Wisdom in Numbers: Using Stakeholder Feedback To Shape a Research Agenda for Integrating Mental Health and Primary Care (Text Version)

On September 28, 2010, Benjamin F. Miller, Charlotte Mullican, C.J. Peek, and Rodger Kessler made this presentation at the 2010 Annual Conference. Select to access the PowerPoint® presentation (450 KB). 

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Slide 1

Wisdom in Numbers: Using Stakeholder Feedback To Shape a Research Agenda for Integrating Mental Health and Primary Care

Charlotte Mullican
Benjamin F. Miller
C.J. Peek
Rodger Kessler

Slide 2

Finding the Gaps
Setting and Agenda
Changing Healthcare

• First there was the AHRQ EPC Report.

Slide 3

The Collaborative Care Research Network (CCRN), a sub-network of the AAFP's National Research Network (NRN), was created so that clinicians from across the country can ask questions and investigate how to make integrating mental health and primary care work more effectively.

Slide 4

The purpose of the Collaborative Care Research Network Research Conference was to respond to the questions raised by the Agency for Healthcare Research and Quality (AHRQ) Evidence Practice Committee (EPC) report: Integration of Mental Health/Substance Abuse and Primary Care.

There were four specific aims for the conference:

1. To establish and prioritize a set of research questions to evaluate collaboration between behavioral health and primary care.
2. To respond to the set of questions identified in the 2008 AHRQ systematic review and other publications concerning the effectiveness of collaborative care.
3. To inform AHRQ about the identified research goals to assist the development of future contract task orders.
4. To inform investigators outside of the existing PBRN community about areas to serve as the focus for investigator initiated research.

Slide 5

Using Stakeholder Opinion To Set a Prioritized Research Agenda

• Wisdom of Crowds.

Slide 6

CJ Peek

• Language is important.

Slide 7

"Is there a lexicon in the house?"
Normal confusion in a new field

Imagine being on a planning committee conference call...

• "Are you saying integrated care and collaborative care are the same thing?"
• "Is integrated behavioral health the same as co-located mental health or primary behavioral healthcare?"
• "What functions have to be on the collaborative care team if it is to be real collaborative care?"
• "What has to be in place in practice to count as the genuine article-and what can be different from practice to practice?"

Do you think your clarity (or lack of it) is shared by the person next to you?

Slide 8

We needed a common 'lexicon' for Collaborative Care

Shared terms for the essence that unites the many local variations as the "genuine article":

• But with a vocabulary for acceptable differences.
• Enough resolution of definitional confusion to allow consistently understood research/evaluation questions.
• Enough clarity of essence to point to business model.
• Developing a common language with which to represent this field to ourselves and others.

Slide 9

Lesson from history: Emerging fields require conceptual systems adequate to the work

Before 1881: 12 different units of electromotive force, 10 units of current, 15 units of resistance.

"The International Electrical Congress of 1881 has borne good fruit... a rapprochement between electricians of all countries. . . and the adoption of an international system of measurement which will be in universal use".
Nature 30, 26-27; 8 May 1884.

After 1881: Volt, Ohm, and Ampere all defined as one conceptual system—as in a mature field. 

Slide 10

To ask research and practice development questions—deal with both the empirical and the pre-empirical

Empirical:

The cat is on the mat—Is it in fact the case?

Image: A cat lying on a mat.

Pre-empirical:

Do we agree enough about: 

• What counts as a cat? 

Image: A dog lying on a mat.

Slide 11

Pre-empirical

• Do we agree enough about: What counts as "is on"?
• Do we agree enough about: What counts as a mat?

Two images: A cat sprawled on the floor, partially on a mat, and another cat sitting curled in the center of a large rug are shown.

Slide 12

Requirements for "lexicon" development method:

1. Consensual but analytic
   (a disciplined process—not a political campaign)
2. Involving "native speakers"
   (implementers and users)
3. Focused on what functionalities look like in practice
   (not just principles, values, abstractions)
4. Amenable to gathering an expanding circle of "owners" and contributors
   (not just an elite group coming with a declaration)
   

Slide 13

Method: Paradigm Case Formulation & Parametric Analysis

1. Describe an incontrovertible case of collaborative care practice.
   ("if that's not collaborative care, I don't know what is!")
   
2. List how that indubitable case could be changed and still be collaborative care.
   ("yes you can change X or delete Y and it's still genuine collaborative care")
   
3. Name the dimensions or parameters along which collaborative care practices can legitimately differ from one another.
   ("our vocabulary for describing and evaluating acceptable variations among practice components")

(Ossorio 2006; The Behavior of Persons)

Slide 14

Paradigm case: Collaborative care is...

1. A team:
   1. Physician, psychologist, care manager.
   2. Working in same space.
   3. Having formal or informal job training for their roles.

   4. Working in one practice culture, eager to address biopsychosocial.

      Transformations (acceptable differences):
      T1. Change "family physician" to any other physician discipline
      T2. Change "psychologist" to any other MH discipline
      T3. Delete "care manager"
      T4. Change "in one clinic" to multiple clinics and clinical partners
      T5. Change "working in same space" to "set of working relationships..."
      T6. Change "single culture" to "commitment to building shared culture."

2. With a shared population & mission: 
   • E. Same panel of clinic pts, same mission of PC, assessment, tx, F/U 

   • F. With BH clinician working under same mission and boundaries of PC

     Transformations (acceptable differences):
     T7. Change "mission of PC" to any other area of medicine
     T8. Change "identified w same panel of pts" to "any subset of pts..."

Slide 15

Paradigm case: Collaborative care is...

3. Using a clinical system:
   • G. Employing population level screening to identify who needs this collab[oration].
   • H. Working [to] form an explicit, unified care plan document w goals & roles.
   • I. With care plans that pay attention to family, culture, lang., school, etc.

   • J. Contained in shared med record, with ongoing communic[ation] & SDM.

     Transformations:
     T9. Change "population level screening" to "other form of ident. syst"
     T10. Change "unified care plan doc" to info in separate record w comm"
     T11. Delete "patient-clinician decision-making" (SDM)

4. Supported by an office practice & financial system:
   • K. Clinic ops systems & mgmt that supports communic, collab, care mgmt.

   • L. Sustainable package of financing e.g., single pool, bundled + FFS, PPF, etc.

     Transformations:
     T12. Delete "office processes clear, effective & efficient as can be found"
     T13. Delete / add any mode of financ. support as long as supports collab
     T14. Substitute "working toward sustainability" for "sustainable fin support"

Slide 16

Paradigm case: Collaborative care is...

Slide 17

Parameters of collaborative care practice (1)

The team:

1. Team composition	PCP + nurse/MA + Care mgr	PCP + nurse/MA + care mgr + consulting BH	PCP + nurse/MA + care mgr + Integr BH	PCP + nurse/MA + care mgr + integr BH + other
2. Level of collaboration or integration	Coordinated—basic collaboration at a distance	Co-located—basic collaboration on-site	Integrated—in partially or fully integrated system

Blount; Doherty, McDaniel & Baird.

Slide 18

Parameters of collaborative care practice (2)

With a shared population and mission.

3. Target population	Primary medical care		Specialty medical care		Specialty MH care
Stage of life	Children	Adults		Geriatrics		End of life
Kessler & Miller; Peek & Baird	Mental health conditions	Psycho-physiological symptoms		Medical / chronic conditions		Complex cases of any kind
Blount	Targeted specific diseases, populations			Non-targeted All comers

Slide 19

Parameters of collaborative care practice (3)

Using a clinical system.

4. Method of population identification	Patient or clinician	Patient or clinician +system indicators	Patient or clinician +universal screening
5. Program scale /maturity	Pilot: demo or test of change	Project: pilots rolled together	Mainstream: full scale way of life
6. Level of pt centeredness / engagement	Little or none chance—up to individuals	Limited some systematic effort	By protocol built into clinical system

Slide 20

Parameters of collaborative care practice (4)

Supported by an office practice and financial system.

7. Level of office practice design & reliability

Informal non-standard processes vary by individual & day

Partially routinized some standards set for some processes

Standard work Whole system operates in standard expected way

Reliability science & Lean concepts

8. Business model / financing	FFS only	FFS + small bundled care mgmt fee	Large bundled care mgmt fee + small FFS	Separate MH and medical fund pools	One pool of funds for all medical or MH care
9. Ability to collect and use practice data	Little or no routine data collected or used		Commitment to building a system to collect & use data		Mature data collection and use in decision-making

Slide 21

Rodger Kessler

• Into the research.

Slide 22

"You cannot solve problems by continuing to use the same solutions that created the problem in the first place."

—Albert Einstein

Slide 23

Conceptual Model of the CCRN

The Domains of the CCRN:

• Efficacy
  • Disease specific interventions within an organized care framework (e.g., Katon & Unutzer, 2006; Unutzer et al., 2002).
• Comparative Effectiveness
  • What are the critical elements required in general practice to accomplish the desired outcomes?
• Translation
  • Broad implementation of research findings into practice.
• Policy
  • Practice guidelines; public health and professional society recommendations.

Notes: The CCRN was created to enhance the evidentiary support for mental health in primary care. As the AHRQ EPC report showed, we do not know what elements of integration are vital in producing the desired goals. Through a practice based research structure, the CCRN will be able to aggregate data from multiple primary care sites with integrated mental health and learn more about what works when we integrate. The CCRN aims to ultimately impact policy through the research gathered.

Slide 24

"If we want more evidence-based practice, we need more practice-based evidence."

—Larry W. Green

Slide 25

We Need new RCT's

Relevant
Contextual
Timely

Intervention studies

Slide 26

The Two Generations of Questions

Descriptive (Generation A):

• • What is currently occuring in collaborative care?
  • What are the elements, frequencies and variations in practice models, target populations and other dimensions?

Evaluative (Generation B):

• • What collaborative care arrangements work best for whom?
  • What are the outcomes and the relationship of variations to outcomes?

Slide 27

The problem

You're 30 yards above the ground in a balloon
You must be a researcher
Yes. How did you know?
Because what you told me is absolutely correct but completely useless
You must be a policy maker
Yes, how did you know?
Because you don't know where you are, you don't know where you're going, and now you're blaming me

Slide 28

The End

• Finale

Slide 29

References

• Peek, C.J. (2009). Toward a conceptual system for the field of collaborative care: A starter lexicon for the Collaborative Care Research Network (conference white paper).
• Ossorio P.G. (2006). Conceptual-Notational Devices. Chapter in The Behavior of Persons, The Collected Works of Peter. G. Ossorio, Vol V. Descriptive Psychology Press, Ann Arbor, MI.
• The 1881 Electrical Congress of Paris. Nature 30, 26-27; 8 May 1884.