Strategies for Obtaining Stakeholder Feedback on Integrated Care

1. Session # B5b October 29, 20111:30 PM Strategies for Obtaining Stakeholder Feedback on Integrated Care David Johnson, MSW, ACSW Lori Lackman-Zeman, PhD Collaborative Family Healthcare Association 13th Annual Conference October 27-29, 2011 Philadelphia, Pennsylvania U.S.A.

2. Faculty Disclosure We have not had any relevant financial relationships during the past 12 months. CFHA 13th Annual Conference, October 29, 2011

3. Need/Practice Gap & Supporting Resources • The ultimate success of integrated care programs is dependent upon the people involved. Yet few tools have been developed and presented that facilitate the capture of data from major stakeholders: • Behavioral health staff • Medical staff—physicians, nurses • Consumers (patients) • Establishing mechanisms/tools to obtain these data facilitate program evaluation as well as inform ongoing program design. CFHA 13th Annual Conference, October 29, 2011

4. Objectives • Identify the importance of obtaining input and feedback from major stakeholders in the development and continuous quality improvement of integrated care. • Describe variables included in surveys of staff and consumers relevant to integrated care. • Provide example tools for three major stakeholder groups. • Define the role of consumer advisory boards. CFHA 13th Annual Conference, October 29, 2011

5. Expected Outcome • Participants are able to identify methods and strategies to solicit data from stakeholders related to integrated care. • Participants are able to identify relevant factors/variables to evaluate when seeking information from stakeholders. CFHA 13th Annual Conference, October 29, 2011

6. Learning Assessment We encourage you participation and interaction during our presentation to facilitate a better understanding of our presentation materials. CFHA 13th Annual Conference, October 29, 2011

7. Clinic Settings • Wayne State University Physician Group operates a number of specialty and general medicine clinics. • Over the past five years, the Department of Psychiatry has implemented integrated care programs in conjunction with Internal Medicine’s HIV Clinic; two “safety net” General Medicine Clinics, and an OB/GYN clinic • These Clinics are all centrally located in Detroit CFHA 13th Annual Conference, October 29, 2011

8. Population Served • Black/African Americans, ~80%; • Low income, 82% earn less than $20,000 per year; • Most individuals are uninsured or underinsured • Detroit is a City that has been in decline over the past ten years losing over 25% of its population from 2000 to 2010. This is attendant with numerous psychosocial stressors and problems—housing, transportation. CFHA 13th Annual Conference, October 29, 2011

9. Program Design • Each site has is its own unique features and operational structures, but they a number of program components in common: • Co-location of behavioral health professionals in the health clinic • Collaboration between behavioral and physical health staff • Screening for behavioral health conditions (instruments and process vary by clinic) • Interventions focus on promoting overall health while addressing psychosocial stressors • Follow-up and case management CFHA 13th Annual Conference, October 29, 2011

10. Stakeholders, a blending of cultures • Physicians, nurses and physical medicine staff • Behavioral health professionals, psychiatrists, psychologists, social workers, peer advocates • Consumers/patients CFHA 13th Annual Conference, October 29, 2011

11. Knowledge and Skills Domains • Physicians and physical health professionals • Conditions and diseases that impact health from acute episodic illness to chronic disease such as diabetes, cancer, HIV • Prevention, immunizations, blood pressure checks, cancer screening • Behavioral health • Psychosocial stressors and psychiatric conditions related to mood, anxiety, thought disorders, and behavioral interactions and interpersonal relations • Consumers • Values, beliefs, attitudes, preferences regarding health and well-being CFHA 13th Annual Conference, October 29, 2011

12. Strategies to Obtain Stakeholder Feedback • Physician and Nurse Surveys • Behavioral Health Surveys • Consumer/Patient Surveys • Satisfaction Survey • Service preference/needs and Stigma • Social Media • Consumer Advisory Board CFHA 13th Annual Conference, October 29, 2011

13. Physicians and Medical Staff • What is the perceived need for integrated care? • What is the perceived degree of expertise to address behavioral health issues? • What are values and attitudes regarding integrated care? • What are the perceived barriers—system and patient—to integrated care? CFHA 13th Annual Conference, October 29, 2011

14. Physicians and Nursing Staff • Experience and expectations in managing patients with psychiatric conditions • Knowledge—theoretical and experiential learning • Skills—applying knowledge to address psychiatric conditions • Comfort—level of ease to assess and intervene with patients experiencing a psychiatric condition CFHA 13th Annual Conference, October 29, 2011

15. Physician and Nurse Survey • 35-item, self-administered questionnaire • Completed by 85 physicians, residents, and nurse practitioners in a general medicine clinic • 43 individuals completed a baseline and a follow-up questionnaire after working in the clinic for at least 6 months • Items grouped into 5 factors: • Expertise Value/Attitude • System/Patient Barriers Need • Confidence in BH Services CFHA 13th Annual Conference, October 29, 2011

16. Barriers • It takes too long to obtain an appointment for • Psychiatric Services • Substance Abuse Services • Too many logistics to make a referral for • Psychiatric Services • Substance Abuse Services • Too little time to make a referral for: • Psychiatric Services • Substance Abuse Services • I have little confidence in the value of • Psychiatric Services • Substance Abuse Services CFHA 13th Annual Conference, October 29, 2011

17. Expertise • I have knowledge to address a patients co-occurring psychiatric condition such as: • Depression, anxiety, or relationship issues • Bipolar disorders, psychosis, or personality disorders • Alcohol or substance use disorders • I am skilled…. • I am comfortable… CFHA 13th Annual Conference, October 29, 2011

18. Value/Attitude Regarding Integrated Care • It is important in the evaluation and treatment of health conditions to address any co-occurring • Psychiatric Conditions • Substance Use Disorders • I actively seek out mental health specialists in addressing patient’s psychiatric needs • I actively coordinate a patient’s care with psychiatric service providers • I believe it is important to have a mental health professional co-located in the clinic CFHA 13th Annual Conference, October 29, 2011

19. Need • Number of patients believed to have a psychiatric condition • Number of patients believed to have a substance use disorder • How often during medical exam inquire about psychiatric condition • How often during medical exam inquire about substance use disorder • How much time during a medical exam spend on psychiatric or substance use disorder CFHA Annual Conference, October 29, 2011

20. Confidence in Behavioral Health specialists • Confidence in the value of specialty mental health services • Confidence in the value of specialty substance abuse treatment/services. CFHA Annual Conference, October 29, 2011

21. Survey Response Data CFHA Annual Conference, October 29, 2011

22. Physician Baseline and Follow-up Mean Ratings (N=43 Pairs) CFHA 13th Annual Conference, October 29, 2011

23. Using Physician Survey Results • In one clinic when we learned from physician feedback that they could not identify BH staff we took actions to increase the presence of BH staff in the hall way of the exam rooms. • Launched a pre-clinic meeting for all staff on duty for that clinic. • Structured time for BH staff to be available for Resident/Attending Physician briefing on patients. • Developed written materials and handouts. CFHA 13th Annual Conference, October 29, 2011

24. Behavioral Health Professionals • Understanding the nature of practice in outpatient medical settings • Knowledge and skills to practice in a co-located, integrated care setting • Comfort and confidence for working in primary care • Nature of interactions between physical and behavioral health conditions CFHA Annual Conference, October 29, 2011

25. Questionnaire • A 23-item questionnaire • Likert type responses of Strongly agree to Strongly Disagree, ranging from 1 to 5 • 6 items addressed perceptions of work in primary care clinics • 4 items related to issues of comfort and confidence in working in primary care • 4 items addressed understanding and knowledge about interactions with primary care physicians • 9 items related to knowledge and skills for practice in a primary care clinic CFHA Annual Conference, October 29, 2011

26. BH Professionals Survey • 28 individuals involved in integrated care programs • Questionnaire administered at the start of a structured training program conducted for BH professionals who were working in various program sites. • Follow-up approximately 5 months later, reflecting continued work experience and training. CFHA Annual Conference, October 29, 2011

27. Perceptions of Work in Primary Care CFHA Annual Conference, October 29, 2011

28. Comfort and Confidence CFHA 13th Annual Conference, October 29, 2011

29. Interactions with Primary Care Physicians CFHA 13th Annual Conference, October 29, 2011

30. Knowledge and Skills CFHA 13th Annual Conference, October 29, 2011

31. Using Behavioral Health Staff Feedback • Scheduling BH staff for “Clinic Duty” no scheduled appointments during assigned clinic time; to be present in the exam room area • Pre-clinic meetings • Flags on exam doors to denote which profession in exam room with patient • Issues white board—identify scheduled patients and any special needs/concerns • All staff meetings CFHA 13th Annual Conference, October 29, 2011

32. Consumer Survey on Integrated Care—Assessing Behavioral Health Services

33. Consumer Perceptions and Preferences Related to Co-located Care • Standardized questions asked by research assistant • Rating likelihood of service use by type of service • Preference for service location • Interest in timing, type, and frequency of services • A convenience sample of 58 clinic consumers CFHA 13th Annual Conference October 29, 2011

34. Accessing BH Services CFHA 13th Annual Conference, October 29, 2011

35. Importance of BH service features (N=58) CFHA 13th Annual Conference, October 29, 2011

36. Rate how you would prefer to set up BH visits(N=55) CFHA 13th Annual Conference, October 29, 2011

37. Preference of Frequency of BH Service CFHA 13th Annual Conference, October 29, 2011

38. Comfort with Type of BH Service CFHA 13th Annual Conference, October 29, 2011

39. Patient Satisfaction Survey • A review of the literature did not turn up any patient satisfaction surveys that were reflective of co-located, integrated care programs • Personal inquiries to co-located, integrated care programs did not result in the identification of an instrument • 23-item questionnaire developed that included items on psychosocial and mental health issues CFHA 13th Annual Conference, October 29, 2011

40. Patient Ratings from a General Medicine Clinic CFHA 13th Annual Conference, October 29, 2011

41. Patient’s Receiving BH Service-- Ratings CFHA 13th Annual Conference, October 29, 2011

42. Community Advisory Board (CAB) • Consumers identified by program staff and CAB members to serve on an advisory board • CAB selects officers, schedules meetings, and sets agenda • CAB selects a person to attend program operations meetings that addresses daily operations, quality improvement, program evaluation and program development CFHA 13th Annual Conference , October 29, 2011

43. CAB cont. • Utilization data presented to CAB for review and suggestions regarding engagement • Set up a suggestion box • Suggested topics to be investigated for program enhancement—access to technology • Identifying topics for support groups • Promoting community involvement—World AIDS Day, Testing Day • Promoted development of peer advocate program CFHA 13th Annual Conference, October 29, 2011

44. CAB Raised Issue of using Internet to Support Clinic Programs • Resulted in a survey of a convenience sample of consumers in the client • Do individual receiving health care services in an HIV Clinic have access to cell phones and the Internet? • Do these individuals want to receive information related to their health via text messages or email? • Reported results to CAB • Promoted discussion about social networking and program applications CFHA 13th Annual Conference, October 29, 2011

45. Regarding technology… • A significant number of individuals receiving services in the health clinic have access to cell phones and the Internet. • However: • A large number of these individuals do not want to receive text messages about their health. • Likewise, a large number do not want to exchange emails with heath providers related to their health. CFHA 13th Annual Conference, October 29, 2011

46. Summary • Using structured surveys and questionnaires has provided an efficient way to obtain data from three major groups of stakeholders • A consumer advisory board provides a ready “focus group” to test out ideas and receive feedback on program issues and concerns CFHA 13th Annual Conference, October 29, 2011

47. Summary Cont. • Taken together, data supports that co-location and integration increases access for consumers and provides greater opportunity to connect with consumers over time in promoting and assisting consumers to achieve health goals. Consumers like co-located services. CFHA 13th Annual Conference, October 29, 2011

48. Summary Cont. • The physician and behavioral health survey suggests that in a brief period of time there is little movement in beliefs and perceived abilities to work in co-located, integrated care programs. • Nonetheless, feedback lead to a number of operational and structural changes to increase collaboration and integration. CFHA 13th Annual Conference, October 29, 2011

49. Presenters David Johnson, MSW, ACSW Wayne State University School of Medicine, Department of Psychiatry and Behavioral Neurosciences djohnso@med.wayne.edu Lori Lackman Zeman, PhD Wayne State University School of Medicine, Department of Psychiatry and Behavioral Neurosciences lzeman@med.wayne.edu CFHA 13th Annual Conference, October 29, 2011