|
Many older individuals experience serious mental health and/or
substance abuse (MH/SA) problems that affect their quality of life as well as
their ability to function independently in the community.
Although prevalence rates vary in epidemiological studies among older
adults, it is clear that older adults experience high rates of depression and
anxiety disorders, as well as alcohol abuse and dependence.
Older adults seek and receive MH/SA services more often from their
primary care providers than from specialty MH/SA providers.
With the projected increase in the number of older Americans in the
years to come, it is evident that both the clinical and policy communities need
to be well informed as to the nature and effectiveness of different service
delivery models for treating MH/SA problems.
SAMHSA has
developed a multisite study to compare the effectiveness of service delivery
models that treat older adults with MH/SA problems in primary care as opposed
to enhanced specialty MH/SA settings. The study, Primary Care Research in
Substance Abuse and Mental Health Services for the Elderly (PRISM-E), hopes to
identify differences in clinical and cost outcomes between models referring
consumers to enhanced specialty mental health and/or substance abuse services
outside the primary care setting and those providing such services within the
primary care setting itself.
Anticipated contributions to the fields of aging, mental
health, and substance abuse include: the statistical power afforded by a large
sample of participants to test a number of important hypotheses; it is the
largest study of depression in older adults; it is the largest study of alcohol
use in the elderly; this is the first study of integration versus referral
service models in older adults; past studies look at usual versus collaborative
care while PRISM-E compares integrated care versus specialty care with
enhancements relating to access; this is the first effectiveness study of
integration in older adults; other major studies focus on compliance to
clinical guidelines; the PRISM-E
study focuses on real world integration and diverse clinical sites.
This study has been carried out in three phases, covering a
6-year period. The project is
currently in its sixth and final year. The intent of this study was to
randomize a large number of older persons with MH/SA problems to either
integrated or enhanced referral models of MH/SA care.
Study, participants were assessed at baseline, 3 months, and 6 months to
determine changes in clinical symptoms and functioning over the course of
treatment. Participants have been
enrolled from 11 sites, which represent roughly 50 clinical settings and
include a variety of providers from managed care environments, community health
clinics, The Department of Veterans Affairs (VA) facilities, and group practice
settings. The study sites
represent a rich diversity of ethnic/minority and rural/urban populations.
The following domains will be measured in the study:
-
A large battery of treatment outcome measures for all participants
-
Quantitative
measurement and qualitative description of service interventions through
process evaluation, detailed program manuals, and structured site visits
-
Measures of degree of integration of clinical sites on seven dimensions
-
Survey of provider attitudes
-
Measures of operational costs, including pharmacy data
Study sites underwent two rounds of peer-reviewed competition
to be in the multisite study. SAMHSA’s investment in this project over the
initial 4-year study period has been $14,319,266.
An additional 2-year supplement to the Coordinating Center (CC) was
awarded, adding an additional $1,000,000 in SAMSHA funds. Further investments
have been made by other federal agencies: a) The VA has made a substantial
contribution to the study by providing data from 5 clinical sites.
They have provided $3.5 million to five VA medical centers in direct
funding for two years of the study.
The VA system has also contributed in kind support to help with the management
of the study through a distinct VA coordinating body.
An interagency agreement with the VA committed the clinical operations
of the five VA study sites to conform to the study protocol. These sites were
chosen through two phases of competition; b) The Health Resources and Services
Administration (HRSA) has contributed $676,000 over the 4-year project period
to provide additional services enhancements.
HRSA continues to provide service enhancement funds during the 2-year study
extension to the three sites that are federally qualified health clinics, for
an additional investment of $312,000; c) An interagency agreement with CMS will
contribute relevant Medicaid and Medicare data to link to outcome data from the
study participants.
Harvard Medical School, Brigham & Women’s Hospital, and
John Snow, Inc. have joined together to serve as the CC for this multi-site
study. The CC’s role is multifaceted, providing leadership, administrative
support, and technical expertise in the development and implementation of the
multi-site protocol.
The CC has assembled a multidisciplinary and multicultural
team of investigators and consultants with expertise in the major technical
areas relevant to the program. These
areas include geriatrics/gerontology, mental health, substance abuse, primary
care, cost and health economics, and multi-site research methods.
The CC staff has extensive experience in managing large studies and in
providing training and technical assistance to community-based health care
organizations.
The study has conducted 40,000 clinical screenings on over
25,000 persons. The study exceeded the enrollment targets set by the study,
with 2271 participants enrolled. The
rate of participant follow-up has been high, reaching nearly 80% at most sites
for three and six month follow-ups.
Through the work of primary investigators at study sites,
multiple presentations and symposia have been given in a variety of national
conferences over the last several years to introduce the study and the design.
Multiple presentations have been given at conferences sponsored by The
Gerontological Society of America (GSA), American Psychiatric Association
(APA), and the UPBEAT National Meeting sponsored by the VA. A paper has been
published in the Journal of Aging and Health in February 2004, outlining the
design and sample characteristics of the PRISM-E study.
Several publications of findings from site-specific data or
the screening data have been submitted or accepted for publication.
The Steering Committee has designated a set of about two dozen core
papers that have been outlined and are currently being developed for
publication. Additional papers are also being organized or are underway that
address secondary questions from the multi-site dataset or from a variety of
unique data collected at the site-level only.
For example, several VA sites have collected additional data to address
questions about care for those persons having post-traumatic stress
disorders.
|