2017 Community Engagement Pilot Grants - Awardee Abstracts: Fallon Cluxton-Keller, PhD, Sarah Lord, PhD
Fallon Cluxton-Keller, PhD
Integrated video-based family therapy for peripartum depression in home visited adolescents: A pilot study
Public investment in the Federal Maternal, Infant and Early Childhood Home Visiting (HV) Program is substantial and growing. It serves about 145,500 families at risk for child abuse annually and aims to improve many outcomes, including maternal mental health. Over a third of clients report clinically significant peripartum depressive symptoms, and about 40% are adolescent mothers (pregnant and post-delivery). Family conflict increases rates of peripartum depression in adolescent mothers. Although home visitors provide clients with referrals for treatment, it is infrequently obtained or not completed due to many barriers (e.g., no childcare). There is a need for a treatment model that would bypass the barriers. The purpose of the proposed study is to partner with two Federal HV Program sites to implement an evidence- based treatment for depression, using HIPAA-compliant video-based communication technology (Vidyo), in adolescent mothers. This implementation-effectiveness hybrid trial includes 12 depressed adolescent mothers and their families.
It has three aims:
1. Explore the feasibility of integrating the treatment model into two Federal HV Program sites in New Hampshire.
2. Test the acceptability of the treatment model among depressed adolescent mothers and their families.
3. Explore preliminary impacts of the treatment on maternal depressive symptoms, emotion regulation and parenting attitudes, and family functioning at two months post-intervention.
If funded, the findings could serve as a catalyst for future research that influences mental health practices and policies. We will use our results as the basis for an NIMH application for a larger study that rigorously tests this innovative treatment model.
The Federal Maternal, Infant and Early Childhood Home Visiting (HV) Program serves about 145,500 vulnerable families at risk for child abuse annually and aims to improve several outcomes, including maternal mental health. Most clients are insured by Medicaid, and about 40% are adolescent mothers (pregnant and post-delivery). Each tax dollar invested in the Federal HV Program saves $5.70 due to reductions in child abuse and associated costs. Untreated peripartum depression results in poor outcomes, including child abuse, for home visited families. Peripartum depression is prevalent in clients in that 36% report prenatal depressive symptoms and 34% report postpartum depressive symptoms. Family conflict increases rates of peripartum depression in adolescent mothers. Home visitors refer depressed adolescent mothers for treatment. Yet, those who are referred infrequently obtain treatment or do not complete it if they do obtain it due to many barriers (e.g., geographical distance, no childcare). Mental health clinicians have significant barriers (e.g., geographical distance, financial and time constraints) that prevent them from making round-trip visits to family homes. There is a need for a family-based treatment for peripartum depression that is integrated into home visiting and would bypass these barriers. The purpose of the proposed study is to partner with two Federal HV Program sites to implement an evidence-based treatment for depression, through use of HIPAA-compliant video-based communication technology (Vidyo), in adolescent mothers living in rural communities. If funded, the findings from this pilot study could serve as a catalyst for future research that influences mental health practices and policies.
Sarah Lord, PhD
Empowering mothers with opioid use disorders to create and implement a Plan of Safe Care for their infants using an electronic care management system
Prenatal opioid use impacts an estimated 8% of births in the northeastern U.S, and is associated with increased morbidity and mortality for mothers and infants. Federal rules mandate notification of child protective services and the development of a Plan of Safe Care (PSC) for infants affected by prenatal substance use. Lack of clarity about PSC expectations contributes to avoidance of care by women with substance use disorders (SUD), limits access to services, and increases burden on the child welfare system.
A Community-based Participatory Research approach will explore needs, barriers, and capabilities of women with SUD through focus groups at two community addiction programs and interviews with child welfare workers. Participant feedback will inform adaptation of an existing digital care management platform for women to develop and implement a PSC using mobile technology. The platform will be pilot tested by end-users. Qualitative data will be coded thematically and survey data analyzed descriptively.
Through comparison of pre/post assessments, we anticipate increased engagement in maternal self-care, better preparation for parenting, and improvement in perceived stress, parenting competence, and self-efficacy through a digitally supported PSC. Results will be reported through publication and presentations to stakeholder organizations.
Conclusions: The use of innovative digital technology for enhancing parenting efficacy in women with SUD has the potential to transform clinical approaches to PSC development nationally.
Pilot data on the use of digital health technology to improve parenting outcomes for women with SUD will support funding proposals to NIH and PCORI in 2017.
Perinatal opioid use is a national public health crisis, with an estimated 8% of deliveries affected in Northern New England. Of 12,000 annual births in NH, as many as 1,000 infants will be prenatally exposed to opioids in 2017. Federal law requires child protective services to develop a Plan of Safe Care (PSC) for all infants affected by prenatal substance use. Lack of clarity about PSC expectations disempowers women, contributes to avoidance of care, and increases burden on the child welfare system. Over 40% of child maltreatment cases in NH are associated with parental substance misuse, many of which might be avoided if families were engaged earlier.
The majority of pregnant and parenting women with SUD in rural communities have access to computer and mobile technologies. Research demonstrates that digital reminders and other aids can help people with addiction sustain recovery and engage in self-care. However, the use of technology to help women develop supports for parenting has not been tested. Our research team will work with women and other stakeholders to adapt an existing digital application to support an individualized PSC.
This project involves partnership with two addiction treatment programs, Habit OPCO and Groups Recover Together, and with child welfare professionals. Women with SUD have traditionally feared engagement with the child welfare system. This project allows mothers to participate fully in developing a PSC proactively, and has the potential to transform approaches to this issue nationally.
2017 Dartmouth CO-OP Community Engaged Research Pilot Awards - Awardee Abstracts
Community Care for Veterans: Care Integration Across Health Systems
PI: James Schlosser, MD MBA - Chief of Staff, Manchester VA Medical Center
Co-PI: Sarah Kemble, MD - MPH VA, Central Western Massachusetts
Co-PI: Donald Kollisch, MD - White River Junction, VT - VA Medical Center
Community Partner: William Roy - VA & R Chairman, New Hampshire American Legion
Scientific AbstractVeterans’ use of simultaneous VA and community medical care (dual care) is increasing. VT and NH are home to more than 160,000 mostly rural Veterans. Previous studies have shown that rural Veterans use more dual care, are older and more likely to be disabled (West, 2016). Recent legislation authorized Veterans to receive care by community providers if they met certain mileage or service timeliness criteria. There is preliminary evidence of patient safety, quality and satisfaction issues with dual care.
We will conduct a multi-method current state analysis of dual care for Veterans in New Hampshire and Vermont. We will elicit Veterans’ and primary care (PC) providers’ perceptions by (a) conducting Veteran survey assessments in 12 VA and non-VA community PC practices; (b) engaging with the DAV and American Legion to conduct four Veteran focus groups; (c) conducting PC provider surveys with participating practices; and d) conducting two virtual provider focus groups. Preliminary results will be shared with stakeholders to develop shared interpretation of findings. Final results will be shared with stakeholders and funding offices through a final report (suitable for publication).
This project will identify key strengths and vulnerabilities of dual care system integration for VT and NH Veterans. These findings will be useful in generating hypotheses for dual care system innovation and improvement. Pilot results will be summarized with possible full-project funding authorities including VA Office of Rural Health, Office of Community Care and Health Services Research and Development. Future projects will include point-of-service prospective data collection.
“Teen Speak-Out”: Engaging Rural Teenagers to Develop Community-Driven Interventions to Address Stress
PI: Melanie Lawrence, MD - Newbury Health Clinic, Newbury, VT
Co-PI: Maureen Boardman, NP - Little Rivers Health Care, Bradford, VT
Community Partner: Kevin Lawrence, MS, Work-Based Learning Coordinator, Riverbend Career and Technical Center, Bradford, VT
Scientific AbstractStress is associated with teen risk behavior. Strong negative association of stress with substance misuse, mental health difficulties, academic problems, poor decision-making and diminished physical wellbeing in adolescents is established. What individual and social factors are associated with stress among teens in rural communities?
Community engagement activities are Teen Speak-Out sessions, organized/facilitated by a Teen Advisory Board with the goal of development and implementation of at least one intervention addressing teen stress. Using quantitative and qualitative methods including anonymous surveys, preliminary data on factors and interventions impacting adolescent stress will provide the foundation for larger grant proposals to study this issue more broadly.
Results of project activities will be submitted for oral/poster presentation at Practice-based Research Network and North American Primary Care Research Group Annual Meetings. Disseminate project findings through manuscripts.
Teen Speak Out activities will produce information and interventions to be integrated in clinical and community practice. Teen participants will share experiences with School Board and high school staff with specific recommendations of how teen stress might be addressed in their school/community.
Results will provide the foundation for a program of research targeting development and evaluation of technology- and non-technology-based intervention solutions to support teens in managing stress and life challenges. Information gathered from teens will be used to develop external grant proposals to study the teen-identified intervention approaches more broadly. With the results gathered during this project, we anticipate being able to apply for PCORI or NIH R21/R34 funding.
Development of a “Recovery Self-Management App” Utilizing Mindfulness-Based Audio Exercises for Relapse Prevention in a Primary-Care Opioid Addiction Treatment Setting: Engaging with Patients in Treatment and Community Partners
PI: Jessica Bloom-Foster, MD - Eastern Maine Medical Center, Bangor, ME
Co-PI: Patrick McFarlane PHM-NP - Eastern Maine Medical Center, Bangor, ME
Scientific AbstractOpioid addiction is a growing problem nationally and in Maine, with escalating morbidity and mortality from injection drug use and overdose. Treatment is hampered by high rates of relapse. A brief intervention model teaching mindfulness skills supported by mobile health technology could improve outcomes in a rural, primary care setting.
We propose a technology-enhanced pilot project to follow an ongoing feasibility cohort study where we recruit subjects starting Medication Assisted Treatment (MAT) with buprenorphine and provide a brief scripted mindfulness training. Recommended 5 minutes daily (minimum) home practice is supported by a preloaded MP3 player and paper logbook. Outcomes up to 6 months will be correlated with home practice rates.
The technology-enhanced pilot will replace the MP3 player and logbook with a smartphone “app” containing audio files and other multimedia resources. The app will allow push-notifications as practice reminders, and will automatically upload data on practice time and surveys to a secure server.
A community-based substance abuse counselor and 4 patients will participate in development of the app, patient recruitment, and a post-study focus group.
We will compare behavior uptake (practice rates), perceived effectiveness, and craving scales to the ongoing MP3-based study outcomes. Focus groups will provide a qualitative comparison. Results will be reported at national and regional meetings and submitted for publication in appropriate journals.
This project will establish feasibility of using mobile health technology to enhance addiction treatment in primary care. Our goal is a NIDA grant for a randomized trial of integrative addiction treatment enhancements.
2016 Awardee Abstracts: Paul Barr, PhD; Elizabeth Carpenter-Song, PhD; Sarah Pratt, PhD
Paul Barr, PhD
Health Care Options for People Experiencing Depression (HOPE*D): Phase1: End-user views and requirements of clinic-based interactive Option Grid decision aid for major depressive disorder
Individuals with major depressive disorder (MDD) experience limited shared decision-making (SDM). Decision aids (DAs) can increase SDM and treatment alignment with patient preferences, improving initiation and maintenance and expediting recovery. With community partners, we developed an Option Grid decision aid (OGDA) for MDD. An existing online version has not been refined for in-clinic use. This project aims to inform a digital platform linking routine screening to an in-clinic Option Grid decision aid (iOGDA) for MDD in primary care.
Four focus groups, each with 6-12 individuals with MDD or clinicians will inform iOGDA’s scope. Participants will be recruited from Dartmouth-Hitchcock Nashua and Mental Health America (MHA). Usability testing of the online OGDA for MDD will identify refinements for iOGDA development. General public (n=5) will be recruited from DHMC and clinicians (n=5) from D-H Nashua. Focus group analysis will use a thematic framework approach. User issues and satisfaction with the online OGDA will inform an iOGDA paper-prototype.
Results will be reported in a peer-reviewed journal and at MHA and Dartmouth Coop annual conferences. Community partners will disseminate results through social media and community outreach.
This project links decision support to MDD screening at the point-of-care. This can improve screening efficiency and increase shared decision-making in MDD and could be used in other health conditions.
With a lifetime prevalence of 13%, major depressive disorder (MDD) affects many Americans with enormous social, financial and health-related impact. Individuals with MDD are not adequately engaged in treatment decision-making, negatively impacting their care. Decision aids (DAs) increase patient engagement and align treatment with patient preferences, yet implementation is challenging. Digitized DAs embedded within clinic workflows may help. This study will inform development of a digital platform, the in-clinic Option Grid decision aid (iOGDA) for MDD, linking MDD screening to decision support. Dartmouth-Hitchcock (D-H) Nashua primary care clinics, including both the southern New Hampshire community of individuals with MDD and clinicians involved in their care, are major stakeholders in this research. D-H Nashua, a member of the D- H Population Health Collaboratory, has been involved in planning and pilot work for this project. Also involved have been a caregiver partner and a consumer partner, who will continue to contribute to study design, analysis and dissemination of the proposed research. Finally, SAMHSA and Mental Health America were integral partners on a prior study that will inform the content of the iOGDA, and they will contribute to participant recruitment and grassroots dissemination of results for the proposed study. This project will form the basis for development of a digital decision aid system that can be seamlessly embedded into clinical care pathways. This enables linkage of real time decision support to individuals screening positive for depression while facilitating depression screening in primary care as recommended by the US Preventive Services Task Force.
Elizabeth Carpenter-Song, PhD
Mental Health at the Margins: Engaging Low-Income Rural Individuals and Families to Enhance Wellbeing and Reduce Mental Health Disparities
The majority of people with mental illnesses in the U.S. do not receive treatment and the problem appears to be worse in rural areas. Despite higher rates of depression and suicide, and substance use rates equal to those in urban areas, rural populations are less likely than urban populations to receive treatment. Low-income rural individuals are particularly vulnerable as both rural poverty and mental health disparities are deepening.
By partnering with members of a marginalized rural community, we aim to develop strategic plans to improve mental health. The proposed project is guided by the principles of Participatory Action Research and will combine in-depth interview methods with community engagement techniques.
Results will be widely disseminated to community and academic audiences. Specifically, information will be shared with our community partners through bi-monthly Advisory Board meetings, the Haven newsletter, and with the Board of Directors. Results will also be disseminated through the ReThink Health initiative. Findings will also be disseminated in scholarly journals in the fields of mental health services and translational research.
The overarching goal is to create an infrastructure to promote systematic learning from the lived experiences of a hidden population to inform person- and community-centered strategies to reduce rural mental health disparities.
This project aims to place the voices and lived experiences of people who live ‘at the margins’ by virtue of poverty, mental health and substance use challenges, oppression, and stigma at the center of designing truly patient-centered mental health services. Current services are not working well for many individuals and families: most people struggling with mental health and substance use issues are not receiving treatment. The problem is worse in rural areas.
There are many well-known barriers to receiving mental health treatment in rural areas: lack of access to providers; transportation challenges; stigma; and cultural values that discourage asking for help. In this project, we aim to partner with community members to answer the questions: What can we do to improve mental health among rural, low-income individuals and families? How can mental health and community resources meet the needs of a hidden population?
We will partner with service-users and other stakeholders from the Upper Valley Haven to learn from the lived experiences of a hidden population. The Haven serves people struggling with poverty in Vermont and New Hampshire. Members of the Haven community will be involved in all aspects of the project: serving as Advisory Board members, participating in interviews and community discussions, helping to interpret findings, and spreading the key lessons of what is learned to other members of the Haven, research, social services, and clinical communities. Building a strong community-academic partnership will sustain our ability to continue learning from those ‘at the margins’ to improve health and healthcare.
Sarah Pratt, PhD
Evaluation of Fitness Promotion for People with Developmental Disabilities
The life expectancy of people with developmental disabilities (DD) is 15-20 years less than the general population, largely attributable to higher rates of obesity, sedentary lifestyle, cardiovascular disease, and poor nutritional habits. Published studies demonstrate that people with DD can be engaged in exercise and fitness programs, but most are small, pre-post pilots with modest effects on weight and other fitness indicators. Community Partners (CP), the community mental health center and area agency in Strafford County is embarking on a major change in their routine practice by focusing on whole health and wellness. CP, along with the University of New Hampshire Institute on Disability (UNH-IOD), have embarked on adapting a fitness program designed for people with serious mental illness, In SHAPE, to address the needs of obese and sedentary people with DD. The specific aims of this study include assessing the feasibility and acceptability of the adapted program as measured by enrollment of 10-12 participants and their care providers within 3 months, drop-out of less than 20% of participants over 1 year, and average adherence to In SHAPE sessions of 70% or more. The study will also explore the potential effectiveness of the program using behavioral and fitness measures such as weight, minutes of exercise, physical endurance, and gym attendance. Pre-post measures will be collected at baseline and 6-months. Positive findings will be reported in a peer reviewed journal and will be used to apply for funding from the National Institute on Disability and Rehabilitation Research.
Community Partners (CP), the area agency for Strafford County, serves 305 individuals with developmental disabilities (DD), at least 40% of whom are overweight or obese. Many people with DD have poor eating habits and rarely exercise, leading to higher risk of heart disease, and greater health care costs to treat resulting medical problems. CP has engaged Dartmouth researchers to translate findings from research on the In SHAPE health promotion intervention to develop a fitness program for individuals with DD that will enhance the quality and extend the length of their lives. The program will also provide education on healthy eating and exercise to care providers. Community-engaged partners who will be core members of the research team include CP, family members of people with DD, and the UNH-IOD. Improving the health and fitness of people with DD may help them lead more productive lives, enabling them to contribute in meaningful ways to society as a whole through employment or volunteering, increasing the sense of belonging to their communities. Working together on health goals with care providers may also strengthen these relationships, leading to greater life satisfaction and lower levels of stress. Specially trained CP staff will provide the adapted In SHAPE program to clients and care providers, using a person-centered approach. This evaluation will determine whether the In SHAPE-DD program helps people with DD to become more fit, and whether this model that should be used by other area agencies in NH and across the country.