Population Based Care: The Heart of the Primary Care Behavioral Health Model

Patricia J. Robinson PhD patti1510@msn.com Mountainview Consulting Group, Inc. patriciarobinsonphd.com

Healthcare Consultant and Trainer, Yakima, WA

Jeffrey T. Reiter, PhD, ABPP jeffreiter2@gmail.comCo-Director, Primary Care Behavioral Health ServiceHealthPoint Community Health Centers Seattle, WA

Collaborative Family Healthcare Association 13th Annual ConferenceOctober 27-29, 2011 Philadelphia, Pennsylvania U.S.A.

Session #: D5Concurrent Session Period 5 October 29, 2011Time 1:30-2:30

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Faculty Disclosure• We currently have the following relevant financial

relationships during the past 12 months:• Springer Media + Business – Co-Authors

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Need/Practice Gap & Supporting Resources

What is the scientific basis for this talk?

• A population based care approach promotes better outcomes for a population of patients and for individual patients in that population.

“Tools, Teamwork and Tenacity: An Office System for Cancer Prevention.” Carney PA, Dietrich AJ, Keller A, Landgraf J, O'Connor GT. Journal of Family Practice. 1992;35(4):388–394.

Robinson, T. N. (1999). Reducing children’s television viewing to prevent obesity: A randomized controlled trial. Journal of the American Medical Association, 282(16), 1561–1567.

Epstein, L. H., Valoski, A. M., Vara, L. S., McCurley, J., Wisniewski, L., Kalarchian, M. A., et al. (1995). Effects of decreasing sedentary behavior and increasing activity on weight change in obese children. Health Psychology, 14(2), 109–115.

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Need/Practice Gap & Supporting Resources

What is the scientific basis for this talk?

• Barriers to implementation of population-based care programs for behavioral health problems in primary care include lack of training of behavioral health providers in the community population-based care perspective and the availability of research studies that support dissemination.

Glasgow, R. E., Lichtenstein, E., & Marcus, A. C. (2003). Why don’t we see more translation of health promotion research to practice? Rethinking the efficacy-to-effectiveness transition. American Journal of Public Health, 93(8), 1261–1267.

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Objectives• Describe the Primary Care BH model and how it

supports development of population-based care programs for primary care patients with behavior problems

• List principles of population-based care • Use the High Impact Patient Group (HIP-G) tool to

identify a group of concern in the participant's home clinic

• Use the Population Based Care Principles (PBCP) tool to generate possible programmatic changes to the way medical and primary care services are delivered to a high impact patient group

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Expected OutcomeAfter being introduced to a model that serves as a platform for development of population-based care programs, participants will feel more confident about pursing the development of these programs. After learning more about the gap between research and practice and how this impacts development of population-based programs for patients with behavior problems, participants will be more interested in developing studies that support dissemination. With increased awareness of 2 tools for developing population-based programs, participants will be more likely to initiate population-based program development activities in their clinic.

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Learning AssessmentA learning assessment is required for CE credit.

1. Rate your level of knowledge of an integration model that provides a platform for development of population-based care programs that address primary care patient behavior problems. (1 = no information; 10 = very knowledgeable)

2. Rate your current knowledge about the gap between research and practice and how this impacts development of population-based programs for patients with behavior problems. (1 = no information; 10 = very knowledgeable).

3. Rate your current interest in developing / requesting studies that better support development of population-based programs for patients with behavior problems (1 = low interest; 10 = high interest).

4. Rate your current intention to initiate population-based programs for patients with behavior problems (1 = low intention; 10 = high intention).

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Population-Based Health

Population Selection

Program Development

This presentation focuses on using Population-Based Health Strategies in the PCMH

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What is the “population health perspective”?

• “A population health perspective encompasses the ability to assess the health needs of a specific population; implement and evaluate interventions to improve the health of that population; and provide care for individual patients in the context of the culture, health status, and health needs of the populations of which that patient is a member.”

American Association of Medical Colleges (AAMC)9

Population-Based Approach Five Principles

1. A community perspective2. A clinical epidemiology perspective

(population-based data)3. Evidence-based practice4. Emphasis on effective outcomes5. Emphasis on primary prevention

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Important Considerations

“When caring for a population, you should measure outcomes for all your patients with the targeted condition, not just those who come to your office. This is largely what differentiates population- based care from traditional, individual- centered care.”

Rivo

• “The term population-based medicine refers to the broadest aspects of community medical care, from primary prevention through tertiary care; … disease state management (DSM) … (is) the subset of population-based care that focuses on disease control . . .”

Weiss

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Two Strategies for Population Health Intervention

High-Risk Strategy• Intervention directed only at

those who are high-risk• Overall impact on disease burden

in whole population may be small– But individuals receiving intervention

benefit more

• Examples:– IMPACT (depression)– Chronic Care Model– Other population-specific strategies

we will discuss later

Population Strategy• Assumes occurrence of disease

reflects behavior/circumstances of society as a whole

• Small, favorable shift in a risk factor across a population can produce large benefit to population as a whole

• Examples:– 2 point ↓ in mean DBP of population

leads to 14%↓ in new stroke cases– ↓ population fat consumption is

more effective for ↓ heart disease than chol-lowering meds for pts with high cholesterol

PCBH*: A Model for Both Strategies• Member of primary care team, work side-by-side• Consultation to improve PCP mgmt of beh’l issues

– Wide variety of interventions and goals– Brief visits, limited follow-up– Immediate feedback to PCP– Any behaviorally-based problem, any age

• Aim for immediate access, high patient volume• Oversees population-based interventions for various

problems, from initiation to maintenance• * Robinson and Reiter, 2006

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A Model for Both Strategies (cont’d)High-Risk Strategy

• BHC role:– Identifies important

populations for program development

– Reviews available data– Surveys PCPs and RNs– Makes presentations and

works to develop cohesion– Participates actively in PBC

program development committees

– Provides important clinical component

Population Strategy• “Community or ‘population’

interventions can succeed by making small changes in a large number of people, rather than large changes in a small number of people.”—AMA (2002)

• PCBH Goals:• Higher patient volume, lower

intensity of care• Increase PCP skill in and use of

behavioral interventions• Improve PCP efficiency and

satisfaction

How does research relate to population-based care program development?

Re-Aim Issue Efficacy Studies

Reach Homogeneous, highly motivated sample; exclude those with complications, other comorbid problems

Efficacy or effectiveness

Intensive, specialized interventions that attempt to maximize effect size; very standardized; randomized designs

Adoption Usually 1 setting to reduce variability; settings with many resources and expert staff

Implementation Implemented by research staff closely following specific protocol

15Glasgow, 2003

How does research relate to population-based care program development?

Re-Aim Issue Effectiveness Studies

Reach Broad, heterogeneous, representative sample; often use a defined population

Efficacy or effectiveness

Brief, feasible interventions not requiring great expertise; adaptable to setting; randomized, time series, or quasi-experimental designs

Adoption Appeal to and work in multiple settings; able to be adapted to fit setting

Implementation Implemented by variety of different staff with competing demands, using adapted protocol

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Glasgow, 2003

High Impact Patient Group 4 (HIP-G 4) tool

Use to identify a target population for a pathway program in your clinic 1.Who is in the group and how many people are in the group? Age; gender; risk factor status; disease status; health care system metrics (such as rates of use)2.What services do patients in the group receive now?3.What is the evidence for the current approach? 4.What is the impact of the current approach? On providers? On the health care system? On patient satisfaction? On patient health status (including QOL)?

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Population-Based Care (Pop-BC 4) tool

Use to develop program to improve care to high impact target population1. What change (s) could be made to improve delivery of

evidence-based treatments to the target population? 2. What are the clinic resources for attempting to improve

care to the target population? Provider interest, BH resources, space, financial impact

3. How will you measure impact of change? Providers? Health care system? Patient satisfaction? Patient health status (including QOL)

4. Do you have a detailed plan that includes a pilot and a steering committee?

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Illustration of the HIP-G 4 Tool: Chronic Pain and Opiate Misuse

1. Who is in the group and how many people are in the group? All patients aged 18 and above who have received > 3 consecutive

months of refills of narcotics2. What services do patients in the group receive now?Phone and clinic visits with nurses and PCPs, and sometimes a BHC3. What is the evidence for the current approach?Multi-disciplinary treatment and CBT is associated with improved

clinical outcomes; group medical visit approach reduces costs by reducing use of ER services

4. What is the impact of the current approach? Providers and patients are dissatisfied. No data on patient health

status and QOL is readily available. Cost data is not available.

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Illustration of the Pop-BC 4 Tool: Chronic Pain

1. What change(s) could be made to improve delivery of evidence-based treatments to the target population?

Create a pathway that requires referred patients to see the BHC for an orientation visit and enrollment in a monthly group medical visit, link RX refills to classes, involve nurse in tracking key outcomes in a registry (signed patient agreement, assignment to class, violations of agreement)

2. What are the clinic resources for attempting to improve care to the target population?

Strong interest, capable BHC3. How will you measure impact of change? Track visits, assess patient QOL at monthly group medical visits, assess provider

and patient satisfaction every 6 months4. Do you have a detailed plan that includes a pilot and a steering committee?Initial pilot with 3 PCPs for 6 month period; steering committee including PCP,

BHC, RN, and Clinic director20

Population-Based Care for Primary Care Patients with Behavioral Problems

Learning AssessmentA learning assessment is required for CE credit.

1. Rate your level of knowledge of an integration model that provides a platform for development of population-based care programs that address primary care patient behavior problems. (1 = no information; 10 = very knowledgeable)

2. Rate your current knowledge about the gap between research and practice and how this impacts development of population-based programs for patients with behavior problems. (1 = no information; 10 = very knowledgeable).

3. Rate your current interest in developing / requesting studies that better support development of population-based programs for patients with behavior problems (1 = low interest; 10 = high interest).

4. Rate your current intention to initiate population-based programs for patients with behavior problems (1 = low intention; 10 = high intention).

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Session Evaluation

Please complete and return theevaluation form to the classroom monitor

before leaving this session.

Thank you!

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