Caring for the Whole Person

Study Overview
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Brief Summary
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The goal of this study is to identify outcomes associated with Behavioral Health Integration (BHI) that matter to patients, to compare changes in outcome over time to measure the impact of different BHI models on different patients, and to create and maintain an Integration Learning Collaborative.

Detailed Description
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Twelve safety net clinics have been selected to be a part of this study. The clinics vary on a BHI continuum level, which includes minimal collaboration, basic collaboration at a distance, basic collaboration on site, close collaboration (partially integrated) and close collaboration (fully integrated). Twelve-thousand patients will be randomly selected from the 12 clinics to be invited to participate in the study. Patients who elect to participate will complete a survey at baseline to collect patient-reported outcomes and again twelve months later. The Oregon All Providers All Claims (APAC) database will be accessed to analyze financial data regarding the patients at baseline and 12 months. The hypothesis is that the degree of clinic BHI will predict patient outcomes.

Official Title
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Caring for the Whole Person: A Patient-Centered Assessment of Integrated Care Models in Vulnerable Populations

Conditions
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Behavioral Health

Intervention / Treatment
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* Other: Access to Care
* Other: Depression Screening
* Other: Patient-Provider Relationship
* Other: Patient-Clinic Interactions
* Other: Stigma
* Other: Provider Continuity
* Other: Symptom Severity
* Other: Diagnoses
* Other: Social support
* Other: Preventive Screening
* Other: Inpatient Hospitalization Utilization
* Other: Inpatient Readmissions
* Other: Post-Admission follow-up


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Age >= 18 Received care at a safety net care clinic in Oregon Exclusion Criteria: -

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Safety Net Clinic Patients<br>A Cohort of patients in 12 different primary care clinics will be studied to measure how changes in different integration factors impacts the following patient reported outcomes at baseline and 12 months: Access to Care, Patient-Provider Relationship, Patient-Clinic Interactions, Stigma, Provider Continuity, Symptom Severity, Diagnoses, and Social Support. Health care claims data will be accessed to analyze Depression Screening, Preventive Screening, Inpatient Hospitalization Utilization, Inpatient Readmissions, and Post-Admission follow-up at baseline and 12 months. | Other: Access to Care<br>* Patient reported outcome survey administered at baseline and 12 months to measure satisfaction with access to care.<br>Other: Depression Screening<br>* Analysis of health care claims data for depression screenings at baseline and 12 months.<br>Other: Patient-Provider Relationship<br>* Patient reported outcome survey administered at baseline and 12 months to measure satisfaction with patient-provider relationship.<br>Other: Patient-Clinic Interactions<br>* Patient reported outcome survey administered at baseline and 12 months to measure satisfaction with patient-clinic interactions.<br>Other: Stigma<br>* Patient reported outcome survey administered at baseline and 12 months to measure perceived stigma.<br>Other: Provider Continuity<br>* Patient reported outcome survey administered at baseline and 12 months to measure satisfaction with provider continuity.<br>Other: Symptom Severity<br>* Patient reported outcome survey administered at baseline and 12 months to measure symptom severity.<br>Other: Diagnoses<br>* Patient reported outcome survey administered at baseline and 12 months to measure diagnoses.<br>Other: Social support<br>* Patient reported outcome survey administered at baseline and 12 months to assess social support and outlets.<br>Other: Preventive Screening<br>* Analysis of health care claims data for preventive screenings at baseline and 12 months.<br>Other: Inpatient Hospitalization Utilization<br>* Analysis of health care claims data for Inpatient Hospitalization Utilization at baseline and 12 months.<br>Other: Inpatient Readmissions<br>* Analysis of health care claims data for Inpatient Hospitalization Readmissions at baseline and 12 months.<br>Other: Post-Admission follow-up<br>* Analysis of health care claims data for Post-Admission follow-up at baseline and 12 months.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in patient reported outcomes | Change in patient reported outcomes at baseline and 12 months | 12 months | 
| Change in health care claims | change in health care claims at baseline and 12 months | 12 months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Integration, Primary Care, Behavioral Health, Health Care Reform, Medical Home, Accountable Care Organization