| Primary | Change in Patient Activation in Care (PAM, a 13-item Scale) | Assessed using the PAM, a 13-item scale that renders a total activation score. This measure gauges the knowledge, skills, and confidence of patients essential to managing their own health and health care. It divides into progressively higher levels of activation: starting to take a role, building knowledge and confidences, taking action, and maintaining behaviors. The raw score scale for the PAM ranges from 13 to 52. The activation scale for the PAM ranges from 0 to 100. The lower values represent a poor outcome while higher values represent a better outcome. | Includes those who completed the measure at baseline and whose measure was able to be scored (ie. was not missing data which would have rendered it unusable in analysis) | Posted | | Mean | Standard Deviation | units on a scale | | Baseline and every 6 months over 2 year active intervention period | | | | ID | Title | Description |
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| OG000 | Patient Self-Directed Care | See intervention description Patient Self-Directed Care: Patient self-management toolkits, web portal with information on health conditions, personal health care use data, health tracking tools and wellness programs | | OG001 | Provider-Supported Integrated Care | See intervention description Provider-Supported Integrated Care: Registered nurse on staff at community mental health centers with access to patient-level physical health information to: 1) work with patients on coordinating their care, 2) enhance communication between providers and payer, and 3) provide patient wellness support and education |
| | | Title | Denominators | Categories |
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| Baseline | - ParticipantsOG000438
- ParticipantsOG001615
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| | Group IDs | Group Description | Statistical Method | Statistical Comment | P-Value | P-Value Comment | Parameter Type | Parameter Value | Dispersion Type | Dispersion Value | Confidence Interval Sides | Confidence Interval % | CI Lower Limit | CI Upper Limit | CI Lower Limit Comment | CI Upper Limit Comment | Estimate Comment | Tested Non-Inferiority | Non-Inferiority Type | Non-Inferiority Comment | Other Analysis Description |
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| Treatment by time interaction test | Mixed Models Analysis | | <0.0001 | | | | | | | | | | | | | | Superiority | | | | Test for gender by treatment by time interaction | Mixed Models Analysis |
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| Primary | Change in Health Status ( SF-12v2™): Physical Health Sub-scale | Health status is measured using the SF-12v2™, a widely used and practical health survey tool consisting of 12 questions and two sub-scales for measuring physical and mental health status and symptom effects and functioning. The physical health component summary score is created using a weighted sum of all 12 items and then a scoring algorithm places negative weights on four of the health domains and positive weights on the other four health domains. Scores range from 0-100 and better physical health is indicated by a higher score. | Includes those who completed the measure at baseline and whose measure was able to be scored (ie. was not missing data which would have rendered it unusable in analysis) | Posted | | Mean | Standard Deviation | units on a scale | | Baseline and every 6 months over 2 year active intervention period | | | | ID | Title | Description |
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| OG000 | Patient Self-Directed Care | See intervention description Patient Self-Directed Care: Patient self-management toolkits, web portal with information on health conditions, personal health care use data, health tracking tools and wellness programs | | OG001 | Provider-Supported Integrated Care | See intervention description Provider-Supported Integrated Care: Registered nurse on staff at community mental health centers with access to patient-level physical health information to: 1) work with patients on coordinating their care, 2) enhance communication between providers and payer, and 3) provide patient wellness support and education |
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| Primary | Change in Engagement in Primary/Specialty Care | The frequency of primary/specialty care visits over two 12-month time periods. | Study participants who were Medicaid eligible for 80% of the year prior to the data collection time point | Posted | | Mean | Standard Deviation | Frequency of visits in 12-month periods | | Updated annually using claims data over 2 year active intervention period | | | | ID | Title | Description |
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| OG000 | Patient Self-Directed Care | See intervention description Patient Self-Directed Care: Patient self-management toolkits, web portal with information on health conditions, personal health care use data, health tracking tools and wellness programs | | OG001 | Provider-Supported Integrated Care | See intervention description Provider-Supported Integrated Care: Registered nurse on staff at community mental health centers with access to patient-level physical health information to: 1) work with patients on coordinating their care, 2) enhance communication between providers and payer, and 3) provide patient wellness support and education |
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| Primary | Change in Health Status ( SF-12v2™): Mental Health Sub-scale | Health status is measured using the SF-12v2™, a widely used and practical health survey tool consisting of 12 questions and two sub-scales for measuring physical and mental health status and symptom effects and functioning. The mental health component summary score is created using a weighted sum of all 12 items and then a scoring algorithm places negative weights on four of the health domains and positive weights on the other four health domains (reverse of the weighting used for the physical health component summary score). Scores range from 0-100 and better mental health is indicated by a higher score. | Includes those who completed the measure at baseline and whose measure was able to be scored (ie. was not missing data which would have rendered it unusable in analysis) | Posted | | Mean | Standard Deviation | units on a scale | | Baseline and every 6 months during the active intervention period | | | | ID | Title | Description |
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| OG000 | Patient Self-Directed Care | See intervention description Patient Self-Directed Care: Patient self-management toolkits, web portal with information on health conditions, personal health care use data, health tracking tools and wellness programs | | OG001 | Provider-Supported Integrated Care | See intervention description Provider-Supported Integrated Care: Registered nurse on staff at community mental health centers with access to patient-level physical health information to: 1) work with patients on coordinating their care, 2) enhance communication between providers and payer, and 3) provide patient wellness support and education |
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| Secondary | Change in Hope (Hope Scale) | Assessed using the Hope Scale, an instrument designed to measure hope that has been previously used in health services research. Twelve items are rated on a four-point response scale ranging from "definitely false" to "definitely true" and summed to produce a total score. The hope scale ranges from 1 to 10, with 1 being no hope and 10 being filled with hope. | Includes those who completed the measure at baseline and whose measure was able to be scored (ie. was not missing data which would have rendered it unusable in analysis) | Posted | | Mean | Standard Deviation | Units on a scale | | Baseline and every 6 months during the active intervention period | | | | ID | Title | Description |
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| OG000 | Patient Self-Directed Care | See intervention description Patient Self-Directed Care: Patient self-management toolkits, web portal with information on health conditions, personal health care use data, health tracking tools and wellness programs | | OG001 | Provider-Supported Integrated Care | See intervention description Provider-Supported Integrated Care: Registered nurse on staff at community mental health centers with access to patient-level physical health information to: 1) work with patients on coordinating their care, 2) enhance communication between providers and payer, and 3) provide patient wellness support and education |
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| Secondary | Change in Quality of Life (QLESQ) | Patient quality of life is measured using the QLESQ (Quality of Life Enjoyment and Satisfaction Questionnaire) in which participants respond on a scale of 1 (very poor) to 5 (very good) their level of satisfaction with a variety of social and physical domains. The total raw score ranges from 14 to 70 or 0-100%. Only the first 14 items yield the raw total score as the last two items are standalone. The raw total score is transformed into a percentage maximum possible score using the following formula: (raw total score-minimum score)/(maximum possible raw score-minimum score). The lower values/percentages represent a poor outcome while higher values/percentages represent a better outcome. The information below reflects raw scores (rather than percentages). | Includes those who completed the measure at baseline and whose measure was able to be scored (ie. was not missing data which would have rendered it unusable in analysis) | Posted | | Mean | Standard Deviation | Units on a scale | | Baseline and every 6 months over 2 year active intervention period | | | | ID | Title | Description |
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| OG000 | Patient Self-Directed Care | See intervention description Patient Self-Directed Care: Patient self-management toolkits, web portal with information on health conditions, personal health care use data, health tracking tools and wellness programs | | OG001 | Provider-Supported Integrated Care | See intervention description Provider-Supported Integrated Care: Registered nurse on staff at community mental health centers with access to patient-level physical health information to: 1) work with patients on coordinating their care, 2) enhance communication between providers and payer, and 3) provide patient wellness support and education |
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| Secondary | Change in Medication Adherence - Diabetes | Claims data used to calculate diabetes medication possession ratio (MPO) for participants diagnosed with diabetes in 6 month time periods. If the (first_fill - last_end_Date) > 180 then MPR = (total days supply - (first_fill - last_end_Date) - 180 ) / 180. If the total duration was not greater than 180 days, MPR = total days supply / 180. | The N for the time point with the greatest # of participants who were prescribed a diabetes medication. | Posted | | Mean | Standard Deviation | Medication possession ratio | | Updated annually using claims data over 2 year active intervention period | | | | ID | Title | Description |
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| OG000 | Patient Self-Directed Care | See intervention description Patient Self-Directed Care: Patient self-management toolkits, web portal with information on health conditions, personal health care use data, health tracking tools and wellness programs | | OG001 | Provider-Supported Integrated Care | See intervention description Provider-Supported Integrated Care: Registered nurse on staff at community mental health centers with access to patient-level physical health information to: 1) work with patients on coordinating their care, 2) enhance communication between providers and payer, and 3) provide patient wellness support and education |
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| Secondary | Change in Functional Status (Sheehan Disability Scale) | Functional status is measured using the Sheehan Disability Scale which assesses functional impairment in three domains including: work/school, social and family life. Respondents rate the extent to which work/school, social life and home life or family responsibilities are impaired by symptoms. The three items from the Sheehan Disability Scale are summed together into a single measure of global functional impairment. This measure ranges from 0 to 30, with 0 being unimpaired and 30 being highly impaired. | Includes those who completed the measure at baseline and whose measure was able to be scored (ie. was not missing data which would have rendered it unusable in analysis) | Posted | | Mean | Standard Deviation | Units on a scale | | Baseline and every 6 months over 2 year active intervention period | | | | ID | Title | Description |
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| OG000 | Patient Self-Directed Care | See intervention description Patient Self-Directed Care: Patient self-management toolkits, web portal with information on health conditions, personal health care use data, health tracking tools and wellness programs | | OG001 | Provider-Supported Integrated Care | See intervention description Provider-Supported Integrated Care: Registered nurse on staff at community mental health centers with access to patient-level physical health information to: 1) work with patients on coordinating their care, 2) enhance communication between providers and payer, and 3) provide patient wellness support and education |
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| Secondary | Change in Emergent Care Use (Claims Data) | Behavioral and physical health claims data will be obtained to determine frequency of emergent service use for participants over 12-month time periods. | # of individuals with 80% Medicaid eligibility in the 12 months prior to the data collection time point. | Posted | | Mean | Standard Deviation | frequency of visits in 12-month periods | | Updated annually using claims data over 2 year active intervention period | | | | ID | Title | Description |
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| OG000 | Patient Self-Directed Care | See intervention description Patient Self-Directed Care: Patient self-management toolkits, web portal with information on health conditions, personal health care use data, health tracking tools and wellness programs | | OG001 | Provider-Supported Integrated Care | See intervention description Provider-Supported Integrated Care: Registered nurse on staff at community mental health centers with access to patient-level physical health information to: 1) work with patients on coordinating their care, 2) enhance communication between providers and payer, and 3) provide patient wellness support and education |
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| Secondary | Change in Lab Monitoring - Overall | Frequency of lab tests (glucose, lipids, EKG) in 12 month periods | Study participants who were Medicaid eligible for 80% of the year prior to the data collection time point | Posted | | Mean | Standard Deviation | frequency of lab tests in 12 mo. period | | Updated annually using claims data over 2 year active intervention period | | | | ID | Title | Description |
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| OG000 | Patient Self-Directed Care | See intervention description Patient Self-Directed Care: Patient self-management toolkits, web portal with information on health conditions, personal health care use data, health tracking tools and wellness programs | | OG001 | Provider-Supported Integrated Care | See intervention description Provider-Supported Integrated Care: Registered nurse on staff at community mental health centers with access to patient-level physical health information to: 1) work with patients on coordinating their care, 2) enhance communication between providers and payer, and 3) provide patient wellness support and education |
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| Secondary | Change in Patient Satisfaction With Care | Change in patient satisfaction with care was assessed using the Patient Assessment of Care for Chronic Conditions (PACIC). Each item of the PACIC is on a 1 to 5 scale. The total score is the average of all 20 item scores. Higher scores represent increased frequency of structured chronic care. | Includes those who completed the measure at baseline and whose measure was able to be scored (ie. was not missing data which would have rendered it unusable in analysis) | Posted | | Mean | Standard Deviation | Units on a scale | | Baseline and every 6 months over 2 year active intervention period | | | | ID | Title | Description |
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| OG000 | Patient Self-Directed Care | See intervention description Patient Self-Directed Care: Patient self-management toolkits, web portal with information on health conditions, personal health care use data, health tracking tools and wellness programs | | OG001 | Provider-Supported Integrated Care | See intervention description Provider-Supported Integrated Care: Registered nurse on staff at community mental health centers with access to patient-level physical health information to: 1) work with patients on coordinating their care, 2) enhance communication between providers and payer, and 3) provide patient wellness support and education |
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| Secondary | Change in Medication Adherence - Antipsychotics | Claims data used to calculate antipsychotic medication possession ratio (MPR) for participants in 6 month time periods. If the (first_fill - last_end_Date) > 180 then MPR = (total days supply - (first_fill - last_end_Date) - 180 ) / 180. If the total duration was not greater than 180 days, MPR = total days supply / 180. | The N for the time point with the greatest # of participants who were prescribed a antipsychotic medication. | Posted | | Mean | Standard Deviation | Medication possession ratio | | Updated annually using claims data over 2 year active intervention period | | | | ID | Title | Description |
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| OG000 | Patient Self-Directed Care | See intervention description Patient Self-Directed Care: Patient self-management toolkits, web portal with information on health conditions, personal health care use data, health tracking tools and wellness programs | | OG001 | Provider-Supported Integrated Care | See intervention description Provider-Supported Integrated Care: Registered nurse on staff at community mental health centers with access to patient-level physical health information to: 1) work with patients on coordinating their care, 2) enhance communication between providers and payer, and 3) provide patient wellness support and education |
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| Secondary | Change in Medication Adherence - Hypertension | Claims data used to calculate antihypertensive medication possession ratio (MPR) for participants in 6 month time periods. If the (first_fill - last_end_Date) > 180 then MPR = (total days supply - (first_fill - last_end_Date) - 180 ) / 180. If the total duration was not greater than 180 days, MPR = total days supply / 180. | The N for the time point with the greatest # of participants who were prescribed a antihypertensive medication. | Posted | | Mean | Standard Deviation | Medication possession ratio | | Updated annually using claims data over 2 year active intervention period | | | | ID | Title | Description |
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| OG000 | Patient Self-Directed Care | See intervention description Patient Self-Directed Care: Patient self-management toolkits, web portal with information on health conditions, personal health care use data, health tracking tools and wellness programs | | OG001 | Provider-Supported Integrated Care | See intervention description Provider-Supported Integrated Care: Registered nurse on staff at community mental health centers with access to patient-level physical health information to: 1) work with patients on coordinating their care, 2) enhance communication between providers and payer, and 3) provide patient wellness support and education |
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| Secondary | Change in Medication Adherence - Antidepressants | Claims data used to calculate antidepressant medication possession ratio (MPR) for participants in 6 month time periods. If the (first_fill - last_end_Date) > 180 then MPR = (total days supply - (first_fill - last_end_Date) - 180 ) / 180. If the total duration was not greater than 180 days, MPR = total days supply / 180. | The N for the time point with the greatest # of participants who were prescribed am antidepressant medication. | Posted | | Mean | Standard Deviation | Medication possession ratio | | Updated annually using claims data over 2 year active intervention period | | | | ID | Title | Description |
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| OG000 | Patient Self-Directed Care | See intervention description Patient Self-Directed Care: Patient self-management toolkits, web portal with information on health conditions, personal health care use data, health tracking tools and wellness programs | | OG001 | Provider-Supported Integrated Care | See intervention description Provider-Supported Integrated Care: Registered nurse on staff at community mental health centers with access to patient-level physical health information to: 1) work with patients on coordinating their care, 2) enhance communication between providers and payer, and 3) provide patient wellness support and education |
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| Secondary | Change in Lab Monitoring - Glucose | Frequency of glucose lab tests in 12 month periods | Study participants who were Medicaid eligible for 80% of the year prior to the data collection time point | Posted | | Mean | Standard Deviation | frequency of lab tests in 12 mo. period | | Updated annually using claims data over 2 year active intervention period | | | | ID | Title | Description |
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| OG000 | Patient Self-Directed Care | See intervention description Patient Self-Directed Care: Patient self-management toolkits, web portal with information on health conditions, personal health care use data, health tracking tools and wellness programs | | OG001 | Provider-Supported Integrated Care | See intervention description Provider-Supported Integrated Care: Registered nurse on staff at community mental health centers with access to patient-level physical health information to: 1) work with patients on coordinating their care, 2) enhance communication between providers and payer, and 3) provide patient wellness support and education |
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| Secondary | Change in Lab Monitoring - Lipids | Frequency of lipid lab tests in 12 month periods | Study participants who were Medicaid eligible for 80% of the year prior to the data collection time point | Posted | | Mean | Standard Deviation | frequency of lab tests in 12 mo. period | | Updated annually using claims data over 2 year active intervention period | | | | ID | Title | Description |
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| OG000 | Patient Self-Directed Care | See intervention description Patient Self-Directed Care: Patient self-management toolkits, web portal with information on health conditions, personal health care use data, health tracking tools and wellness programs | | OG001 | Provider-Supported Integrated Care | See intervention description Provider-Supported Integrated Care: Registered nurse on staff at community mental health centers with access to patient-level physical health information to: 1) work with patients on coordinating their care, 2) enhance communication between providers and payer, and 3) provide patient wellness support and education |
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| Secondary | Change in Lab Monitoring - EKG | Frequency of EKG tests in 12 month periods | Study participants who were Medicaid eligible for 80% of the year prior to the data collection time point | Posted | | Mean | Standard Deviation | frequency of EKG tests in 12 mo. period | | Updated annually using claims data over 2 year active intervention period | | | | ID | Title | Description |
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| OG000 | Patient Self-Directed Care | See intervention description Patient Self-Directed Care: Patient self-management toolkits, web portal with information on health conditions, personal health care use data, health tracking tools and wellness programs | | OG001 | Provider-Supported Integrated Care | See intervention description Provider-Supported Integrated Care: Registered nurse on staff at community mental health centers with access to patient-level physical health information to: 1) work with patients on coordinating their care, 2) enhance communication between providers and payer, and 3) provide patient wellness support and education |
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