Protocol Assignment Forum: Mapping

Great job! Love the figures and the content!

For Q1. Just a question: Is there any way you can kick the HgA1c to the PCP to manage? Mental Health providers treating “preliminary treatment for any abnormalities with metformin” may not be necessary and may pose a risk. Treating asymptomatic diabetes (as, I assume that if they have symptoms, their PCP/ER would have worked up for DM) is for benefits (decreased CV mortality, etc.) that won’t be seen acutely so there is no rush to preliminarily treat…just my thought.

For Q2. I think your choice of Theory of Behavior Change was a good idea and I agree with you that it fits best for provider behavior change and to incorporate the pieces of the other models was awesome, as well.

For Q3. Solid. I would suggest letting primary care know that they may have an increase in e-consult utilization and pager use, as well. (not related to the Q at hand but just thinking about future problems...)

Christina - nice job, I agree with Vicki and really like the figures.

In thinking about targeting physicians for behavior change, it looks like most of your interventions appeal to their "patient care" side, meaning that most of your messaging is aimed at reminding them how to be good physicians and why it will help their patients. I think you can also strengthen the "what's in it for me" side of things too by focusing on things that they may care about in terms of themselves and their own practice. Some potential ideas or questions that might spark ideas:

-integration with PCPs to allow a more free flow of dialogue and help with management

-potential for better patient satisfaction ratings (which ultimately leads to higher reimbursement!) through patient's being happy with their pyschiatrists thinking of them as a whole person

-any monetary benefit in terms of reimbursement/what they can bill for?

-any "mission" or "goal" from the administration (department or hospital) that you can relate (cost savings, patient satisfaction, etc)?

Love the figure(s) and i think really coming together. 

agree with you the difficulty of linking PCPs into this, and see you goal as to build in primary care into the routine psychiatric practice. 

you highlighted perceived behavior control as a potential emphasis of intervention. Was wondering if you had considered current examples of lab/screening monitoring that occurs by psychiatrists. For example, clozaril needs monthly cbc monitoring for a period of time-- how is that currently managed in psychiatry? are there reminders or auto-ordering lab tools that can be transferred to diabetes screening/testing. 

I like the way you display the factors that influence the attitudes, social norms and perceived behavioral control.. I would also consider how the “External Factors” are mediated through these 3 constructs.  Lack of phlebotomy and lack of access to primary care input/guidance can also affect attitudes and perceived behavioral control.

I like your Specific Interventions.  When you look at the Primary Care literature on ways to improve screening (and there are MANY studies in this area), one of the most effective is to take the simple act out of the hands of the doctor and place it within the broader team’s responsibilities.  So that medical assistants or nurses are responsible for reviewing and ordering (or pending) the screening test as part of the check-in process.  You will still need the “management” side support—what to do with the results and treatments… but I would separate this “behavior” from the principal behavior of conducting the screening test.

Love the social marketing ideas.  Keep the action/response of doing or not doing something centrally contained within the individual (in this case the psychiatrist).  So the “bad” thing that will happen for the psychiatrist if they don’t screen is that patient’s will be sicker, and harder to manage their psychiatric illness, and perhaps they will also deal with a lot more strife with the patient and their family/caregivers because of the uncontrolled diabetes.  The “good” thing that will happen to psychiatrists if they do screen is some personal acknowledgement or reward if you set-up the intervention correctly.  Right now, the rewards are so far off and hard to attribute to the behavior that they are not very strong motivators for behavior change.  Whereas the “bad” things that happen (side effects) DO happen in real time, and the psychiatrist is likely to experience them.

Christina,

This is a great project.  You have honed in on a high risk population that is traditionally underserved/underscreened for metabolic conditions.  Couple other factors at play (you can decide where they fit in the behavioral model):

There is an attitude that the psychological issues are so much more important than the diabetes risk, that this risk is inadequately discussed with patients and caregivers at the onset of treatment.  Although many may ultimately decide the risk is worth the treatment, few are actually provided the implications of what it means to develop diabetes, or this is heavily downplayed compared to the benefit of the drugs.  I have heard from some mental health advocates that they have felt condemned to diabetes without much choice.

The other factor is that management of diabetes is itself, a behavioral health challenge.  There are lifestyle choices and other self-management that is made even more difficult by co-morbid behavioral health issues.  Some have suggested bouncing back screening and management to the PCP.  I would guess PCPs would really dislike getting a bunch of people with behavioral health issues AND diabetes thrown their way (can you imagine in a health center?  That's like a quadruple slot appointment with no real uptick in reimbursement).  Finding ways to empower psychiatrists to take on the screening, communication with PCPs regarding appropriate treatment if they identify diabetes, but then playing an integral part in behavior modification for their patients to help manage the disease.  A solid relationship with behavioral health-focused diabetes educators would also be a good idea for the psychiatrists.  CDEs are missing from your community list.  I would definitely include them.