goodie: Weight loss in Primary Care: Lessons Learned

• Dr. Jodi Polaha: Demonstrating Traction at the End Point: A Model and an Example

• Dr. Jennifer Funderburk: Integration in a University Health System: An Example

• Audience practice and discussion

Can we effectively target weight loss in a primary care setting?

Purpose

• Enhance the identification of individuals who were overweight and obese in a primary care clinic

• Use a two-group design to examine whether providing specialized training and materials (Enhanced Care Group) increased weight loss beyond increasing attention to weight (Minimal Contact)

Setting

• Family Medicine Clinic• Lackland AFB, San Antonio, TX• Serving Active Duty, Family Members, and Retirees• 3 separate teams of providers

• 7 providers per team• Each provider worked with a nurse and technician• 2 teams randomly selected to provide enhanced care program;

remaining team provided minimal contact program• Participants received the treatment that their PCP was assigned

Procedures Training• Enhanced Care Providers (i.e., physicians, PAs, nurses)

• Discussed rationale for targeting weight• Provided specific instructions on how to initiate weight

conversations and how to begin to target weight• Provided w/ materials including handouts, calorie books,

pedometers

• Minimal Contact Providers• Discussed rationale for and value in targeting weight• Provided with general information (e.g., food pyramid)

ProceduresIdentification

• BMI charts placed by scales• Technicians trained to use BMI chart• Brochures placed in the charts of individuals identified as

overweight or obese• Brochure handed to patient by provider

• Instructed patients how to make a follow-up appointment, if they were interested

The Planned Procedure

Procedure

1 Y e a r F /U

A p po in tm en t 6

A p p in tm e n ts 4 -5

A p po in tm en t 3

A p po in tm en t 2

E CA p po in tm en t 1

1 Y ea r F /u

A p po in tm en t 6

A p po in tm e n t 4 -5

A p po in tm en t 3

A p po in tm en t 2

M CA p po in tm en t 1

In d en tifie d a s ove rw e igh t o r ob e se

Procedures Enhanced Care Group

• Appointment 1 (PCP 15 min; nurse 15 min)

• Complete paper work (ICD, demographics, binge eating screen)

• Set 10% weight loss goal in 6 months• Maintenance goal for 6 months• Discuss motivators and barriers• Provided w/ calorie book• Food diary for 12 days

• Appointment 2 (PCP 15 min; nurse 15 min)

• 2 – 4 weeks later• Review food diary and C.A.M.E.S.• Review barriers and motivators

ProceduresEnhanced Care Group

• Appointment 3 (PCP 15 min; nurse 15 min)• 2 – 4 weeks later• Discuss physical activity• Provided w/ pedometer

• Set baseline and increase by 10%• Appointment 4 – 5

• In clinic, phone, email• Review progress. Discuss barriers and motivators

• Appointment 6 (PCP 15 min; nurse 15 min)• Set maintenance goals

• 1 year follow-up

ProceduresMinimal Contact Group

• Appointment 1 (PCP 15 min; nurse 15 min)

• Complete paper work (ICD, demographics, binge eating screen)

• Discuss cutting calories and increased exercise• No specific tools or training provided for PCP• PCP could recommend any weight loss strategy

• Appointment 2 – 5 (PCP 15 min; nurse 15 min)

• Discuss any problems• Appointment 6

• Plan for 6 month maintenance• 1 Year follow-up

ProcedureParticipants

EC MC Total

N 32 27 59

Age (M yrs (SD)) 54 (10) 49 (14) 52 (12)

% Female 78% 74% 76%

Status Active Duty Family Member Retired

3%72%25%

7%67%26%

5%70%25%

Weight (M lbs (SD)) 213 (31) 206 (48) 210 (41)

No significant differences (α = .05) between groups

Results

EC MC F

# of clinic follow-up sessions

3.4 (2.4) 2 (1) 6.47 (p < .05)

• Insufficient data for meaningful analysis of weight change at the 6-month point

ResultsIndividuals Available for Follow-up at 1 Year

EC MC

N (% of original sample) 24 (75%) 13 (48%)

Age (M yrs (SD)) 56 (9) 56 (13)

% Female 75% 70%

Status Active Duty Family Member Retired

067%33%

8%54%39%

Initial Weight (M lbs (SD)) 208 (41) 204 (35)

Weight Change (M lbs (SD)) -11 (14)a -10 (19)

% Weight Change (M lbs (SD)) -5.8% (6.9%) -5.7% (9.4%)

a Significantly lower (p < .01) when comparing pre-weight and 1 yr f/u wt

% Weight Loss per Individual at 1 Year

-25

-20

-15

-10

-5

0

5

10

15

Weig

ht

Ch

an

ge (

%)

EC• MC

ResultsIntent to Treat Analysis

• Assuming that there was no change in weight for those who were not contacted• No significant difference between groups• Pre-weight and post-weight comparisons maintain the same

pattern

What did we learn about the effectiveness of targeting weight in primary care?

Challenges

• Maintaining • Provider & team adherence to plan• Follow-up appointments• Variable team involvement

• Researcher involvement• Deployment• Challenges of coordination• Challenges of oversight

• Turnover in clinic• Change in clinic structure

Lessons Learned• Preparation

• Review the literature: specialty care vs. primary care• What works?

• Buy in: bottom-up & top down• Consider the ethical guidelines

• Treatment Adaptation• Consider the feasibility of the design

• Primary care settings are sensitive to change• EVERY change can impact the process

• Treatment Implementation• Identify “Champion(s)”• Must be present• S#$t happens…develop redundancies

• Data Driven Process• Need a method for monitoring/informing progressGoodie et al. (2013)

Demonstrating Traction at the Endpoint

Damschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R., Alexander, J. A., & Lowery, J. C. (2009). Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science, 4, 1-50.

Demonstrating Traction at the Endpoint

Damschroder, et al. (2009).

1. PREPARATION

Preparation: Screening for Postpartum Depression

Inner and Outer Setting Individuals Involved

Demonstrating Traction at the Endpoint

Damschroder, et al. (2009).

2. TREATMENT ADAPTATION

Treatment Adaptation:Screening for Postpartum Depression

Demonstrating Traction at the Endpoint

Damschroder, et al. (2009).

3. TREATMENT IMPLEMENTATION

Treatment Implementation:Screening for Postpartum Depression

Demonstrating Traction at the Endpoint

Damschroder, et al. (2009).

4. DATA DRIVEN PROCESS

Data Driven Process:Screening for Postpartum Depression

1 3 5 7 9 11 13 15 17 190

5

10

15

20

WCC

DayNu

mb

er o

f C

od

es B

illed

Integrated Behavioral Health Program in a University Health Setting

• Preparation:• Setting• Champion: lead physician• Designed integrated PCBH model

• Treatment Adaptation• Identified objectives of the program

1) Improve patient access to behavioral health services, especially for students reporting subthreshold-severe symptoms during primary care visits

2) Provide a training opportunity for Advanced doctoral psychology students

3) Provide support to primary care teams necessary to help them implement the recommended screening for depression, alcohol misuse, tobacco use

• Piloted integrated PCBH model for three semesters

• Treatment Implementation/Data driven Process• Feedback from primary care staff, behavioral health providers, and

patients• Leadership meetings on regular basis• Semester meetings with staff/providers• Self-report autonomous surveys of patients and providers

• Created a process for collecting regular information about the program

Integrated Behavioral Health Program in a University Health Setting

Integrated Behavioral Health Program in a University Health Setting

Pt #Pt

Name

Date of

Visit

Schd appt (1) or Walk-

in (2)

Reason for Visit (dep, anx, adj,

sleep, tob, alc, other-describe) Age

Sex(F or M)

Race (Asian, Black,

Hispanic, Other, White)

Year(Fr, So, Jr, Sr, Grad)

Type of Follow-up Scheduled(in-person, telephone,

pt will call, n/a better,

n/a referred, declined)

Target Date for

Follow-up

Refto CC

Ref to

PSC

Conclusion• End point research and evaluation is important.• Simple, clinical process data can have significant value to

the field.• Use of a model helps increase traction, integrity of data,

and coalescence of data around a common concept.

Session Evaluation

Please complete and return theevaluation form to the classroom monitor before

leaving this session.

Thank you!

Bibliography / ReferenceWorksheet based on: Damschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R., Alexander, J. A., & Lowery, J. C. (2009). Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science, 4, 1-50.  Funderburk, J.S. & Fielder, R.L. (2013). A Primary Mental Health Care Model for Advanced Practicum Training in a University Health Clinic. Training and Education in Professional Psychology, 7(2), 112-122. Doi: 10.1037/a0032022 Funderburk, J.S., Fielder, R., DeMartini, K., and Flynn, C. (2012) Integrating Behavioral Health Services into a University Health Center: Patient and Provider Satisfaction, Families, Systems, and Health, 30(2), 130-140. doi: 10.1037/a0028378  Polaha, J. & Nolan (2014). Dissemination and implementation science: research for the real world medical family therapist. In J. Hodgson, T. Mendenhall, & A. Lamson (Eds). Medical Family Therapy. Switzerland: Springer International.

Learning Assessment

• A learning assessment is required for CE credit.

• A question and answer period will be conducted at the end of this presentation.