Online CBT for Depression, Anxiety, Insomnia and other disorders in

Transcription

Technology Helping Those with
Addictions and Those Treating
Addictions
Bridget Cepalia
Director, Digital Innovations
Magellan Healthcare
Kemi Alli, M.D.
Chief Executive Officer
Henry J. Austin Health Center
Magellan’s
Computerized Cognitive
Behavioral Therapy
Solutions for substance use and
related health conditions
About the speakers
Bridget Cepalia is the director of digital innovations at Magellan Healthcare. In this role, she leads
new product development for Magellan’s Computerized Cognitive Behavioral Therapy (CCBT)
platform and other digital solutions, including behavioral health SmartScreening. Cepalia also
collaborates closely with clients and prospects to serve multiple populations including Medicaid,
insured, government, and employer groups in a variety of settings.
Cepalia joined Magellan in 2014 when Cobalt Therapeutics, a virtual therapeutic care platform
which addresses 90 percent of behavioral health disorders, was acquired by Magellan. She
previously served as project manager at Cobalt, whose suite of software addresses common
conditions including substance abuse, insomnia, depression, anxiety, panic, phobia and Obsessive
Compulsive Disorder. Prior to her time at Cobalt, Cepalia worked in the pharmaceutical industry.
Cepalia is a tireless volunteer for numerous local community organizations. She received her
bachelor’s degree from Pace University.
3
Copyright 2016 Magellan Health, Inc.
About the speakers
Kemi Alli , M.D. is chief executive and medical officer for the Henry J. Austin Health Center. She graduated from Rutgers
the State University of NJ in 1991. She went on to attend medical school and residency at UMDNJ, Robert Wood
Johnson Medical School in New Brunswick, NJ. Dr. Alli has been the Chief Executive Officer at Henry J. Austin Health
Center, a federally qualified health center, since May 2015. Prior to becoming the CEO, she was the Chief Medical
Officer from 2008 to 2015. She has been a board-certified pediatrician practicing at Henry J. Austin for over 18 years.
Recently she has led several primary care enhancement initiatives to reduce health disparities, improve patient health
outcomes and access to care. One such initiative decreased wait times from 37 days for an established patient to get an
appointment to just under two days. She currently presents this work to colleagues from across the nation. She is
continuing this transformative re-design of the healthcare delivery process at Henry J. Austin by implementing an
integrated healthcare system, including both substance misuse/abuse and behavioral healthcare illnesses and
treatment in the primary care medical home.
Dr. Alli is an active member of the community, working on the board of directors for Thomas Edison State University
and several other not-for-profit agencies in the city, including the Trenton Health Team, Inc. (THT) where she serves as
treasurer of the board working on initiatives like advance access scheduling, reducing inappropriate ED utilization and
implementing a city-wide health information exchange system. As part of the board for the Mercer Alliance to End
Homelessness, she works with organizations like the Rescue Mission of Trenton to reduce homelessness in Trenton and
improve the health outcomes of the chronically homeless. She also actively serves on several committees, including
Horizon NJ Health’s quality peer review committee and utilization management committee and the Mercer County
Integrated Care Collaborative, which is a group of mental health providers collaborating to provide a model of
integrated primary and mental/behavioral healthcare.
Through all her work, Dr Alli’s sole goal continues to be to help improve the quality of life for the residents in the great
city of Trenton.
4
Disclosure
Bridget Cepalia and Kemi Alli, MD have no relevant financial relationship or
commercial interest that could be reasonably construed as a conflict of
interest.
5
Learning objectives
6
1.
Explain the problems computerized cognitive behavioral therapy (CCBT)
addresses
2.
Differentiate between traditional psychological treatment methods and CCBT
3.
Show that utilizing self-guided care solutions improves outcomes
4.
Explain how digital solutions can be used to lower behavioral health treatment
costs
5.
Discuss how CCBT for substance abuse can provide medication-free adjunct to
current treatment plan
6.
Discuss how treatment for insomnia can benefit those with depression and
substance abuse
Setting the stage: A unique vision of care
We have a unique vision of better and more affordable care in the fast-growing,
highly complex and high-cost areas of healthcare.
Moving beyond
traditional healthcare
by offering an
integrated clinical
portfolio of population
health solutions
7
A smarter approach to
pharmacy benefits
management, delivering
easy-to-use tools and
clinical excellence to drive
better decision making, all
in a customer-first culture
An innovative partner for integrating care
Henry J. Austin Health Center, Inc. (HJAHC) is a federally qualified health center
located in Trenton, New Jersey.
HJAHC provides patient-centered, comprehensive, accessible, efficient, quality
primary care, mental health and substance abuse treatment services to the
culturally diverse greater Trenton community. With exceptional, dedicated, well
trained team delivers best practice healthcare, working with community partners
to provide an extraordinary customer service and quality outcomes.
Since 2013, primary care providers at HJAHC use behavioral health screening in
conjunction with RESTORETM, MoodCalmerTM, FearFighterTM, SHADETM, and
OCFigtherTM. The goal of this project has been to screen for behavioral health
problems and provide proven tools (e.g. CCBT programs) for clinicians to offer to
individuals who screen positive but do not need to be referred to a live clinician
for face-to-face therapy.
8
The problems
Common & costly conditions
10
Access & care delivery problems
Delays in access
Lack of standardization
Chronic disease drives cost
High rate of
inappropriate prescriptions
11
•
•
•
Shortage of expert CBT clinicians
Fulfilling 1% of documented need
Across the U.S. and world
•
•
•
Quality varies
Using “CBT” techniques loosely
Not required to be certified to use CBT
•
•
•
Over 65 is fastest growing population
High rates of comorbidities
Polypharmacy
•
•
•
•
•
•
•
More than direct cost of medications
Using off label
Not meeting dx criteria
Fall risk (driver of readmissions)
Side effects: weight gain
Morbidity and mortality
Addiction- benzodiazepines, sleep meds, stimulants
Substance abuse high co-morbididity with insomnia
& depression
Substance abuse can exacerbate sleep difficulties, which may then
present risk for relapse
Sleep problems are a frequent complaint among those struggling with
substance use disorders
Preliminary data shows that screening, brief intervention and referral
to treatment in primary care or emergency settings can reduce highrisk drug and alcohol use up to 74%
Those with alcohol / other drug use disorders also experience
depressed mood source
12
Case study: Insomnia and integrated care
An example of how Magellan leverages unique pharmacy, behavioral and technology expertise
•
•
•
•
•
•
•
•
•
13
30%-40% say they suffer each year (NIH); 10%-15% say they suffer chronically (NIH)
Insomnia is usually the most treated complaint in behavioral settings and a top 5 in primary
care! CBT is usually considered the best option but is rarely sought or available.
Increases direct medical costs by $924-$1,143 over a six month period1
Insomnia causes 2x missed work days and 2.5x errors at work compared to those without
insomnia2
Treating insomnia improves outcomes in a variety of conditions including depression and
heart disease3
Relative risk for MDD: 4.04
Medication for insomnia linked to 1.36 OR for mortality when hypnotic or anxiolytic used in
previous month5
CBT for sleep, combined with medication, improves remission for MDD from 33.3% to 61.5%6
Sleep problems facilitate alcohol relapse
1 - Cost Burden of Untreated Insomnia—Ozminkowski et al SLEEP, Vol. 30, No. 3, 2007; 2 Insomnia, Who Pays the Costs?—Godet-Cayré et al SLEEP, Vol. 29, No. 2, 2006; 3 Clinical Correlates of Insomnia in Patients with Chronic Illness - Arch Intern
Med. 1998;158:1099-1107;4 - Breslau, Biol Psy 1994; 5 - Belleville, C Jour Psy 2010; 6 Manber et al SLEEP 2008; 7 - Brower et al 1998, Alcoholism
The solutions
Healthcare
delivery areas
we impact
Delivers
Data Driven
Innovations
Lowers
Pharmacy
Spend
Standardizes
Care
Facilitates
Behavioral
Integration
with
Primary
Care
Removes or
Reduces
Medication
Risks
Addresses
Costly
Co-morbid
Conditions
Greatly
Improves
Access
Empowers
participants
15
Adheres to
Treatment
Guidelines
CBT & CCBT
Thoughts
Situations
Feelings
#1
Recommended
care for anxiety,
sleep & OCD; first
line option for
depression, and
substance use
16
Actions
Suite of CCBT programs
 On demand web and mobile-based
software programs that have been
shown to decrease the need for
higher levels of care and decrease
costs.
 The programs have English and
Spanish speaking versions that can
be used independently or with
clinical support.
 Researched and developed by
leading experts from academic
institutions with many clinical trials
on the efficacy of the software
published in peer-reviewed
journals.
 The programs are self-paced,
private, confidential, and HIPAA
compliant.
17
The data
Impact & CCBT efficacy
These conditions are present in >25% of all adults and make up
> 90% of behavioral health complaints
 4 out of 5 improve
sleep
 Reduces specialty
care by two-thirds
 Improves workplace
performance
 52% reduction in
depression severity
 High satisfaction
ratings
symptoms of fear
and panic
direct costs
hazardous use
 Significant reduction
in binge drinking
 3.4 hours per day
reduction in time
ritualizing and
obsessing
Our programs comprise the most studied suite of CCBT software with more than two
decades of research and nearly a dozen randomized, controlled trials.
19
The most studied suite of CCBT programs
1.
2.
3.
4.
In press. P. Morgan, et. al. [2016]. Computer Based Cognitive Behavioral Therapy. Connecticut Community Mental Health Center
Hermes, E., & Rosenheck, R. [2015]. Implementing Computer-Based Psychotherapy among Veterans in Outpatient Treatment for Substance Use Disorders. Psychiatric Services, 67, 2, 176-183.
Graff, L.A., Kaoukis, G., Vincent, N., Piotrowksi, A., & Ediger. J. [2012]. New models of care for Psychology in Canada’s health services. Canadian Psychology, 53, 165-177.
Hebert, E. A., Vincent, N., Lewycky, S., & Walsh, K. [2010]. Attrition and adherence in the online treatment of chronic insomnia. Behavioral Sleep Medicine, 8, 3, 141-50. doi: 10.1080/15402002.2010.487457.
VA Research: Implementing CCBT among veterans in
a randomized controlled trial.
Outpatient
Treatment
for Substance Use Disorders
a randomized controlled
trial
5.
Holmqvist, M., Vincent, N., & Walsh, K. [2013]. Web-vs telehealth-based delivery of cognitive behavioral therapy for insomnia:
6.
7.
8.
9.
10.
11.
12.
Vincent, N., & Lewycky, S. [2009]. Logging on for better sleep
of the effectiveness of online treatment for insomnia. Sleep, 32, 6, 807-15.
Vincent, N., Lewycky, S., Hart Swain, K., & Holmqvist, M. [2009]. Logging on for Nodding off: Empowering patients through the use of computerized cognitive behavioural therapy [cCBT]. The Behavior Therapist. 32, 123-126.
Vincent, N., Walsh, K., & Lewycky, S. [2010]. Sleep locus of control and computerized cognitive- behavioral therapy [cCBT]. Behaviour Research and Therapy, 48, 8, 779-783.
Vincent, N., & Walsh, K. [2013]. Stepped Care for Insomnia: An Evaluation of Implementation in Routine Practice. American Academy of Sleep Medicine.
Vincent, N., Walsh, K., & Lewycky, S. [2013]. Determinants of success for computerized CBT: Examination of an insomnia program. Behavioral Sleep Medicine, 11, 1-13.
Vincent, N., & Walsh, K. [2013]. Hyperarousal, sleep scheduling, and time in bed as mediators of outcome in computerized cognitive-behavioral therapy [cCBT] for insomnia. Behaviour Research and Therapy, 51, 161-166.
Cuijpers, P., Marks, I., van Straten, A., Cavanagh, K., Gega, L., & Andersson, G. [2009]. Computer-aided psychotherapy for anxiety disorders: a meta-analytic review. Cognitive Behaviour Therapy, 38, 2, 66-82.
Sleep Medicine, 1.
14.
15.
16.
17.
18.
Gega, L., Norman, I., & Marks, I. [2007]. Computer-aided vs. tutor-delivered teaching of exposure therapy for phobia/panic: Randomized controlled trial with pre-registration nursing students. International
Journal of Nursing Studies, 44[3], 397-405.
Gega, L., Marks, I., & Mataix-Cols, D. [2004]. Computer-aided CBT self help for anxiety and depressive disorders: experience of a London clinic and future directions. Journal of Clinical Psychology, 60, 2, 147-157.
Hayward, L., MacGregor, A. D., Peck, D. F., & Wilkes, P. [2007]. The Feasibility and Effectiveness of Computer-Guided CBT [FearFighter] in a Rural Area. Behavioural and Cognitive Psychotherapy, 35, 4, 409-419.
Kenwright, M., Liness, S., & Marks, I. [2001]. Reducing demands on clinicians by offering computer-aided self-help for phobia/panic. Feasibility study. The British Journal of Psychiatry: the Journal of Mental Science, 179, 456-459.
Kenwright, M., Marks, I., Gega, L., & Mataix-Cols, D. [2004]. Computer-aided self-help for phobia/panic via internet at home: a pilot study. The British Journal of Psychiatry: The Journal of Mental Science, 184448-449.
MacGregor, A., Hayward, L., Peck, D., & Wilkes, P. [2009]. Empirically grounded clinical interventions clients' and referrers' perceptions of computer-guided CBT [FearFighter]. Behavioural and Cognitive Psychotherapy, 37[1], 1-9.
19.
20.
21.
22.
23.
24.
Marks, I. M., Kenwright, M., et. al.[2004]. Saving clinicians' time by delegating routine aspects of therapy to a computer:
in phobia/panic disorder. Psychological Medicine, 34, 1, 9-17.
Marks, I. M., Cuijpers, P., Cavanagh, K., van, S. A., Gega, L., & Andersson, G. [2009]. Meta-analysis of computer-aided psychotherapy: problems and partial solutions. Cognitive Behaviour Therapy, 38, 2, 83-90.
McCrone, P., Marks, I. M., Mataix-Cols, D., Kenwright, M., & McDonough, M. [2009]. Computer- aided self-exposure therapy for phobia/panic disorder: a pilot economic evaluation. Cognitive Behaviour Therapy, 38, 2, 91-99.
McDonough, M., & Marks, I. M. [2002]. Teaching medical students exposure therapy for phobia/panic - randomized, controlled comparison of face-to-face tutorial in small groups vs. solo computer instruction. Medical Education, 36, 5, 412-417.
National Institute for Health and Clinical Excellence [2006]. Computerised cognitive behavioural therapy for depression and anxiety. Review of Technology Appraisal 51.
Schneider, A. J., Mataix-Cols, D., Marks, I. M., & Bachofen, M. [2005]. Internet-Guided Self-Help with or without Exposure Therapy for Phobic and Panic Disorders. Psychotherapy and Psychosomatics, 74, 3, 154-164.
25.
Kelly, P., Kay-Lambkin, F.J., Baker, A.L., Deane, F.P., Brooks, A.C., Mitchell, A., Marshall, S., Whittington, N. & Dingle, G.A. [2012]. Study protocol:
13.
More than two
decades of
research and
Several studies and clinical trials specific a randomized controlled trial
nearly a dozen
to substance use (including illicit drugs
randomized
and alcohol) and addiction
A randomized controlled trial of a computer-based
controlled trials
depression and substance abuse intervention for people attending residential substance abuse treatment. BMC Public Health, 12[1]:
Article Number 13. DOI: 10.1186/1471- 2458-12-11322325594
treatment for depressive and addictive disorders: results of a
26.
Kay-Lambkin, F.J., Baker, A.L., Kelly, B., & Lewin, T.J. [2011]. Clinician-assisted computerised versus therapist-delivered
27.
Kay-Lambkin, F.J., Baker, A.L., Lewin, T.J. & Carr, V.J. [2011]. Acceptability
28.
White, A., Kavanagh, D., Stallman, S., Klein, B., Kay-Lambkin, et. al.[2010]. Online alcohol interventions: A systematic review. Journal of Medical Internet Research, 12[5]: e62p1-e62p12.
randomised controlled trial. Medical Journal of Australia, 195[3]: S44-S50.
of a clinician-assisted computerized psychological intervention for comorbid mental
health and substance use problems: Treatment adherence data from a randomized controlled trial. Journal of Medical Internet Research, 13[1], e11p1-e11p11.
controlled trial of CBT
for co-existing depression and alcohol problems: Short-term outcome. Addiction, 105
29.
Baker, A., Kavanagh, D., Kay-Lambkin, et. al. [2010]. Randomised
[1]: 87-99.
30.
Kay-Lambkin, F.J., Baker, A., Lewin, T.J., & Carr, V.J. [2009].
31.
32.
33.
Kay-Lambkin, F.J. [2008]. Technology and Innovation in the Psychosocial Treatment of Methamphetamine Use, Risk and Dependence. Drug and Alcohol Review, 27[3]: 318-325.
Greist, J. H., Osgood-Hynes, D. J., Baer, L., & Marks, I. M. [2000]. Technology-Based Advances in the Management of Depression: Focus on the COPE; Program. Disease Management and Health Outcomes, 7, 4.]
Marks, I. M., Mataix-Cols, D., Kenwright, M., Cameron, R., Hirsch, S., & Gega, L. [2003]. Pragmatic evaluation of computer-aided self-help for anxiety and depression. The British Journal of Psychiatry : the Journal of Mental Science, 183, 57-65.
34.
Kenwright, M., Marks, I., Graham, C., Franses, A., & Mataix-Cols, D. [2005].
35.
Greist, J. H., Marks, I. M., Baer, L., Kobak, K. A., Wenzel, K. W., Hirsch, M. J., Mantle, J. M., & Clary, C. M. [2002]. Behavior Therapy for Obsessive-Compulsive Disorder Guided by a Computer or by a Clinician Compared With Relaxation as a Control.
The Journal of Clinical Psychiatry, 63, 2, 138-145.
Nakagawa, A., Marks, I. M., Park, J. M., Bachofen, M., Baer, L., Dottl, S. L., & Greist, J. H. [2000]. Self-treatment of obsessive-compulsive disorder guided by manual and computer-conducted telephone interview. Journal of Telemedicine and
Telecare, 6, 1, 22-6. http://www.ncbi.nlm.nih.gov/pubmed/10824386
Marks, I. M., Baer, I., Greist, J. H., & Park, J. M. [1998]. Home self-assessment of obsessive- compulsive disorder. Use of a manual and a computer-conducted telephone interview: two UK-US studies. The British Journal of Psychiatry, 172, 406.
Bachofen, M., Nakagawa, A., Marks, I. M., Park, J. M., Greist, J. H., Baer, L., Wenzel, K. W., & Dottl, S. L. [1999]. Home self-assessment and self-treatment of obsessive-compulsive disorder using a manual and a computer-conducted telephone
interview: replication of a UK-US study. The Journal of Clinical Psychiatry, 60, 8, 545-9.
36.
37.
38.
Computer-based psychological treatment for comorbid depression and substance use
problems: A randomised controlled trial of clinical efficacy. Addiction, 104, 378- 388. [Top 1% of highly cited papers in 2009, 30 citations]
Brief scheduled phone support from a clinician to enhance computer-aided selfhelp: randomized controlled trial. Journal of Clinical Outcomes
Psychology, 61, 12, 1499-508.
improve when
paired with telephonic support
20
Recent research on efficacy, adoption & engagement
CCBT more effective than care as usual
 In an NIMH study (results released May 12, 2016), researchers found
that providing CCBT software is a more effective treatment for
anxiety and depression than doctors' usual primary care.
 The study included 704 participants
 83% adopted the use of a CCBT software program
 On average, participants completed 5.3 sessions
 At 6-month follow-up, participants reported significant
improvements in depression and anxiety symptoms.
 Another study (results published December
1, 2015) conducted by VA researchers in a
veteran-specific outpatient setting for
substance use, found that 67% of
participants who used one CCBT program
agreed they would engage in another CCBT
program in the future.
21
Efficiencies
22
•
Cost savings: Cost per unit improvement varies based on software costs and level of training of
“guide.” (At $200 per patient, administered by Ph.D. or M.D. FearFighter, demonstrates 63%
savings; savings increase quickly with lower price and lower training level)
•
Primary care tool set: Successfully integrated into primary care and other settings as programs
are self-contained and do not require knowledge of CBT to offer
•
Leveraging R.N., M.D., other clinicians: One CBT clinician can see many more patients. (With
Restore one Ph.D. has gone from managing 145 patients a year to approx. 650 without
sacrificing outcomes.) Non-CBT trained clinicians, including peer counselors and those in
primary care, can support validated CBT programs
•
Instant availability: Available 24/7/365 via a HIPPA-compliant website with a username and
password
•
Decreasing “step-ups” in care: Patients can receive a medication-free option and often avoid
long-term medications or face-to-face therapy. (Referrals for face-to-face specialty care in a
clinic decreased by 66% for insomnia when patients were offered online program.)
•
Rural and “clinically isolated” access: No geographic or specialty boundaries
22
Our CCBT program received the highest rating
from SAMHSA’s NREPP Program Review
Our CCBT software, reviewed by The Substance Abuse and Mental Health Services
Administration (SAMHSA), is the only program of its kind to be included in SAMHSA’s
National Registry of Evidence-Based Programs and Practices and to receive its highest rating –
EFFECTIVE – without reservation.
23
The patient experience
CCBT experience
Smartscreening: Behavioral Health Screen
Efficient: FearFighter Program Explanation
Video narration: RESTORE Narration
Use of multimedia: Fight or Flight
Interactivity: MoodCalmer Pleasurable Activities Planner
Vignettes: FearFighter, MoodCalmer
Multilingual: Spanish
Administration: Tracking members with Enterprise
Weekly sessions replicate traditional therapy structures and can be
accessed privately at the convenience of the participant
25
CCBT for substance use and comorbid depression
SHADETM
Program structure
• The SHADE™ program is 10 weeks
long
• Participants are expected to
complete one module per week
and work on homework or
exercises between modules
• The modules vary in length from
30 – 50 minutes
Online module elements
• SHADE™ will assign several monitoring and activity
worksheets to complete
• Participants will be asked to monitor their mood
during the week and practice relaxation exercises
• Worksheets help generalize the lessons learned
during a SHADE™ module into everyday life
26
• Throughout SHADE™, participants have the
opportunity to view video footage of people who
suffer similar conditions. Both “Rob” and “Liz” are
available at various times in the SHADE™ sessions to
provide extra information about the activities
participants are completing
CCBT for insomnia and sleep problems
RESTORETM
Program structure
• Typically the program takes 6
weeks to complete.
• There are 6 modules and it is
recommended to go through the
modules one week at a time
• The modules vary in length from
25 to 40 minutes
• The program keeps track of which modules have been
completed and, once a module has been completed,
clients can go back and repeat it as often as they wish
• Between modules, clients will be asked to:
•Track their sleep daily using the ‘Sleep Diary’
•Complete homework and work on exercises
27
• Each online module contains the same elements but
various new program support materials and tools are
introduced throughout the program
• There are four repeating elements in each module: the
‘Resource Room’, the ‘Sleep Diary’, progress graphs and
homework
CCBT program for mild to moderate depression
MoodCalmerTM
Program structure
• The program consists of 4
sessions, each lasting up to 20
minutes
• Participants are advised to
complete one session at a time
• At the end of each session the
participant completes a short
feedback questionnaire
• Participants have the option to view 2 case studies
whether they have completed the exercise from the
based on people’s real-life experiences of depression previous session
and CBT
• Given instructions and motivation to complete
• There is an online exercise to help identify signs and
interactive exercise by rating their sense of pleasure,
symptoms of depression
accomplishment and mood before and after a
• The program checks with the user to determine
planned activity
28
CCBT program for anxiety, panic, and phobia
FearFighterTM
Program structure
• FearfighterTM is a 9-week
program. Participants’ progress
through each module is tracked
and, upon the completion of
each module, new review
resources are made available
• Modules vary in length from 30
to 45 minutes
• Each online module contains the same elements, and
various new program support materials and tools are •
introduced throughout the program
• FearFighterTM provides customized multimedia
content, teaches skill-building exercises, and provides •
clinical vignettes to motivate and help overcome
29
anxieties and fears
FearFighter™ diary is an essential part of the
program. Participants complete their diary and other
challenging core belief exercises online
FearFighter™ participants also create and maintain a
fear hierarchy with SMART goals
CCBT program for obsessive compulsive disorder
OCFighterTM
Program structure
• OCfighterTM is a 9-week program
• At the beginning of the program
and end of each step,
participants are navigated to the
activity box
• Icons unlock after a step is
completed to allow access to
new exercises or information
• OCFighter™ is a fully multimedia program. Navigating • Participants are introduced to 2 case studies, Carol
from one section to another will either be automatic
and Bill. Both characters are based on real-life
or based on the user confirming an option on-screen
characters
by the click of the mouse
• The Major Rituals exercise is accompanied by a brief
• The program comprises of a series of videos,
introductory video explaining the purpose of the
interactive exercises
exercise
30
Integrating CCBT with primary care
Integrating CCBT with primary care
Identification of patients with behavioral health problems
Identification in primary care is challenging so many models of integration include systematic
screening as one element to improve care.
Use of well-validated screens
Using screens such as the PHQ-9 for depression and the GAD-7 for anxiety, helps identify
individuals who have behavioral health conditions.
Referral to various types of care
Once screening identifies a need; the participant is then referred to various types of care
depending on the severity of the behavioral health condition.
Including guideline recommended care
Treatment guidelines suggest that the first step for insomnia, anxiety (including panic attacks
and phobias) & OCD should be cognitive behavioral therapy (CBT) and that CBT should be
offered as a first line option for depression and substance use.
When Computerized CBT (CCBT) is accessed over the Internet
CCBT can be overseen by a wide variety of different clinicians, none of whom needs to be
trained in CBT. The face-to-face time needed to be spent with the patient is determined by
the clinician depending on the type of condition and its severity. The average is
approximately 10 minutes/week.
32
Workflow @ Henry J. Austin Health Center
Appointment: Patient comes to clinic for their annual or sick visit
Screening: The patient completes behavioral health screening, administered by a staff member.
The screening determines if the patient has a BH condition and generates a report for review. The
report can be sent to a medical record or printed out for the patient’s chart.
Referral: Once a need is identified the patient is referred to a level of appropriate care, depending
on their severity.
Enrollment and utilization: Clinician or other staff member brings patient to a computer to enroll
the patient in CBT program. CCBT programs are accessed over the Internet. They can be overseen
by a wide variety of different clinicians none of whom needs to be trained in CBT.
Workflows adjusted by practice/location to best support staff
33
Identifying behavioral health conditions
PHQ-2 (depression)
 If positive, 7 more
GAD-2 (anxiety)
ISI-3 (insomnia)
DAST-1 (drugs)
AUDIT -1(alcohol)
34
Mar-15
Apr-15
May-15
Jun-15
Jul-15
Aug-15
Sep-15
Oct-15
Nov-15
Dec-15
Jan-16
Feb-16
Mar-16
Screening for BH conditions
Unique pts
receiving BH
screens
1749
1874
1948
1830
1751
1722
1905
1856
1585
1595
1610
1610
1615
Unique pts w/
positive BH
screens
427
396
432
395
327
392
446
366
337
348
362
390
318
272
227
180
189
172
254
349
302
315
223
230
212
212
# of patients seen
by BHC
Percent screened positive
30%
25%
20%
15%
10%
5%
0%
35
Mar-15 Apr-15 May-15 Jun-15
Jul-15
Aug-15 Sep-15
Oct-15 Nov-15 Dec-15
Jan-16
Feb-16 Mar-16
Mar-15
Apr-15
May-15
Jun-15
Jul-15
Aug-15
Sep-15
Oct-15
Nov-15
Dec-15
Jan-16
Feb-16
Mar-16
Magellan CCBT utilization
11
20
23
18
14
20
15
14
14
10
22
7
9
11
19
20
18
13
20
14
14
13
10
21
7
9
Session 1 completers by
month
8
17
15
15
11
15
10
13
11
9
19
7
7
2 or more session
completers by month
1
11
6
10
5
9
9
8
6
4
6
2
3
Program completers by
month
0
2
2
4
2
6
2
3
1
1
0
0
1
Unique Patient Summary
Newly Engaged Patients by
Month
Multiple Login's
25
20
15
10
5
0
Mar-15
36
Apr-15
May-15
Jun-15
Jul-15
Aug-15
Sep-15
Oct-15
Newly Engaged Patients by Month
Multiple Login's
2 or more session completers by month
Program completers by month
Nov-15
Dec-15
Jan-16
Session 1 completers by month
Feb-16
Mar-16
Patient engagement program
• Helpful for motivating individuals to return to the clinic to use the CCBT programs
• Creates a sustainable model at FQHCs when users return to the clinic to utilize the
Magellan CCBT programs
• More of our clients are asking for or interested in using this method to engage
patient population
• Specifically in Medicaid & FQHC populations
Two workflows:
1. Technical issues via Magellan CCBT programs: patient given $10 gift card for time
and inconvenience
2. For someone to consider starting the module: patient given $10 to start module –
and another after completing second session
Total
Total gift cards distributed
177
37
Average per
Time period
month
16
10 months
Revenue-generating opportunity
CPT codes
Medical codes used to report medical, surgical and diagnostic procedures and services to
entities (e.g., physicians, health insurance companies, accreditation organizations)
90832
• Used when BHC staff meet with patients face-to-face for 30 minutes for onsite use of
Magellan CBT programs
– Used by physician/NP/PA/CNS/psychologist/LCSW
– For 16-37 minutes of mental health consultation
– Blended rate is $88.00.
• About33% of HJAHC patients are uninsured or underinsured patients which leads
to an average actual reimbursement rate of $59.00
90791
• Used when clinic staff uses wellness screening tool with patients to screen for
behavioral health conditions and interpret results
• In use at clinics in NJ
– Used for psychiatric diagnostic interview examination
38
CCBT PHQ outcomes
PHQ Outcomes Summary
% of engaged patients who
improve*
60%
65%
Standardized measurement tools are
embedded in the programs to measure
baseline symptom levels and monitor
progress throughout the programs. These
standardized tests and questionnaires allow
generalization of clinical results across the
HJA patient population. While the sample
size is still very small, the results are
promising. Engaged patients are patients
who complete two or more sessions (and
therefore have a pre-test and post-test
score).
19%
*as reported by PHQ data built into the Magellan
CBT software programs used by HJA patients.
Average % of improvement*
18%
% of severe cases who improve*
69%
Average % of improvement (for
severe cases)*
% of moderate cases who
improve*
Average % of improvement (for
moderate cases)*
% who improve after completing
4 or more sessions*
% who improve after completing
program*
39
23%
65%
71%
Bibliography / references
Cuijpers, P., Marks, I., van Straten, A., Cavanagh, K., Gega, L., & Andersson, G. (2009). Computer-aided psychotherapy for anxiety disorders: a meta-analytic review. Cognitive Behaviour Therapy,
38, 2, 66-82. http://www.ncbi.nlm.nih.gov/pubmed/20183688
Gega, L., Norman, I., & Marks, I. (2007). Computer-aided vs. tutor-delivered teaching of exposure therapy for phobia/panic: Randomized controlled trial with pre-registration nursing students.
International Journal of Nursing Studies, 44(3), 397-405. doi:10.1016/j.ijnurstu.2006.02.009 http://www.ncbi.nlm.nih.gov/pubmed/16631177
Gega, L., Marks, I., & Mataix-Cols, D. (2004). Computer-aided CBT self help for anxiety and depressive disorders: experience of a London clinic and future directions. Journal of Clinical Psychology,
60, 2, 147-157. http://www.ncbi.nlm.nih.gov/pubmed/14724922
Hayward, L., MacGregor, A. D., Peck, D. F., & Wilkes, P. (2007). The Feasibility and Effectiveness of Computer-Guided CBT (FearFighter) in a Rural Area. Behavioural and Cognitive Psychotherapy,
35, 4, 409-419. http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=1116764
Kenwright, M., Liness, S., & Marks, I. (2001). Reducing demands on clinicians by offering computer-aided self-help for phobia/panic. Feasibility study. The British Journal of Psychiatry: the Journal
of Mental Science, 179, 456-459. http://www.ncbi.nlm.nih.gov/pubmed/11689405
Kenwright, M., Marks, I., Gega, L., & Mataix-Cols, D. (2004). Computer-aided self-help for phobia/panic via internet at home: a pilot study. The British Journal of Psychiatry: The Journal of Mental
Science, 184448-449. http://www.ncbi.nlm.nih.gov/pubmed/15123511
MacGregor, A., Hayward, L., Peck, D., & Wilkes, P. (2009). Empirically grounded clinical interventions clients' and referrers' perceptions of computer-guided CBT (FearFighter). Behavioural and
Cognitive Psychotherapy, 37(1), 1-9. doi:10.1017/S135246580800492X http://www.ncbi.nlm.nih.gov/pubmed/19364403
Marks, I. M., Kenwright, M., McDonough, M., Whittaker, M., & Mataix-Cols, D. (2004). Saving clinicians' time by delegating routine aspects of therapy to a computer: a randomized controlled trial
in phobia/panic disorder. Psychological Medicine, 34, 1, 9-17. http://www.ncbi.nlm.nih.gov/pubmed/14971623
Marks, I. M., Cuijpers, P., Cavanagh, K., van, S. A., Gega, L., & Andersson, G. (2009). Meta-analysis of computer-aided psychotherapy: problems and partial solutions. Cognitive Behaviour Therapy,
38, 2, 83-90. doi: 10.1080/16506070802675239. http://www.ncbi.nlm.nih.gov/pubmed/20183689
McCrone, P., Marks, I. M., Mataix-Cols, D., Kenwright, M., & McDonough, M. (2009). Computer- aided self-exposure therapy for phobia/panic disorder: a pilot economic evaluation. Cognitive
Behaviour Therapy, 38, 2, 91-99. doi: 10.1080/16506070802561074. http://www.ncbi.nlm.nih.gov/pubmed/19306148
McDonough, M., & Marks, I. M. (2002). Teaching medical students exposure therapy for phobia/panic - randomized, controlled comparison of face-to-face tutorial in small groups vs. solo
computer instruction. Medical Education, 36, 5, 412-417. http://www.ncbi.nlm.nih.gov/pubmed/12028390
National Institute for Health and Clinical Excellence (2006). Computerised cognitive behavioural therapy for depression and anxiety. Review of Technology Appraisal 51.
http://www.nice.org.uk/nicemedia/pdf/TA097guidance.pdf
Schneider, A. J., Mataix-Cols, D., Marks, I. M., & Bachofen, M. (2005). Internet-Guided Self-Help with or without Exposure Therapy for Phobic and Panic Disorders. Psychotherapy and
Psychosomatics, 74, 3, 154-164. http://www.ncbi.nlm.nih.gov/pubmed/15832066
Graff, L.A., Kaoukis, G., Vincent, N., Piotrowksi, A., & Ediger. J. (2012). New models of care for Psychology in Canada’s health services. Canadian Psychology, 53, 165-177.
http://psycnet.apa.org/index.cfm?fa=buy.optionToBuy&id=2012-01736-001
Hebert, E. A., Vincent, N., Lewycky, S., & Walsh, K. (2010). Attrition and adherence in the online treatment of chronic insomnia. Behavioral Sleep Medicine, 8, 3, 141-50. doi:
10.1080/15402002.2010.487457. http://www.ncbi.nlm.nih.gov/pubmed/20582757
40
Bibliography / references
Holmqvist, M., Vincent, N., & Walsh, K. (2013). Web-vs telehealth-based delivery of cognitive behavioral therapy for insomnia: a randomized controlled trial. Sleep Medicine, 1.
http://www.ncbi.nlm.nih.gov/pubmed/24461370
Vincent, N., & Lewycky, S. (2009). Logging on for better sleep: randomized controlled trial of the effectiveness of online treatment for insomnia. Sleep, 32, 6, 807-15.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690569/
Vincent, N., Lewycky, S., Hart Swain, K., & Holmqvist, M. (2009). Logging on for Nodding off: Empowering patients through the use of computerized cognitive behavioural therapy (cCBT). The Behavior Therapist. 32, 123-126.
http://www.abct.org/docs/PastIssue/32n6.pdf
Vincent, N., Walsh, K., & Lewycky, S. (2010). Sleep locus of control and computerized cognitive- behavioral therapy (cCBT). Behaviour Research and Therapy, 48, 8, 779-783. http://www.ncbi.nlm.nih.gov/pubmed/20627268
Vincent, N., & Walsh, K. (2013). Stepped Care for Insomnia: An Evaluation of Implementation in Routine Practice. American Academy of Sleep Medicine. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3578678/
Vincent, N., Walsh, K., & Lewycky, S. (2013). Determinants of success for computerized CBT: Examination of an insomnia program. Behavioral Sleep Medicine, 11, 1-13. http://www.ncbi.nlm.nih.gov/pubmed/23286463
Vincent, N., & Walsh, K. (2013). Hyperarousal, sleep scheduling, and time in bed as mediators of outcome in computerized cognitive-behavioral therapy (cCBT) for insomnia. Behaviour Research and Therapy, 51, 161-166.
http://www.ncbi.nlm.nih.gov/pubmed/23353579 Greist, J. H., Osgood-Hynes, D. J., Baer, L., & Marks, I. M. (2000). Technology-Based Advances in the Management of Depression: Focus on the COPE; Program. Disease Management and Health Outcomes, 7, 4.)
http://link.springer.com/article/10.2165/00115677-200007040-00003
Marks, I. M., Mataix-Cols, D., Kenwright, M., Cameron, R., Hirsch, S., & Gega, L. (2003). Pragmatic evaluation of computer-aided self-help for anxiety and depression. The British Journal of Psychiatry : the Journal of Mental
Science, 183, 57-65. http://www.ncbi.nlm.nih.gov/pubmed/12835245
Kelly, P., Kay-Lambkin, F.J., Baker, A.L., Deane, F.P., Brooks, A.C., Mitchell, A., Marshall, S., Whittington, N. & Dingle, G.A. (2012). Study protocol: A randomized controlled trial of a computer-based depression and substance
abuse intervention for people attending residential substance abuse treatment. BMC Public Health, 12(1): Article Number 13. DOI: 10.1186/1471- 2458-12-11322325594 http://www.biomedcentral.com/1471-2458/12/113
Kay-Lambkin, F.J., Baker, A.L., Kelly, B., & Lewin, T.J. (2011). Clinician-assisted computerised versus therapist-delivered treatment for depressive and addictive disorders: results of a randomised controlled trial. Medical
Journal of Australia, 195(3): S44-S50. http://www.ncbi.nlm.nih.gov/pubmed/21806518
Kay-Lambkin, F.J., Baker, A.L., Lewin, T.J. & Carr, V.J. (2011). Acceptability of a clinician-assisted computerized psychological intervention for comorbid mental health and substance use problems: Treatment adherence data
from a randomized controlled trial. Journal of Medical Internet Research, 13(1), e11p1-e11p11. http://www.ncbi.nlm.nih.gov/pubmed/21273184
White, A., Kavanagh, D., Stallman, S., Klein, B., Kay-Lambkin, F., Proudfoot, J., Drennan, J., Connor, J., Baker, A., Hines, E., Young, R. (2010). Online alcohol interventions: A systematic review. Journal of Medical Internet
Research, 12(5): e62p1-e62p12. http://www.ncbi.nlm.nih.gov/pubmed/21169175
Baker, A., Kavanagh, D., Kay-Lambkin, F., Hunt, S., Lewin, T.J., Carr, V. & Connolly, J. (2010). Randomised controlled trial of CBT for co-existing depression and alcohol problems: Short-term outcome. Addiction, 105 (1): 8799. http://www.ncbi.nlm.nih.gov/pubmed/19919594
Kay-Lambkin, F.J., Baker, A., Lewin, T.J., & Carr, V.J. (2009). Computer-based psychological treatment for comorbid depression and substance use problems: A randomised controlled trial of clinical efficacy. Addiction, 104,
378- 388. (Top 1% of highly cited papers in 2009, 30 citations) http://www.ncbi.nlm.nih.gov/pubmed/19207345
Kay-Lambkin, F.J. (2008). Technology and Innovation in the Psychosocial Treatment of Methamphetamine Use, Risk and Dependence. Drug and Alcohol Review, 27(3): 318-325.
http://www.ncbi.nlm.nih.gov/pubmed/18368614 Teplin D, Raz B, Daiter J, Varenbut M, Tyrrell M (2006). Screening for
substance use patterns among patients referred for a variety of sleep
complaints. Am J Drug Alcohol Abuse 32:111–120.
Davoudi, M., & Rawson, R. A. (2010). Screening, brief intervention, and referral to treatment (SBIRT) initiatives in California: Notable trends, challenges, and recommendations. Journal of Psychoactive Drugs, 42, 239-248.
United Nations Office on Drugs and Crime. (2012). World drug report. 2012. New York, United States.
41

Online CBT for Depression, Anxiety, Insomnia and other disorders in

Transcription

Similar documents

I`m helping to end MS by participating in the 2016 Jayman BUILT MS

The Board of Directors of Qatar Fuel (WOQOD) is pleased to invite

5 `S` Training Program at ABV-IIITM, Gwalior on 21.07.2016

Porky Expo Flyer

The NeuLion Report

Accessing Your Behavioral Health Benefits

Sept 30-Oct 2, 2016 Nov 4-6, 2016 @Camp Tadmor

4 star ALOE HOTEL, PAPHOS

the Guidelines for the registration on

Ticket plus hotel packages for the Chelsea Flower Show 2016