Activation, self-management, engagement, and retention in behavioral health care: a randomized clinical trial of the DECIDE intervention

Abstract

Importance: Given minority patients' unequal access to quality care, patient activation and self-management strategies have been suggested as a promising approach to improving mental health care.

Objective: To determine whether the DECIDE (Decide the problem; Explore the questions; Closed or open-ended questions; Identify the who, why, or how of the problem; Direct questions to your health care professional; Enjoy a shared solution) intervention, an educational strategy that teaches patients to ask questions and make collaborative decisions with their health care professional, improves patient activation and self-management, as well as engagement and retention in behavioral health care.

Design, setting, and patients: In this multisite randomized clinical trial performed from February 1, 2009, through October 9, 2011 (date of last follow-up interview), we recruited 647 English- or Spanish-speaking patients 18 to 70 years old from 13 outpatient community mental health clinics across 5 states and 1 US territory. A total of 722 patients were included in analyses of secondary outcomes.

Interventions: Three DECIDE training sessions delivered by a care manager vs giving patients a brochure on management of behavioral health.

Main outcomes and measures: Primary outcomes were patient assessment of activation (Patient Activation Scale) and self-management (Perceived Efficacy in Patient-Physician Interactions). Secondary outcomes included patient engagement (proportion of visits attended of those scheduled) and retention (attending at least 4 visits in the 6 months after the baseline research assessment), collected through medical record review or electronic records.

Results: Patients assigned to DECIDE reported significant increases in activation (mean β = 1.74, SD = 0.58; P = .003) and self-management (mean β = 2.42, SD = 0.90; P = .008) relative to control patients, but there was no evidence of an effect on engagement or retention in care.

Conclusions and relevance: The DECIDE intervention appears to help patients learn to effectively ask questions and participate in decisions about their behavioral health care, but a health care professional component might be needed to augment engagement in care. DECIDE appears to have promise as a strategy for changing the role of minority patients in behavioral health care.

Trial registration: clinicaltrials.gov Identifier: NCT01226329

Figure 1

Flow of Study Participants Through Recruitment, Intervention, and Follow-up Assessment Of 1473 patients approached, 724 were randomized and 647 were included in the primary outcome analysis.

Figure 2

Timing of Interviews and Training for Participants in the Control and Intervention Arms CM indicates care manager; RA, research assistant.