Effectiveness of DECIDE in Patient-Provider Communication, Therapeutic Alliance & Care Continuation
| Status: | Completed |
|---|---|
| Conditions: | Psychiatric, Psychiatric |
| Therapuetic Areas: | Psychiatry / Psychology |
| Healthy: | No |
| Age Range: | 18 - 80 |
| Updated: | 3/10/2019 |
| Start Date: | September 2013 |
| End Date: | October 2016 |
The purpose of this study is to learn more about how patients and healthcare providers
interact in order to improve shared decision making. The investigators plan to test an
intervention with two separate educational components—one for patients and one for
providers—designed to encourage patients to ask questions and increase their level of
involvement in their own care, while simultaneously training providers to be more receptive
to patients' questions and concerns. Patients in the intervention group will receive three
short (30-45 minute) trainings focused on developing and asking questions and will be
interviewed three times over the course of the intervention to see how it has affected the
quality of their care. Providers receiving the intervention will participate in three
separate trainings, including a 12-hour group workshop, an additional two hour training, and
six hours of individual instruction, including personalized feedback based on three
audio-recorded patient visits. Previous studies looking at patient engagement and involvement
in decision-making have shown that increased engagement is linked with improved outcomes, but
that providers are sometimes not prepared to develop a collaborative relationship with
patients. The investigators think that training both patients and providers to work together
and communicate more effectively will improve quality of care and increase patient
satisfaction more than interventions that focus on only one side of the clinical encounter.
One of the major goals in studying patient-provider communication is to improve shared
decision-making and see how it contributes to racial and ethnic disparities in mental health
care, since minority patients have been shown to be less involved in care and have been shown
to be perceived and treated differently by providers.
interact in order to improve shared decision making. The investigators plan to test an
intervention with two separate educational components—one for patients and one for
providers—designed to encourage patients to ask questions and increase their level of
involvement in their own care, while simultaneously training providers to be more receptive
to patients' questions and concerns. Patients in the intervention group will receive three
short (30-45 minute) trainings focused on developing and asking questions and will be
interviewed three times over the course of the intervention to see how it has affected the
quality of their care. Providers receiving the intervention will participate in three
separate trainings, including a 12-hour group workshop, an additional two hour training, and
six hours of individual instruction, including personalized feedback based on three
audio-recorded patient visits. Previous studies looking at patient engagement and involvement
in decision-making have shown that increased engagement is linked with improved outcomes, but
that providers are sometimes not prepared to develop a collaborative relationship with
patients. The investigators think that training both patients and providers to work together
and communicate more effectively will improve quality of care and increase patient
satisfaction more than interventions that focus on only one side of the clinical encounter.
One of the major goals in studying patient-provider communication is to improve shared
decision-making and see how it contributes to racial and ethnic disparities in mental health
care, since minority patients have been shown to be less involved in care and have been shown
to be perceived and treated differently by providers.
The Center for Multicultural Mental Health Research (CMMHR) at Cambridge Health Alliance has
recently been selected for funding by the Patient Centered Outcomes Research Institute
(PCORI) to address the importance of patient-provider communication, shared decision making,
and therapeutic alliance. Our research team demonstrated that a psycho-educational
intervention (DECIDE-PA) improves patient activation and self-management in behavioral health
care. However, the investigators found that providers were unresponsive or reacted negatively
to patients' activation. In response, the investigators propose to combine DECIDE-PA with
provider coaching (DECIDE-PC) to increase providers' receptivity to patient activation, and
improve Shared Decision Making (SDM). The investigators also focus on quality of care,
responding to clinic administrators who require interventions that improve quality of
behavioral health care (mental health and substance treatments).
Aims: 1) Test the effectiveness of DECIDE PA+PC compared to usual care in improving SDM and
patient-perceived quality of behavioral health care; 2) Test whether patient-centered
communication and therapeutic alliance mediate the effect of the DECIDE PA+PC intervention on
SDM; 3) Explore whether ethnic/racial or language matching between patient and provider
moderates the effect of DECIDE PA+PC on SDM and quality of behavioral health care.
Intervention: The DECIDE PA+PC intervention is designed to improve the quality of mental
health care for adult behavioral health patients by engaging minority participants in asking
questions about their treatment. The intervention is administered to patients and providers
and is designed to improve patient activation, self-management, and therapeutic alliance.
For patients, the DECIDE PA is designed to help patients identify concerns about their
condition or treatment and generate questions for providers regarding these concerns. The
DECIDE PA intervention consists of 3-4 brief training sessions for patients delivered by Care
Managers.
For providers, the DECIDE PC is designed to help providers improve therapeutic alliance,
patient-provider communication, continuance in care, and satisfaction with services for
patients in concordant and discordant ethnic/racial dyads. The DECIDE PC training for
providers consists of 1.5 days of training which focuses on augmenting patient-centered
communication and therapeutic alliance as a possible underlying pathway by which SDM can take
place. The training also addresses 1) lack of perspective taking; 2) frequent attributional
errors that providers make; and 3) decreased receptivity to patient participation and
collaboration in decision making. The training includes provider coaching totaling 15-20
hours.
Methods: For Aim 1, implement a randomized controlled trial comparing DECIDE-PA+PC with usual
care on Shard Decision Making (SDM) and perceived quality of care. Identify treatment effects
using multi-level models that account for nesting of observations, patients, providers, and
clinics. For Aim 2, identify underlying mechanisms of the effect of the DECIDE-PA+PC
intervention on SDM. Mediation analysis techniques are used that allow for rigorous testing
of causal pathways and statistical adjustment for spurious correlation is used in instances
where mediators and SDM measurement are contemporaneous. For Aim 3, expand Aim 1 models to
test whether DECIDE-PA+PC impacts SDM and perceived quality differentially by ethnic/racial
concordant/discordant dyads.
Usual Care: Usual care across clinics is described by clinicians as answering their patients'
questions during the clinical encounter. Clinicians report that on average they perceive
their patients as having limited involvement in decision-making. No DECIDE training for
patients or providers will be applied to the control condition while the control provider and
control patient are participating in the study. Once the control provider and control patient
complete their participation in the study, they will be offered the DECIDE trainings.
Participating Sites: The investigators plan to administer the intervention to patients and
providers at four participating Cambridge Health Alliance clinics, along with Beth Israel
Deaconess Medical Center, Boston Children's Hospital, South Cove Community Health Center,
Edward M Kennedy Health Center (Great Brook Valley Health Center), and two community health
centers through Harbor Health Services (Neponset Health Center and Geiger Gibson Community
Health Center).
recently been selected for funding by the Patient Centered Outcomes Research Institute
(PCORI) to address the importance of patient-provider communication, shared decision making,
and therapeutic alliance. Our research team demonstrated that a psycho-educational
intervention (DECIDE-PA) improves patient activation and self-management in behavioral health
care. However, the investigators found that providers were unresponsive or reacted negatively
to patients' activation. In response, the investigators propose to combine DECIDE-PA with
provider coaching (DECIDE-PC) to increase providers' receptivity to patient activation, and
improve Shared Decision Making (SDM). The investigators also focus on quality of care,
responding to clinic administrators who require interventions that improve quality of
behavioral health care (mental health and substance treatments).
Aims: 1) Test the effectiveness of DECIDE PA+PC compared to usual care in improving SDM and
patient-perceived quality of behavioral health care; 2) Test whether patient-centered
communication and therapeutic alliance mediate the effect of the DECIDE PA+PC intervention on
SDM; 3) Explore whether ethnic/racial or language matching between patient and provider
moderates the effect of DECIDE PA+PC on SDM and quality of behavioral health care.
Intervention: The DECIDE PA+PC intervention is designed to improve the quality of mental
health care for adult behavioral health patients by engaging minority participants in asking
questions about their treatment. The intervention is administered to patients and providers
and is designed to improve patient activation, self-management, and therapeutic alliance.
For patients, the DECIDE PA is designed to help patients identify concerns about their
condition or treatment and generate questions for providers regarding these concerns. The
DECIDE PA intervention consists of 3-4 brief training sessions for patients delivered by Care
Managers.
For providers, the DECIDE PC is designed to help providers improve therapeutic alliance,
patient-provider communication, continuance in care, and satisfaction with services for
patients in concordant and discordant ethnic/racial dyads. The DECIDE PC training for
providers consists of 1.5 days of training which focuses on augmenting patient-centered
communication and therapeutic alliance as a possible underlying pathway by which SDM can take
place. The training also addresses 1) lack of perspective taking; 2) frequent attributional
errors that providers make; and 3) decreased receptivity to patient participation and
collaboration in decision making. The training includes provider coaching totaling 15-20
hours.
Methods: For Aim 1, implement a randomized controlled trial comparing DECIDE-PA+PC with usual
care on Shard Decision Making (SDM) and perceived quality of care. Identify treatment effects
using multi-level models that account for nesting of observations, patients, providers, and
clinics. For Aim 2, identify underlying mechanisms of the effect of the DECIDE-PA+PC
intervention on SDM. Mediation analysis techniques are used that allow for rigorous testing
of causal pathways and statistical adjustment for spurious correlation is used in instances
where mediators and SDM measurement are contemporaneous. For Aim 3, expand Aim 1 models to
test whether DECIDE-PA+PC impacts SDM and perceived quality differentially by ethnic/racial
concordant/discordant dyads.
Usual Care: Usual care across clinics is described by clinicians as answering their patients'
questions during the clinical encounter. Clinicians report that on average they perceive
their patients as having limited involvement in decision-making. No DECIDE training for
patients or providers will be applied to the control condition while the control provider and
control patient are participating in the study. Once the control provider and control patient
complete their participation in the study, they will be offered the DECIDE trainings.
Participating Sites: The investigators plan to administer the intervention to patients and
providers at four participating Cambridge Health Alliance clinics, along with Beth Israel
Deaconess Medical Center, Boston Children's Hospital, South Cove Community Health Center,
Edward M Kennedy Health Center (Great Brook Valley Health Center), and two community health
centers through Harbor Health Services (Neponset Health Center and Geiger Gibson Community
Health Center).
Patient Inclusion Criteria:
-Patients ages 18-80 who are receiving mental health treatment at one of the collaborating
clinics.
Patient Exclusion Criteria:
-Patients will be excluded if they screen with mania, psychosis, or suicidality to ensure
their safety and minimize the stress of receiving the intervention. Patients over the age
of 65 will be assessed with a cognitive functioning screening instrument and excluded if
possible cognitive impairment is indicated.
Provider Inclusion Criteria:
-Providers will be permitted to participate in this study if they are regular, paid staff
that provide behavioral health services at any of the participating clinics. No other
criteria will be required.
We found this trial at
8
sites
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185 Cambridge Street
Boston, Massachusetts 02114
Boston, Massachusetts 02114
617-724-5200
Phone: 617-724-4987
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Boston, Massachusetts 02215
Phone: 617-667-0651
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Boston, Massachusetts 02215
Principal Investigator: Pamela Peck, PsyD
Phone: 617-667-0651
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Cambridge, Massachusetts 02139
Phone: 617-724-1237
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