Fidelity and Outcomes in Community Care

Transcription

1 Faculty Disclosure Alex Kopelowicz, MD Dr. Kopelowicz has listed no financial interest/arrangement that would be considered a conflict of interest. Fidelity and Outcomes in Community Care Alex Kopelowicz, M.D. Professor and Vice-Chair Department of Psychiatry and Biobehavioral Medicine David Geffen School of Medicine at UCLA 1

2 Purpose This presentation will discuss: The current state of behavioral health quality measures One approach to measurement using First Episode Psychosis as an example Results of using the process (RAISE study) Implementation strategies 2

3 Challenges to Improving Behavioral Healthcare Failure to Identify Failure to Use Treatment with Best Evidence Not Enough Providers Lack of Integrated Treatment Model Barriers to Data Sharing Lack of Accountability Limited Focus on Outcomes 3

4 Does Better Fidelity to Evidence-based Treatment Make a Difference? A critical but rarely studied question There appears to be some evidence in the treatment of depression Very few studies have assessed the treatment of schizophrenia and only one has focused on First Episode Psychosis The NIMH RAISE Project The NIMH RAISE Project The National Institute of Mental Health Recovery After an Initial Schizophrenia Episode (RAISE) Project tested whether early, aggressive, and pre-emptive intervention can slow or halt clinical and functional deterioration in schizophrenia RAISE research objectives: Design and test effective interventions for early phase schizophrenia Engineer rapid adoption and implementation of effective treatment packages by engaging end users at the start of intervention development Assess clinical, functional, and economic outcomes Generate information relevant to key stakeholders, including health care policy makers 4

5 RAISE ETP Site Distribution Early Treatment Program Sites 5

6 Study Design RAISE Early Treatment Program Community Care NAVIGATE All services at your center decided by best clinical practice An experimental package of services NAVIGATE SERVICES Pharmacological Treatment COMPASS: A decision support system for prescribers Family Education Program (FEP) Supported Employment and Education (SEE) Individual Resiliency Training (IRT) 6

7 COMPASS Computerized clinical decision making tool accessed via a secure web-based platform. Designed to facilitate patient-prescriber communication Prior to visit, information is entered about symptoms, side effects, treatment preferences, medication adherence and attitudes, substance use, vital signs and lab results These data are summarized by COMPASS program for review by the psychiatrist at the beginning of the visit Standardized assessments done by the psychiatrist (e.g., mini-bprs) were informed by the previously entered data Integrating patient priorities and clinician assessments, COMPASS provided suggested guideline treatments Together they make treatment decisions informed by these recommendations (i.e., shared decision making). COMPASS: General Principles Recommendations should be based on data; avoid expert hunches about treatment Preference given to medications with data from studies with the relevant patient groups Consider the use of long-acting formulations of antipsychotics for maintenance treatment for all subjects COMPASS incorporates these principles and provides an ongoing record of treatment and clinical response 7

8 NAVIGATE Patients Had More Medication Visits NAVIGATE Patients Were More Likely To Be Prescribed An Antipsychotic 8

9 NAVIGATE Patients Were More Likely To Be Prescribed An Antipsychotic Conforming To First Episode Treatment Principles NAVIGATE Patients Were Less Likely To Be Prescribed An Antidepressant 9

10 NAVIGATE Patients Were Less Likely To Experience Side Effects NAVIGATE Participants Stayed in Treatment Longer: Time to Last Mental Health Visit (Difference between treatments, p=0.004) 10

11 Differential Improvement in QLS and PANSS Total Score Differential Improvement in CDSS Total Score treatment-by-time interaction, p=

12 Does Better Fidelity to Evidence-based Treatment Make a Difference? NIMH-funded RAISE-ETP study compared an integrated treatment program called NAVIGATE with Clinician Choice treatment 404 first episode Psychosis patients over 2 years Patients who got Clinician Choice treatment improved but, NAVIGATE treated patients stayed in treatment longer and had more improvement in overall symptoms, depression and quality of life than patients given Clinician Choice treatment 12