patient-centered strategies to improve health and health ......annual meeting oct. 31-nov. 2, 2017...

ANNUALMEETING

OCT. 31-NOV. 2, 2017ARLINGTON, VA

#PCORI2017

Patient-Centered Strategies to Improve Health and Health Outcomes for Vulnerable Populations

November 1, 2017

ANNUAL MEETING | #PCORI2017

November 15, 2017 2

Welcome & Introductions

• Moderator: Cheryl Pegus, MD, MPH, Clinical Professor of Population Health, New York University LagoneHealth


November 15, 2017 3

Increasing CRC Screening among Hispanic Primary Care Patients

• Principal Investigator: Ron Myers, PhD, Professor and Director of the Division of Population Science, Thomas Jefferson University

• Patient/Stakeholder Partner: Myra Piña, MD, Executive Director, Fé Foundation of the Hispanic Chamber of Commerce of the Lehigh Valley


November 15, 2017 4

Patient-Centered Trauma Treatment for PTSD and Substance Abuse: Is It an Effective Treatment Option

• Principal Investigator: Annette Crisanti, PhD, Research Associate Professor of Psychiatry and Behavioral Sciences, University of New Mexico

• Patient/Stakeholder Partner: Gina James, Research Assistant, Division of Community Behavioral Health, Department of Psychiatry and Behavioral Sciences, University of New Mexico


November 15, 2017 5

Lowering the Risk of Heart Problems for People in Appalachian Kentucky

• Principal Investigator: Debra Moser, PhD, RN, FAAN, Professor, University of Kentucky College of Nursing

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Increasing Colorectal Cancer (CRC) Screening among Hispanic Primary Care Patients

Ronald E. Myers, PhD and Myra D. PiñaProfessor

Executive Director of the Fé Foundation

November 1, 2017


7

Ronald E. Myers, PhD and Myra D. Piña

• Have nothing to disclose.

November 15, 2017

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&ved=0ahUKEwjZ_YyLvOvWAhVH6SYKHd9qAC4QjRwIBw&url=http://www.philly.com/philly/business/thomas-jefferson-and-phila-university-complete-merger-20170629.html&psig=AOvVaw26xyMUucoNMwOeHd9GwkYn&ust=1507910919581421

http://www.lehighvalleylive.com/breaking-news/index.ssf/2012/08/lehigh_health_network_transfer.html


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Objectives

At the conclusion of this activity, the participant should be able to:• Describe intervention impact on overall screening

adherence• Describe intervention impact on test-specific screening

adherence• Describe intervention impact on screening decision

stage

November 15, 2017


9November 15, 2017

Colorectal Cancer and Screeningin the US Hispanic/Latino Population

Incidence: 12,400Deaths: 3,800Localized disease: 38%Screening non-adherence: 50%

• 80% by 2018 Campaign Goal:o Increase the number and % of non-adherers who screen

Cancer Facts & Figures for Hispanic/Latinos 2015-2017; National Center for Health Statistics. Health, United States, 2015: With Special Feature on Racial and Ethnic Disparities. Hyattsville, MD, 2016


November 15, 2017 10

Study Participants

Patients from 5 Lehigh Valley Health Network (LVHN) Primary Care Practices, Southeastern PA

• Hispanic men and women aged 50-75 years of age• Visited practice within previous 2 years• No family history of CRC or colon polyps• No personal history of CRC, colon polyps, or inflammatory

bowel disease• Screening nonadherence

o 80% by 2018 Campaign Goal in LVHN:30% adherers + [70% nonadherers (71%)]



Patient and Stakeholder Advisory Committee

(PASAC)

PASAC Structure• 12 members came from community groups,

religious organizations, health support groups, primary care practices, and include LVHN health system primary care provider, specialist, and administrator representatives.

• Project staff and members met 3 X a year at a convenient health system location

• Members included veterans, clergy, patient support, housewives, nurses, and a diabetes support group president.

• Meetings were facilitated by a bilingual moderator and were conducted in both English and Spanish.

PASAC Function/Feeling• Members provided input on study materials,

intervention methods, and strategies for reaching the population.

• Members were part of the research team, with the role of advising the staff on realities of working with the population and the health system.

• Members felt an additional role was to learn and educate members of the Hispanic community about cancer screening.

• Members viewed themselves as an extension of the community, with a duty to share their knowledge to guide research and to improve the community health.



StandardIntervention

(n=203)

Decision Support and Navigation Intervention

(n=197)

Study Design

Consented, Surveyed, andRandomized (N=400)

Endpoint Survey (n = 123)

and Chart Audit(n = 203)

Endpoint Survey (n = 123)

and Chart Audit(n = 197)



Decision Support and Navigation Intervention (DSNI)

Patient Education• Send informational

booklet, FIT kit, and colonoscopy scheduling instructions

Support & Navigation• Identify preferred test• Determine likelihood of

screening and barriers to adherence

• Develop screening plan and navigate through adherence

Patient Reminder• Send reminder

Provider Engagement• Send patient’s

screening plan to practice

• Send screening status report and encourage follow-up as needed

Standard Intervention (SI)

Patient Education• Send informational

booklet, FIT kit, and colonoscopy scheduling instructions

Patient Reminder• Send reminder



Hypotheses

• H1: Overall screening adherence in DSNI Group > SI Group

• H2: Test-specific adherence in DSNI Group > SI Group

• H3: Screening decision stage in DSNI Group > SI Group



Table 1. Baseline Survey Data (N=400)Characteristic N (%)

Age

< 60 Years 277 (69)

> 60 Years 123 (31)

Race

White 133 (33)

Black 118 (30)

Other/Unknown 149 (37)

Gender

Female 235 (59)

Male 165 (41)



Table 1. Baseline Survey Data (continued)Characteristic N (%)

Marital Status

Married or Living as Married 192 (48)

Not Married 208 (52)

Language Spoken at Home

Spanish 331 (83)

Both Spanish and English 41 (10)

English 28 (7)

Insurance Status

Insured 281 (70)

Not Insured or Unsure 119 (30)



Table 1. Baseline Survey Data (continued)

Test Preference N (%)

Prefer Colonoscopy 39 (10)

Equal Preference 275 (69)

Prefer Fecal Immunochemical Blood Test (FIT)

86 (21)

Total 400 (100)



Findings• Overall CRC screening adherence was almost 5 times

greater in the DSNI Group than in the SI Group

• FIT screening and colonoscopy screening adherence were more than 4 times greater and almost 9 times greater, respectively, in the DSNI Group than in the SI Group

• Forward change in CRC screening decision stage was almost 5 times more likely in the DSNI Group than in the SI Group



Dissemination at a LVHN Community Conference

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&ved=0ahUKEwi4rqDbtuvWAhWDPiYKHepIAeQQjRwIBw&url=https://www.cdc.gov/pcd/issues/2013/12_0192.htm&psig=AOvVaw3G36MsmCvebCwpb1VKVoTO&ust=1507909475826681

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&ved=0ahUKEwi4rqDbtuvWAhWDPiYKHepIAeQQjRwIBw&url=https://www.cdc.gov/pcd/issues/2013/12_0192.htm&psig=AOvVaw3G36MsmCvebCwpb1VKVoTO&ust=1507909475826681



Conclusions

• A patient-centered CRC screening intervention for Hispanic primary care patients in the LVHN was successfulo A decision support and navigation interention (DSNI) had

a substantial and statistically significant positive impact on patient CRC screening adherence and readiness to screen compared to a standard intervention (SI)

• Infrastructure and research are needed to support the implementation of the DSNI and other evidence-based interventions in the LVHN and other health systems.



• Patient Centered Outcomes Research Institute (EAIN 2471) and Thomas Jefferson University supporto Develop a scalable model (the Reducing Cancer Disparities by

Engaging Stakeholders (RCaDES) Initiative) for adapting and implementing evidence-based cancer screening interventions in health systems

• Apply the model to CRC and lung cancer screening

Intervention Adaptation and Implementation

The RCaDES Initiative

Center for Health Decisionsat Jefferson

CancerDisparities

ANNUALMEETING


#PCORI2017Cancer

Disparities

The RCaDES Initiative

Center for Health Decisionsat Jefferson

1. Identify Evidence Based Intervention (EBI)

2. Define EBI Core Components for Adaptation

4. Adapt EBI Core Components

3. Train patients and stakeholders in EBI Adaptation

5. Implement the Adapted EBI

6. Disseminate Lessons Learned

Cancer Centers - Health Systems - Payers - Employers

The Road Ahead


23

Learn More

• www.pcori.org

• [email protected]

• #PCORI2017

• www.YourURL.url

November 15, 2017



Thank You!Ronald E. Myers, PhD and Myra D. PiñaProfessorExecutive Director of the Fé Foundation November 1, 2017

ANNUALMEETING


#PCORI2017

Effectiveness of Peer-Delivered Services in the Provision of Trauma-Specific TreatmentAnnette S. Crisanti, Ph.D1. and Regina James2, CPSW1Associate Professor, Department of Psychiatry and Behavioral Sciences, UNM

[email protected]; 2Research Assistant, Department of Psychiatry and Behavioral Sciences, UNM

[email protected]

11/01/2017

mailto:[email protected]

mailto:[email protected]


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A.S. Crisanti and R. James• No disclosures

• This work was supported through a PCORI Program Award (CE-12-11-4484)

• All statements in this report, including its findings and conclusions, are solely those of the authors and do not necessarily represent the views of PCORI, its Board of Governors or Methodology Committee.

November 15, 2017


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ObjectivesAt the conclusion of this activity, the participant should be able to:• Understand the need for substance abuse

treatment in rural communities• Describe the value of peer support workers,

especially in rural communities• Describe the effectiveness of peer support

workers in the provision of trauma-specific treatment

November 15, 2017


28November 15, 2017


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Need for Substance Abuse Treatment

November 15, 2017

NEW MEXICO 2010-2014


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Strategies to Address the Behavioral Health Needs of Underserved Communities

• Increase Peer Support Services• A Peer Support Worker is someone who uses

his or her lived experience of recovery from mental illness and/or addiction, plus uses skills he or she learned in formal training, to deliver services in behavioral health settings to promote mind-body recovery and resilience. SAMHSA –HRSA Center for Integrated Health Solutions. Who are Peer Providers?

November 15, 2017


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Peer Support Worker in NM• In NM, the peer support worker training

requires 40 hrs. of classroom training over 5-days followed by a certification exam through the NM Credentialing Board for Behavioral Health Professionals.

• Training topics include professionalism, ethics, components of recovery and resiliency, mental health and substance use disorders, communication skills and stress management.

November 15, 2017



Effectiveness of Peer Support WorkersIncluding peers as part of behavioral health has been associated with:

- Increased engagement- Reduced inpatient hospitalizations- Improved relationships with providers- Higher levels of empowerment- Higher levels of activation- Higher levels of hopefulness and recovery

(Chinman et al., 2014)



Undertaking & Managing the Research• Patients were in multiple paid, influential positions,

including:• Project Director• Group facilitators (delivered intervention)• Group support coordinator (helped with

engagement and retention)• Researchers (data collection)• Steering committee members


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Risk Factors for Substance Abuse

November 15, 2017

• Family and Community• Exposure to substances• Abuse• Genetic/Family History• Stressful/Negative Life

Events• Trauma Exposure• Peer Pressure• Depressed Mood• Low Self-Esteem• Delinquent Behavior• Disrupted Family

Environments• Lack of Coping Skills

“The more I use, the more I won’t

feel anything. The pain is so bad you just want to die.”

Quote from A Trauma SurvivorSeeking Safety Manual, (Najavits, L. 2002)


35November 15, 2017

-Seeking Safety (SS), is an evidence-based, manualized, present-focused counseling model to help people attain safety from trauma and/or substance abuse. Mostly delivered in group format.-Research is based on using trained clinicians to implement the treatment, including, counselors, social workers, psychologists.

Is peer-delivered SS as effective as SS delivered by clinicians?


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Primary Objective & Hypothesis

November 15, 2017

• Determine the effectiveness of peer-led SS groups compared to clinical-led SS groups in decreasing substance use and PTSD symptoms and improving coping skills, overall mental health & physical health.

Hypothesis:• Peer-led SS groups would be AS EFFECTIVE as clinician-

led SS groups in decreasing substance use and PTSD symptoms and improving coping skills, overall mental health & physical health.


37November 15, 2017

Project Overview• Three years: August 2013 – July 2016• Primary Data Collection Peer-Operated CB Setting - N=291

• Expanded to Residential Treatment Program for SUDs for three months enrolled 47 individuals into research

• Target Population: • Rio Arriba County; • Adults 18+; • PTSD and/or Substance Abuse determined by a licensed clinician

using the Mini International Neuropsychiatric Interview (M.I.N.I) for Alcohol Dependence/Abuse, Substance Dependence/Abuse and PTSD

• 9% met criteria for PTSD only• 26% met criteria for SUD only• 65% met criteria for both


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Project Overview: Intervention

November 15, 2017

• RCT, Comparative Effectiveness Study• Intervention - SEEKING SAFETY (SS):

• Groups were gender specific• Treatment group – SS Peer-Led Groups • Control Group – SS Clinician-Led Groups

• Male licensed clinical mental health counselor (LPCC) with a M.A. in counselling

• Female licensed Alcohol and Drug Abuse Counselor (LADAC) with a M.S. in Developmental Psychology

• 12 group sessions, one session per week, open-enrollment

• 6 sessions defined as a “completed treatment”


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Relevant Outcomes

November 15, 2017

Baseline 3-Month 6-Month

Face-to-face interviews: $20.00 each• PTSD Symptoms• Substance use• Coping skills • Mental health• Physical health


40November 15, 2017

Intakes N = 533

Assessments N = 431

Eligible N = 422

Determined Not Eligible Among Inside Out Only

N = 9

Clinician GroupN = 145

Peer-Led GroupN = 146

StartedTreatment and

Completed BaselineN = 291


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Demographics

November 15, 2017

N = 291 Clinician-Led Peer-Led Overall

Age (range) 35 (18 – 64) 35 (18-60) 35 (18-64)

Female 43% 46% 44%

Male 57% 54% 56%

Hispanic 83% 85% 84%

Caucasian 62% 59% 60%

Native Amer. 11% 12% 11%

Unemployed 80% 75% 77%


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At least Six Sessions

November 15, 2017

52.7%

30.8%

16.4%

57.2%

31.0%

11.7%

0% 20% 40% 60% 80% 100%

Never

3 months

6 months

% Participants

Com

plet

ion

Tim

e

Peer-led Clinician-led


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Analysis

November 15, 2017

• Linear mixed models were fitted to each of the outcome measures to assess the effect of intervention group

• Full models included covariates for:• treatment arm• age • gender • ethnicity • completion of SS • any missed follow-up interviews • site• living status • time point• Interaction time point by treatment arm


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PTSD Symptoms: Cl vs. PL

November 15, 2017

Measured by the PCL-C

Higher scores mean higher severity; Range: 17-85

PTSD Symptoms

Decreased over Time 48.2

44.7 43.3

47.243.9 42.1

17

27

37

47

57

67

77

Baseline 3 months 6 months

Clinician-Led Peer-Led


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Days of Drug Use in Past 30 Days: CL vs. PL, Peer Operated Community-Based

November 15, 2017

25.0

21.3 21.124.0

20.319.1

0

5

10

15

20

25

30




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Days of Drug Use in Past 30 Days: CL vs. PL, Residential Treatment

November 15, 2017

4.3 3.9

9.56.0 6.9

10.0

0

5

10

15

20

25

30

Baseline 3 months 6 monthsClinician-Led Peer-Led


47

Coping Skills: CL vs. PL

November 15, 2017

Measured by the Coping Scale Range: 0 - 90Higher scores mean better coping skills

Coping Skills Increased over

Time

46.5 48.352.1

45.748.6 51.2

0

10

20

30

40

50

60




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Mental Health Functioning: CL vs. PLMeasured by the SF36 range is 0% to 100%

Higher scores mean better functioning

November 15, 2017

35.7 40.2 41.8

36.341.2 42.9

0

20

40

60

80

100



Mental health Functioning

Increased over Time


49

Physical Health Functioning: CL vs. PLMeasured by the SF36 range is 0% to 100%Higher scores mean better functioning

November 15, 2017

52.7 51.5 50.9

50.8 50.2 49.8

0

10

20

30

40

50

60




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Dissemination and Implementation (D&I)

November 15, 2017

• PL-Seeking Safety is covered under group recovery services (Medicaid)

• Research on barriers to D&I has identified lack of skilled personnel as one of the most important to address to improve implementation of evidence-based practices

• Development of a Peer Guide as a Supplement to the SS Manual

• Future research needs to address ways to improve physical health among those receiving services for mental health and/or substance abuse


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Learn More and Questions

• www.pcori.org

• [email protected]

• #PCORI2017

November 15, 2017



Discussant Dialogue

• Robert McNellis, MPH, PA, Senior Advisor for Primary Care, Agency for Healthcare Research and Quality

• Gladys Lundy, MA, Lead Stakeholder, Compass Study


Moderated Questions & Answers

• In case we are unable to address all questions during Q&A, there are sheets around the room to list 1) your contact information 2) your question/comment and 3) who your question/comment is for. PCORI will share this with session participants and either respond to questions and/or connect session attendees and participants.



Thank You!

patient-centered strategies to improve health and health ......annual meeting oct. 31-nov. 2, 2017...

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