TRANSFORM DEPCARE: A Theoretical approach to improving patient engagement and shared decision making for minorities in collaborative depression care

该提案的目标是测试电子共享决策(ESDM)工具是否可以 在初级保健中增加对抑郁症的协作性护理(CC)。据预测，抑郁症是 到2030年，全球慢性病负担的第二大贡献者，并造成 生活质量和死亡率。CC通过抑郁症护理经理整合初级和行为健康 他们提供抗抑郁药物依从性咨询和/或心理治疗。CC使抑郁率翻了一番 与初级保健提供者单独主导的抑郁症治疗相比，尤其是在种族和 并使死亡率降低24%，每年节省近1300美元。 有耐心的。尽管这一模式有可能改善获得心理健康的机会，但实施工作显示 提供商CC转介率和9-50%的低患者参与率，特别是在少数族裔患者中。 为了确定导致CC患者参与度较低的因素，我们在8个小组中进行了焦点小组研究 实施CC的医疗系统，代表33家诊所和100万家主要是医疗补助的少数族裔 病人。我们了解到，关键的医生级别的障碍包括讨论治疗的时间/资源有限 选择并向护理经理进行“热情交接”；患者层面的障碍包括对 治疗选择、沟通不畅、耻辱、语言障碍和动力不足。我们应用了一个理论- 让利益相关者参与选择可接受的、可行的干预措施的知情过程，并确定 SDM将针对最大数量的CC参与障碍。SDM涉及一个协作过程 提供者和患者共同做出健康决策，这是一种经过验证的改进方法 抑郁症治疗启动和指南一致的护理，特别是在少数族裔，但广泛使用 受到时间和资源的限制。因此，我们开发并阿尔法测试了一款iPad， 视频辅助的交互式ESDM工具，可减少SDM采用的障碍并瞄准CC参与。 我们假设，自动化SDM过程的最先进的ESDM工具将激活 提供者、工作人员和患者以及与电子健康记录的接口将提高CC的效率 招生(主要结果)。我们建议改进和调整ESDM原型(目标1)，并进行 对4家初级保健疗养院进行阶梯式楔形试验，以评估实施我们 关于提供者行为的ESDM工具(目标2)、患者在CC中的登记情况(目标3)、患者对抑郁症的依从性 1440名初中生的治疗(治疗或抗抑郁药物)和抑郁症状(探索性目标) 在我们的医疗系统中照顾病人。我们的研究有可能产生一种信息灵通、可扩展的理论 ESDM工具，可提高CC计划和潜在的其他基于团队的方法的覆盖范围。

The goal of this proposal is to test whether an electronic shared decision making (eSDM) tool can increase the uptake of collaborative care (CC) for depression in primary care. Depression is projected to be the second largest contributor to chronic disease burden in the world by 2030, and contributes to disparities in quality of life and mortality. CC integrates primary and behavioral health through depression care managers who provide antidepressant adherence counseling and/or psychotherapy. CC doubles the rate of depression remission in comparison to primary care provider-led depression treatment alone, particularly in racial and ethnic minorities, and results in a 24% reduction in mortality and nearly $1300 in net annual savings per patient. Despite this model's potential to improve access to mental health, implementation efforts reveal low provider CC referral rates and low patient engagement rates of 9-50%, particularly in minority patients. To identify factors contributing to poor patient engagement in CC, we conducted focus groups in 8 healthcare systems implementing CC, representing 33 clinics and 1 million predominantly Medicaid, minority patients. We learned that key physician-level barriers included limited time/resources to discuss treatment options and conduct “warm handoffs” to care managers; patient-level barriers included poor knowledge of treatment options, miscommunication, stigma, language barriers, and low motivation. We applied a theory- informed process of engaging stakeholders to select an acceptable, feasible intervention and determined that SDM would target the greatest number of barriers to CC engagement. SDM involves a collaborative process whereby providers and patients make health decision together, and is a proven approach for improving depression treatment initiation and guideline concordant care, particularly in minorities, but widespread use has been limited by time and resources. Accordingly, we developed and alpha tested an iPad delivered, video-assisted, interactive eSDM tool that would reduce barriers to SDM uptake and target CC engagement. We hypothesize that a state-of-the-art eSDM tool that automates the SDM process, activates providers, staff, and patients and interfaces with the electronic health record will improve efficient CC enrollment (primary outcome). We propose to refine and adapt the eSDM prototype (Aim 1) and conduct a stepped wedge trial across 4 primary care medical homes to assess the effectiveness of implementing our eSDM tool on provider behavior (Aim 2), patient enrollment in CC (Aim 3), patient adherence to depression treatment (therapy or antidepressants) and depressive symptoms (Exploratory Aims) amongst 1440 primary care patients in our healthcare system. Our study has the potential to produce a theory-informed, scalable eSDM tool that improves the reach of CC programs and potentially other team-based approaches.