Amy M. Bauer

Aligning health information technologies with effective service delivery models to improve chronic disease care

OBJECTIVE Healthcare reforms in the United States, including the Affordable Care and HITECH Acts, and the NCQA criteria for the Patient Centered Medical Home have promoted health information technology (HIT) and the integration of general medical and mental health services. These developments, which aim to improve chronic disease care, have largely occurred in parallel, with little attention to the need for coordination. In this article, the fundamental connections between HIT and improvements in chronic disease management are explored. We use the evidence-based collaborative care model as an example, with attention to health literacy improvement for supporting patient engagement in care. METHOD A review of the literature was conducted to identify how HIT and collaborative care, an evidence-based model of chronic disease care, support each other. RESULTS Five key principles of effective collaborative care are outlined: care is patient-centered, evidence-based, measurement-based, population-based, and accountable. The potential role of HIT in implementing each principle is discussed. Key features of the mobile health paradigm are described, including how they can extend evidence-based treatment beyond traditional clinical settings. CONCLUSION HIT, and particularly mobile health, can enhance collaborative care interventions, and thus improve the health of individuals and populations when deployed in integrated delivery systems.

Use of mobile health (mHealth) tools by primary care patients in the WWAMI region Practice and Research Network (WPRN).

Purpose: The purpose of this study was to determine the prevalence of mobile health (mHealth) use among primary care patients and examine demographic and clinical correlates. Methods: Adult patients who presented to 1 of 6 primary care clinics in a practice-based research network in the northwest United States during a 2-week period received a survey that assessed smartphone ownership; mHealth use; sociodemographic characteristics (age, sex, race/ethnicity, health literacy); chronic conditions; and depressive symptoms (2-item Patient Health Questionnaire). Data analysis used descriptive statistics and mixed logistic regression. Results: Of 918 respondents (estimated response rate, 67.4%), 55% owned a smartphone, among whom 70% were mHealth users. In multivariate analyses, smartphone ownership and mHealth use were not associated with health literacy, chronic conditions, or depression but were less common among adults >45 years old (adjusted odds ratio, 0.07–0.39; P < .001). Only 10% of patients learned about mHealth tools from their physician, and few (31%) prioritized their providers involvement. Conclusions: Use of mHealth technologies is lower among older adults but otherwise is common among primary care patients, including those with limited health literacy and those with chronic conditions. Findings support the potential role of mHealth in improving disease management among certain groups in need; however, greater involvement of health care providers may be important for realizing this potential.

Associations of physical symptoms with perceived need for and use of mental health services among Latino and Asian Americans

Although many believe that low rates of perceived mental health need and service use among racial/ethnic minorities are due, in part, to somatization, data supporting this notion are lacking. This study examined two hypotheses: (1) increased physical symptoms are associated with lower perceived need for mental health services and actual service use; and (2) physical symptoms are most strongly associated with perceived mental health need and service use among first-generation individuals. Data come from the National Latino and Asian-American Study, a nationally-representative household survey in the United States conducted from 2002 to 2003. Participants reported on the presence of fourteen physical symptoms within the past year. Perceived mental health need was present for individuals who endorsed having an emotional or substance use problem or thinking they needed treatment for such a problem within the past year. After adjusting for sociodemographic and clinical covariates, the number of physical symptoms was positively associated with perceived mental health need and service, an effect that differed by generation. Among first-generation individuals, physical symptoms were associated with increased perceived need and service use. Physical symptoms were not significantly associated with perceived need or service use among third-generation Latinos, but were associated with service use among third-generation Asian-Americans. Physical symptoms do not appear to interfere with mental health problem recognition or service use. In contrast, individuals, especially of the first-generation, with more physical symptoms were more likely to perceive need for and utilize mental health services. Our findings do not support the notion that physical symptoms account for low rates of perceived mental health need and service use among Latino and Asian-Americans.

Opioid poisonings in Washington State Medicaid: trends, dosing, and guidelines.

Background:Opioid poisonings have increased as use of prescription opioid medications have increased. To reduce these poisonings, guidelines for chronic opioid use have been implemented. However, if opioid poisonings occur in individuals who do not have high prescribed doses and who are not chronic opioid users, the current guidelines may need revision. Objectives:To examine changes in rates of methadone and other opioid poisonings after implementation of the WA State Opioid Guideline in 2007 and to examine the prescription history before poisonings. Methods:The study sample consisted of individuals who had at least 1 paid claim for an opioid prescription in the Medicaid fee-for-service system between April 2006 and December 2010 and had an emergency department or inpatient hospital claim for an opioid poisoning. Results:Methadone poisonings occurred at 10 times the rate of other prescription opioid poisonings and increased between 2006 and 2010. Rates of other prescription opioid poisonings appeared to level off after implementation of the WA opioid guideline in 2007. Among individuals with nonmethadone opioid poisonings, only 44% had chronic opioid use, 17% had prescribed doses in the week before the poisoning >120 mg/d morphine-equivalent dose (MED), 28% had doses <50 mg/d MED, and 48% had concurrent sedative prescriptions. Conclusions:It may be prudent to revise guidelines to address opioid poisonings occurring at relatively low prescribed doses and with acute and intermittent opioid use. Research is needed to establish the best strategies to prevent opioid poisonings.

Integrating Behavioral Health into Primary Care

Abstract Depression is one of the more common diagnoses encountered in primary care, and primary care in turn provides the majority of care for patients with depression. Many approaches have been tried in efforts to improve the outcomes of depression management. This article outlines the partnership between the University of Washington (UW) Neighborhood Clinics and the UW Department of Psychiatry in implementing a collaborative care approach to integrating the management of anxiety and depression in the ambulatory primary care setting. This program was built on the chronic care model, which utilizes a team approach to caring for the patient. In addition to the patient and the primary care provider (PCP), the team included a medical social worker (MSW) as care manager and a psychiatrist as team consultant. The MSW would manage a registry of patients with depression at a clinic with several PCPs, contacting the patients on a regular basis to assess their status, and consulting with the psychiatrist on a weekly basis to discuss patients who were not achieving the goals of care. Any recommendation (eg, a change in medication dose or class) made by the psychiatrist was communicated to the PCP, who in turn would work with the patient on the new recommendation. This collaborative care approach resulted in a significant improvement in the number of patients who achieved care plan goals. The authors believe this is an effective method for health systems to integrate mental health services into primary care. (Population Health Management 2016;19:81–87)

Effectiveness of the Engagement and Counseling for Latinos (ECLA) Intervention in Low-income Latinos

Background:Persistent disparities in access and quality of mental health care for Latinos indicate a need for evidence-based, culturally adapted, and outside-the-clinic-walls treatments. Objective:Evaluate treatment effectiveness of telephone (ECLA-T) or face-to-face (ECLA-F) delivery of a 6–8 session cognitive behavioral therapy and care management intervention for low-income Latinos, as compared to usual care for depression. Design:Multisite randomized controlled trial. Setting:Eight community health clinics in Boston, Massachusetts and San Juan, Puerto Rico. Participants:257 Latino patients recruited from primary care between May 2011 and September 2012. Main Outcome Measures:The primary outcome was severity of depression, assessed with the Patient Health Questionnaire-9 and the Hopkins Symptom Checklist-20. The secondary outcome was functioning over the previous 30 days, measured using the World Health Organization Disability Assessment Schedule (WHO-DAS 2.0). Results:Both telephone and face-to-face versions of the Engagement and Counseling for Latinos (ECLA) were more effective than usual care. The effect sizes of both intervention conditions on Patient Health Questionnaire-9 were moderate when combined data from both sites are analyzed (0.56 and 0.64 for face-to-face and telephone, respectively). Similarly, effect sizes of ECLA-F and ECLA-T on the Hopkins Symptom Checklist were quite large in the Boston site (0.64 and 0.73. respectively) but not in Puerto Rico (0.10 and 0.03). Conclusions and Relevance:The intervention appears to help Latino patients reduce depressive symptoms and improve functioning. Of particular importance is the higher treatment initiation for the telephone versus face-to-face intervention (89.7% vs. 78.8%), which suggests that telephone-based care may improve access and quality of care.

Tackling the global mental health challenge : a psychosomatic medicine/consultation-liaison psychiatry perspective

Background Consultation–liaison (C–L) psychiatry, informed by principles of psychosomatic medicine, is well-positioned to address the global impact of mental disorders through primary care C–L models. Objective/Method The authors review the international burden of mental disorders, highlighting medical comorbidity, undertreatment, and the rationale for enhancing primary-care management. Results C–L psychiatry fosters the skills required for global mental health work. The authors describe successful C–L models developed in a low-income country (Ethiopia) and an under-resourced region of a high-income country (Australia). Conclusion C–L psychiatrists have the potential to marshal their unique skill-set to reduce the global burden of mental disorders.

Are patient characteristics associated with quality of depression care and outcomes in collaborative care programs for depression

OBJECTIVE To determine whether demographic or clinical characteristics of primary care patients are associated with depression treatment quality and outcomes within a collaborative care model. METHODS Collaborative depression care, based on principles from the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) trial, was implemented in six community health organizations serving disadvantaged patients. Over 3 years, 2821 patients were treated. Outcomes were receipt of quality treatment and depression improvement. RESULTS Logistic regression analyses revealed that patients who were older, more depressed or more anxious were more likely to be retained in treatment and to receive appropriate pharmacotherapy. Whereas gender and depression severity were unrelated to depression outcomes, significantly more patients who preferred Spanish (59.1%) than English (48.5%, P<.01) improved within 12 weeks in multivariate analyses. High baseline anxiety was associated with a lower probability of improvement, and older age showed a similar trend. Survival analyses demonstrated that patients who preferred Spanish or were less anxious improved significantly more rapidly than their counterparts (P<.001). CONCLUSIONS Patients with more anxiety received higher quality care but experienced worse depression outcomes than less anxious patients. Spanish language preference was strongly associated with depression improvement. This collaborative care program attained admirable outcomes among disadvantaged Spanish-speaking patients without extensive cultural tailoring of care.

Variations in depression care and outcomes among high-risk mothers from different racial/ethnic groups.

UNLABELLED PURPOSE. To examine variations in depression care and outcomes among high-risk pregnant and parenting women from different racial/ethnic groups served in community health centres. METHODS As part of a collaborative care programme that provides depression treatment in primary care clinics for high-risk mothers, 661 women with probable depression (Patient Health Questionnaire-9 ≥ 10), who self-reported race/ethnicity as Latina (n = 393), White (n = 126), Black (n = 75) or Asian (n = 67), were included in the study. Primary outcomes include quality of depression care and improvement in depression. A Cox proportional hazard model adjusting for sociodemographic and clinical characteristics was used to examine time to treatment response. RESULTS We observed significant differences in both depression processes and outcomes across ethnic groups. After adjusting for other variables, Blacks were found to be significantly less likely to improve than Latinas [hazard ratio (HR): 0.53, 95% confidence interval (CI): 0.44-0.65]. Other factors significantly associated with depression improvement were pregnancy (HR: 1.52, 95% CI: 1.27-1.82), number of clinic visits (HR: 1.26, 95% CI: 1.17-1.36) and phone contacts (HR: 1.45, 95% CI: 1.32-1.60) by the care manager in the first month of treatment. After controlling for depression severity, having suicidal thoughts at baseline was significantly associated with a decreased likelihood of depression improvement (HR: 0.75, 95% CI: 0.67-0.83). CONCLUSIONS In this racially and ethnically diverse sample of pregnant and parenting women treated for depression in primary care, the intensity of care management was positively associated with improved depression. There was also appreciable variation in depression outcomes between Latina and Black patients.

Depression care and treatment in a chronically ill Medicare population

OBJECTIVE The purpose of this study is to examine depression care among chronically ill Medicare Advantage beneficiaries. METHODS This study includes 5898 Medicare Advantage members with a depression diagnosis enrolled between 2008 and 2010 in a care management program. Two depression care indicators were created: (a) any depression care (≥ 1 antidepressant prescription or ≥ 1 specialty mental health visit) and (b) among those receiving any depression care, those receiving an antidepressant prescription for ≥ 90 days or ≥ 2 specialty visits. Multivariable analysis using logistic regression was used to examine correlates of depression care. RESULTS Among those <65 years old, 72% received any depression care with 75% receiving ≥ 90 days of an antidepressant and/or ≥ 2 specialty visits. Among ≥ 65 years old, 65% received any depression care with 67% receiving ≥ 90 days of an antidepressant and/or ≥ 2 specialty visits. For both age groups, female gender, medical comorbidities and dual eligibility were positively associated with an antidepressant prescription. In the older group, female gender was positively associated with at least a 90-day supply of an antidepressant prescription, while substance use disorders were negatively associated with receiving a minimum of 90 days of an antidepressant. Regional differences and certain psychiatric comorbidities were also associated with receiving depression care. CONCLUSION Two thirds of the depressed patients in this Medicare Advantage population received depression care. Further studies are needed to examine the effects of quality improvement efforts in the context of care management programs for chronically ill older adults.