Welcome to the March 2019 research review, where I review some of the latest research findings and developments in the field of integrated behavioral health. Per usual, I include links to the articles in the headings and then snippets from the abstract below the heading.
As integration becomes more of the norm and less the exception, researchers are investigating model of integration in different arenas and for different populations. For example, two studies in this month’s review looked at integration of services for patients with debilitating conditions like co-morbid mental health and somatic disorder and dementia. I am also seeing more development and information on the practice of integration in community mental health settings, sometimes referred to as bi-directional integration. As is often the case, clinical practice outpaces research and evaluation as care delivery systems create and test new solutions for giving patients the care that they need. Researchers can learn a lot by joining with providers who are working at the leading edge of clinical practice.
One final highlight I leave you is the new ambitious framework for state-wide integration of Medi-Cal services in the great state of California. Although not a research study, I include it here because the plan includes major policy recommendations to reach state-wide integration by 2025, including the incorporation of value-based payments into the financing of behavioral health services. Although it remains to be seen whether it becomes adopted by decision-makers in the Golden State, the framework certainly offers much to consider.
Clinical Workflows and the Associated Tasks and Behaviors to Support Delivery of Integrated Behavioral Health and Primary Care
Integrating primary care and behavioral health is an important focus of health system transformation. Cross-case comparative analysis of 19 practices in the United States describing integrated care clinical workflows. Surveys, observation visits, and key informant interviews analyzed using immersion-crystallization. Staff performed tasks and behaviors-guided by protocols or scripts-to support 4 workflow phases: (1) identifying; (2) engaging/transitioning; (3) providing treatment; and (4) monitoring/adjusting care. Shared electronic health records and accessible staffing/scheduling facilitated workflows. Stakeholders should consider these workflow phases, address structural features, and utilize a developmental approach as they operationalize integrated care delivery.
Barriers and facilitators to the integration of mental health services into primary health care: a systematic review
Twenty studies met the inclusion criteria out of the 3353 search results. The most frequently reported barriers to integration of mental health services into PHC were (i) attitudes regarding program acceptability, appropriateness, and credibility; (ii) knowledge and skills; (iii) motivation to change; (iv) management and/or leadership; and (v) financial resources. In order to come up with an actionable approach to addressing the barriers, these factors were further analyzed along a behavior change theory. The analysis from this review provides evidence to inform policy on the existing barriers and facilitators to the implementation of the mental health integration policy option. Not all databases may have been exhausted.
Augmenting Mental Health in Primary Care: A One-Year Study of Deploying Smartphone Apps in a Multi-Site Primary Care / Behavioral Health Integration Program
The objectives of this study were to a) test the feasibility of using mental health applications to augment integrated primary care services; b) solicit feedback from patients and providers to guide implementation, and c) develop a mental health apps toolkit for system-wide dissemination. Our findings indicate mental health apps are applicable and relevant to patients within integrated primary care settings in safety-net health systems. Behavioral health providers perceive the clinical value of using these tools as part of patient care, but require training to increase their comfort-level and confidence applying these tools with patients. To increase provider and patient engagement, mobile apps must be accessible, simple, intuitive and directly relevant to patients’ treatment needs.
Management of comorbid mental and somatic disorders in stepped care approaches in primary care: a systematic review
Several stepped care models in primary care already account for comorbidities, with depression being the predominant target disorder. To determine their efficacy, the identified strategies to account for comorbidities should be investigated within stepped care models for a broader range of disorders.
Using examples from the UK and USA, we describe recent advances to integrate behavioral and primary care for new target populations including people with serious mental illness, people at the extremes of life, and for people with substance use disorders. We summarize mechanisms to incentivize integration efforts and to stimulate new integration between health and social services in primary care. We then present an outline of recent enablers for integration, concentrating on changes to funding mechanisms, developments in quality outcome measurements to promote collaborative working, and pragmatic guidance aimed at primary care providers wishing to enhance provision of behavioral care.
Using a non‐randomized control design, the 3DFD model was offered in two inner‐city boroughs in London, UK, where diabetes health professionals could refer adult residents with diabetes, suboptimal glycaemic control [HbA1c ≥ 75 mmol/mol (≥ 9.0%)] and mental health and/or social problems. In the usual care group, there was no referral pathway and anonymized data on individuals with HbA1c ≥ 75 mmol/mol (≥ 9.0%) were collected from primary care records. Change in HbA1c from baseline to 12 months was the primary outcome, and change in healthcare costs and biomedical variables were secondary outcomes.
3DFD participants had worse glycaemic control and higher healthcare costs than control participants at baseline. 3DFD participants had greater improvement in glycaemic control compared with control participants [−14 mmol/mol (−1.3%) vs. −6 mmol/mol (−0.6%) respectively, P < 0.001], adjusted for confounding. Total follow‐up healthcare costs remained higher in the 3DFD group compared with the control group (mean difference £1715, 95% confidence intervals 591 to 2811), adjusted for confounding. The incremental cost‐effectiveness ratio was £398 per mmol/mol unit decrease in HbA1c, indicating the 3DFD intervention was more effective and costed more than usual care.
Integrated care for adults with dementia and other cognitive disorders
The importance of better care integration is emphasized in many national dementia plans. The inherent complexity of organizing care for people with dementia provides both the justification for improving care integration and the challenges to achieving it. The prevention, detection, and early diagnosis of cognitive disorders mainly resides in primary care, but how this is best integrated within the range of disorders that primary care clinicians are expected to screen is unclear. Models of integrated community dementia assessment and management have varying degrees of involvement of primary and specialist care, but share an emphasis on improving care coordination, interdisciplinary teamwork, and personalized care. Integrated care strategies in acute care are still in early development, but have been a focus of investigation in the past decade. Integrated care outreach strategies to reduce transfers from long-term residential care to acute care have been consistently effective. Integrated long-term residential care includes considerations of end-of-life care. Future directions should include strategies for training and education, early detection in anticipation of disease modifying treatments, integration of technological developments into dementia care, integration of dementia care into general health and social care, and the encouragement of a dementia-friendly society.
Advancing integrated care in England
Implementing integrated care models requires providers to develop new capabilities, which is challenging with resource constraints and often conflicting policy priorities. Given the current funding and legislative context for the NHS, we assessed effective and practical paths to accelerate the adoption of better integrated, higher-value care. We sought to identify feasible modifications in the NHS’ policies and feasible steps for NHS providers to take based on growing experiences in England and globally with integrated care.
This paper puts forth an ambitious framework to transform a fragmented system in California in which Medi-Cal enrollees with complex behavioral and physical health needs often fail to receive needed care that must be coordinated across multiple and disparate service delivery systems. This framework builds on areas of strength within the current structures while addressing the systemic barriers to improving care due to the current organization, financing, and administration of physical health care, mental health care, and SUD care in Medi-Cal.
As a Pediatrician, I Don’t Know the Second, Third, or Fourth Thing to Do: A Qualitative Study of Pediatric Residents’ Training and Experiences in Behavioral Health
Despite a mandated 1-month rotation in developmental-behavioral pediatrics (DBP), pediatric residents report inadequate training in behavioral health care. As a first step in much needed curriculum development in this area, this study sought to assess learner experiences regarding the management of behavioral health problems during residency. Four focus groups were conducted for residents in years 1-3 of training in 2 residency programs in a northeastern state. Transcripts were analyzed and coded by researchers through qualitative classical content analysis. The exploratory analysis revealed 9 key themes: time requirements, rapport building, resources and referrals for behavioral health, psychiatric medications, diagnosis vs. treatment, working with families, the importance of behavioral health, fears of working with a pediatric population, and training issues. These qualitative data further identify gaps in the behavioral health training of pediatric residents and may inform future innovations in training curricula.
Ethical considerations for behavioral health professionals in primary care settings.
In general, psychology training has been slow to adapt to a changing market and systems. Many of the most common dilemmas encountered in primary care are actually reflective of “cultural” and professional differences between medical and psychological service provision ethics and tradition. Therefore, the commentary we provide may not point the reader to one clear, irrefutable solution to a problem or dilemma; in fact, there are surely many more than we can outline here. However, we share a recommended framework for working through ethical dilemmas in integrated primary care (IPC). (PsycINFO Database Record (c) 2018 APA, all rights reserved)
Evidence Brief: Use of Patient Reported Outcome Measures for Measurement-Based Care in Mental Health Shared Decision-Making
An evidence brief on measurement based care (MBC) practices in mental health care, specifically in the context of using standardized patient-reported outcome measures in shared decision-making with individual Veterans. Findings from this evidence brief will be used to inform guidance for MBC within the VHA. This rapid review found no studies of the specific VA-recommended approach of using any of 4 recommended patient-reported outcome measures (PROMs) for implementing measurement-based care (MBC) in the context of shared decision-making in mental health. However, we identified other promising approaches to use of PROMs for MBC in mental health.
This study examined the availability of primary care and wellness services in community mental health centers (CMHCs) and outpatient mental health facilities (OMHFs). We used data from the 2016 National Mental Health Services Survey to examine the proportion of facilities that reported offering integrated primary care and wellness services (smoking and tobacco cessation counseling, diet and exercise counseling, and chronic disease and illness management). The study used logistic regression to model the odds that a facility offered integrated primary care as a function of facility characteristics. Across states, 23% of CMHCs and 19% of OMHFs offered integrated primary care. The odds of offering integrated primary care were significantly higher among facilities that reported more quality improvement practices, prohibited smoking, or offered wellness services. Less than one third offered smoking and tobacco cessation counseling or other wellness services. Integrated primary care remains uncommon in CMHCs and OMHFs and is more likely among facilities with certain characteristics.