Value-based Purchasing in Implementation of Depression Care in Community Clinics

描述(申请人提供)：到2019年，将有多达4000万低收入美国人依赖社区卫生诊所(CHCs)提供初级保健。抑郁症和其他行为健康状况是这一人群疾病负担的主要来源。实施循证行为保健是社区卫生服务机构的优先领域。这项研究的目的是评估基于价值的采购(VBP)的作用，这是一项政策战略，以加强CHC中循证护理的有计划的实施。VBP是一种工具，通过将付款与具有预先指定的绩效目标的提供商组织联系起来，促进质量改进。这项拟议的研究将利用华盛顿州精神卫生整合计划(MHIP)发起的一个独特的VBP计划。MHIP实施协作护理模式，这是一种突出的、以证据为基础的模式，将行为卫生保健整合到初级保健中。MHIP的多阶段VBP嵌入了几个理想的设计特征，并提供了一个难得的机会来产生关于VBP支持循证慢性护理实施的有效性的概括性结论。我们将根据华盛顿州金县和皮尔斯县52家CHC的12,000多名患者的MHIP登记和医疗保健索赔，对现有数据进行回顾分析。这项研究的目的是评估MHIP VBP在以下方面的影响：1.合作医疗中心采用协作护理；以及2.患者结局。我们将根据CHC在患者发作水平上对协作护理的关键护理流程要素的表现来衡量采用情况。患者的结果包括抑郁症状、住院、急诊室使用和总医疗费用。我们的分析策略将利用由 滚动登记参加MHIP的患者。这项研究将产生关键知识，以帮助政策制定者决定是否使用VBP来加强CHC中循证护理的实施，以及如何最好地设计VBP以最大限度地发挥其影响。

DESCRIPTION (provided by applicant): As many as 40 million low-income Americans will rely on community health clinics (CHCs) for primary care by 2019. Depression and other behavioral health conditions are a major source of disease burden in this population. Implementation of evidence-based behavioral health care is a priority area for CHCs. The goal of this study is to assess the role of Value-Based Purchasing (VBP), a policy strategy, to enhance planned implementation of evidence-based care in CHCs. VBP is a tool to spur quality improvement by linking payment to provider organizations with pre-specified performance targets. The proposed study will leverage a unique VBP program initiated by the Washington State Mental Health Integration Program (MHIP). MHIP implements the Collaborative Care model, a prominent, evidence-based model to integrate behavioral health care into primary care. MHIP's multi-phase VBP embeds several desirable design features and offers a rare opportunity to produce generalizable findings on the effectiveness of VBP to support implementation of evidence-based chronic care. We will conduct retrospective analysis of existing data based on MHIP registry and health care claims of over 12,000 patients from 52 CHCs in Washington State's King and Pierce Counties. Aims of the study are to assess the effects of MHIP VBP on: 1. Adoption of Collaborative Care by CHCs; and, 2. Patient outcomes. We will measure adoption based on CHC performance of key process-of-care elements of Collaborative Care at the patient-episode level. Patient outcomes include depression symptoms, hospitalization, emergency room use and total health care costs. Our analytical strategy will exploit the natural experiment created by the rolling enrollment of patients into MHIP. Specifically, we will compare outcomes pertaining to patient-episodes that occurred pre-, peri-, and post- VBP while controlling for the continuous learning and adopting processes at CHCs. Preliminary data suggest overall low adoption pre-VBP, substantial improvement over time, and CHC behavioral responses to VBP incentives that are consistent with the conceptual framework of the proposed study. This study will generate critical knowledge to assist policymakers with their decisions on whether to use VBP to enhance implementation of evidence-based care in CHCs and how to best design VBP to maximize its impact.