Happy Holidays everyone! Welcome to the regular Research Review blog post. The post where I save you time searching the integrated/collaborative care research literature by doing all the work myself! Use that time to buy presents for your loved ones.
Here are some themes below: First, I continue to see more articles on integrated care for special populations like older adults, frail adults, and college students. Second, I am seeing more articles on workforce development. See the articles below on preparing trainees to work with patients with serious illness or dementia. Third, the VA seems the publish the most research in our field. They have some very productive researchers! Very glad to see all their great work published.
Each section below has a heading, article titles with hyperlinks, and then truncated abstracts. I hope this review helps you in seeing the latest and greatest in publications. Enjoy!
Integrated primary care: development of a patient satisfaction measure
No measure has been created to specifically assess patient satisfaction with integrated primary care. The current study aimed to develop such a measure through a qualitative approach with the use of semi-structured individual interviews with patients from two integrated primary care practices. Thematic analysis was used to identify themes across the data. The results yielded positive patient impressions of integrated primary care and suggested that the questionnaire could be a successful way to gather more information about patient satisfaction with the unique elements of integrated care. Implications, limitations, and future research suggestions are also explored.
Measurement-based care (MBC) in behavioral health is the systematic use of validated measurement tools to guide clinical decision making and collaborative treatment planning. Although benefits of MBC for clinicians and patients have been supported by research, it appears to be underutilized in clinical settings. This study examined the effectiveness of a MBC implementation plan informed by the theory of planned behavior in a large, integrated primary care program at a Veterans Affairs hospital over 18 months. Results corroborate the theory of planned behavior as a model in which to guide systematic MBC implementation. MBC implementation challenges and recommendations are discussed.
Improving PHQ9 Utilization Rates in a Primary Care–Mental Health Integration Setting
Measurement-based care (MBC) uses standardized measurement to systematically monitor treatment response over time. Although MBC is underutilized in mental health settings, primary care–mental health integration (PC-MHI) settings are expected to provide MBC. This article describes a quality improvement (QI) process to increase Patient Health Questionnaire-9 (PHQ9) utilization within a PC-MHI setting. Following intervention, provider PHQ9 utilization rates increased to 98% and 88% at baseline and follow-up.
The aim of the current study was to conduct the first examination of barriers to and facilitators of implementing brief interventions for at-risk drinking and tobacco use among integrated BHPs. BHPs (N = 285) working in a primary care setting for at least 6 months with at least 10% effort allocated to clinical activities were recruited through professional listservs (August-September 2016) and completed an online survey that assessed barriers to and facilitators of delivering brief tobacco and alcohol interventions in routine clinical practice. The primary barriers to addressing tobacco use and at-risk drinking reported by BHPs was the perception that patients did not want to discuss or did not want to change these behaviors. The primary facilitators of addressing tobacco use and at-risk drinking were patients identifying cessation or reduction as a treatment goal, positive provider-patient relationship, and receiving referrals specifically for tobacco or alcohol use.
The aim of this project was to collect preliminary effectiveness data for Brief Cognitive Behavioral Therapy for Chronic Pain (Brief CBT-CP), an abbreviated, modular form of treatment designed for use in primary care. A clinical demonstration project was conducted in which Brief CBT-CP was delivered to primary care patients by 22 integrated care providers practicing in the Primary Care Behavioral Health model of Veterans Health Administration primary care clinics. Brief measures were used at each appointment to collect patient reported clinical outcomes. Multi-level modeling suggested that a composite measure of pain intensity and functional limitations showed statistically significant improvements by the third appointment (Cohen’s D=0.65). Pain-related self-efficacy outcomes showed a similar pattern of results but of smaller effect size (Cohen’s D=0.22). Exploratory analysis identified that Brief CBT-CP modules addressing psychoeducation and goal setting, pacing, and relaxation training were associated with the most significant gains in treatment outcomes. These findings provide early support for the effectiveness of Brief CBT-CP when delivered by providers in every day Primary Care Behavioral Health settings.
High Quality of Care Persists With Shifting Depression Services From VA Specialty to Integrated Primary Care
We examined overall quality of depression care and tested whether increasing clinic engagement in VA’s Primary Care-Mental Health Integration (PC-MHI) services was associated with differences in depression care quality over time.We conducted a retrospective longitudinal cohort study of 80,136 Veterans seen in 26 Southern California VA PC clinics. Clinic PC-MHI engagement rates were not associated with significant depression care quality differences. Study patients treated in PC clinics with greater PC-MHI engagement received similarly high-quality depression care, and even higher quality for vulnerable patients. Findings support increasing use of PC-MHI models to the extent that they confer some advantage over existing services (e.g., access, patient satisfaction) other than quality of care.
We sought to identify the major themes through which patients described their integrated behavioral health care experiences as a means of informing and improving clinic processes of integrated health care delivery. We captured viewpoints from 16 patients who experienced an integrated behavioral health care model from 2 primary care clinics and completed at least 3 visits with a behavioral health provider (BHP). The interview process yielded 3 major themes related to the BHP including (a) the BHPs’ clinic presence made behavioral health care more convenient and accessible, (b) BHPs worked within time and program limitations, and (c) BHPs helped with coping, wellness, and patient-care team communication.
The aim of our study was therefore to examine whether frail community-dwelling older persons’ perspectives on quality of primary care according to the dimensions of the CCM are associated with the productivity of the patient-professional interactions. Our study was part of a large-scale evaluation study with a matched quasi-experimental design to compare outcomes of frail community-dwelling older persons that participated in a proactive, integrated primary care approach based on (elements of) the CCM and those that received usual primary care. Frail community-dwelling older persons’ perspectives on quality of primary care were associated with perceived productivity of their interactions with the GP and practice nurse in both the intervention group and the control group. We found no significant differences in overall perceived quality of care and perceived patient-professional interaction between the intervention group and control group at baseline and follow-up.
The aim of this systematic review was to identify important patient-related outcomes of integrated care provided to older adults. A systematic search of 5 databases to identify studies comprising older adults assessing hospital admission, length of hospital stay, hospital readmission, patient satisfaction and mortality in integrated care settings. Twelve studies were included (2 randomised controlled trials, 7 quasi-experimental design, 2 comparison studies, 1 survey evaluation). Five studies investigated patient satisfaction, 9 hospital admission, 7 length of stay, 3 readmission and 5 mortality. Findings show that integrated care tends to have a positive impact on hospital admission rates, some positive impact on length of stay and possibly also on readmission and patient satisfaction but not on mortality. Integrated care may reduce hospital admission rates and lengths of hospital stay. However due to lack of robust findings, the effectiveness of integrated care on patient-related outcomes in later life remain largely unknown.
This study aimed to assess the quality of collaboration between GPs and psychologists from the psychologists’ perspective and to identify factors associated with satisfactory collaboration. A questionnaire was sent by post to all private psychologists in a region of France in February, 2017. The main barriers reported were lack of time, lack of understanding and poor interactions/communication. Sixty-nine percent of psychologists felt that GPs knew little about their work. Psychologists had professional exchanges with an average of three local GPs and received referral information for 12% of new patients. Out of 10 new patients, 2 were referred by a GP. In a multivariate analysis, satisfactory collaboration was significantly associated with the number of GPs psychologists exchanged with (OR 1.29), receipt of referral information (OR 2.18) and a positive assessment of GPs’ understanding of psychologists’ activity (OR 3.35). Psychologists considered the collaboration between GPs and psychologists as substandard, as well as GPs’ knowledge of psychologists’ activity.
POLICY or MANAGEMENT
With the integration of behavioral health services into primary care and other medical specialties, the community of providers and the public must address a number of questions, including: What models of care are there for these services? What kinds of providers supply these services? Are these providers trained behavioral health providers or extenders in some form? And, as these systems of care are constructed, who makes use of them? The purpose of this study is to address these questions as well as to consider some of the challenges of attending to the spectrum of needs that will arise as integrated healthcare services expand. Consideration of these questions may serve to clarify the impact that these models of healthcare will have in ways that may be readily apparent and, at the same time, in ways that may be subtler and less comprehensible.
This brief, produced with support from Blue Shield of California Foundation and the California Health Care Foundation, describes how integrated financing influences the coordination of physical and behavioral health services at the care delivery or practice level. It distills insights from providers in three states — Arizona, New York, and Washington — that have recently transitioned to integrated managed care. Based on their insights, the brief highlights recommendations for states seeking to improve health outcomes through advancing greater physical-behavioral health integration organized within three key areas: (1) data and quality measures; (2) payment and business practices; and (3) integrated clinical service delivery.
The GPP has incentivized a shift toward providing value in health care for the uninsured, not just volume of services provided. The GPP’s incentives established a new model for providing health care to California’s remaining uninsured. The approach changes the way California’s PHCSs receive federal funds to care for the uninsured. The GPP’s point structure both rewards the provision of care in primary care and other lower-intensity settings and discourages care provided in the ER or inpatient settings, with point values for the latter forms of care decreasing over time. As this evaluation has shown, these incentives have led to an increase in both the number of uninsured served and a change in the type of care provided, as uninsured patients are receiving care in more-appropriate settings.
We will describe findings from a national VHA education needs survey of integrated BHPs and an in-depth qualitative study examining primary care for Persons with Dementia (PwD) in two large VHA healthcare systems. We will discuss how geriatric experts can serve as trainers to address current gaps in primary care of PwD.
In 2017, the Department of Veterans Affairs began a national rollout of a comprehensive interprofessional competency-based training utilizing a regional, train-the-trainer program. This paper describes the training program and preliminary outcomes for the regional and local trainers. Initial findings indicate statistically significant improvement at 3 and 6 months on the Primary Care Behavioral Health Provider Adherence Questionnaire-2 in several domains, attainment and sustainment of demonstrated clinical skill in role play situations, and improvement in 30-min appointment length fidelity. Implications for other health care systems are discussed with a focus on practical lessons learned for interprofessional training aimed at improving fidelity in IPC practice.
Core competency frameworks to close behavioral health training gaps in primary care exist, but these have not extended to some of the distinct skills and roles required in serious illness care settings. This paper seeks to address this issue by describing a common framework of training competencies across the full spectrum of clinical responsibility and behavioral health expertise for those working at the interface of behavioral health and serious illness care. We used a mixed-method approach to develop a model of behavioral health and serious illness care and to delineate seven core skill domains necessary for practitioners working at this interface. Existing opportunities for scaling-up the workforce as well as priority policy recommendation to address barriers to implementation are discussed.
The present paper discusses the potential value of incorporating the prevention of behavioral health problems into the annual physical/wellness checkup and proposes a detailed system for how this might be accomplished.
In this study, we aimed to assess (1) the agreement between patient self-reports and general practitioner (GP) reports of the chronic conditions affecting the patients and (2) the agreement between patients and GPs on health priorities in a primary care setting. From April to May 2017, 233 patients were recruited from 16 GP practices. Agreement between patients and their GPs varied widely depending on the diseases reported. Low agreement on health priorities suggests a need for improvement to ensure better alignment between patient and physician perspectives.
The present study investigates the organization of primary care behavioral health within student health centers and assesses the relationship between organizational structure and practice integration among physical and mental health services. We collaborated with the American College Health Association to distribute a 54-item survey to representatives of each ACHA member institution. A total of 189 (26.3%) surveys were obtained and included 86 (46%) integrated (health/counseling) centers and 101 (54%) nonintegrated centers. Significant differences in levels of practice integration were noted between these two groups. Significant correlations were found between levels of practice integration and the presence of behavioral health staff. The organization and delivery of physical and behavioral healthcare services for students is considerably integrated and collaborative. Adding behavioral health clinicians to the primary care college health setting increases integrated care practice without embarking on full administrative integration of physical and mental health services.