Title: Training Residents in Behavioral Health Service Delivery in Primary Care: A Demonstration Project

Transcription

1 APPLICANT INFORMATION Applicant Name: Jeffrey Shahidullah Institution/School: Geisinger Health System Highest Degree Completed: PhD Position: Postdoc/Fellow If student, year in school: Are you enrolled in a degree/fellowship program: Yes Location: Geisinger Health System Degree: Licensure Mentor Name: Paul W. Kettlewell, Chief Pediatric Psychologist Mentor Institution: Geisinger Health System PROJECT INFORMATION Title: Training Residents in Behavioral Health Service Delivery in Primary Care: A Demonstration Project Description: Pediatricians are positioned to serve an increasing number of youth presenting with behavioral health concerns in primary care. One common barrier to providing effective care is the lack of training that PCPs receive in behavioral health (Serby et al., 2002). Most primary care medicine residency program directors report that behavioral health training is important and should be emphasized more in their programs (Chin et al., 2000). In fact, most directors of accredited primary care residency training programs in internal medicine and pediatrics acknowledge that the training on this topic is minimal or suboptimal (Leigh et al., 2006). Although training directors in family practice programs tend to report the highest levels of satisfaction with the current status of their behavioral health training, 41% still describe the training as minimal or suboptimal (Leigh et al., 2006). Recognizing the lack of formal training in behavioral health that medical providers receive, the American Academy of Pediatrics (2009), in a policy statement, highlighted key aspirational behavioral health competencies (ADHD, anxiety, depression, suicide) for pediatricians. The AAP posits that the attainment of these competencies requires innovations in residency training. This study will empirically evaluate an innovation in training by delivering a behavioral health curriculum to pediatric residents in a setting in which behavioral health services are integrated in primary care. The curriculum is delivered by behavioral health providers who are embedded within the patient-centered medical home. Description of the enhanced training curriculum for pediatric residents:

2 Service Delivery Component Warm hand-offs. Consists of on-site behavioral health providers (BHPs; psychologists) collaborating with residents on BH concerns through direct patient care Behind-the-scenes consults. Consists of on-site BHPs collaborating with residents through indirect (informal discussions in resident clinic workroom) patient care In-vivo performance feedback. Consists of BHPs observing/providing feedback to residents in their conducting evaluations for ADHD, anxiety, depression, and/or suicide; feedback includes completion of a checklist of components of an evaluation based on AAP/AACAP practice parameters and discussion of strengths/improvement areas Didactic Component Lectures. Consists of BHPs delivering bi-weekly lectures on common BH concerns; lectures focus on AAP/AACAP practice parameters for ADHD, anxiety, depression, & suicide, as well as other commonly presenting concerns Readings and quizzes. Consists of assigned readings before lecture with corresponding quizzes; feedback and discussion of correct answers to the quizzes; readings include AAP/AACAP practice parameters and relevant articles regarding evaluation and treatment (Pediapred, Pediatrics in Review) Vignettes and case discussions. Consists of reading vignettes describing BH concerns and identifying appropriate evaluation steps, diagnosis, and treatment plans based on practice parameters; case discussions are built into lectures and discussed as a group The goals of the proposed project are to: 1) Evaluate current levels of pediatric residentâ s attitudes, knowledge and skills in in behavioral health service delivery. 2) Evaluate the effectiveness of a pediatric resident training curriculum in behavioral health. We will compare changes in attitudes, knowledge, and skills of pediatric residents who are exposed to three different BH service delivery models: (1) Integrated Behavioral Health Service Delivery plus Didactic Training Model; (2) Didactic Training only Model (no integrated service delivery component); and (3) training as usual program. The definition of TAU is that which occurs in a typical pediatric training program, which is often a mandatory 1-month block rotation in developmental/behavioral pediatrics. Assessing pre/post changes in attitudes, knowledge and skills allows investigators to determine, from an implementation science framework, what â œdosageâ is optimal for future pediatricians among three relatively feasible options. Research question: What is the most effective dosage program to facilitate future pediatrician's attainment of the behavioral health competencies highlighted in the 2009 Policy Statement? Hypothesis: It is hypothesized that the current level of behavioral health training that residents receive (TAU) does not equip residents to meet the behavioral health competencies espoused by AAP at the end of their residency training. Rather, the provision of a model in which residents provide patient care in an integrated fashion with behavioral health providers along with receiving didactic lectures as part of a formal curriculum will provide the type of experiential exposure to managing behavioral health concerns that is more conducive to learning and enhancing clinical competencies. Setting: The setting for this project will take place at 3 different sites. All 3 sites are as part of large accredited pediatric residency training programs in suburban cities in the Northeastern U.S. Each site serves a patient catchment area containing low to middle income populations. The role that I play is currently in one of the settings which provides integrated behavioral health

3 service delivery and didactic training to residents. I provide these services as a pediatric psychology postdoctoral fellow. Participants: Participants consist of first, second, and third year pediatric residents at three residency programs in the Northeastern U.S. All three residency training program sites admit 11 residents per year (33 total in matriculation). Therefore, there will be 99 total participants in the study who are targeted for participation. There are no exclusionary criteria in this study as data will collected from all residents who elect to participate. Recruitment will occur via working with the residency training program directors at each of the three sites to establish a time and a place in which all residents are instructed to be at one time. After residents at each site are congregated they are advised by the research assistants, who are responsible for data collection, that their participation in the study is voluntary and that there are no consequences if they choose not to participate. No participation incentives are provided to participants who complete the questionnaire. However, participants who volunteer to sit for a focus group are provided with a complementary meal ($10 value). Procedures: Measure #1. Attitudes, Knowledge, and Skills Questionnaire. This measure was developed by the investigators of this study and consisted of 23-items. Items 1-12 consisted of demographic questions about personal history as well as education and training history. Items consisted of residentâ s ratings of their level of confidence in their knowledge about a widerange of pediatric behavioral health concerns. Item 19 consisted of an item that elicited openended information of what topics residents feel they would like to learn more about. Items consisted of questions requiring respondents to demonstrate their knowledge of AAP/AACAP practice parameters for evaluation and treatment of ADHD, anxiety, depression, and suicide. The range of possible scores ranged: ADHD, 0-25; anxiety, 0-15; depression, 0-23; suicide, 0-5. Measure #2. Focus Groups. 1st, 2nd, and 3rd year pediatric residents at each site will participate in a 1.5 hour long focus groups. The goal will be for 4 to 6 residents from each year to participate in focus groups. Focus groups follow a basic script inquiring further about attitudes, knowledge, and skills in behavioral health. The purpose of the focus groups are to obtain qualitative data that cannot be obtained through a basic questionnaire. Analysis: Data analysis will consist of multiple methods given the quantitative and qualitative nature of our data collection approach. A full-time research assistant will be responsible for transcribing and coding audio-taped focus group results and for coding questionnaire data. Focus group data will also be coded by co-investigators and inter-rater reliability will be assessed. Qualitative data will be analyzed using descriptive statistics. Quantitative data will be analyzed using STATA software to assess whether there are statistically significant differences among residents at training sites. Project Timeline: July Collect baseline data across sites (questionnaires/focus groups) July Initiate year 1 curriculum across sites May Submit manuscript to refereed journal which

4 describes curriculum and baseline data June Collect post year 1 data across sites (questionnaires/focus groups) July Initiate year 2 curriculum across sites Sept Present baseline and post year 1 data at CFHA Conference in Charlotte, NC June Collect post year 2 data across sites (questionnaires/focus groups) July Initiate year 3 curriculum across sites March Submit presentation to CFHA Conference discussing results from 3 year pilot June Collect post year 3 data across sites (questionnaires/focus groups) July Submit â White Paperâ summary of research project results to SDBP July Submit manuscript to refereed journal to present end of study results from 3 year pilot How will you know you have achieved your project's goals? We will know that we have achieved our goals if we had 1) obtained evaluation data on current levels of attitudes, knowledge, and skills in behavioral health for pediatric medical residents across all 3 study sites, and 2) obtained evaluation data from pediatric medical residents after they have received 3 years of the training curriculum at each of the 3 study sites. The project will be successful if, at the end, we are able to identify the dosage and modality of training pediatric medical residents that is most effective for increasing attitudes, knowledge, and skills in behavioral health. How do you plan to use the information you gather in this project? From a clinical practice quality improvement perspective, we plan to determine the effectiveness of the various curricula for the purpose of long-term implementation at our training sites. We also hope that other training programs at our institutions (family medicine, internal medicine, emergency medicine) can learn from our training curricula and implement similar initiatives within their programs. From a research perspective, we plan to submit a research paper and poster to CFHA to present our study's results after 1 year and 3 years. We also plan to submit a manuscript describing our study's results to a refereed journal. How does this project advance the field of collaborative care? While most research on integrated behavioral health care initiatives in primary care have focused on improving patient outcomes, access to care, and overall costs of care. Another factor that often gets overlooked is the impact of behavioral health integration and training on the child-serving system as a whole. By training PCPs to more effectively screen for, evaluate and manage commonly occurring pediatric behavioral health conditions, we are effectively increasing the internal capacity for this system to deliver effective behavioral health care. Through delivering foundational training to pediatric residents through a formal residency program curriculum, the impact made on future behavioral health service delivery could be multiplicative rather than case of one's concerns. How does this project advance you professionally? The goal for the project in which funding is requested is to be able to empirically determine not only the effectiveness, but also the feasibility of implementing such a formal behavioral health curriculum to pediatric residents. The data will prove useful in leading to the development of a

5 large-scale proposal related to training pediatric residents to effectively screen, evaluate, and manage commonly occurring behavioral health conditions. With data from this study to show which methods and dosages of residency training are most amenable to what are very compact and busy resident schedules, I hope to develop a proposal for a Health and Human Resources and Services Administration (HRSA) grant in order to fund the large scale implementation and evaluation of the curriculum to train future pediatricians to address mental and behavioral health issues in primary care. Fortunately, I will continue to be well positioned in the coming years to carry out such a proposal. I was recently hired to begin as an assistant professor of psychology at one of the participating research sites of this study once I complete my current postdoctoral fellowship position in July. I will hold a joint-appointment within the Psychology Department as well as the Department of Pediatrics at the participating medical school. I have developed strong partnerships with their Residency Training Program Director as their residents are currently participating in the curriculum and study. Additionally, I also have established partnerships for on-going research with the Residency Training Program directors at the other two training sites in this study. I hope to expand to additional training sites over the next 5 years, as well as investigate various applications of the curriculum with the goal of continual improvement. For example, adaptations may consist of evaluating the effect of a social-worker delivered, rather than a psychologist-delivered curriculum to consider cost-effectiveness variables. Other considerations include methods to increase the intensity level of individualization and generalizability of training in cost-and time-effective ways. One method of interest is the possibility of including standardized patients in the curriculum whereby residents can practice clinical interviewing skills. Other considerations pertain to the didactic curriculum that is being delivered. It will be important to ascertain which didactics can account for the largest gain in generalizable skill development. For example, rather than teaching practice parameters for individual behavioral health conditions, it may be more advantageous and practical to teach residents on common factors that are consistent across conditions such as anxiety, depression, eating disorders, substance abuse, etc. This may also include a module on effective communication skills such as motivational interviewing in primary care. This project will contribute to my career practice and research plan to increase the capacity of child-focused providers in primary care to address the behavioral health needs of children and adolescents. My focus on primary care as a target venue is due to the accessibility it affords to families and youth and the coordination of care it offers in the context of the medical home. Specific long-term goals I have include the development of a joint training program in which medical providers and psychologists can learn and train together in a capacity in which their unique skill-sets and interests can foster an improved emphasis on inter-disciplinary collaboration. Specifically, I hope to develop a joint training curriculum that involves training doctoral-level psychologists and residents to address behavioral health needs in primary care in a coordinated fashion. I will aim for a HRSA- Graduate Psychology Education (GPA) training grant.