Roshan Bastani, PhD, Beth Glenn, PhD, Russ Glasgow, PhD

CPCRN Spring Virtual MeetingApril 15, 2013

My Own Health Report (MOHR) Project

(Previously PRO Project)Goal: Integrate Patient Reported Behavioral Health Domains into

Routine Primary Care Practice

Patient-Reported Behavioral Health DomainsDomain Final Measure (Source)1.Demographics 9 items: Sex, date of birth, race, ethnicity, English fluency, occupation, household

income, marital status, education, address, insurance status, veteran’s status. Multiple sources including: Census Bureau, IOM, and National Health Interview Survey (NHIS)

2. Overall Health Status 1 item: BRFSS Questionnaire

3. Eating Patterns 3 items: Modified from Starting the Conversation (STC). (Adapted from Paxton, AE et al. Am J Prev Med, 2011; 40(1):67-71.)

4. Physical Activity 2 items: The Exercise Vital Sign (Sallis, R. Br J Sports Med 2011; 45(6):473–474)

5. Stress 1 item: Distress Thermometer (Roth AJ, et al. Cancer 1998; 15(82):1904-1908.)

6. Anxiety and Depression

4 items: Patient Health Questionnaire - Depression & Anxiety (PHQ-4) (Kroenke K, et al. Psychosomatics 2009; 50(6):613-621.)

7. Sleep 2 items: a. Adapted from BRFSS b. Neuro-QOL (Item PQSLP04)

8. Smoking/ Tobacco Use

2 items: Tobacco Use Screener (Adapted from YRBSS Questionnaire)

9. Risky Drinking 1 item: Alcohol Use Screener (Smith PC, et al.  J Gen Intern Med 2009; 24(7):783-788)

10. Substance Use 1 item: NIDA Quick Screen (Smith PC, et al.  Arch Intern Med 2010, 170(13): 1155-1160.)

BackgroundRound 1 of Funding to UCLA

Step 1: Key Informant Interviews Solicited input from clinic leaders/staff regarding implementation of PRO measure within workflow

Participants represented 4 FQHCs in CA and partner clinics in Virginia, Vermont, and Massachusetts

Results suggested high interest among providers but concerns about duplication of data collection and added time and cost burden

Step 2: Paper and Pencil Implementation of PRO Measure

Participating clinics implemented measure with N = ≥ 50 patients plus post-implementation key informant interviews and brief patient survey

Majority of patients “screened positive” for multiple domains

Clinic follow-up of identified concerns varied widely

Patients had few difficulties or complaints about measure itself

Round 2 of Funding: Nine Sites Funded (5 PBRN; 4 FQHC)Name change: My Own Health Report (MOHR)

Pragmatic Trial– Cluster randomized trial of 9 pairs of clinics (5 PBRN; 4 FQHC)

– Study was designed to maximize flexibility and adoption (e.g., clinics with different levels of HIT use, experience with QI)

– Standard delivery of automated assessment tool, feedback, goal setting materials, and suggestions for follow-up

– Delivery of these components is customized to each setting

– Study goal: sustainable, routine implementation of MOHR assessment and intervention

CA1 PBRN 1 FQHC

TX2 FQHCs

NC1 FQHC

VA3 PBRNs

VT1 PBRN

Pragmatic Features

Relevant Diverse, real-world primary care settings; and staff who do all the intervention

Rigorous Cluster randomized, delayed intervention design

Rapid One year from concept, planning, and Execution Low Cost and Cost informative

Transparent Report on adaptations, failures, lessons learned

Design of Pragmatic Trial

MOHR Assessment(all non-acute adult visits for 3-4

months, n = ~300)

Months 0 1 2 3 4 5 6 7 8 9 10 11 12

Early Implementation Sites (4 FQHC, 5 PBRN)

Delayed Implementation Sites (4 FQHC, 5 PBRN)

Intervention (Provider & Patient

Feedback Reports + F. U)

Intervention (Provider & Patient

Feedback Reports + F. U)

Patient Experiences

Survey (n = 300)

Optional: 2nd MOHR Assessment(only for those who completed MOHR)

Arrow = between group

comparisonImplementation of

MOHR Tool

Patient Experiences

Survey (n = 300)

MOHR Online Assessment Tool: Developed by Alex Krist (VCU)

(Transfer of “co-ordinating center” from UCLA to VCU)

Features:

Health Risk Assessment (13 domains)

Solicitation of Patient Priorities – e.g., ready to change; want to discuss with doctor

Patient Health Summary Report – e.g., things they are doing well; areas for improvement

Online Access to Patient Summaries – Can look up specific patients

Online Tracking of Implementation Progress across Sites– e.g., number of patients that were screened, % screened + for specific

domains

Screenshots from MOHR Online Assessment Tool

Health Risk Assessment

Soliciting Patient Priorities

Soliciting Patient Priorities

Patient Health Summary Report

Access to Patient Summaries

Online Tracking of Implementation Progress

Design of Pragmatic Trial

MOHR Assessment(all non-acute adult visits for 3-4

months, n = ~300)

Months 0 1 2 3 4 5 6 7 8 9 10 11 12

Early Implementation Sites (4 FQHC, 5 PBRN)

Delayed Implementation Sites (4 FQHC, 5 PBRN)

Intervention (Provider & Patient

Feedback Reports + F. U)

Intervention (Provider & Patient

Feedback Reports + F. U)

Patient Experiences

Survey (n = 300)

Optional: 2nd MOHR Assessment(only for those who completed MOHR)

Arrow = between group

comparisonImplementation of

MOHR Tool

Patient Experiences

Survey (n = 300)

Patient Experience Survey (PES)

20 item survey to be administered 2-8 weeks post-visit

Eligibility for PES: all patients reporting for non-acute care visits during implementation period for both clinics within each pair (regardless of MOHR use)

The PES assesses patient perceptions regarding: – Assessment of the specific health behavior and psychological domains

related to recent clinic visit– Collaborative goal-setting within each domain– Clinic/provider follow-up for each domain– Quality of clinic/provider communication– Patient-centeredness of care provided by their clinic

Context & Cost Assessments

Goals of Contextual AssessmentTo identify and describe contextual phenomena that may impact MOHR implementation

To provide information on external validity and factors important for transferring MOHR to other settings

Goals of Cost Assessment

To assess clinic resources & time needed to implement MOHR

To provide information to practices considering MOHR implementation as well as to funding agencies and payers

Study Outcomes Summary

• Between group comparison– Patient Experiences Survey

• Within group implementation outcomes:– REACH: % eligible patients completing the health assessment– Follow-up health assessment: only for patients who complete

online and provide email address– Contextual assessment– Cost assessment