Enhancing Engagement by Integrating Goals and Concerns That Matter to Patients

NCT ID: NCT06898593

Last Updated: 2025-08-21

Study Results

Results pending

The study team has not published outcome measurements, participant flow, or safety data for this trial yet. Check back later for updates.

Basic Information

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Recruitment Status

RECRUITING

Clinical Phase

NA

Total Enrollment

2448 participants

Study Classification

INTERVENTIONAL

Study Start Date

2025-04-02

Study Completion Date

2027-06-30

Brief Summary

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The goal of this clinical trial is to learn if adding patients' goals and concerns to measurement-based collaborative care can tailor care and provide a more holistic view of treatment, thereby improving engagement in care among adult patients receiving collaborative care. The main questions it aims to answer are:

* Does using a clinical decision support system (which includes an enhanced pre-visit questionnaire and patient-level dashboard) improve patient engagement in the collaborative care model?
* Does using a clinical decision support system improve patient and clinician satisfaction with care?

Researchers will compare the enhanced collaborative care with traditional collaborative care.

Patient participants will complete pre-visit questionnaires before their collaborative care appointments. Responses will be viewed by the clinician and/or patient in a visual dashboard inside the electronic health record.

Detailed Description

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Dartmouth Health (DH) has implemented the evidence-based Collaborative Care Model (CoCM) of integrated behavioral health in primary care.

CoCM includes (a) an initial behavioral health assessment with validated patient-reported outcomes, including the Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder (GAD-7) scale, (b) joint care planning and treatment with pharmacotherapy and/or psychotherapy, (c) monitoring using a registry to track treatment and patient-reported outcomes, and (d) caseload review with a psychiatric consultant.

There are several limitations associated with CoCM, including loss of patients between referral and treatment, failure to complete CoCM, and a limited ability to monitor for post-treatment relapse in depressive symptoms. These limitations are associated with low motivation to engage in BH services and patient perceptions that providers cannot accommodate their needs.

The scientific premise of the project is that structured collection and use of personalized treatment goals and concerns will improve patient engagement with CoCM, extending service impact. This study will highlight patient priorities for healthcare services to the CoCM team and will overcome clinical translational science challenges associated with patients' goals and concerns being neither fully documented nor available to support care, improvement, and research.

Enhancing patient-generated data collected through CoCM (e.g., PHQ-9; GAD-7) with patients' goals and concerns will reduce barriers to engagement in BH services by overcoming patient perceptions that services are misaligned with needs. Previous studies demonstrate that agenda setting processes that elicit priorities can improve clinicians' understanding of patients' concerns, increase patients' perceptions that what matters most is heard and incorporated into care plans, and increase likelihood of patients adhering to treatment recommendations.

Clinicians and patient stakeholders will use human-centered co-design principles to (a) enhance the existing CoCM pre-visit questionnaire (PVQ) to capture patient-reported goals and concerns, and (b) build a patient-level clinical decision support system (CDSS) that visualizes PVQ responses and clinical information within the electronic health record (EHR) for in-visit use by clinicians and patients. PVQs will support the patient in defining their visit agenda and providing an opportunity to align care with their immediate psychosocial and clinical needs. PVQs will be configured in Epic's MyChart® patient portal, allowing for completion at home prior to the visit or with a tablet upon clinic check-in. PVQ responses will be directly imported via a smart phrase into a clinical note template that clinicians can edit during the visit, reducing documentation burden and complexity. The care plan will be based on joint clinician and patient input and be available to the patient in the patient portal after the visit.

Intervention rollout will involve coaching CoCM care managers to use the CDSS following an established process. This will include a quality improvement curriculum to optimize use of the CDSS within clinical workflows and to incorporate patient preferences into decision-making. Training and support will be provided to care managers via monthly sessions informed by monitoring and feedback to assess and resolve challenges.

Conditions

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Anxiety Disorders Depression Disorders

Study Design

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Allocation Method

RANDOMIZED

Intervention Model

CROSSOVER

Stepped-wedge cluster-randomized controlled trial (3 steps of 2 clinics each)
Primary Study Purpose

HEALTH_SERVICES_RESEARCH

Blinding Strategy

NONE

Study Groups

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Clinical Decision Support System

Collaborative care model, with a clinical decision support system (CDSS) which includes an enhanced pre-visit questionnaire and dashboard to visualize patient-reported information and clinical information.

Group Type EXPERIMENTAL

Collaborative care model with clinical decision support system

Intervention Type BEHAVIORAL

A new patient-level clinical decision support system (CDSS) will include enhancing the existing pre-visit questionnaire to capture patient-reported goals and concerns, and displaying pre-visit questionnaire responses and clinical information within a patient-level dashboard in the electronic health record (EHR) for use by clinicians and patients.

Collaborative care model (usual care)

Standard collaborative care model of integrated behavioral health.

Group Type ACTIVE_COMPARATOR

Collaborative care model

Intervention Type BEHAVIORAL

Collaborative care model of integrated behavioral health and primary care.

Interventions

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Collaborative care model with clinical decision support system

A new patient-level clinical decision support system (CDSS) will include enhancing the existing pre-visit questionnaire to capture patient-reported goals and concerns, and displaying pre-visit questionnaire responses and clinical information within a patient-level dashboard in the electronic health record (EHR) for use by clinicians and patients.

Intervention Type BEHAVIORAL

Collaborative care model

Collaborative care model of integrated behavioral health and primary care.

Intervention Type BEHAVIORAL

Other Intervention Names

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dashboard pre-visit questionnaire

Eligibility Criteria

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Inclusion Criteria

* Patients enrolled in the Collaborative Care Model (CoCM) at Dartmouth Health

Exclusion Criteria

* Patients not enrolled in the Collaborative Care Model (CoCM) at Dartmouth Health
Minimum Eligible Age

18 Years

Maximum Eligible Age

100 Years

Eligible Sex

ALL

Accepts Healthy Volunteers

No

Sponsors

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National Center for Advancing Translational Sciences (NCATS)

NIH

Sponsor Role collaborator

Dartmouth College

OTHER

Sponsor Role collaborator

Dartmouth-Hitchcock Medical Center

OTHER

Sponsor Role lead

Responsible Party

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Anna Tosteson

Principal Investigator

Responsibility Role PRINCIPAL_INVESTIGATOR

Principal Investigators

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Anna Tosteson, ScD

Role: PRINCIPAL_INVESTIGATOR

Dartmouth College

Locations

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Dartmouth Hitchcock Concord Family Medicine

Concord, New Hampshire, United States

Site Status RECRUITING

Dartmouth Hitchcock Medical Center

Lebanon, New Hampshire, United States

Site Status RECRUITING

Dartmouth-Hitchcock Heater Road Internal Medicine

Lebanon, New Hampshire, United States

Site Status RECRUITING

Dartmouth Hitchcock Manchester Family Practice

Manchester, New Hampshire, United States

Site Status RECRUITING

Dartmouth Hitchcock Nashua Family Practice

Nashua, New Hampshire, United States

Site Status RECRUITING

Dartmouth Hitchcock Nashua General Internal Medicine

Nashua, New Hampshire, United States

Site Status RECRUITING

Countries

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United States

Central Contacts

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Irina Perreard, PhD

Role: CONTACT

603-646-5449

Aricca Van Citters, MS

Role: CONTACT

603-646-5668

Facility Contacts

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Matthew Duncan, MD

Role: primary

603-650-4725

Matthew Duncan, MD

Role: primary

603-650-4725

Matthew Duncan, MD

Role: primary

603-650-4725

Matthew Duncan, MD

Role: primary

603-650-4725

Matthew Duncan, MD

Role: primary

603-650-4725

Matthew Duncan, MD

Role: primary

603-650-4725

References

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Barr PJ, Thompson R, Walsh T, Grande SW, Ozanne EM, Elwyn G. The psychometric properties of CollaboRATE: a fast and frugal patient-reported measure of the shared decision-making process. J Med Internet Res. 2014 Jan 3;16(1):e2. doi: 10.2196/jmir.3085.

Reference Type BACKGROUND
PMID: 24389354 (View on PubMed)

Curran GM, Bauer M, Mittman B, Pyne JM, Stetler C. Effectiveness-implementation hybrid designs: combining elements of clinical effectiveness and implementation research to enhance public health impact. Med Care. 2012 Mar;50(3):217-26. doi: 10.1097/MLR.0b013e3182408812.

Reference Type BACKGROUND
PMID: 22310560 (View on PubMed)

Basch E, Barbera L, Kerrigan CL, Velikova G. Implementation of Patient-Reported Outcomes in Routine Medical Care. Am Soc Clin Oncol Educ Book. 2018 May 23;38:122-134. doi: 10.1200/EDBK_200383.

Reference Type BACKGROUND
PMID: 30231381 (View on PubMed)

Oliver BJ, Nelson EC, Kerrigan CL. Turning Feed-forward and Feedback Processes on Patient-reported Data into Intelligent Action and Informed Decision-making: Case Studies and Principles. Med Care. 2019 May;57 Suppl 5 Suppl 1:S31-S37. doi: 10.1097/MLR.0000000000001088.

Reference Type BACKGROUND
PMID: 30985594 (View on PubMed)

Tse CS, Van Citters AD, Ricci B, Freundlich NZ, Lee M, Shah SA, Melmed GY, Siegel CA, van Deen WK; IBD Qorus. Identifying and Predicting the Goals and Concerns Prioritised by Individuals with Inflammatory Bowel Disease. J Crohns Colitis. 2022 Mar 14;16(3):379-388. doi: 10.1093/ecco-jcc/jjab142.

Reference Type BACKGROUND
PMID: 34350943 (View on PubMed)

Van Citters AD, Holthoff MM, Kennedy AM, Melmed GY, Oberai R, Siegel CA, Weaver A, Nelson EC. Point-of-care dashboards promote coproduction of healthcare services for patients with inflammatory bowel disease. Int J Qual Health Care. 2021 Nov 29;33(Supplement_2):ii40-ii47. doi: 10.1093/intqhc/mzab067.

Reference Type BACKGROUND
PMID: 34849970 (View on PubMed)

Boudreau DM, Capoccia KL, Sullivan SD, Blough DK, Ellsworth AJ, Clark DL, Katon WJ, Walker EA, Stevens NG. Collaborative care model to improve outcomes in major depression. Ann Pharmacother. 2002 Apr;36(4):585-91. doi: 10.1345/aph.1A259.

Reference Type BACKGROUND
PMID: 11918503 (View on PubMed)

Related Links

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Other Identifiers

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1UM1TR004772-01

Identifier Type: NIH

Identifier Source: secondary_id

View Link

STUDY00033019 | STUDY02002511

Identifier Type: -

Identifier Source: org_study_id

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