Community Partners in Care is a Research Project Funded by the National Institutes of Health

Not Applicable

Completed

Conditions: Depression
Information Dissemination
Social Determinants of Health

Interventions: Other: Quality Improvement Program
Behavioral: Resources for Services Expert Team
Behavioral: Community Engagement and Planning Council

Registration Number: NCT01699789

Lead Sponsor: RAND

Brief Summary: CPIC is a community initiative and research study funded by the NIH. CPIC was developed and is being run by community and academic partners in Los Angeles underserved communities of color. CPIC compares two ways of supporting diverse health and social programs in under-resourced communities to improve their services to depressed clients. One approach is time-limited expert technical assistance coupled with culturally-competent community outreach to individual programs, on how to use quality improvement toolkits for depression that have already been proven to be effective or helpful in primary care settings, but adapted for this study for use in diverse community-based programs in underserved communities. The other approach brings different types of agencies and members in a community together in a 4 to 6-month planning process, to fit the same depression quality improvement programs to the needs and strengths of the community and to develop a network of programs serving the community to support clients with depression together. The study is designed to determine the added value of community engagement and planning over and above what might be offered through a community-oriented, disease management company. Both intervention models are based on the same quality improvement toolkits that support team leadership, care management, Cognitive Behavioral Therapy, medication management, and patient education and activation. Investigators hypothesized that the community engagement approach would increase agency and clinician participation in evidence-based trainings and improve client mental health-related quality of life. In addition, during the design phase, community participants prioritized adding as outcomes indicators of social determinants of mental health, including physical functioning, risk factors for homelessness and employment. Investigators hypothesized by activating community agencies that can address health and social services needs to engage depressed clients, these outcomes would also be improved more in the collaboration condition. Investigators also hypothesized that the collaboration approach would increase use of services.

Detailed Description: Underserved communities of color in low income, largely ethnic-minority neighborhoods face an excessive burden of illness from depression due to higher prevalence of depression and lower access to quality care. Evidence-based quality improvement (QI) programs for depression in primary care settings-where many low-income and minority patients receive their only mental health care-can enhance quality of depression care and improve health outcomes. These programs are under-utilized in community-based health care settings, and have not been adapted for use across diverse agencies (social service, faith based, primary and specialty care) that could partner to support disease management for depression. Partners in Care (PIC)and WE Care are interventions designed to improve access to evidence-based depression treatments (medication management or psychotherapy) for primary care patients and, in WE Care, social service clients. PIC evaluated a services delivery intervention while WE Care was an effectiveness trial with study-provided treatments. Both studies promoted use of the same evidence-based treatments. Both PIC and WE Care programs improved use of evidence-based treatments for depression and health outcomes for African Americans and Latinos. The PIC interventions reduced health outcome disparities evident in usual care in the first follow-up year and at five-year follow-up. While these findings offer hope to underserved communities, such communities have poor resources to support implementation of these programs, and may have historical distrust in research and health care settings. There is no evidence-based approach to support agency networks in underserved communities in implementing QI programs for depression. To address this information gap, investigators created Community Partners in Care (CPIC), a group-level randomized, controlled trial, with randomization at the level of an agency site or "unit." The trial is being fielded in two underserved communities, Hollywood and South Los Angeles, and conducted through a community- participatory, partnered research (CPPR) approach.

The specific aims of the study are:

1. To engage two underserved communities in improving safety-net care for depression.

2. To examine the effects of a community-engagement approach to implementing evidence-based depression quality improvement toolkits (PIC/WE Care) through a community collaborative network across services sectors, compared to technical assistance to individual programs from the same services sectors coupled with culturally-competent outreach to implement the same toolkits. The outcomes are: a) client access to care, quality of care and health outcomes, with the primary outcome being mental-health related quality of life and additional outcomes reflecting social determinants of mental health of interest to the community (physical health, homelessness risk factors, employment); b) services utilization and costs; c) agency adoption of PIC/WE Care; d) and provider attitudes, knowledge and practice.

3. To describe the process of implementation of the community engagement intervention.

CPIC was awarded funds from the Patient Centered Outcomes Research Institute (PCORI) in 2013 to accomplish the following 3 aims:

1. To compare the long-term (3-year) effectiveness of community engagement and planning versus agency technical assistance to implement depression QI and improve depressed clients' health status and risk for homelessness

2. To determine how depressed clients in under-resourced communities prioritize diverse health and social outcomes and identify their preferences for services to address priority outcomes

3. To identify capacities of providers to respond to depressed clients' priorities and to generate recommendations for building capacity to better address clients'priorities.

We hypothesize that community engagement and planning will be more effective than technical assistance in improving 3-year outcomes and that clients will prioritize quality of life. We expect to find gaps in provider capacities to address client priorities that network strategies could address.

Our primary outcome for the long-term follow-up is mental health related quality of life and secondary outcomes are use of healthcare and community services for depression and physical functioning and homeless risk factors.

In 2014, CPIC was awarded funds from the National Institute on Minority Health and Health Disparities (NIMHD) to use existing quantitative CPIC data and collect new qualitative data to describe pathways to reducing disparities. The funding allows us to longitudinally track the implementation of the CEP model in a new county-wide initiative to develop community networks to promote healthy neighborhoods. The aims under this additional funding are:

1. To determine pathways to reducing mental health and social disparities by conducting community-academic partnered analyses of CPIC data by 1) examining intervention effects for disparity subgroups (African Americans, Latinos, gender groups, insurance and housing status groups); 2) identifying predictors and mediators of barriers to access/services and client outcomes; 3) analyzing intervention effects on provider workforce diversity; and 4) generating explanatory models for intervention effects and their sustainability by interviewing CPIC administrators and providers, as well as prior and current clients.

2. To explore the generalizability and replicability of the CPIC partnered model and, more broadly, to inform the process of incorporating science into policy by conducting a longitudinal case study of the CEP model implementation in a county-wide "neighborhood health" initiative in Los Angeles to reduce mental health and social disparities.

As a result of this study, we will be able to explain how community-engaged and participatory models of intervention implementation can reduce health and social disparities and ultimately achieve public health impact. Study findings will be disseminated widely using traditional academic, community-valued, and policy-relevant dissemination channels.

Recruitment & Eligibility

Status: COMPLETED

Sex: All

Target Recruitment: 1246

Inclusion Criteria

Administrators

Age 18 and above
Work or volunteer for an enrolled program in the study and be designated as a liaison by the program

Providers

Age 18 and above
Have direct contact with patients/clients

Clients

Age 18 and above
Score 10 or greater on modified Patient Health Questionnaire (PHQ-8)

Exclusion Criteria

grossly disorganized by screener staff assessment Not providing personal contact information

Administrators - Under age 18

Providers

Under age 18

Clients

Under age 18
Gross cognitive disorganization by screener staff assessment
Providing no contact information

Study & Design

Study Type: INTERVENTIONAL

Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
Resources for Services	Resources for Services Expert Team	The Resources for Services condition offers time-limited technical assistance to individual agencies, coupled with outreach from a community engagement specialty, to participate in structured reviews of components of the Quality Improvement Program Intervention as implemented by the Resources for Services Expert Team.
Resources for Services	Quality Improvement Program	The Resources for Services condition offers time-limited technical assistance to individual agencies, coupled with outreach from a community engagement specialty, to participate in structured reviews of components of the Quality Improvement Program Intervention as implemented by the Resources for Services Expert Team.
Community Engagement and Planning	Community Engagement and Planning Council	The Community Engagement and Planning arm supported 4 months of planning for the Community Engagement and Planning Council consisting representatives of all assigned programs in biweekly 2 hour meetings to fit trainings in the Quality Improvement Program to the community and develop strategies across programs to collaborate as a network. The CEP Council developed a written plan for training and monitoring and supported implementation of the training plan. CEP sites were provided with enrolled client lists.
Community Engagement and Planning	Quality Improvement Program	The Community Engagement and Planning arm supported 4 months of planning for the Community Engagement and Planning Council consisting representatives of all assigned programs in biweekly 2 hour meetings to fit trainings in the Quality Improvement Program to the community and develop strategies across programs to collaborate as a network. The CEP Council developed a written plan for training and monitoring and supported implementation of the training plan. CEP sites were provided with enrolled client lists.

Primary Outcome Measures

Name	Time	Method
Percent of Participants With Poor Mental Health Quality of Life, MCS12≤ 40	36 months follow-up	From the Short Form, 12-item quality of life measure, mental health-related quality of life is the primary client outcome. Poor mental health related quality of life is defined as MCS12≤ 40 (one standard deviation below population mean).
Percent of Participants With PHQ-9 Score ≥ 10	6 months follow-up	Patient Health Questionnaire 9-item version (PHQ-9) at least mild depression (score ≥ 10)
Percent of Participants With PHQ-8 Score ≥ 10	36 months follow-up	Patient Health Questionnaire 8-item version (PHQ-8) at least mild depression (score ≥ 10)

Secondary Outcome Measures

Name	Time	Method
Medication Visits Among MHS Users in the Past 6 Months	6 months follow-up
Faith-based Visits With Depression Service if Faith Participation in the Past 6 Months	6 months follow-up	For this sector, depression/mental health service is defined by client report of having assessment, counseling, education, medication discussion or referral for depression or emotional or mental health problems.
Total Mental Health Related Outpatient Visits in the Past 6 Months	12 months follow-up	Total outpatient visits for depression, mental health or substance abuse from emergency rooms, primary care or public health, mental health, substance abuse, or social-community services sectors in the past 6 months
Percent of Participants With Use of Any Antidepressant in the Past 6 Months	36 months follow-up
N of Outpatient Mental Health Visits in Past 6 Months	36 months follow-up
N of Outpatient Visits to a Substance Abuse Treatment Agency or Self Help Group in the Past 6 Months	36 months follow-up
Percent of Participants With Mental Wellness	6 months follow-up	Mental wellness is defined as at least a good bit of time in the prior 4 weeks on any of three items: feeling peaceful or calm, being a happy person, having energy
Percent of Participants Reported Organized Life	6 months follow-up	A response of somewhat or definitely true to "my life is organized" versus unsure or somewhat false or definitely false
Percent of Participants With Physically Active	6 months follow-up	Physically Active is defined as at least active to "How physically active you are?"
Percent of Participants With Homeless or ≥ 2 Risk Factors for Homelessness	6 months follow-up	Defined as current homelessness or living in a shelter or having at least 2 risk factors (e.g., no place to stay for at least 2 nights or eviction from a primary residence, financial crisis, or food insecurity in the past 6 months)
Percent of Participants With Working for Pay	6 months follow-up
Percent of Participants With Any Missed Work Day in Last 30 Days, if Working	6 months follow-up
Percent of Participants With Hospitalization for Behavioral Health in the Past 6 Months	12 months follow-up	self-reported services use in the past 6 months for overnight hospital stays for mental health or substance abuse
Percent of Participants With >=4 Hospital Nights for Behavioral Health in the Past 6 Months	6 months follow-up	self-reported services use in the past 6 months with \>=4 overnight hospital stays for any emotional, mental, alcohol, or drug problem, median cut point for baseline variable
Percent of Participants With >=2 Emergency Room Visits in the Past 6 Months	6 months follow-up	self-reported services use in the past 6 months with \>=2 emergency room visits in past 6 months, median cut point for baseline variable
Percent of Participants With Any MHS Outpatient Visit in the Past 6 Months	12 months follow-up	self-reported mental health outpatient visit from mental health provider, including psychiatrists, psychologists, social workers, psychiatric nurses, or counselors in the past 6 months
Percent of Participants With Any PCP Visit With Depression Service in the Past 6 Months	12 months follow-up	self-reported services use in the past 6 months with any primary care visit for depression
Percent of Participants With >= 2 PCP Visits With Depression Services, if Any	6 months follow-up
Park or Community Center Visits With Depression Service if Went to Park or Community Center in Past 6 Months	6 months follow-up	For this sector, depression/mental health service is defined by client report of having assessment, counseling, education, medication discussion or referral for depression or emotional or mental health problems.
Percent of Participants With Faith-based Program Participation in the Past 6 Months	12 months follow-up	Went to any religious or spiritual places such as a church, mosque, temple, or synagogue in the past 6 months
Percent of Participants With Any Use of Park and Recreation or Community Centers in the Past 6 Months	12 months follow-up
Percent of Participants With Use of an Antidepressant Medication for 2 Months or More in the Past 6 Months	12 months follow-up
PCS-12 Scores on 12-Item Physical Health Summary Measure, Comparison Between CEP and RS Groups	36 months follow-up	12-item physical composite score (PCS-12). Possible scores on range from 0 to 100, with higher scores indicating better physical health
Nights Hospitalized for Behavioral Health Reason in the Past 6 Months	36 months follow-up	self-reported number of overnight hospital stays for any emotional, mental, alcohol, or drug problem in past 6 months
Percent of Participants With Any Faith-based Services for Depression in the Past 6 Months	36 months follow-up
N of Emergency Room or Urgent Care Visits in the Past 6 Months	36 months follow-up
N of Visits to Primary Care in Past 6 Months	36 months follow-up
N of Outpatient Visits to Primary Care for Depression Services in the Past 6 Months	36 months follow-up
N of Social Services for Depression Visits in the Past 6 Months	36 months follow-up
Number of Calls to Hotline for Substance Use or Mental Health Problem in the Past 6 Months	36 months follow-up
N of Days on Which a Self-help Visit for Mental Health Was Made in the Past 6 Months	36 months follow-up
Percent of Participants With Use of Any Mood Stabilizer in the Past 6 Months	36 months follow-up
Percent of Participants With Use of Any Antipsychotic in the Past 6 Months	36 months follow-up
Percent of Participants With Any Visit in Health Care Sector in the Past 6 Months	36 months follow-up
Percent of Participants With Any Community-sector Visit for Depression in the Past 6 Months	36 months follow-up
Percent of Participants With Any Depression Treatment in the Past 6 Months	36 months follow-up	Antidepressant use for at least two months or at least four outpatient visits to mental health or primary care setting for depression services
Survival Analysis for Time to the First Clinical Remission	from baseline to 3 years	clinical remission: Patient Health Questionnaire, PHQ-8 score \<10. Cox Proportional Hazard model was used to examine the impact of the intervention on speed of clinical remission over the 3 years follow-up period, defined as the first assessment with clinical remission (PHQ-8\<10).
Survival Analysis for Time to the First Community-Defined Remission	from baseline to 3 years	Community-Defined Remission: PHQ-8\<10 or MCS-12\>40 or any mental wellness. Cox Proportional Hazard model was used to examine the impact of the intervention on speed of community-defined remission over the 3 years follow-up period, defined as the first assessment with community-defined (PHQ-8\<10 or MCS-12\>40 or any mental wellness)
Percent of Participants With Clinical Remission	4 years follow-up	Clinical remission defined as Patient Health Questionnaire-2 (PHQ-2) score \< 3.
Percent of Participants With Community-Defined Remission	4 years follow-up	Community-Defined Remission defined as PHQ-2\<3, MCS-12\>40, or mental wellness