Background and Significance : Youth (13-20 years) with intellectual and/or developmental disabilities (I/DD) often struggle with depression and anxiety disorders, which adversely impacts transition to adulthood. Integrated behavioral health care coordination, in which care coordinators and behavioral health specialists work together to provide systematic, cost-effective, patient-centered care, is an effective strategy to improve access to behavioral health services and address factors that impact transition to adulthood, including depression/anxiety symptoms. Current widely used care coordination models, such as Title V Maternal and Child Health Bureau (MCHB) care coordination (operating in \> 40 states), do not include behavioral health services. Coordination of CarE for Complex Kids (CHECK), is a behavioral health risk classification and intervention delivery program that was designed for integration into care coordination programs, such as MCHB care coordination, and implemented under Centers for Medicare and Medicaid (CMS) Healthcare Innovation Award (#C1C1CMS331342-01-00; 2014-2018, $19.4 million, \>6,000 youth enrolled). It is unknown whether an integrated behavioral health care coordination strategy, such as MCHB care coordination plus CHECK, would be more acceptable and lead to better youth health and transition outcomes, in comparison to standard care coordination (e.g., MCHB care coordination). Results would guide future investment in improving outcomes for youth with I/DD.
Aims: This study is a two-arm randomized clinical trial to evaluate the comparable efficacy of (1) MCHB Care Coordination alone vs. (2) MCHB Care Coordination plus CHECK in: (Aim 1) decreasing symptoms and episodes of depression and anxiety over time among at-risk transition-age youth with I/DD; (Aim 2) improving health behaviors, adaptive functioning and health related quality of life among transition-age youth with I/DD; (Aim 3) increasing health care transition (HCT) readiness among transition-age youth with I/DD; and (Aim 4) improving engagement and satisfaction with care coordination among stakeholders across multiple levels.
Comparators: 1. IL MCHB Care Coordination 2. IL MCHB Care Coordination + CHECK
1. MCHB Care Coordination: funded through the Social Security Act of 1935 Title V Maternal and Child Health Services Block Grant Program, this is the oldest and most universal care coordination model for children with I/DD. The University of Illinois at Chicago (UIC) Division of Specialized Care for Children (DSCC) is the Illinois (IL) state Title V MCHB care coordination agency and has annual contact with over 19,000 families and youth in IL. MCHB (known as DSCC) Care Coordination involves: comprehensive needs assessments, person-centered planning, and linkage to health care and social resources. MCHB care coordination has established efficacy, feasibility, and acceptability in improving child and family functioning, youth health, and health care access.
2. MCHB Care Coordination plus CHECK: includes all elements of MCHB care coordination, described above, plus the CHECK program. CHECK consists of: a trained, behavioral health care team; an evidence-based treatment algorithm to classify risk for depression and anxiety (minimal, subclinical and clinical symptomatology) and guide treatment advancement \[Tier 1/selective: cognitive behavioral psychoeducation; Tier 2/indicated: cognitive-behavioral prevention groups; Tier 3/treatment: individualized or group cognitive behavioral treatment (CBT)\]; as well as structures and processes to support communication, coordination and data sharing between MCHB care coordinators and CHECK staff. The CHECK Tiers are based upon the Coping with Depression-Youth curriculum and employ a psychoeducational approach to teach youth cognitive behavioral skills to prevent or reduce depression and anxiety symptoms and episodes (Clarke et al; integrative CBT model). The CHECK program was implemented within a large, community-based care coordination system, reached Level 6 integration (Full Collaboration in a Transformed /Merged Integrated Practice), and demonstrated feasibility, acceptability and favorable impacts on health, engagement and other outcomes.
Study Population: The investigators will recruit N=780 (N1=390; N2=390) transition-age youth with I/DD (13-20 years) from the IL MCHB Care Coordination program (i.e., DSCC), which serves a large racially, geographically, and socioeconomically diverse population across IL (23.65% Hispanic/Latino; 20.13% African American; 3.53% Asian; 50.20% White; 0.12% American Indian/Native Alaskan; 0.06% Native Hawaiian/other Pacific Islander) (57.00% male; 40.20% female; 2.70% transgender/non binary). Eligibility criteria include being a current DSCC participant, aged 13-20 years, with a minimum 4th grade reading level, and prior diagnosed I/DD. I/DD are chronic conditions, beginning at birth or prior to age 22 years, and include physical, learning, language, and/or behavioral impairments. Participants must be competent to consent. Exclusion criteria include severe intellectual disability (ID) (i.e., IQ\<50) and reading below a 4th grade level. Assuming 10% loss to follow-up, the investigators require N = 780 for the 2-arm study.
Analytic Plan: The experimental design of the study is a 2 Group (MCHB care coordination vs. MCHB care coordination + CHECK intervention), 4 Times (0 baseline, 6, 12, and 24 months) repeated measures design. The goal is to determine whether the combination of MCHB care coordination plus CHECK yields greater improvement in patient outcomes over time than MCHB care coordination alone. The outcomes are continuous approximately normal multi-item scales (AIM 1: depression/anxiety symptomatology; AIM 2: health behaviors, adaptive functioning and health related quality of life; AIM 3: health care transition readiness; and AIM 4: engagement and satisfaction) which will be analyzed using linear mixed models (LMMs) that are the modern standard for analysis of repeated measures. The generalized linear mixed model (GLMM) will be used to analyze repeated outcomes that are categorical or counts (AIM 1: depression and anxiety episodes). In this design, contrasts can be used to test omnibus and group-specific (interaction) changes from baseline. Our primary model will include covariates for stratification variables (Z, W). Moreover, by introducing patient subgroups (S), it is possible to examine 3-way interactions (G T S) to test for the heterogeneity of treatment effects.
