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#MHMSiTexas Tale of 8 Cities Continued: Preliminary Results from Evaluating Integrated Behavioral Health
#MHMSiTexas
Tale of 8 Cities Continued:
Preliminary Results from Evaluating Integrated Behavioral Health
#MHMSiTexas
What is Integrated Care?
#MHMSiTexas
#MHMSiTexas
The integrated behavioral health model incorporates enhanced primary and behavioral care, medication therapy management, community-based lifestyle programs, and teams of community health workers to conduct home visits. The key to integration is ongoing, systematic communication between hospital, clinic, mental health case managers, and the team of community health workers who provide services to participants in their homes and at community based educational sessions.
#MHMSiTexas
Study Question & Design
#MHMSiTexasRandomized Controlled Trial
#MHMSiTexasDetails of Sample at Baseline
353 Study Participants
176 Intervention/177 Control
PHQ-9 Quality of Life BMI HbA1cBlood Pressure
5.5 General Health = 67.3
Mental Health = 78.5
Physical Health = 55.2
33.3 10.4Systolic = 136.1
Diastolic = 79.8
** Represents averages of full sample **
#MHMSiTexas
** Represents percentages of full sample **
Female
Spanish Speaking
70.5%Graduated from
High School
Private PayEmployed
67.7%
39.3%
8.2%10.4%
Details of Sample at Baseline
#MHMSiTexas
Reverse Co-location
Integrated Behavioral Health (IBH) Model
#MHMSiTexas
Through the Si Texas project, Tropical Texas Behavioral Health is implementing a Reverse Co-location Integrated Behavioral Health Model.
The approach is called “reverse co-location” as it is more common to integrate mental health providers into a primary care setting than to integrate primary care into a mental health setting.
Primary care services are delivered to clients with severe and persistent mental illness (SPMI) from a primary care clinic co-located within the behavioral health clinic.
Reverse Co-location
Integrated Behavioral Health (IBH) Model
#MHMSiTexas
Study Question & Design
#MHMSiTexasRandomized Controlled Trial
#MHMSiTexas
#MHMSiTexas
Number of Participants: 417
250 in intervention group and 167 in control group
Race93.5% WhiteEthnicity92.6% HispanicAge18-24 11.5%25-34 22.8%35-44 26.9%45-54 22.8%55-64 12.9%65+ 3.1%
Gender
55.4 % Female / 44.6% Male
Primary Language
68.1 % English / 31.7% Spanish
Employment Status
54.2% reported having severe problems with employment
Education
Below High School 18.5%
Some High School 38.0%
GED/HS Grad/Some College 33.9%
Associates/Bachelor Degree 5.5%
Details of Sample at Baseline
#MHMSiTexas
HBA1C
• Full Sample 6.2%
• Intervention Group 6.3%
• Control Group 6.1%
BMI
Full Sample 33.8
Intervention Group 34
Control Group 34
Mean Cholesterol
Full Sample 186.9
Intervention Group 188.2
Control Group 185.0
Blood Pressure
• Full Sample 127.2/78.9
• Intervention Group 125.5/79
• Control Group 129.6/79
PHQ-9 Score
Full Sample 11.8
Intervention Group 12
Control Group 12
ANSA Life Functioning
Full Sample 2.8 Domains
Intervention Group 3 Domains
Control Group 3 Domains
Details of Sample at Baseline
#MHMSiTexas
Primary Care Behavioral Health Model
#MHMSiTexas
Mercy
• Primary Care Behavioral Health Model (SAMHSA)
• Started at Levels 3-4 of Integration
• Ultimate goal is a Level 5 of Integration
Primary Care Behavioral Health Model
#MHMSiTexas
Mercy
Study Question & Design
#MHMSiTexasRandomized Controlled Trial
#MHMSiTexas
Mercy
#MHMSiTexas
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Alcohol
Smoking
Married
Language
Employment
Age
Ethnicity
Sex Female
Hispanic
<44
Unemployed
Spanish
Married
Non-smoker
Non-drinker
411
Details of Sample at Baseline
#MHMSiTexas
42 6 5 .2 7.3 71125/
74
BMI W/C PHQ-9 GAD 7 CAGE HbgA1C DUKE B/P
MEAN BASELINE
32.9
Details of Sample at Baseline
#MHMSiTexas
Primary Care Behavioral Health
To improve and promote overall healthwithin the general population
#MHMSiTexas
Study Question & Design
#MHMSiTexasQuasi-experimental design
#MHMSiTexasQuasi-experimental design
#MHMSiTexas
69.7%FEMALE
SPANISH SPEAKING
44.3%
47.5%UNEMPLOYED
40.3%COMPLETED LESS THAN
HIGH SCHOOL366 ENROLLED
62.8%HISTORY OF OBESITY
AGE RANGE
31 - 59
PRIVATE PAY
48.4%
SMOKERS
21.8%
NO PHYSICAL ACTIVITY
41.1%
AVERAGE PHQ-9 SCORE
11.60AVERAGE GAD-7 SCORE
10.24
PHYSICAL: 40.10MENTAL: 57.70
33.43AVERAGE BMI
AVERAGE DUKE HEALTH
PROFILE SCORES
SOCIAL: 60.90GENERAL: 53.20
Details of Sample at Baseline
#MHMSiTexas
Disease Management Model
#MHMSiTexas
Disease Management Model
• Preventive Care Management Unit is implemented in 2 outpatient Clinics [primary health and behavioral – mental health and substance abuse]
• Adapt elements of the evidence based DCM with assistance from network providers and TAMIU research team.
• DCM will allow us to increase access, fast track referrals, improve compliance, educate the population and further integrate behavioral health into the medical disease management processes.
#MHMSiTexas
Study Question & Design
#MHMSiTexas
Randomized Controlled Trial
#MHMSiTexas
#MHMSiTexas
≤ 34
≤ 34 ≤ 34
35-4
4
35-4
4
35-4
4
45-
54
45-
54
45-
5455-6
4
55-6
4
55-6
4
65+
65+
65+
%
10%
20%
30%
40%
Full Sample InterventionGroup
Control Group
Age
MaleFemale
0% 20% 40% 60% 80%
Full Sample
Intervention Group
Control Group
Sex
Full Sample
97%Hispanic
61.60%
Education - Full Sample
Less than high school Associates degree
Bachelor’s degree High school diploma
Master’s degree Some college
Details of Sample at Baseline
#MHMSiTexas
Full Sample Intervention Group Control Group
(n=590) (n=298) (n=292)
Measure Mean (SD) Mean (SD) Mean (SD)
HbA1c 8.70 (1.9) 8.70 (1.9) 8.70 (1.9)PHQ-9 Score 4.70 (5.1) 4.40 (4.0 5.00 (5.2)BMI 32.20 (6.6) 32.50 (6.9) 31.80 (6.2)Systolic 134.30 (19.1) 133.90 (18.7) 134.70 (19.6)Diastolic 77.90 (10.7) 78.20 (10.4) 77.70 (11.0)General Health (Duke HP) 73.00 (17.9) 73.80 (17.1) 72.10 (18.8)
Baseline
Details of Sample at Baseline
#MHMSiTexas
#MHMSiTexas
585 Patients
DESIGN
POPULATION SIZEPopulation
#MHMSiTexasIntegration Model
8.0% 30 140/90 10
Duke ProfilePHQ9
#MHMSiTexas
BMI
BP
A1C
PHQ9
General Health Score
Employment Status
Insurance Status
35.6
133.6/81.5
7.7
6.1
65.4 (100 best score)
Unemployed99.3%
Uninsured100%
Age 51
Ethnicity Hispanic
Meet Dean
#MHMSiTexasPopulation Data
35.6
133.6
81.5
6.1 7.7
65.4
98.8 100
51
0
20
40
60
80
100
120
140
160
Type 2 Obese
Pre-hypertensive
Duke
Below uncontrolled
diabetesMild
Depression
#MHMSiTexas
NCDV NuCare program combines components from two evidence based models
• Integrated Care Model -Druss et al. (2001)
• Collaborative Care Model – Sanchez & Watt (2012)
Veronica Gonzalez, M.S.,LPC- Project LeadMelinda Melo, Project Coordinator
#MHMSiTexas
#MHMSiTexas
#MHMSiTexasIntervention Site- Mission NCDV Total Enrolled Participants-323Comparison Site- Memorial NCDV Total Enrolled Participants-233
Averages of Key Outcomes in Sample
PHQ-9, HbA1c, Body Mass Index (BMI), Quality of Life, Blood Pressure
Mission Memorial
PHQ-9: 5.1
HbA1c: 8.6
BMI: 33.3
Quality of Life
General Health Score: 71.7
Mental Health Score: 82.1
Physical Health Score: 60.4
Blood Pressure
Systolic: 133.2
Diastolic: 77.0
PHQ-9: 3.5
HbA1c: 8.5
BMI: 33.5
Quality of Life
General Health Score: 75.3
Mental Health Score: 82.8
Physical Health Score: 62.6
Blood Pressure
Systolic: 132.3
Diastolic: 78.4
#MHMSiTexasDemographics’ Percentages
Female, Spanish Speaking, Employed, Smokers, Physically Active
Mission Memorial
SmokingEveryday Smoker: 6.2%
Someday Smoker: 1.9%Physically Active
1-2 times/week: 25.1%
3-4 times/week: 15.5%
5-6 times/week: 5%
Daily: 18.3%
Employed: 38.4%Spanish Speaking: 81.1%Gender
Male: 26.9%
Female 73.1%
SmokingEveryday Smoker: 3.5%
Some day Smoker: 3.5%Physically Active
1-2 times/week: 18.3%
3-4 times/week: 9.1%
5-6 times/week: 8.7%
Daily: 19.1%
Employed: 40.9%Spanish Speaking: 85.9%Gender
Male: 33.9%
Female: 66.1%
#MHMSiTexas
Melissa A. Valerio, PhD, MPHEvaluator for REAL, Inc. – TRIP for Salud y Vida ProgramCampus Dean and Associate Professor,
UT School of Public Health in San Antonio
Session # track letter and number
CFHA 19th Annual ConferenceOctober 19-21, 2017 • Houston, Texas
#MHMSiTexas
Faculty Disclosure
The presenters of this session have NOT had any
relevant financial relationships during the past 12
months.
#MHMSiTexas
TRIP for Salud y Vida has been developed to respond to a specific need identified by community partners to expand the reach of Project Salud y Vida to improve health outcomes through enhanced integrated services and systematic and seamless offering of transportation.
REAL, Inc.
#MHMSiTexasREAL, Inc.
TRIP for Salud y Vida developed to respond to a specific need identified by community partners to expand the reach of Project Salud y Vida to improve health outcomes through enhanced integrated services and systematic and seamless offering of transportation.
• Entire consumer population for TRIP for Salud y Vida has a severe mental illness (SMI) diagnosis (e.g., severe depression, bipolar or schizophrenia).
The IBH component of the TRIP for Salud y Vida model includes two key collaborative care elements: (1) co-located mental and primary health services with a case manager to link patients and
track follow-up and (2) patient education provided by community health workers.
#MHMSiTexasMethods
• Non-randomized quasi-experimental design (QED)
• 5 clinic sites (3 intervention
and 2 comparison)
• Enrollment of 500 consumers (250 per study arm)
• Shared measurements (Blood pressure, Body Mass Index (BMI), HbA1c), depression (using the Patient Health Questionnaire [PHQ-9]) and quality of life (using the Duke Health Profile)
#MHMSiTexasKey Outcomes
#MHMSiTexasAbout Si Texas
Yes to good health in Texas = ¡Sí Texas!
Sí Texas: Social Innovation for a Healthy South Texas is a Methodist Healthcare Ministries
regional (outside Bexar County) program that supports local organizations as they change
the way they deliver healthcare.
8 sub-grantees served 7,661 unique patients to-date
#MHMSiTexasChallenges and Barriers
Patients
• Social Determinants of Health
• Geo-Political Issues
• Stigma of Behavioral Health
• Follow-Through/Patient Compliance
Subgrantees
• Status of Strategic Planning
• Leadership Engagement
• Change Management
• Communication of Priorities
• Provider Buy-In
Capacity Building
and Technical Assistance for Sustainability
Evaluation Clinical Skills Advocacy and PolicyFinancial Sustainability Federal Compliance IT and Data SystemsLeadership Development Resource Development Peer ConnectionStrategic Planning Communications Quality Improvement
Guided by lessons learned and best practices
#MHMSiTexas
12 Counties
PROJECT TARGET
AREA
Project Target Area
#MHMSiTexasChange is Possible, Necessary, Desired by Patients
Our Mission
• To serve by improving the physical,
mental and spiritual health of those least
served in the Rio Texas Conference of The
United Methodist Church.
• “Serving Humanity to Honor God.”
#MHMSiTexasWhat’s Next
Building the Foundation for Scaling
• Subgrantees Complete Evaluations
• Dissemination Planning
• Strategic Scaling
• Expanding Capacity Building
• Quality Improvement
#MHMSiTexasReferences
• Cohen, et.al. Agency for Healthcare Research and Quality (AHRQ). Guidebook of Professional Practices for Behavioral Health and Primary Care Integration: Observations from Exemplary Sites. March 2015. Includes: AHRQ and The Academy. Self-Assessment Checklist for Integrating Behavioral Health and Ambulatory Care.
• Heath B, Wise Romero P, and Reynolds K. A Review and Proposed Standard Framework for Levels of Integrated Healthcare.Washington, D.C. SAMHSA-HRSA Center for Integrated Health Solutions. March 2013
• Massoud MR, Nielsen GA, Nolan K, Nolan T, Schall MW, Sevin C. A Framework for Spread: From Local Improvements to System-Wide Change. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2006.
• Meadows Mental Health Policy Institute and St. David’s Foundation. Best Practices in Integrated Behavioral Health: Identifying and Implementing Core Components. June 2016
• Ottoson, J.M., & Hawe, P. (2009). Knowledge utilization, diffusion, implementation, transfer, and translation: Implications for evaluation. New Directions for Evaluation, 124, 1-108. SAMHSA-HRSA Center for Integrated Health Solutions and National Council for Behavioral Health Core Competencies for Integrated Behavioral Health and Primary Care. January 2014.
• SAMHSA-HRSA Center for Integrated Health Solutions and National Council for Behavioral Health. Can We Live Longer? Integrated Healthcare’s Promise.
• University of Washington AIMS Center. Patient-Centered Integrated Behavioral Health Care Principles & Tasks. 2012.
• Ventureneer. Scaling Impact: A Primer for Nonprofits. Proceedings of The Social Impact Exchange Conference 2010.
• Weiss, et.al. The Harvard Family Research Project. Harvard Graduate School of Education. Published in The Evaluation Exchange, Vol XV, Number 1, Spring 2010.
• Corso, Kent & Hunter, Christopher & Dahl, Owen & Kallenberg, Gene & Manson, Lesley. (2016). Integrating Behavioral Health into the Medical Home: A Rapid Implementation Guide.
