The Right Question Project-Mental Health: An Intervention to Increase Engagement and Retention in Mental Health Care
Condition: Mental Disorders
MeSH terms: Mental Disorders
Study type: Interventional

Summary: 
      The Right Question Project-Mental Health (RQP-MH) is a three-session health education
      intervention that teaches clients to participate effectively in mental health care. The
      methodology teaches clients to identify important issues of their illness or treatment,
      formulate questions, and devise plans to communicate and act in effective ways that address
      factors impacting their mental health care, with the expectation that this behavior will
      increase patient-provider communication and improve the therapeutic alliance between patient
      and provider.

      The investigators hypothesize that participants receiving the intervention will be more
      likely to engage and remain in mental health care, and that they will report higher
      activation and self-management scores as compared to control patients.
    

Detailed description: 
      The intervention is one of two Cambridge Health Alliance (CHA) projects from the University
      of Puerto Rico-Cambridge Health Alliance Research Center of Excellence (UPR-CHA RCE). The
      overall goal of the project is to evaluate an intervention that teaches patients a set of
      skills needed to facilitate a more active patient role in the mental health encounter,
      emphasizing the patient's decision-making process during mental health treatment. The project
      also aims to support collaborative provider-patient relationships in order to increase
      engagement and retention and, consequently, reduce service disparities. The intervention has
      been pilot-tested in the Right Question Project-Mental Health I (RQP-MH I) study (Alegría,
      2008), conducted as part of the UPR-CHA EXPORT Center from September 2004 through February
      2006.

      The first aim of the current project is to conduct a multi-site randomized controlled trial
      to test the Patient Activation and Self-Management (PASM) intervention, also called RQP-MH
      II, in predominantly Latino mental health clinics. The investigators will assess the
      intervention's impact on engagement and retention in mental health care. The second aim is to
      explore the racial/ethnic differences in the effect of the RQP-MH II intervention for Latinos
      as compared to non-Latino whites, as little is known about the impact of patient
      race/ethnicity on the effectiveness of patient activation interventions. The fourth aim is to
      explore the role of patient-provider communication and therapeutic alliance as mediators of
      the relationship between patient activation and engagement and retention in care. It is
      expected that increased patient-provider communication and a stronger therapeutic alliance
      will result from increased participation in the decision-making process. These potential
      changes in the process of care are expected to consequently increase patient engagement
      (keeping scheduled appointments) and retention (reduction of premature unilateral
      termination) in mental health care.

      Data shows that patients may not readily state their concerns in their medical visits (Roter
      et al., 1997; Korsch, Gozzi & Francis, 1968) and usually refrain from engaging in
      information-seeking (Beisdecker & Beisdecker, 1990). Minority patients are even less likely
      than their white counterparts to have a collaborative relationship with providers
      (Cooper-Patrick et al., 1999). This is a problematic situation particularly for minority
      patients, such as Latinos, who cherish maintaining a warm personal connection with their
      providers (American Medical Association, 1994) and may worry that bringing up questions or
      asking for explanations might jeopardize the relationship.

      Minority patients may not be as informed about diagnosis, prognosis, and medication side
      effects (Schaafsma, Raynor & de Jong-van den Berg, 2003) and consequently feel disappointed
      that they do not receive needed information (Levinson et al., 1993). They may therefore be
      less compliant with treatment (Kalichman et al., 1999), and more likely to drop out of care
      (Takeuchi et al., 1992). Minority patients may have a less comprehensive understanding of
      mental health care compared to White patients (Miranda and Cooper, 2004). As a result, they
      are at a greater risk of assuming that the provider's decisions reflect their best interest
      (Flynn et al., 2004). This is exemplary of Latinos who hold traditional role expectations
      that oppose active involvement in the clinical encounter and prefer to delegate decisions
      about their care to their providers (Levinson et al., 2005; Xu, Borders & Arif, 2003).

      To contend with difficulties in communication, most interventions focus on provider training
      (Post, Cegala & Miser, 2002), with less attention on teaching patients how to effectively
      express their concerns and questions to their providers (Andersen & Sharpe, 1991; Roter,
      1977). Yet results from assessments of self-management of chronic conditions (Hall, Roter &
      Katz, 1988; Stewart et al., 1993) indicate that greater patient activation and
      self-management in treatment can augment satisfaction with care (Blanchard et al., 1990),
      improve the health care process (Rosenberg, Lussier & Beaudoin, 1997; Epstein et al., 1993),
      ensure the receipt of guideline concordant treatments (Clever et al., 2006), and potentially
      enhance health outcomes (Kaplan, Greenfield & Ware, 1989).

      Most studies of patient activation and self-management in the field of mental health care
      have not been conducted with minority populations of low literacy nor in a language other
      than English. Most have not included mixed-methods (qualitative and quantitative) to evaluate
      the effectiveness of the intervention, and have not obtained cost information that can help
      evaluate whether changes in patient activation and self-management, or in treatment
      engagement and retention, could potentially produce savings in treatment or health care
      outcomes.

      The proposed project is expected to fill this gap, assessing the effects of a patient
      activation and self-management intervention using a mixed-methods approach, with three data
      collection periods. The investigators hypothesize that patients participating in the patient
      activation and self-management intervention will be significantly more likely to engage and
      remain in mental health care, and will report significantly higher activation and
      self-management scores as compared to control patients. Given the relationship of patient
      participation and health outcomes, increasing Latino patient's participation in
      decision-making a as mechanism to eliminate service disparities is the goal of the proposed
      intervention.
    

Intervention name(s): Right Question Project - Mental Health (RQP-MH); Pamphlet
Intervention type(s): Behavioral; Behavioral
Intervention description(s): The RQP-MH trainings each take approximately 45 minutes to complete and are delivered approximately three weeks apart. The manualized intervention uses a Question Formulation Technique (QFT) and a Framework for Active Decision-Making (FADM). The QFT consists of asking patients to generate and revise questions to obtain more informative answers from their providers. The FADM teaches participants to identify questions that will help them consider their role in a decision, the process of decision-making, and the reasons behind a decision. All intervention sessions will be taught by a bachelors-level "Care Manager."; Participants in this group receive a handout called "Managing Your Mental Health" (available in Spanish and English) that provides tips on how to manage mental health through the proper maintenance of physical health and stress.
Other intervention name(s): Patient Activation and Self-Management (PASM) intervention
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Health Services Research
Keywords: Minority Groups; Decision Making; Patient Participation; Mental Health Services; retention; attendance; patient activation; Hispanic Americans; patient-provider communication