The PACE/PACENET Behavioral Health Laboratory Project

Despite advances in the assessment and treatment of behavioral health disorders among older
adults, such disorders remain inadequately diagnosed and managed in later life. This is
troubling in light of the fact that behavioral health issues often serve as the catalyst for
a variety of negative psychosocial and physical health outcomes in later life, including
changes in social network functioning, physical disability and morbidity, loss of
independence, and institutionalization. Factors such as limited provider resources for
conducting frequent monitoring, variability in patient preferences and symptom severity,
patients' lack of treatment acceptance and engagement, low medication adherence, formal and
informal social support and aid, and logistic issues (e.g., transportation, finances, etc.)
all work in concert to influence patient identification and disease management. Yet, these
factors are difficult to address when managing conditions using traditional mental health
(MH) care delivery models that rely primarily on referrals to specialty care and/or
face-to-face contact.

Recognizing that traditional MH care delivery models and treatment strategies do not address
both practice- and patient-level logistical issues that are particularly relevant in
behavioral health care, where frequent clinical visits for monitoring and therapeutic contact
are key components in the successful treatment of patients, the investigators have adopted a
strategy of delivering disease management by way of telephone assessments. The Behavioral
Health Laboratory (BHL) is a flexible and dynamic telephone-based clinical service designed
to help identify and manage behavioral health issues. The principles of the program include:
MH as a key component to overall physical health; the need to make early MH screening,
assessment, and referral to services a part of common practice; the value in utilizing
technology in accessing and delivering MH care; and the importance of research- and
evidence-based practice.

An untoward outcome of the efforts to improve rates of treatment is the increased and
sometimes inappropriate use of psychotropic medication. Among the general population, the use
of psychotropic medication and rates of psychotropic polypharmacy continue to rise, with
increased use of medication for both anxiety and depression in both primary care and
specialty care. The rates of use have raised concerns regarding inappropriate prescribing
among the elderly.

Results from the investigators' initial program of care management services for PACE/PACENET
cardholders support the above concerns related to psychotropic medication prescription in the
elderly and also raise additional questions about off-label or inappropriate prescribing. The
program results indicate that the PACE/PACENET population is mostly female with a mean age of
78.1 years (SD 7.0), and an SF-12 Physical Component Score of 41.6. The average Patient
Health Questionnaire-9 (PHQ-9) score for those on antidepressants was 6.1 (5.4), with no
statistically significant difference between medication groups (F(2.436)=2.14, p=0.12); just
9 (6.3%) of those receiving anxiolytics met criteria for an anxiety disorder, which was not
significantly different than other medication classes (x2(2)=1.77, p=0.41). Overall, 208
(47.4%) participants in the sample did not meet criteria for any mental health disorder,
including 80 (55.9%) of those receiving anxiolytics.

Thus, the purpose of the current project is to evaluate the impact of the PACE/PACENET BHL
clinical programs on older Pennsylvanians and to evaluate the feasibility and impact of
enhancements to the current clinical program. The clinical contract for services targets
PACE/PACENET beneficiaries who have been newly prescribed an antidepressant, antipsychotic,
and/or anxiolytic, and, where appropriate, the caregivers. In order to obtain a
representative sample of PACE/PACENET enrollees, the PACE/PACENET program uses a stratified
sampling method for the identification and referral of eligible beneficiaries to the
PACE/PACENET BHL Clinical Program. Stratification is conducted with respect to two
variables--county and medication type, with individuals randomly selected from each strata.
Current clinical participants are not being sampled or contacted specifically for research
purposes. The research portion of this project relates only to the evaluation of those
enrolled in the clinical program and to the delivery and evaluation of the enhancements to
the current program.

The PACE/PACENET BHL Research Participants:

1. Enhanced BHL Program Participants:

Upon completion of the initial PACE/PACENET BHL Program interview, the investigators
will randomly select a subset up to 2400 enrollees for the Enhanced BHL Program and
invite the enrollees to participate in the Enhanced Program. If the enrollee is not able
to complete the full initial BHL interview due to cognitive impairment (either as
identified by cognitive screening or caregiver report), the caregiver may be invited to
participate in the caregiver component of the Enhanced BHL Program, the Telehealth
Education Program (TEP) Module.

2. BHL Program Evaluations: Participants recruited for the evaluation component of the BHL
Programs (Standard and Enhanced) will fall into the following categories:

1. Evaluation of BHL Clinical Data: In order to examine factors such as participant
clinical and sociodemographic characteristics, process of care, prescription
refills, and use of services, the investigators will ask up to 6000 enrollees for
permission to use the clinical data collected during the BHL interviews. To
accomplish this component of the evaluation, the investigators will orally consent
all individuals who at least begin a Core interview to allow use of the clinical
data for research purposes. Participants do not need to consent to use of the
clinical data as a prerequisite to participating in the clinical program. The
clinical data will include their prescription data supplied by the PACE/PACENET
program.

2. 3/6 Month Outcome Evaluation: In order to examine long-term outcomes, participants
who complete an initial clinical interview will be offered participation in an
outcome evaluation at 3 and 6 months.

Subject Recruitment and Screening:

1. BHL Clinical Data Evaluation: Following completion of the initial PACE/PACENET BHL
clinical assessment (i.e., "Core assessment"), all enrollees will be asked for
permission to use the clinical data collected during the BHL interviews.

2. Enhanced Program Recruitment: Following completion of the initial PACE/PACENET BHL
clinical assessment, a subset of enrollees will be asked to participate in the Enhanced
BHL Program. Randomization to the Enhanced Program will occur within strata as
determined by index medication type and Core interview assessment outcome (i.e.,
clinically significant depression and/or anxiety symptoms, no clinically significant
symptoms, cognitive impairment). After obtaining informed consent, a separate simple
randomization protocol will be followed within each substratum of enrollees. For each
substratum every other participant will be offered participation in the Enhanced BHL
Program.

3. 3/6 Month Outcome Evaluation Recruitment: Following completion of the initial
PACE/PACENET clinical assessments and agreement to participation in the Enhanced Program
or our Standard Clinical Program, enrollees or the caregivers will be asked to
participate in an evaluation of the BHL program at 3 and 6 months from the initial
PACE/PACENET BHL clinical interview.

Study Procedures:

The Enhanced BHL Program:

1. The Enhanced BHL Program: Upon completion of the Core interview, a subset of enrollees
will be randomly selected to participate in the Enhanced BHL Program (i.e., Enhanced
Monitoring Module or Enhanced Care Management Module). For enrollees who do not report
clinically significant mental health symptoms the Enhanced Program consists of the
Standard Monitoring Module enhanced with a discussion of continuing versus discontinuing
the medication. The Behavioral Health Provider (BHP) will follow-up with the enrollee
after 6 weeks to discuss continuing versus discontinuing the medication. For enrollees
who report clinically significant depression, anxiety, and/or pain symptoms the Enhanced
Program consists of Care Management. The model incorporates the use of a BHP who has
expertise in mental health assessment and is well versed in the delivery of
algorithm-based management strategies for disorders such as depression and anxiety. The
role of the BHP is to facilitate treatment and provide informal psychosocial therapy,
using motivational interviewing techniques, in a manner that is consistent with the
Agency for Health Care Policy and Research (AHCPR) guidelines. The BHP monitors and
encourages patient acceptance and adherence to treatment recommendations through
support, education, and motivational engagement. The BHP initiates care management when
enrollees are not responding to the initial treatment or as clinically needed based on
the initial Core interview and needs assessment. The BHP also uses problem solving
therapy to assist patients. The frequency and number of contacts for each individual
will vary; individuals typically engage in 1-2 contacts per month for several months.
Written updates are provided to the prescribing clinician, as clinically indicated.

In cases where caregivers complete an initial interview and endorse cognitive impairment
in the care-recipient enrollee, a random sample of caregivers will be offered
participation in the Enhanced BHL Telehealth Education Program (TEP). TEP is an
existing, manualized program developed and validated with caregivers of veterans with
moderate to severe dementia. The program consists of various modules which seek to
provide both education and psychosocial support for individuals caring for older adults
with moderate to severe cognitive impairment. Based on the responses from the Caregiver
Core Interview and participant preference, the BHP and caregiver will determine which
TEP modules will be covered over the course of TEP. If no modules are identified as
relevant (or the caregiver declines all modules), the BHP will still follow-up with the
caregiver, offering unstructured supportive phone calls. Delivering the program over the
telephone allows access to education and support without having to manage the
difficulties of getting the enrollee out of the house or finding supervision for the
enrollee in order to attend face-to-face sessions.

2. 3/6 Month Outcome Evaluation: In order to evaluate individual-level outcomes and rates
of clinical improvement at 3 and 6 months, the investigators will attempt to collect
follow-up data from all enrollees/caregivers who have completed the initial PACE/PACENET
BHL Clinical Program assessment. Using data extracted from the enrollee follow-up
assessments, the investigators will examine psychological, behavioral, and cognitive
symptoms, physical disability, health care utilization, and access to community
resources. Using data extracted from caregiver follow-up assessments, the investigators
will be able to evaluate care recipients' behavioral, psychological, and cognitive
symptoms and level of physical functioning, in addition to caregiver burden and safety
concerns.

Inclusion Criteria:

1. To be eligible for the Enhanced BHL Program, the only inclusion criterion is to have
participated in an initial telephone assessment as part of the current PACE/PACENET
BHL Clinical Program. If a patient cannot complete a full assessment due to cognitive,
hearing, or speech impairment, the patient may identify a caregiver to complete the
Caregiver Interview. To be eligible for the TEP (caregiver support group) component of
Enhanced Care, the enrollee must exhibit cognitive impairment; if only the Caregiver
Interview was completed, responses from the caregiver regarding the enrollee's
cognition (score of 2 or greater on "AD-8 Dementia Screening Interview" and/or a
dementia diagnosis) will be used as an indication of impairment in lieu of the
enrollee's BOMC score.

2. Similarly, to be eligible for the BHL Program Evaluations (i.e., BHL Clinical Data
Evaluation, 3/6 Month Outcome Evaluation), the inclusion criterion is to have
participated in an initial telephone assessment as part of the current PACE/PACENET
BHL Clinical Program. As above, enrollees who do not complete the initial assessment
are still eligible if a caregiver is available to complete the Caregiver Interview.

3. Enrollment in the current PACE/PACENET BHL Clinical Program. Though not part of the
research program, the current program targets older, community-dwelling adults (i.e.,
65 years and older) enrolled in the PACE/PACENET programs, who have filled at least
one new prescription for an antidepressant, antipsychotic, and/or anxiolytic
medication. The BHL program does require the basic ability to communicate by
telephone; either the enrollee or an identified caregiver must meet this criterion for
participation in the BHL Clinical Program.

Exclusion Criteria:

Exclusion criteria for participation in the Enhanced BHL Program and the 3/6 Month Outcome
Evaluation are:

1. having severe cognitive impairment (BOMC score 14 or greater) in the absence of a
caregiver, and/or

2. endorsement of psychosis or mania during the initial clinical interview, and/or

3. a PHQ score of 25 or greater, and/or

4. positive drug abuse screen, and/or

5. alcohol dependence.

Enrollees endorsing any of above mentioned exclusions will be offered assistance with
referral to community specialty-care resources as part of the PACE/PACENET BHL Clinical
Program.

Exclusion criteria for caregiver participation in the TEP component of Enhanced Care is
lack of report of cognitive impairment when only the Caregiver interview was completed.