Improving Adolescent Primary Care Through An Interactive Behavioral Health Module (California)

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Summary:

Most adolescents visit a health care provider once a year, presenting an opportunity to integrate behavioral and emotional health screening into clinical care. Yet despite clinical guidelines, providers’ rates of screening adolescents for risky health behaviors and depression are lower than recommended. Therefore, new strategies are needed to increase behavioral health screening in primary care. Clinical decision support (CDS) has tremendous potential to improve behavioral health care for adolescents.

This exploratory project developed an interactive behavioral and emotional health module that was integrated into adolescent health care delivery. The module, Health e-Check, included a risk assessment for adolescents and a CDS intervention tool for providers. The module was piloted and assessed in adolescent primary care practices by the San Francisco Bay Collaborative Research Network (CRN) through the University of California, San Francisco (UCSF).

The specific aims of this project were as follows:

  • Develop a theoretically based interactive behavioral and emotional health module for adolescents that can be integrated into health care delivery, serving as both a risk assessment and an intervention tool to enhance adolescent behavior change.
  • Pilot-test the implementation of the computerized module and screening system in adolescent primary care, assessing clinician, adolescent, and system outcomes.

The study was conducted in two phases. In the first phase, the research team developed Health e-Check, a tablet screening module covering multiple behavioral risk areas and emotional health, able to be completed by adolescents in 5 minutes. The responses were integrated into the electronic medical record and used to generate a customized printout for providers. The printout included information about the adolescent’s behaviors and speaking prompts for providers to use when discussing health behaviors with teens.

In the second phase, the module was implemented in two primary care clinics serving diverse populations of adolescents. Qualitative and quantitative methods were used to assess the acceptability of the intervention, determine whether the intervention increased provider rates of screening and counseling, and assess the effects of the intervention on adolescent behavioral health. The results indicated that the module was acceptable to adolescents and providers. Provider rates of behavioral health screening and counselling increased. Adolescents reported being more comfortable and honest when completing the screening by computer than with a provider. The research team concluded that Health e-Check has the potential to improve behavioral health screening for adolescents and future research should focus on adaptation of the module for integration across diverse health delivery systems.

Improving Adolescent Primary Care Through An Interactive Behavioral Health Module - 2012

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    PAR: HS08-269: Exploratory and Developmental Grant to Improve Health Care Quality through Health Information Technology (IT) (R21)
  • Grant Number: 
    R21 HS 020997
  • Project Period: 
    September 2011 – August 2013
  • AHRQ Funding Amount: 
    $155,821
  • PDF Version: 
    (PDF, 277.84 KB)

Summary: Most adolescents visit a health care provider once a year, presenting an opportunity to integrate behavioral and emotional health screening into clinical care. Yet despite clinical guidelines, providers consistently screen adolescents for risky health behaviors and depression at rates lower than recommended. Therefore, new strategies are needed to increase behavioral health screening in primary care. Health information technology (IT) with clinical decision support (CDS) has tremendous potential to improve health care quality and subsequent behavioral health outcomes for adolescents. Although many adolescent health problems are amenable to behavioral intervention and most teenagers are comfortable using interactive technology, few health IT interventions have been integrated into adolescent care.

This exploratory project is developing a theoretically based interactive behavioral and emotional health module that can be integrated into adolescent health care delivery and will serve as both a risk assessment and intervention tool to enhance adolescent behavior change. The module is being piloted in adolescent primary care practices, assessing clinician, adolescent, and system outcomes. The study is being conducted within the San Francisco Bay Collaborative Research Network (CRN) through the University of California, San Francisco (UCSF). A sample of adolescents aged 12-to-18 is being recruited from various ethnically and economically diverse clinics within the network. Multiple approaches and data sources will be utilized to conduct quantitative and qualitative analyses on each of the outcomes of interest.

The overarching goal of this project is to better understand how the proposed intervention addresses the diverse needs of teenagers, informs the contextual factors that contribute to quality of implementation in varied clinic contexts, and informs strategies for adaptation and integration in larger-scale health IT implementation. Ultimately, this project will inform the development and implementation of health information tools into the primary care setting, while also focusing on technology that supports patient- centered care.

Specific Aims:

  • Develop a theoretically based interactive behavioral and emotional health module for adolescents that can be integrated into health care delivery, serving as both a risk assessment and an intervention tool to enhance adolescent behavior change. (Achieved)
  • Pilot-test the implementation of the computerized module and screening system in adolescent primary care, assessing clinician, adolescent, and system outcomes. (Ongoing)

2012 Activities: The focus of activity was on hiring a research associate, developing the computerized screening module, conducting baseline data collection, planning the integration of the screening module into clinic sites, finalizing the provider printout to accompany the adolescent screening module, initiating the pilot testing within the study clinic sites, and finalizing post-implementation assessments.

Model development involved drafting a paper mock-up version and initial Web-based version to solicit feedback on the questions and wording about topics such as depression and substance use, nutrition and physical activity, safety, tobacco, sexual health, and home and school environment. With feedback from adolescents and providers, revisions were made to the wording of questions and additional screening items were incorporated to include questions on bullying and binge drinking. The technology team integrated this feedback into the screening module in September 2012 and linked the CRAFFT substance use screening tool to incorporate additional substance use information.

The study team collected baseline data utilizing an adolescent report of the visit survey and then conducted preliminary analyses on provider rates of screening adolescents on the various risk behavior areas. A pre- intervention survey was also conducted with providers to collect data on knowledge and self-efficacy to screen adolescents on multiple behavioral health areas. Baseline provider reports will be compared with data collected from the providers’ post-module implementation in clinic sites.

The provider printout was drafted and feedback solicited from clinicians in both of the clinics on an iterative basis using paper prototype versions. The printout will provide customized information on the behaviors of teens (reflecting their responses on the screening tool) and include prompts and cues for providers during conversations with teenagers. In 2013, the automated provider printout will be piloted, finalized, and integrated into the clinics to be utilized by the providers during adolescent well-visits; an administrative screen will be developed to allow the providers to view, print, and integrate/copy the data from the provider printout into the electronic medical record at UCSF. This integration step requires a modified version of the printout for electronic medical record integration. Both versions of the printout will be pilot-tested in clinic sites before being fully implemented.

The pilot of the full version of the screening tool began in late 2012. The study team is assessing teens’ perception of individual screening items as well as the look and feel of the module. As pilot-testing moves forward, the study team will test the integration of the module into the flow of clinic visits at each site.

As last self-reported in the AHRQ Research Reporting System, project progress and activities are mostly on track, and project budget funds are moderately underspent. Budget underspending will be resolved with the hiring of a project research associate.

Preliminary Impact and Findings: There are no findings to date.

Target Population: Pediatric*, Teenagers

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Knowledge Creation

* This target population is one of AHRQ’s priority populations.

Improving Adolescent Primary Care Through An Interactive Behavioral Health Module - 2011

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    PAR: HS08-269: Exploratory and Developmental Grant to Improve Health Care Quality through Health Information Technology (IT) (R21)
  • Grant Number: 
    R21 HS 020997
  • Project Period: 
    September 2011 - August 2013
  • AHRQ Funding Amount: 
    $155,821
  • PDF Version: 
    (PDF, 182.83 KB)

Summary: Most adolescents visit a health care provider once a year, providing an opportunity to integrate behavioral/emotional health screening into clinical care. Yet despite clinical guidelines, providers screen adolescents for risky health behaviors and depression at rates consistently lower than recommended. Therefore, new strategies are needed to increase behavioral health screening in primary care. Health information technology (IT), such as an electronic health record with clinical decision support (CDS), has tremendous potential to improve health care quality and subsequent behavioral health outcomes for adolescents. Many adolescent health problems are amenable to behavioral intervention, and most teenagers are comfortable using interactive computerized technology, yet few health IT interventions have been integrated into adolescent care.

This exploratory project is developing a theoretically-based interactive behavioral/emotional health module for adolescents that can be integrated into health care delivery, serving as both a risk assessment and an intervention tool to enhance adolescent behavior change. After the module has been developed, it will be piloted in adolescent primary care practices, assessing clinician, adolescent, and system outcomes. The study is being conducted within the San Francisco Bay Collaborative Research Network (CRN) through the University of California, San Francisco (UCSF). From these ethnically- and economicallydiverse clinics, a sample of adolescents ages 12 to18 years will be recruited to participate. Multiple approaches and data sources will be utilized to conduct quantitative and qualitative analyses on each of the outcomes of interest.

The overarching goal of this project is to better understand how the proposed intervention addresses the diverse needs of teenagers, informs the contextual factors that contribute to quality of implementation in varied clinic contexts, and informs strategies for adaptation and integration in larger scale health IT implementation. Ultimately, this project will help inform the development and implementation of health information tools into the primary care setting while also focusing on technology that supports patient-centered care.

Specific Aims:

  • Develop a theoretically-based interactive behavioral/emotional health module for adolescents that can be integrated into health care delivery, serving as both a risk assessment and an intervention tool to enhance adolescent behavior change. (Ongoing)
  • Pilot-test the implementation of the computerized module/screening system in adolescent primary care, assessing clinician, adolescent, and system outcomes. (Upcoming)

2011 Activities: During the first quarter, the project staff focused on: 1) reviewing existing interactive modules to determine appropriateness of materials for application to development of this particular behavioral health module; 2) contacting medical directors and other key staff in clinics that have expressed support for involvement in development and integration of the intervention module in their clinic site; and 3) obtaining institutional review board approval for the research project from the Committee on Human Research at UCSF.

The study team continues to communicate regularly with UCSF colleagues to discuss adaptation and options for development of the adolescent health module, as well as the details of module development and building off their existing adolescent screening tool. In addition, the team is investigating how a screening tool might be integrated broadly within the new UCSF electronic medical record system.

As last self-reported in the AHRQ Research Reporting System, project progress and activities are on track, and project budget spending is on target.

Preliminary Impact and Findings: This project has no findings to date.

Target Population: Pediatric*, Teenagers

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Knowledge Creation

* This target population is one of AHRQ's priority populations.

Improving Adolescent Primary Care Through An Interactive Behavioral Health Module - Final Report

Citation:
Ozer E. Improving Adolescent Primary Care Through An Interactive Behavioral Health Module - Final Report. (Prepared by the University of California, San Francisco under Grant No. R21 HS020997). Rockville, MD: Agency for Healthcare Research and Quality, 2014. (PDF, 191.52 KB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services. 
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