Better Care, Same Cost - Reducing Unplanned Care for Multi-visit Patients: A Payer-Provider Model.

IMPORTANCE: Many interventions implemented for multi-visit patients (MVP) have been developed to address patient-centric needs of these individuals and reduce unplanned care for ambulatory-sensitive conditions. More rigorous research is needed to better understand the impact of these interventions on changes in care utilization including unplanned care. OBJECTIVE: To evaluate the impact of the Enhanced Care Program (ECP), a payer-provider collaborative model, on unplanned care use and cost of care. DESIGN: Using propensity methods, a comparison group was constructed using insurer membership files. Comparisons were performed using a difference-in-differences analysis. PARTICIPANTS: Patients enrolled in ECP through December 2019 were considered eligible for the study (n = 357). All patients had five or more ED visits in the past year or two or more inpatient hospitalizations in the past year prior to enrollment. EXPOSURES: ECP is a high-intensity outpatient intervention intended to reduce avoidable unplanned care such as ED visits and inpatient hospital stays through home visits, chronic/acute disease management, and intensive care coordination. MAIN MEASURES: The primary outcomes of interest were events per 100 members per year of ED use with return to home, unplanned inpatient and observational status admissions, and unplanned behavioral health inpatient admission, and cost of care per member per month. KEY RESULTS: Overall total unplanned care encounters were significantly reduced with a difference-in-difference of 320 unplanned care encounters per 100 members per year in the intervention group (p < 0.05). The ECP group showed statistically significant decreases in costs of unplanned ED, unplanned observation admission, and unplanned inpatient behavioral medicine costs, but statistically significant increases in overall pharmacy costs and lab costs. Changes in total costs of care for the ECP group were not statistically different than the control group (p = 0.55). CONCLUSIONS: ECP showed significant reduction of unplanned care for MVP patients.

Trajectory Analysis of Healthcare Utilization Before and After Major Surgery.

OBJECTIVE: To characterize patterns of healthcare utilization before and after surgery and determine any association with pre-operative frailty. SUMMARY BACKGROUND DATA: Frail patients experience worse post-operative outcomes and increased costs during the surgical encounter. Evidence is comparatively lacking for longer-term effects of frailty on post-operative healthcare utilization. METHODS: Retrospective, longitudinal cohort analysis of adult patients undergoing any elective surgical procedure following pre-operative frailty assessment with the Risk Analysis Index (RAI) from 02/2016-12/2020 at a large integrated healthcare delivery and financing system. Group-based trajectory modeling of claims data estimated distinct clusters of patients with discrete utilization trajectories. Multivariable regression predicted membership in trajectories of interest using preoperative characteristics, including frailty. RESULTS: Among 29,067 surgical encounters, four distinct utilization trajectories emerged in longitudinal data from the 12 months before and after surgery. All cases exhibited a surge in utilization during the surgical month, after which most patients returned to "low" [25,473 (87.6%)], "medium" [1,403 (4.8%)], or "high" [528 (1.8%)] baseline utilization states established before surgery. The fourth trajectory identified 1,663 (5.7%) cases where surgery occasioned a transition from "low" utilization before surgery to "high" utilization afterward. RAI score alone did not effectively predict membership in this transition group, but a multivariable model with other preoperative variables was effective (c=0.859, max re-scaled R-squared 0.264). CONCLUSIONS AND RELEVANCE: Surgery occasions the transition from low to high healthcare utilization for a substantial subgroup of surgical patients. Multivariable modeling may effectively discriminate this utilization trajectory, suggesting an opportunity to tailor care processes for these patients.

Perceptions of and Experiences with the COVID-19 Pandemic Among Individuals with Inflammatory Bowel Disease.

The COVID-19 pandemic resulted in increased feelings of emotional distress and disruptions in care across diverse patients subgroups, including those with chronic medical conditions such as inflammatory bowel diseases (IBD). We sought to understand the impact of the pandemic on the physical and emotional well-being of individuals with IBD and concurrent depression and/or anxiety symptoms. We conducted qualitative interviews after the beginning of the pandemic with 46 adults with IBD. Participants reported increased levels of emotional distress, feelings of social isolation, and uncertainty over whether IBD medications put them at increased risk. Young adults discussed feeling as if their lives had been disrupted. In addition, several individuals demonstrated resiliency and emphasized positives about the pandemic, including increased connectivity with family and friends, the convenience of being able to work from home despite their IBD symptoms, and lessened feelings of "missing out." Our findings highlight several opportunities to improve the health and well-being of individuals with IBD and beyond including increased support for combatting social isolation, enhanced counseling about medication risks and benefits, and the incorporation of resiliency skills building.

Reduced Unplanned Care and Disease Activity and Increased Quality of Life After Patient Enrollment in an Inflammatory Bowel Disease Medical Home.

BACKGROUND & AIMS: Specialty medical homes (SMHs) are a new health care model in which a multidisciplinary team and specialists manage patients with chronic diseases. As part of a large integrated payer-provider network, we formed an inflammatory bowel diseases (IBDs) SMH and investigated its effects on health care use, disease activity, and quality of life (QoL). METHODS: We performed a retrospective analysis of 322 patients (58% female; mean age, 34.6 y; 62% with Crohn's disease; 32% with prior IBD surgery) enrolled in an IBD SMH, in conjunction with the University of Pittsburgh Medical Center Health Plan, from June 2015 through July 2016. Patients had at least 1 year of follow up. We evaluated changes in numbers of emergency department visits and hospitalizations from the year before vs after SMH enrollment. Secondary measures included IBD activity assessments and QoL. RESULTS: Compared to the year before IBD SMH enrollment, patients had a 47.3% reduction in emergency department visits (P < .0001) and a 35.9% reduction in hospitalizations (P = .008). In the year following IBD SMH enrollment, patients had significant reductions in the median Harvey-Bradshaw Index score (reduced from 4 to 3.5; P = .002), and median ulcerative colitis activity index score (from 4 to 3; P = .0003), and increases in QoL (median short inflammatory bowel disease questionnaire score increased from 50 to 51.8; P < .0001). Patients in the most extreme (highest and lowest) quartiles had the most improvement when we compared scores at baseline vs after enrollment. Based on multivariable regression analysis, use of corticosteroids (odds ratio [OR], 2.72; 95% CI, 1.32-5.66; P = .007) or opioids (OR, 3.20; 95% CI, 1.32-7.78; P = .01), and low QoL (OR, 4.44; 95% CI, 1.08-18.250; P = .04) at enrollment were significantly associated with persistent emergency department visits and hospitalizations. CONCLUSIONS: We found development of an IBD SMH to be feasible and significantly reduce unplanned care and disease activity and increase patient QoL 1 year after enrollment.

Challenges encountered in the conduct of Optimal Health: A patient-centered comparative effectiveness study of interventions for adults with serious mental illness.

BACKGROUND: The aim of patient-centered comparative effectiveness research is to conduct stakeholder-driven investigations that identify which interventions are most effective for which patients under specific circumstances. Conducting this research in real-world settings comes with unique experiences and challenges. We provide the study design, challenges confronted, and the solutions we devised for Optimal Health, a stakeholder-informed patient-centered comparative effectiveness study focused on the needs of seriously mentally ill individuals receiving case management services in community mental health centers across Pennsylvania. METHODS: Optimal Health, supported by the Patient-Centered Outcomes Research Institute, is a cluster-randomized trial of two evidence-based interventions for improving health and wellness across 11 provider sites. Participants were followed for 18-24 months, with repeated measurements of self-reported health status and activation in care and administrative measurements of primary and specialty health service utilization. Health-related quality of life, engagement in care, and service utilization are to be compared via random effects mixed models. Stakeholders were, and continue to be, engaged via focus groups, interviews, and stakeholder advisory board meetings. A learning collaborative model was used to support shared learning and implementation fidelity across provider sites. RESULTS: From 1 November 2013 through 15 July 2014, we recruited 1229 adults with serious mental illness, representing 85.1% of those eligible for study participation. Of these, 713 are in the Provider-Supported arm of the study and 516 in Patient Self-Directed Care. Across five data collection time points, we retained 86% and 83% of the participants in the Provider-Supported and Self-Directed arms, respectively. LESSONS LEARNED: Lessons learned relate to estimation of the size of our study population, the value of multiple data sources, and intervention training and implementation. The use of historical claims data can lead to an overestimation of eligible participants and, subsequently, a reduced study sample and an imbalance between intervention arms. Disruptions in continuity of care in real-world settings can pose challenges to on-site self-report data collection, although the inclusion of multiple data sources in study design can improve data completeness. Geographic dispersion of rural provider sites and staff turnover can lead to training and intervention fidelity challenges that can be overcome with the use of a "train-the-trainer" model, "wellness champions," and the use of a Learning Collaborative approach. Stakeholder engagement in mitigating these challenges proved to be critical to study progress. CONCLUSION: Conducting real-world patient-centered comparative effectiveness research in healthcare systems that care for seriously mentally ill persons is an important yet challenging undertaking, one which requires flexibility in identifying potential adaptations within all major study phases. Advice from a wide range of stakeholders is critical in development of successful strategies.

Effectiveness of a Staff Promoted Wellness Program to Improve Health in Residents of a Mental Health Long-Term Care Facility.

The current study describes physical and mental health outcomes during a health promotion program for individuals with serious mental illness (SMI). A sample of 43 adults in a long-term residential facility volunteered for an individualized, healthy lifestyle program designed to promote physical activity and combat premature mortality among individuals with SMI. Nurses and residential counselors were trained in the program and encouraged to work collaboratively with the program's personal trainers. Weekly nutrition and activity logs were obtained over the year-long evaluation. Assessments of physical and psychological health indicators were collected quarterly. Qualitative data through focus groups described staff experience. Self-report of moderate and vigorous physical activity improved over time as did fitness level as measured through a walking challenge (p = .001). Significant decreases in weight (p < .001), BMI (p = .001), and total cholesterol (p < .001) were observed from baseline through 12 months. Mean recovery scores (RMQ) were significantly higher between baseline and all time points (p < .001). Participants reported decreasing levels of depression (PHQ-9) by the 12-month time point (p < .001). Staff encouraged participation in physical activity and observed improved motivation and socialization among participants. A health promotion program with participation encouraged by health care staff is effective for increasing physical activity and improving physical and mental health outcomes in individuals with SMI in long-term residential care.

Determinants of functional disability in Huntington's disease: role of cognitive and motor dysfunction.

The clinical syndrome of Huntington's disease (HD) is notable for a triad of motor, cognitive, and emotional features. All HD patients eventually become occupationally disabled; however, the factors that render HD patients unable to maintain employment have not been extensively studied. This review begins by discussing the clinical triad of HD, highlighting the distinction in the motor disorder between involuntary movements, such as chorea, and voluntary movement impairment, with the latter contributing more to functional disability. Cognitive disorder clearly contributes to disability, though the relative contribution compared to motor is difficult to unravel, especially because many of the tests used to asses "cognition" have a strong motor component. The role of emotional changes in disability needs more study. The literature on contributions to functional disability, driving impairment, and nursing home placement is reviewed. Relevant experience is presented from the long-standing JHU HD observational study on motor versus cognitive onset, as well as on cognitive and motor features at the time when individuals discontinued working. Finally, we briefly review government policies in several countries on disability determination. We interpret the data from our own studies and from the literature to indicate that there is usually a close relationship between cognitive and motor dysfunction, and that it is critical to take both into consideration in determining disability. © 2014 International Parkinson and Movement Disorder Society.

Leveraging data to support health equity in an integrated delivery and finance system.

Introduction: To accelerate healthcare transformation and advance health equity, scientists in learning health systems (LHSs) require ready access to integrated, comprehensive data that includes information on social determinants of health (SDOH). Methods: We describe how an integrated delivery and finance system leveraged its learning ecosystem to advance health equity through (a) a cross-sector initiative to integrate healthcare and human services data for better meeting clients' holistic needs and (b) a system-level initiative to collect and use patient-reported SDOH data for connecting patients to needed resources. Results: Through these initiatives, we strengthened our health system's capacity to meet diverse patient needs, address health disparities, and improve health outcomes. By sharing and integrating healthcare and human services data, we identified 281 000 Shared Services Clients and enhanced care management for 100 adult Medicaid/Special Needs Plan members. Over a 1-year period, we screened 9173 (37%) patients across UPMC's Women's Health Services Line and connected over 700 individuals to social services and supports. Conclusions: Opportunities exist for LHSs to improve, expand, and sustain their innovative data practices. As learnings continue to emerge, LHSs will be well positioned to accelerate healthcare transformation and advance health equity.

Predictors of adequate depression treatment among Medicaid-enrolled youth.

PURPOSE: To determine if Medicaid-enrolled youth with depressive symptoms receive adequate acute treatment, and to identify the characteristics of those receiving inadequate treatment. METHODS: We used administrative claims data from a Medicaid-enrolled population in a large urban community to identify youth aged 6-24 years who started a new episode of treatment for a depressive disorder between August 2006 and February 2010. We examined rates and predictors of minimally adequate psychotherapy (four visits in first 12 weeks) and pharmacotherapy (filled antidepressant prescription for 84 of the first 144 days) among youth with a new treatment episode during the study period (n = 930). RESULTS: Fifty-nine percent of depressed youth received minimally adequate psychotherapy, but 13 % received minimally adequate pharmacotherapy. Youth who began their treatment episode with an inpatient psychiatric stay for depression and racial minorities were significantly less likely to receive minimally adequate pharmacotherapy and significantly more likely to receive inadequate overall treatment. CONCLUSIONS: While the majority of youth appear to be receiving minimally adequate acute care for depression, a substantial number are not. Given current child mental health workforce constraints, efforts to substantially improve the provision of adequate care to depressed youth are likely to require both quality improvement and system redesign efforts.

Use of a computerized medication shared decision making tool in community mental health settings: impact on psychotropic medication adherence.

Healthcare reform emphasizes patient-centered care and shared decision-making. This study examined the impact on psychotropic adherence of a decision support center and computerized tool designed to empower and activate consumers prior to an outpatient medication management visit. Administrative data were used to identify 1,122 Medicaid-enrolled adults receiving psychotropic medication from community mental health centers over a two-year period from community mental health centers. Multivariate linear regression models were used to examine if tool users had higher rates of 180-day medication adherence than non-users. Older clients, Caucasian clients, those without recent hospitalizations, and those who were Medicaid-eligible due to disability had higher rates of 180-day medication adherence. After controlling for sociodemographics, clinical characteristics, baseline adherence, and secular changes over time, using the computerized tool did not affect adherence to psychotropic medications. The computerized decision tool did not affect medication adherence among clients in outpatient mental health clinics. Additional research should clarify the impact of decision-making tools on other important outcomes such as engagement, patient-prescriber communication, quality of care, self-management, and long-term clinical and functional outcomes.

Bias-corrected and doubly robust inference for the three-level longitudinal cluster-randomized trials with missing continuous outcomes and small number of clusters: Simulation study and application to a study for adults with serious mental illnesses.

Longitudinal cluster-randomized designs have been popular tools for comparative effective research in clinical trials. The methodologies for the three-level hierarchical design with longitudinal outcomes need to be better understood under more pragmatic settings; that is, with a small number of clusters, heterogeneous cluster sizes, and missing outcomes. Generalized estimating equations (GEEs) have been frequently used when the distribution of data and the correlation model are unknown. Standard GEEs lead to bias and an inflated type I error rate due to the small number of available clinics and non-completely random missing data in longitudinal outcomes. We evaluate the performance of inverse probability weighted (IPW) estimating equations, with and without augmentation, for two types of missing data in continuous outcomes and individual-level treatment allocation mechanisms combined with two bias-corrected variance estimators. Our intensive simulation results suggest that the proposed augmented IPW method with bias-corrected variance estimation successfully prevents the inflation of false positive findings and improves efficiency when the number of clinics is small, with moderate to severe missing outcomes. Our findings are expected to aid researchers in choosing appropriate analysis methods for three-level longitudinal cluster-randomized designs. The proposed approaches were applied to analyze data from a longitudinal cluster-randomized clinical trial involving adults with serious mental illnesses.

Mental health services for children of substance abusing parents: voices from the community.

This qualitative study explores how to improve services for children of parents with Substance Use Disorders (SUD) with unmet mental health needs. Focus groups were conducted with parents and caregivers to identify perceived barriers to services, including: (1) attitudes and beliefs about mental health care, (2) inadequacies in mental health services, (3) children's ambivalence about treatment, and (4) parental disagreement and lack of involvement. Peer support, afterschool activities, and family counseling were identified as potential improvements. This information can serve as a foundation and guide to develop services for the underserved population of children and adolescents of substance abusing parents.

Health Care Provider Perspectives on the Use of a Digital Behavioral Health App to Support Patients: Qualitative Study.

BACKGROUND: Despite the growing evidence indicating the efficacy of digital cognitive behavioral interventions (dCBIs) for behavioral health (BH) treatment, broad and consistent use of such interventions has been limited by knowledge obtained in real-world settings, including factors that impact provider uptake/referral. Engaging providers early in the implementation process offers an opportunity to explore their needs and behaviors, integrate interventions into workflows, and better understand provider setting capabilities. OBJECTIVE: This study assessed providers' views on the feasibility and acceptability of delivering a cognitive behavioral therapy (CBT)-based mobile app in multiple care settings. METHODS: Participating providers included BH and physical health (PH) providers from a women's health center, an outpatient BH clinic, and both rural/urban primary care settings. All participating providers cocreated workflows through facilitated workshops, including establishing feedback loops between the project team and providers and identifying clinical champions at each site. Over a 12-week period, the providers referred adult patients experiencing anxiety or depression to a mobile app-based dCBI, RxWell, and provided other indicated treatments as part of usual care. Referrals were completed by the providers through the electronic medical record. To better understand facilitators of and challenges in integrating RxWell into routine practice and perceptions of sustainability, a series of qualitative interviews was conducted. Interview data were analyzed to identify major themes using an inductive content analysis approach. RESULTS: A total of 19 provider interviews were conducted to discover motivators and barriers for referring RxWell. The providers benefited from a focused discussion on how to incorporate the referral process into their workflow, and knowing the app content was rooted in evidence. Although the providers believed engaging in experiential learning was important, they indicated that more education on the digital health coach role and how to monitor patient progress is needed. The providers thought patient engagement may be impacted by motivation, a lack of comfort using a smartphone, or preference for in-person therapy. The providers also expressed enthusiasm in continuing to refer the app. They liked the ability to provide patients with support between sessions, to have an extra treatment option that teaches BH exercises, and to have a CBT treatment option that overcomes barriers (eg, wait times, copays, travel) to traditional therapy modalities. CONCLUSIONS: Digital intervention success in health care settings relies heavily on engagement of key stakeholders, such as providers, in both design and implementation of the intervention and focused evaluation within intended care setting(s). Scaling digital interventions to meet the mental health needs of patients in usual care settings leans on thoughtfully constructed and streamlined workflows to enable seamless referral of patients by providers. Our findings strongly suggest that providers are supportive of digital tool integration to support the mental health of patients and endorse its use within their routine workflow.

Promoting collaborative psychiatric care decision-making in community mental health centers: Insights from a patient-centered comparative effectiveness trial.

OBJECTIVE: Mental health service-users face important medication decisions; yet not all are active participants in the decision-making process. Little is known about which technology-supported interventions might effectively promote collaborative decision-making in psychiatric care. We compared the effectiveness of two technology-supported collaborative care decision-making approaches. METHOD: We used a cluster-randomized design with a mixed-methods approach. Participants were Medicaid-enrolled adults receiving psychiatric care in participating community mental health centers. Measurement-based care used computerized systematic symptom and medication screenings to inform provider decision-making. Person-centered care supported participants in completing computerized Health Reports and preparing to work with providers on collaborative decision-making about psychiatric care. Primary study outcomes included the patient experience of medication management and shared decision-making during psychiatric care. Analyses examined the impact of both approaches and explored moderating variables. We used qualitative methods to understand participation and implementation experiences. RESULTS: Across 14 sites 2,363 participants enrolled (1,162 in measurement-based care, 1,201 in person-centered care). We observed statistically significant improvements in patient experience of medication management scores for both study arms; however, the clinical significance of this change was minor. We found no significant changes for shared decision-making. Qualitative interviews revealed a range of factors associated usefulness of intervention assessment, provider-service-user communication, and site-level logistics. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: We observed modest positive findings related to our patient-centered outcomes. We identified important implementation facilitators and barriers that can inform the implementation of future comparative effectiveness patient-centered research. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Impact of Behavioral Health Homes on Cost and Utilization Outcomes.

OBJECTIVE: This study evaluated the impact of two behavioral health home (BHH) approaches, provider-supported care and self-directed care, on health care utilization and cost outcomes among adult Medicaid recipients with serious mental illness. METHODS: Eleven community mental health provider sites were randomly assigned to one of the BHH approaches, which each site implemented over a 2-year period. In both approaches, staff were trained in wellness coaching to support patients' progress toward general health and wellness goals. Provider-supported sites employed a full-time on-site registered nurse, who provided consultation to patients and wellness coaches. Each approach had a consistently enrolled treatment group (combined N=859) with a matched comparison cohort that was identified for analysis. Approaches were compared with each other and with baseline, and differences between each approach and its comparison cohort were examined by using analysis of covariance to determine impact on total health care cost, prescription costs, and use and cost of general medical and behavioral health services. RESULTS: Relative to its comparison cohort, each approach achieved significant reductions in total cost (15% for provider-supported care and 26% for self-directed care) and increases in use of outpatient general medical services (43% for provider-supported care and 29% for self-directed care). Compared with self-directed care, provider-supported care resulted in approximately 28% lower use of general medical inpatient services and 26% lower related costs. CONCLUSIONS: BHH approaches in community mental health settings can produce health care savings and decrease use of inpatient health care.

Community-based behavioral health administrator perspectives on sustainability of Dialectical Behavior Therapy: a qualitative evaluation.

BACKGROUND: Substantial resources have been invested in evidence-based practice (EBP) implementation in community settings; however, research suggests that EBPs do not always sustain over time. METHOD: This qualitative study explored the perspectives of 13 community behavioral health agency leaders regarding the sustainability of an EBP 25 to 28 months following the original training period. Administrators from 10 agencies were interviewed to understand the complexities of the implementation process, sustainability of Dialectical Behavior Therapy, and their recommendations to enhance implementation and sustainability. RESULTS: A content analysis revealed five emergent themes: treatment model opinions, resource concerns, staff selection/ turnover, population characteristics, and recommendations for future implementation. CONCLUSIONS: These themes likely would be helpful in informing the design of future implementation and sustainability initiatives sensitive to the challenges of integrating EBPs in community settings.

Increasing minority research participation through collaboration with community outpatient clinics: the STEP-BD Community Partners Experience.

BACKGROUND: Minority populations have been under-represented in mental health research studies. The systematic treatment enhancement program for bipolar disorder developed the Community Partners Program (CPP) to address this issue in a large, prospective treatment study of persons with bipolar disorder. PURPOSE: The primary goal of CPP was to develop a community-based infrastructure for studying bipolar disorder that would enhance the ethnic/racial and socioeconomic diversity of participants. METHODS: Selected academic sites partnered with local clinics (n = 6 partnerships in five cities). This report describes the conceptualization, implementation, and qualitative evaluation of CPP, as well as quantitative analysis of clinical and sociodemographic differences between the samples recruited at academic versus community sites. RESULTS: Quantitative analysis of the 155 participants from the six partnerships revealed enrollment of 45% from minority populations (vs. 15% in academic sites). Significant sociodemographic differences were evident not only between academic and community sites, but within minority and non-minority groups across site types. Notably, clinical differences were not evident between participants from academic and community sites. Review of qualitative data suggests that certain factors around implementation of research protocols may enhance community participation. CONCLUSIONS: Moving research recruitment and participation into community sites was more successful in increasing minority enrollment than efforts to attract such individuals to academic sites. Recommendations for creating and maintaining academic/community partnerships are given. LIMITATIONS: Several important variables were not considered including mood severity, hospitalization, or treatment differences. Minority participants were grouped by combining African American and Hispanics, which may have obscured subgroup differences. A derivation of standard qualitative methods was used in this study.

Psychosocial treatments for bipolar depression: a 1-year randomized trial from the Systematic Treatment Enhancement Program.

CONTEXT: Psychosocial interventions have been shown to enhance pharmacotherapy outcomes in bipolar disorder. OBJECTIVE: To examine the benefits of 4 disorder-specific psychotherapies in conjunction with pharmacotherapy on time to recovery and the likelihood of remaining well after an episode of bipolar depression. DESIGN: Randomized controlled trial. SETTING: Fifteen clinics affiliated with the Systematic Treatment Enhancement Program for Bipolar Disorder. Patients A total of 293 referred outpatients with bipolar I or II disorder and depression treated with protocol pharmacotherapy were randomly assigned to intensive psychotherapy (n = 163) or collaborative care (n = 130), a brief psychoeducational intervention. INTERVENTIONS: Intensive psychotherapy was given weekly and biweekly for up to 30 sessions in 9 months according to protocols for family-focused therapy, interpersonal and social rhythm therapy, and cognitive behavior therapy. Collaborative care consisted of 3 sessions in 6 weeks. MAIN OUTCOME MEASURES: Outcome assessments were performed by psychiatrists at each pharmacotherapy visit. Primary outcomes included time to recovery and the proportion of patients classified as well during each of 12 study months. RESULTS: All analyses were by intention to treat. Rates of attrition did not differ across the intensive psychotherapy (35.6%) and collaborative care (30.8%) conditions. Patients receiving intensive psychotherapy had significantly higher year-end recovery rates (64.4% vs 51.5%) and shorter times to recovery than patients in collaborative care (hazard ratio, 1.47; 95% confidence interval, 1.08-2.00; P = .01). Patients in intensive psychotherapy were 1.58 times (95% confidence interval, 1.17-2.13) more likely to be clinically well during any study month than those in collaborative care (P = .003). No statistically significant differences were observed in the outcomes of the 3 intensive psychotherapies. CONCLUSIONS: Intensive psychosocial treatment as an adjunct to pharmacotherapy was more beneficial than brief treatment in enhancing stabilization from bipolar depression. Future studies should compare the cost-effectiveness of models of psychotherapy for bipolar disorder. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00012558.

UPMC's blueprint for BuILDing a high-value health care system.

National-level demonstration projects and real-world studies continue to inform health care transformation efforts and catalyze implementation of value-based service delivery and payment models, though evidence generation and diffusion of learnings often occurs at a relatively slow pace. Rapid-cycle learning models, however, can help individual organizations to more quickly adapt health care innovations to meet the challenges and demands of a rapidly changing health care landscape. Integrated delivery and financing systems (IDFSs) offer a unique platform for rapid-cycle learning and innovation. Since both the provider and payer benefit from delivering care that enhances the patient experience, improves quality, and reduces cost, incentives are aligned to experiment with value-based models, enhance learning about what works and why, and contribute to solutions that can accelerate transformation. In this article, we describe how the UPMC Insurance Services Division, as part of a large IDFS, uses its Business, Innovation, Learning, and Dissemination (BuILD) model to prioritize, design, test, and refine health care innovations and accelerate learning. We provide examples of how the BuILD model offers an approach for quickly assessing the impact and value of health care transformation efforts. Lessons learned through the BuILD process will offer insights and guidance for a wide range of stakeholders whether an IDFS or independent payer-provider collaborators.

Delivering on the value proposition of precision medicine: the view from healthcare payers.

A long-held assumption and expectation has been that genomics-based precision medicine will provide clinicians with the tools and therapies they need to consistently deliver the right treatment to the right patient while simultaneously reducing waste and yielding cost savings for health systems. The pace of discovery within the field of precision medicine has been remarkable, yet optimal uptake of new genetic tests and genetically targeted therapies will occur only if payers recognize their value and opt to cover them. Coverage decisions require clear evidence of clinical effectiveness and utility and an understanding of how adoption will impact healthcare costs and utilization within a payer's network. Research in precision medicine has often not considered the payer's perspective, and despite demonstrations of clinical effectiveness for many promising precision medicine innovations, coverage determinations have been deferred because relevant findings that payers can use to make informed decisions are lacking. Collaboration among payers, scientists, and clinicians is essential for accelerating uptake and value creation. By pairing clinical outcomes with claims and cost data and collaboratively conducting well-designed pragmatic clinical or observational studies, all stakeholders can learn from more meaningful and relevant outcomes. In turn, there will be a collective understanding of how precision medicine innovations impact the health of populations and care delivery within healthcare systems.