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Study to Promote Innovation in Rural Integrated Telepsychiatry (SPIRIT)
Investigator (PI): Fortney, John
Performing Organization (PO): (Current): University of Washington, School of Medicine, Department of Psychiatry and Behavioral Sciences / (206) 543-3750
Supporting Agency (SA): Patient-Centered Outcomes Research Institute (PCORI)
Initial Year: 2016
Final Year: 2021
Record Source/Award ID: PCORI/PCS-1406-19295
Funding: Total Award Amount: $11,776,419
Award Type: Contract
Award Information: PCORI: More information and project results (when completed)
Abstract: Background: Community health centers care for over 20 million rural, low-income and minority Americans every year. Patients often have complex mental health problems such as post-traumatic stress disorder (PTSD) and bipolar disorder. However, community health centers located in rural areas face substantial challenges in managing these patients due to lack of onsite mental health specialists, stigma, and poor geographic access to specialty mental health services in the community. As a consequence, many rural primary care providers feel obligated, yet unprepared, to manage these disorders, and many patients receive inadequate treatment and continue to struggle with their symptoms. While integrated care models and telepsychiatry referral models are both promising approaches to managing patients with complex mental health problems in rural primary care settings, there have been no studies comparing which approach is more effective for which types of patients. Objectives: The central question examined by this study is whether it is better for offsite mental health specialists to support primary care providers' treatment of patients with PTSD and bipolar disorder through an integrated care model or to use telemedicine technology to facilitate referrals to offsite mental health specialists. Methods: This would be the largest study of rural Americans with a psychiatric disorder ever to be conducted. One thousand primary care patients screening positive for PTSD or bipolar disorder will be recruited from 15 community health centers in three states (Arkansas, Michigan, and Washington) and randomized to the integrated care model or the referral model. Only patients already engaged in specialty mental health care will be excluded. Telephone surveys will be administered to patients at enrollment and at 6- and 12-month follow-ups. Statistical analyses will compare outcomes for patients randomized to the two models. Interviews will also be conducted with a subset of patients to better understand their treatment experiences as described in their own words. In addition, interviews will be conducted with their primary care providers to get their perspective on which model is more effective for their patients and which is more feasible to implement in their clinical practice. Patient outcomes: Telephone surveys will measure access to care, therapeutic alliance with providers, patient-centeredness, patient activation, satisfaction with care, appointment attendance, medication adherence, self-reported clinical symptoms, medication side effects, health-related quality of life, and progress toward life goals. A sub-sample of patients will be invited to participate in qualitative interviews to describe their treatment experience using their own words. Likewise, PCPs will be invited to participate in qualitative interviews to voice their perspective. Patient and stakeholder engagement: The research topic was identified during numerous discussions with patients and providers who participated in previous research projects. The interventions and study methods were jointly designed with a consumer advisory board and a policy advisory board. The consumer advisory board is comprised of patients with PTSD and bipolar disorder as well as representatives from consumer advocacy groups (National Alliance on Mental Illness, Depression Bipolar Support Alliance, No Health Without Mental Health). The policy advisory board is comprised of community health center primary care providers and representatives from their Primary Care Associations, the National Association of Community Health Centers, the Health Resources and Services Administration (HRSA), National Association for Rural Mental Health, and the American Telemedicine Association. To ensure sustained engagement by stakeholders during the course of the project, we will conduct an ongoing evaluation of stakeholder involvement, and refine our partnership structure and processes as necessary. Anticipated impact: This study will be the first to compare two alternative approaches to managing complex mental health problems in rural primary care settings where referral to offsite specialty care is often not a feasible option. Results will inform community health centers across the country about which model to implement. Results have the potential to reduce disparities faced by millions of CHC patients with PTSD and BD. HRSA's current prioritization of integrating mental health into primary care and recent progress in state-level legislation to permit reimbursement for telemedicine should facilitate uptake of whichever approach is found to be more effective.
MeSH Terms:
  • Arkansas
  • Bipolar Disorder /therapy
  • Community Health Services /*organization & administration
  • Community Mental Health Services /*organization & administration
  • Health Policy
  • Health Services Accessibility
  • Humans
  • Medication Adherence
  • Mental Disorders /*therapy
  • Michigan
  • Patient Participation
  • Patient Satisfaction
  • Patient-Centered Care
  • Primary Health Care
  • Program Development
  • Quality of Life
  • Randomized Controlled Trials as Topic
  • * Referral and Consultation
  • Rural Health Services /*organization & administration
  • Rural Population
  • Stress Disorders, Post-Traumatic /therapy
  • Telemedicine /methods
  • United States
  • Washington
Country: United States
State: Washington
Zip Code: 98195
UI: 20162193
CTgovId: NCT02738944
Project Status: Ongoing
Record History: ('2017: Changed Title. Previous Title: Integrated versus referral care for complex psychiatric disorders in rural federally qualified health centers (FQHCs)',)