TRIP for Salud y Vida Transportation for Rural Integrated health Partnership Participatory Approaches to Address Severe Mental Illness?

Session Objectives LearningObjective1:Increasedunderstandingofseverementalillness(SMI)andparticipatoryapproachestopromotecommunitypartnershipsandengagementforthedesignofappropriatehealthstrategiestopromotehealthoutcomesinSMIconsumers.

LearningObjective2:Listmethodstoenhancecommunityengagementandpromotequalityimprovement(QI)inmulti-levelinterventions.Beabletodescribe,patient,community,clinicandorganizationallevelchangesusedtopromoteSMIconsumeroutcomesandincreasequalityoflife.

Overview

 Ruralsettingandreach

 TRIPforSaludyVidaProgramModel

 SocialDeterminantsofHealthforpopulationswithSevereMentalIllness(SMI)

 VoicesLeadershipGroup

 MethodsandPreliminaryFindings

 Strategiestoengage,recruitandretainparticipantsinhealthoutcomesevaluation

Integrated Behavioral Health Model – TRIP for Salud y Vida

REAL, INC. SERVICE AREA

ConnectingSouthTexasCommunitiesandlocationsinbetween!

TheRural EconomicAssistance League, Inc. (REAL) is anon-

profit organization established in 1972 with the mission to

providesafe,caringandqualitycommunitycenteredservices

for the elderly, persons with disabilities and the general

publicbyassistingthemandtheir families inmaintainingan

independentandfulfillinglife.

MISSION & VISION STATEMENT The Rural Economic Assistance League, Inc. (REAL) and Board of Directors desire

to be “The Provider of Choice” to the constituents that reside within our service area. We assure these communities quality care, prompt response, and cost efficiency in our delivery of services. We do not commit fraud, abuse, neglect, or waste. Furthermore, we will not tolerate anyone who does. We believe in honesty, due diligence in provision of services, avoidance of waste

and the necessity of listening to our patients/clients and staff regarding any concerns that they may have. REAL, Inc. is an Equal Opportunity Employer and Equal Opportunity Housing Provider.

“Wherehelpingpeopleisouronlygoal!”

AdultDayActivityHealthServices

HomeHealthCare

Housing

Transportation

AddressingHealthOutcomesFocusonmorethantheindividual

•  Placeeffects–ruralarea

•  Transportation–publictransit

•  Accesstoqualityhealthcareservices

•  HealthLiteracy

•  Cultureandlanguage

WhyTRIP?

Engagement Strategies: CBPR Approach

§  Acknowledgementofauniquesetof

stressorsandstrengths

withinacommunity

Rationale for a Community-Based Participatory Research (CBPR) Approach

Stressors

•  Lackofaccesstohealthy,

affordablefood

•  Lackofaccesstosafeplacesto

bephysicallyactive

•  Exposuretoviolence,poorair

quality,illegaldumping

•  Poorhousingconditions

•  Discrimination

•  Lackofaccesstoaffordable

healthcare

Strengths

•  Knowledgeableand

committedcommunity

membersandleaders

•  Resourcesandservices

providedbycommunityand

faith-basedorganizations

•  Supportivesocialnetworks

•  Engagedcommunitymembers

andorganizations

Theseconditionscontributetotheincreasinggapsinhealthstatuswithincommunities

Defining Community-Based

Participatory Research (CBPR)

Community-based participatory research is a partnership approach to research that:

§  Equitably involves community members, organizational representatives,

and academic researchers in all aspects of the research process.

§  Enables all partners to contribute expertise with shared responsibility and

ownership.

§  Enhances understanding of a given phenomenon.

§  Integrates knowledge gained with action.Israel, Schulz, Parker, and Becker, 1998

Methods

 QuasiExperimentalDesign:3interventionclinics,2comparisonclinics

 FocusonEngagementofVoicesLeadershipGroup

 PartnerGoalsandFeedbackLoops

 QualityImprovement

 ConsumerFeedback

Enhanced Integrated Services

 MovingbeyondIntegratedCaretofocusonhealthwithinthecommunitysettingtopromoteinclusion

 HealthandWellnessClasses–DiabetesSelf-ManagementEducation

 PhysicalActivity–WalkinthePark,WaterAerobics,Yoga,TaiChi

 CookingClasses–LaCocinadeREAL,localshoppingtrips

 Consumerdriventopics–Wills,funeralsandfinancialliteracy

 Art&wellness–Paintinganddesign,crochet,artgallerypresentation

 Understandingdataandresearch

Who participated over time

StudyArm Baseline

Sample

Target

Actual

at

Baseline

6month

Target

(15%

attrition)

Actual

at6

mos

12

month

Target

(15%

attrition)

Actual

at12

mos

Percentof

Retentionof

theEnrolled

Sample

Percent

of

Retention

Target

Intervention 250 302 213 205 180 211 69.8% 117%

Comparison 125 250 212 160 180 153 61.2% 85%

What did we learn?

 Intheirownwords…

 TRIPforSaludyVidaconsumers

Preliminary Results

DHP Depression

•  Depressionscorestendedto

worsenforparticipantsatthe

controlsites,thescoresimproved

overtimeforparticipantsatthe

interventionsites.

•  Theadjustedmeandepression

declined(improved)by-4.56

(95%CI:-8.59to-0.52)at6

monthsandremainedfairly

stableat-4.32(95%CI:-8.30to

-0.34,lowerthanbaselineat12

months.

DHP Anxiety

•  DukeADscorestendedtoworsen

forcomparisonconsumers,the

scoresdeclined(improved)over

timeforconsumersatthe

interventionsites.

•  TheadjustedmeanDukeADscore

declinedby-5.06(95%CI:-8.80to

-1.32)at6monthsandcontinued

todeclineto-5.83(95%CI:-9.50to

-2.16)lowerthanbaselineat12

months.

DHP Pain

•  Painscorestendedtobestablefor

consumersatthecomparison

sites,thescoressignificantly

improvedforconsumersatthe

interventionsites.

•  Themeanpainscoresfor

consumersenrolledatthe

interventionsitesat6months

werelowerby-12.38(95%CI:

-23.51to-1.25)and-13.44(95%

CI:-24.41to-2.47)at12months.

DHP Disability

•  WhiletherewasnodifferenceinDHP

Disabilityscoresbetweenthe

interventionandcontrolsitesat

baseline(p=0.197),meandisability

scoresweresignificantlylowerfor

participantsenrolledatthe

interventionsitesat6and12months.

•  Themeanpainscoresforparticipants

enrolledattheinterventionsitesat6

monthswerelowerby-26.76(95%CI:

-52.51to-1.00)and-15.45(95%CI:

-26.13to-4.76)at12months.

PHQ-9 Depression

•  Bonferroniadjustedpairwisecontrasts

showednostatisticallysignificant

differenceindepressionatbaseline

betweentheinterventionandcontrol

sites(p=0.156).

•  Consumersattheinterventionsitesalso

hadsignificantlylowerdepressionscores

thanparticipantsatthecontrolsitesat6

and12months.Thedifferenceat6

monthswas-2.67(-4.75to-0.59)points,

andthedifferenceat12monthswas

-2.77(95%CI:-4.83to-0.72)points.

Blood Pressure

Body Mass Index (BMI)

•  Changesseeninindividualsmay

havebeenmaxedwiththe

inclusionofallconsumers.

•  GiventhehigherBMIinthe

consumerpopulationandthe

riskfactorofoverweightinthe

SMIpopulationwewillcontinue

toexaminechangesinweight

andBMI.

•  Thesubgroupanalysisis

planned.

Type 2 Diabetes Intervention Control

Follow-upN Mean

Std

DevN Mean

Std

Dev

Baseline

HbA1c 79 7.50 2.41 34 8.21 2.52

6Months

HbA1c 150 6.74 1.90 104 6.69 1.76

Changein

HbA1c41 0.22 0.78 15 -0.26 1.27

12Months

HbA1c 201 6.62 1.94 158 6.76 2.12

Changein

HbA1c63 -0.05 1.40 22 -0.04 1.33

•  Datalimitations.

•  DropsinHbA1cwereseen.

•  Needtoexplorechangesin

thesubgroups

•  Examinationofdifferences

andimpactinchangeover

timebetweenthe

interventiongroupadjusting

forEISparticipationmayyield

significantdifferences

betweenthetwogroups.

•  Thesubgroupanalysisis

planned.

BRIEF 4-Item

 Participantsattheinterventionsiteshada1.52

(95%CI:0.65to2.38)pointshigheradjustedmeanhealth

literacyscoresattime0thanparticipantsatthe

interventionsites,butthe

differencewasnotsignificant.

 Overtimetheintervention

siteshad“lower”healthliteracypertheBRIEF,we

positthattheEISmayhaveimpactedassessments.

BRIEF 4-Item and Transportation Use

Levelof

UtilizationCoefficient StandardError z 95%CI

Low -0.23 0.67 -0.35 -1.54to1.08

Moderate -0.66 0.71 -0.93 -2.04to0.73

High -2.23 0.67 -3.31 -3.55to-0.91

VeryHigh -2.18 0.69 -3.18 -3.52to-0.83

Adjustedmeandifferencesbetweenlevelsofutilizationamongthosewho

usedthetransportationserviceandthosewhodidnotusetheservice

Health Literacy – eHEALS Assessment

Item Baseline(M) 12-months(M) Change

Iknowhowtofindhelpfulhealthresourcesonthe

Internet

2.88 2.62 -0.26

IknowhowtousetheInternettoanswermyhealth

questions

2.90 2.61 -0.29

Iknowwhathealthresourcesareavailableonthe

Internet

2.56 2.48 -0.08

IknowhowtousethehealthinformationIfindonthe

Internettohelpme

2.63 2.49 -0.14

IhavetheskillsIneedtoevaluatethehealthresources

IfindontheInternet

2.62 2.49 -0.13

Icantellhighqualityfromlowqualityhealth

informationontheInternet

2.47 2.41 -0.06

IfeelconfidentinusinginformationfromtheInternet

tomakehealthdecisions

2.50 2.36 -0.14

Strategies for Engagement

Strategies for Engagement  Individuallevel–trustbuilding,voiceandrespect.CommunityHealthWorkerswerekeytoongoingengagementandreachofconsumers

 VoicesLeadershipGroup–advocatesandchampionsoftheprogramwithinthecommunity.Engagementthroughoutandpointedtoneedsandchangesinprogramdelivery

 Communitylevel–workingwithnewpartnersandengagingtheminservingapopulationwithSMI

 Cliniclevel–integrationofclinicstaffintrainings,focusedonchangestoprogramsasneeded.Qualitychecksandgoalsetting

 Organizationallevel–transportationdelivery,coordinationofEISandhiring,MentalHealthFirstAid

Summary

1.  Theuseandintegrationofcommunityhealthworkersinthedeliveryofa

systematicinterventioninruralandclinicalsettingspointstoanopportunity

todesignandeffectivelyreachhighriskpopulations.

2.  TheSMIpopulationisoftentimesisolatedwithinbothurbanandrural

settings;abehavioralhealthapproachthatimprovesaccessthroughset

transportationservicesappearstoimprovehealthandoutcomesovertime.

3.  TheuseoflocalresourcestodeliverEISwasavaluetoboththecommunity

andtheconsumersenrolledintheTRIPforSaludyVidaprogram.

4.  ThesustainabilityofprogramssuchasTRIPbenefitsfromintegrationof

multiplepartners.

Collaborating Partners CoastalPlainsCommunityCenter

CommunityActionCorporationofSouthTexas

KlebergCountyHumanServices–PaisanoTransit

RuralEconomicAssistanceLeague,Inc.

SouthCoastalAreaHealthEducationCenter