An example of how the building blocks can help you think about your activity design is the Telephone-Based Depression Care Management, designed and implemented by the Neighborhood Health Plan of Rhode Island (NHPRI).
NHPRI cares deeply about the quality of care their patients receive. The team thought carefully about their equity activity and took the necessary time to professionally design and implement it. NHPRI staff members were highly motivated to improve care and reduce disparities and they expended significant resources to restructure their care team. Before their evaluation project was funded by Finding Answers, a team of national experts reviewed their proposed activity and thought it showed significant promise.
How did they design their activity?
NHPRI was aware that Latino patients with depression receive less treatment and have poorer treatment outcomes compared to non-Latino White patients. They took several steps to gather information that informed the design of their equity activity, including:
- Conducting a literature review of depression interventions for Latinos.
- Consulting with their staff members and organizational partners, emphasizing feedback from individuals who identified as Hispanic or Latino and individuals with extensive experience working with the Latino patient population.
- Investigating prior effective NHPRI telephone-based interventions for other health conditions.
Based on the information gathered, NHPRI felt that patients needed more intensive, one-on-one care outside of the clinic setting to improve the quality of care and patient follow-up. So, patients were the primary LEVEL of intervention. NHPRI also concluded that patients would benefit from culturally competent education about depression, supportive contacts and reminders for appointments and self-care. These became their primary STRATEGIES.
NHPRI also felt that it was important to culturally tailor their activity and did so by hiring bilingual and Latino depression care managers to work directly with the patients. These new members of the care team would also have the time and skills to work effectively with patients. So, another STRATEGY of their activity became restructuring the care team at the LEVEL of the mircrosystem.
Finally, staff and leadership at NHPRI assumed that using the telephone as the main source of communication between care managers and patients would be convenient, less labor intensive and less expensive than face-to-face meetings. As a result, they chose telecommunication as the primary MODE of delivering their intervention.
The NHPRI activity looks like this when using the Tools building blocks:
LEVEL | STRATEGY | MODE |
Patients | Delivering Education and Training | Telecommunication |
Patients | Providing Psychological Support | Telecommunication |
Patients | Providing Reminders and Feedback | Telecommunication, Print |
Patients | Restructuring the Care Team | * |
*Sometimes, a program won't need a MODE of delivery. For example, NHPRI restructured their care team by adding bilingual and Latino depression care managers. The care managers used the MODES of Telecommunication and Print to deliver the patient-LEVEL STRATEGIES, but 'restructuring the care team' meant making changes to the system, which isn't associated with any particular MODE of delivery.
Did their equity activity succeed?
Unfortunately, NHPRI found that their Latino patients showed little interest in their equity activity. Very few of them chose to participate. The team tried many different methods to increase the number of participating patients, but nothing seemed to work.
What did patients and community leaders have to say?
After holding patient focus groups and consulting with leaders from community based organizations, NHPRI learned it was because the intervention used-up patients’ valuable cell phone minutes that they could not spare. In addition, patients were uncomfortable talking with a stranger on the phone about depression and said they may have been more willing to participate if they had been directly invited by their primary care provider.
What happened?
While many aspects of the NHPRI equity activity were strong and quite logical, they made a key error. Instead of working directly with their patients as part of their root cause analysis they felt that their Latino staff and providers would be able to serve as a sufficient proxy when designing a culturally competent intervention. NHPRI found that patients had different ideas about which STRATEGIES and MODES of delivery would work for them. NHPRI’s experience is not uncommon; any organization will decrease its chances of success if they neglect working directly with their patient population while conducting the root cause analysis and designing their equity activity.