Effectiveness of DECIDE in Patient-Provider Communication, Therapeutic Alliance & Care Continuation
Condition: Mental Disorders
MeSH terms: Mental Disorders
Study type: Interventional

Summary: 
      The purpose of this study is to learn more about how patients and healthcare providers
      interact in order to improve shared decision making. The investigators plan to test an
      intervention with two separate educational components-one for patients and one for
      providers-designed to encourage patients to ask questions and increase their level of
      involvement in their own care, while simultaneously training providers to be more receptive
      to patients' questions and concerns. Patients in the intervention group will receive three
      short (30-45 minute) trainings focused on developing and asking questions and will be
      interviewed three times over the course of the intervention to see how it has affected the
      quality of their care. Providers receiving the intervention will participate in three
      separate trainings, including a 12-hour group workshop, an additional two hour training, and
      six hours of individual instruction, including personalized feedback based on three
      audio-recorded patient visits. Previous studies looking at patient engagement and involvement
      in decision-making have shown that increased engagement is linked with improved outcomes, but
      that providers are sometimes not prepared to develop a collaborative relationship with
      patients. The investigators think that training both patients and providers to work together
      and communicate more effectively will improve quality of care and increase patient
      satisfaction more than interventions that focus on only one side of the clinical encounter.
      One of the major goals in studying patient-provider communication is to improve shared
      decision-making and see how it contributes to racial and ethnic disparities in mental health
      care, since minority patients have been shown to be less involved in care and have been shown
      to be perceived and treated differently by providers.
    

Detailed description: 
      The Center for Multicultural Mental Health Research (CMMHR) at Cambridge Health Alliance has
      recently been selected for funding by the Patient Centered Outcomes Research Institute
      (PCORI) to address the importance of patient-provider communication, shared decision making,
      and therapeutic alliance. Our research team demonstrated that a psycho-educational
      intervention (DECIDE-PA) improves patient activation and self-management in behavioral health
      care. However, the investigators found that providers were unresponsive or reacted negatively
      to patients' activation. In response, the investigators propose to combine DECIDE-PA with
      provider coaching (DECIDE-PC) to increase providers' receptivity to patient activation, and
      improve Shared Decision Making (SDM). The investigators also focus on quality of care,
      responding to clinic administrators who require interventions that improve quality of
      behavioral health care (mental health and substance treatments).

      Aims: 1) Test the effectiveness of DECIDE PA+PC compared to usual care in improving SDM and
      patient-perceived quality of behavioral health care; 2) Test whether patient-centered
      communication and therapeutic alliance mediate the effect of the DECIDE PA+PC intervention on
      SDM; 3) Explore whether ethnic/racial or language matching between patient and provider
      moderates the effect of DECIDE PA+PC on SDM and quality of behavioral health care.

      Intervention: The DECIDE PA+PC intervention is designed to improve the quality of mental
      health care for adult behavioral health patients by engaging minority participants in asking
      questions about their treatment. The intervention is administered to patients and providers
      and is designed to improve patient activation, self-management, and therapeutic alliance.

      For patients, the DECIDE PA is designed to help patients identify concerns about their
      condition or treatment and generate questions for providers regarding these concerns. The
      DECIDE PA intervention consists of 3-4 brief training sessions for patients delivered by Care
      Managers.

      For providers, the DECIDE PC is designed to help providers improve therapeutic alliance,
      patient-provider communication, continuance in care, and satisfaction with services for
      patients in concordant and discordant ethnic/racial dyads. The DECIDE PC training for
      providers consists of 1.5 days of training which focuses on augmenting patient-centered
      communication and therapeutic alliance as a possible underlying pathway by which SDM can take
      place. The training also addresses 1) lack of perspective taking; 2) frequent attributional
      errors that providers make; and 3) decreased receptivity to patient participation and
      collaboration in decision making. The training includes provider coaching totaling 15-20
      hours.

      Methods: For Aim 1, implement a randomized controlled trial comparing DECIDE-PA+PC with usual
      care on Shard Decision Making (SDM) and perceived quality of care. Identify treatment effects
      using multi-level models that account for nesting of observations, patients, providers, and
      clinics. For Aim 2, identify underlying mechanisms of the effect of the DECIDE-PA+PC
      intervention on SDM. Mediation analysis techniques are used that allow for rigorous testing
      of causal pathways and statistical adjustment for spurious correlation is used in instances
      where mediators and SDM measurement are contemporaneous. For Aim 3, expand Aim 1 models to
      test whether DECIDE-PA+PC impacts SDM and perceived quality differentially by ethnic/racial
      concordant/discordant dyads.

      Usual Care: Usual care across clinics is described by clinicians as answering their patients'
      questions during the clinical encounter. Clinicians report that on average they perceive
      their patients as having limited involvement in decision-making. No DECIDE training for
      patients or providers will be applied to the control condition while the control provider and
      control patient are participating in the study. Once the control provider and control patient
      complete their participation in the study, they will be offered the DECIDE trainings.

      Participating Sites: The investigators plan to administer the intervention to patients and
      providers at four participating Cambridge Health Alliance clinics, along with Beth Israel
      Deaconess Medical Center, Boston Children's Hospital, South Cove Community Health Center,
      Edward M Kennedy Health Center (Great Brook Valley Health Center), and two community health
      centers through Harbor Health Services (Neponset Health Center and Geiger Gibson Community
      Health Center).
    

Intervention name(s): DECIDE-PA; DECIDE-PC
Intervention type(s): Behavioral; Behavioral
Intervention description(s): The DECIDE-PA intervention teaches patients strategies for asking questions and communicating more effectively with their behavioral health care provider in order to improve shared decision making.; The DECIDE-PC intervention trains providers in patient-centered communication techniques and encourages providers to be receptive to patients who take a more active role during the clinical encounter in order to improve shared decision making.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Health Services Research
Keywords: Patient-Provider Relationship; Shared Decision Making; Therapeutic Alliance; Mental Health; Minority Health; Patient Activation; Communication