I hope this Research Review blog post finds you virus-free and in good spirits. We are living through history right now with the COVID pandemic. Perhaps this post will give you a break from the ongoing disruptions. This is the post where I save you time searching the hottest integrated/collaborative care research literature by doing all the work myself!
Here are some articles you don’t want to miss: This article on key patient experience outcomes suggests that we are focusing too much on the structural aspects of integration and not enough on the patient experience of integration. Another article recommends we move away from traditional measures of symptoms and toward patient-reported measures of functioning. I also found a systematic review of effective models of integrated care in pediatric settings, which found three key components that administrators should consider when selective a model for their delivery system. Finally, there is a nice policy piece urging CMS to show greater support for behavioral health integration.
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!
The “Behavioral Health Vital Signs” Initiative
Aware of the high prevalence of traumatic experiences including interpersonal violence (IPV) in the safety-net setting and the devastating impact of IPV on mental and physical health, a team at the University of California, San Francisco (UCSF), implemented a multi-sector partnership program called ARISE (Aspire to Realize Improved Safety and Equity) to improve the health and safety of adults and children affected by IPV. Through ARISE, we launched an IPV program by successfully aligning our program goals with the primary care–behavioral health integration goals of the San Francisco Health Network (SFHN), the public health care delivery system in San Francisco. Our collaboration resulted in a key innovation, called the “Behavioral Health Vital Signs,” which catalyzed trauma-informed quality improvement efforts in primary care to address IPV in conjunction with depression and alcohol and substance use.
How to measure the collective intelligence of primary healthcare teams?
Researchers aimed to find a framework or a tool that could help explain collective intelligence in primary healthcare organizations. A broad literature search led researchers to focus more specifically on two interrelated frameworks, both concepts were created within the educational field.
Behavioral Health Integration and Outcomes that Matter to Patients: a Longitudinal Mixed-Methods Observational Study
Research on behavioral health integration (BHI) often explores outcomes for quality and cost, but less is known about impacts of integration work on key patient experience outcomes. A mixed-methods longitudinal study of BHI was conducted in 12 primary care clinics in Oregon to assess how adoption of key integration practices including integrated staffing models, integrated care trainings for providers, and integrated data sharing impacted a set of patient experience outcomes selected and prioritized by an advisory panel of active patients. Results showed that adopting key aspects of integration was not associated with improved patient experience outcomes over time. Patient interviews highlighted several potential reasons why, including an overemphasis by health systems on the structural aspects of integration versus the experiential components and potential concerns among patients about stigma and discrimination in the primary care settings where integration is focused.
Using the Omaha System to Evaluate the Integration of Behavioral Health Services into Nurse-Led Primary Health Care
Integrating behavioral health services into nurse-led primary care at one location ensures that individuals receive a comprehensive array of preventive and restorative services, based on their varying needs. A formative program evaluation of a federally funded behavioral health integration (BHI) project in a small nurse-led clinic used the Omaha System taxonomy to explore the changes in the documented practice of providers due to the BHI implementation. The evaluation provided evidence of the benefits of a collaborative care model to urban low-income, underserved, adults who were predominantly African American/Blacks.
Including Economic Evaluations in Implementation Science
The percent of US adults reporting poor mental health continues to rise,1 and 62% of those who need treatment for a mental health problem do not receive it.2 The integration of mental health care in primary care settings can be instrumental in addressing these unmet needs. Substantial evidence of integrated models points to better mental health access and outcomes3; however, many health care organizations do not implement integrated care due to organizational challenges in implementing these models as well as the resources needed for implementation.4 The field of implementation science is focused on improving the uptake of evidence-based practices such as integrated care, and various implementation strategies are often tested. Implementation strategies can vary in their intensity and resource use as well as their effectiveness in aiding implementation, so weighing the relative cost and benefits of implementation strategies is critical. Unfortunately, implementation studies often lack information on the costs and value of implementation despite the importance of this information to decision makers.
Effectiveness of Peer-Supported Computer-Based CBT for Depression Among Veterans in Primary Care
This study tested whether computerized cognitive-behavioral therapy for depression supported by a peer specialist with lived experience of depression (PS-cCBT) improves mental health–related outcomes for primary care patients. In the U.S. Department of Veterans Affairs, primary care patients with a new diagnosis of depression (N=330) were randomly assigned to 3 months of PS-cCBT or a usual-care control condition. Linear mixed-effects models were used to assess differences in depression symptoms, general mental health status, quality of life, and mental health recovery measured at baseline and 3 and 6 months. In adjusted analyses, participants who received PS-cCBT experienced 1.4 points’ (95% confidence interval [CI]=0.3–2.5, p=0.01) greater improvement in depression symptoms on the Quick Inventory of Depression Symptomatology–Self Report at 3 months, compared with the control group, but no significant difference was noted at 6 months. PS-cCBT recipients also had 2.6 points’ (95% CI=0.5–4.8, p=0.02) greater improvement in quality of life at 3 months on the Quality of Life Enjoyment and Satisfaction Questionnaire Short Form and greater improvement in recovery on the Recovery Assessment Scale at 3 months (3.6 points; 95% CI=0.9–6.2, p=0.01) and 6 months (4.5 points; 95% CI=1.2–7.7, p=0.01). PS-cCBT is an effective option for improving short-term depression symptoms and longer-term recovery among primary care patients newly diagnosed as having depression.
Using Patient-Reported Outcome Measures during Routine Care of Patients with Type 2 Diabetes
The use of patient-reported outcome measures (PROMs) in clinical care has been shown to improve the process and outcomes of care, but many challenges to their routine implementation have been noted and their use is limited. Traditional measures and existing models do not address broad functional status outcomes. PROMs can improve outcomes, particularly when used to manage treatment of specific conditions and can improve communication between patients and providers. Demonstrating models for using PROMs that are meaningful to patients and the clinical care team is a high priority and supports efforts to monitor quality of care.
Utilization and emergency department diversion as a result of pediatric psychology trainees integrated in pediatric primary and specialty clinics.
Purpose: Integrating behavioral health into primary care (PC) is known to be an effective approach to caring for children with complex health care needs. The purpose of this study was to describe the impact of embedding predoctoral psychology interns (PSY residents) in a continuity care clinic on behavioral health care utilization with additional attention paid to diverting emergency department (ED) visits. Method: Doctoral psychology PSY residents participated as team members in pediatric resident continuity care clinics and also were available to consult with specialty and urgent care clinic providers within the ambulatory center. During a 6-month period, services provided by PSY residents were tracked (numbers of warm-handoffs, behavioral consults [including covisits with pediatric residents], psychotherapy appointments, and crisis evaluations). Results: PSY residents completed 184 warm-handoffs, 250 same-day consults, and 223 follow-up appointments. Sixty-five patients attended group therapy sessions offered in the pediatric clinic. Of 23 patients evaluated for suicidal/homicidal ideation (who previously would have been referred immediately to the ED), 21 were stabilized in PC and only 2 required ED services. Conclusion: Integration of PSY trainees resulted in more than 700 rapid behavioral health services in 6 months, and diverted 91% of mental health crises from ED and other possible psychiatric hospitalization. Prior to integration, none of these services were provided on site. In addition to providing interprofessional team training, integrated continuity care clinics can improve access to behavioral health services and offer significant cost-saving opportunities to health care systems. Ways to promote interdisciplinary training will be identified. (PsycINFO Database Record (c) 2020 APA, all rights reserved)
Key Components of Effective Pediatric Integrated Mental Health Care Models: A Systematic Review
What are the key components of effective pediatric integrated mental health care models? In this systematic review of 11 randomized clinical trials involving 2190 participants, population-based care, measurement-based care, and evidence-based mental health services were identified as the most common components of effective pediatric integrated mental health care models. Other model components (eg, treatment-to-target and team-based care) may also be important to address specific outcomes (eg, functional impairment). Findings suggest that 3 pediatric primary care integration model components have the strongest evidence base for improving clinical outcomes, and pediatric primary care administrators may use this information when selecting a model for their delivery system.
Providing Effective Primary Care for Patients with Serious Mental Illness: Additional Components to Enhance Practice
Despite pronounced disparities in mortality and physical health outcomes, no well accepted models exist for integrating primary care with behavioral health for patients with serious mental illness (SMI). This article describes a case study of an enhanced approach to primary care that builds on the patient centered medical home (PCMH) model and adds three additional components: (1) longer and more frequent visits to establish trust and increase adherence, (2) a primary care team that has both the skills to provide effective primary care and the heart to take care of patients with SMI and (3) planned and proactive communication between the behavioral health team and the primary care team.
Using integrated behavioral healthcare to address behavioral health disparities in underserved populations
Despite the growth of behavioral health services in the United States, reports show persistent disparities in racial and ethnic minority populations’ access to them. Primary care practices are often where patients go first for their medical and mental healthcare, placing the burden for treatment of behavioral health problems on primary care physicians. Integrated behavioral healthcare (IBHC), which embeds behavioral health clinicians in medical settings, is growing rapidly and should become an important component of the healthcare system. This paper proposes IBHC as a solution to reduce disparities in access to behavioral health services for underserved populations, specifically Latinx and African American populations, as well as racial and ethnic minority youth. The authors surveyed the literature to describe the history and current use of IBHC and present the case for addressing the behavioral health needs of underserved populations with IBHC. Research suggests that patients treated in IBHC settings experience an improvement in their symptoms and functioning across behavioral health problems. Furthermore, IBHC patients in primary care clinics report satisfaction with care and strong therapeutic alliance with behavioral health clinicians. Preliminary research suggests that IBHC may also reduce stigma and cultural barriers in underserved racial and ethnic minority populations. IBHC provides a unique opportunity to fulfill a critical need by meeting patients where they are. Therefore, we need to focus on improving and expanding IBHC for underserved racial and ethnic minority communities. (PsycINFO Database Record (c) 2019 APA, all rights reserved)
Promoting behavioral health equity through implementation of the Incredible Years within primary care.
Mental health disparities continue to be a concern for racial and ethnic minorities in the United States. Further, approximately 20% of children in the United States have a mental health disorder with less than half of these youth receiving mental health treatment (Polanczyk, Salum, Sugaya, Caye, & Rohde, 2015; Stancin & Perrin, 2014; U.S. Surgeon General, 1999). Integrated primary care has been identified as an ideal place where youth and families can receive mental health services. There is evidence supporting that when psychologists are in primary care, behavioral health outcomes improve and the costs per patient are reduced (Chiles, Lambert, & Hatch, 1999). The objective of this paper is to describe the steps taken to colocate The Incredible Years Parenting Program (IY; Webster-Stratton & Reid, 2010) an evidence-based parenting group, in a pediatric primary care setting at a major metropolitan children’s hospital. The parenting group was delivered as a prevention and early intervention program for an underserved population, specifically focused on parents of children ages 3–6 years, to reduce health disparities and improve access to needed behavioral health care. A case study illustrates the potential benefits to mental health and physical health outcomes through colocation, and ultimately integration, of behavioral health services in primary care. Policy implications for sustainability of group parenting interventions in primary care, the impact on decreasing health disparities, and future directions along this line of research are discussed. (PsycINFO Database Record (c) 2019 APA, all rights reserved)
Program Evaluation of an Integrated Behavioral Health Clinic in an Outpatient Women’s Health Clinic: Challenges and Considerations
Many women receive their regular check-ups and preventive care through a women’s health clinic, including their behavioral health needs. Most of these clinics have not yet developed the capacity to adequately manage behavioral health concerns. We describe our clinical experience integrating behavioral health services into a women’s health clinic. In one year, 108 women (54% White, Mage= 35) were referred for behavioral health treatment 47% were identified using a screening questionnaire, 51% were referred by their women’s health provider and 2% were self-referred. The most common presenting concerns were anxiety (52%) and depressive symptoms (48%). Sixty-one (56%) patients completed an intake assessment, of whom 33 (54%) engaged in follow-up treatment (M = 3.7 treatment sessions, SD = 3.0). Behavioral health screening and treatment appears to be feasible and effective within a women’s health setting. Further research is needed to overcome barriers to referrals and treatment engagement in this population.
Pediatric Mental Health and the Power of Primary Care: Practical Approaches and Validating Challenges
With over 300 school shootings in the past 5 years, the unprecedented use of online social media, and the growing demands of academia, mental illness is quickly becoming one of the top causes of morbidity and mortality in the pediatric population. In the past year, 90% of children in the U.S. visited their pediatric primary care provider (PCP), giving PCPs a unique opportunity to address the mental health needs of their patients. The author conducted a comprehensive review of the literature. This clinical paper seeks to validate the mental health competency of pediatric PCPs, identifies current challenges, and outlines practical approaches to care. The consequences of untreated pediatric mental illness are indisputable. Pediatric PCPs have an obligation to address the growing pediatric mental health crisis directly. By utilizing standardized screening tools, referring to established clinical guidelines, seeking continuing education, and developing a comprehensive list of available resources, pediatric PCPs can incorporate mental health care into primary care.
Intervention Components Targeting Self-Management in Individuals with Multiple Chronic Conditions: An Integrative Review
Multiple chronic conditions (MCC) are becoming increasingly common and self-management (SM) interventions to address MCC are emerging. Prior reviews have broadly examined SM interventions in MCC; however, interventional components were not thoroughly described. Components of SM interventions that have been delivered to individuals with MCC were identified. A review of CINAHL, Cochrane, PubMed, PsycINFO, Scopus, and Embase was completed. This search yielded 13,994 potential studies; 31 studies among those 13,994 studies met inclusion for analysis. The literature is multidisciplinary and describes a wide variety of interventional strategies implementing various combinations of components. A descriptive analysis of the studies’ components, application of the components, delivery methods, and primary outcomes demonstrated clear variations between programs. The most common components noted in the 31 studies were education, action planning/goal setting, self-monitoring, and social/peer support. The variation in SM programs limits conclusive evidence for which components are recommended to improve self-management in individuals with MCC.
Caring for children in child welfare systems: A trauma-informed model of integrated primary care.
Children involved with the child welfare system have high rates of behavioral health concerns, chronic health conditions, and developmental disabilities. Further, as a result of the complicated relationships among the court system, child protective services, and caregivers (i.e., biological, kinship, and/or foster caregivers) and the high volume of health-, behavior-, and development-related services children in care need, the services they receive tend to be fragmented and problem driven. On top of these challenges, children involved with the child welfare system have been exposed to trauma, and often more than one form of trauma. Taken together, these factors point to the need for care that is trauma-informed and integrated whereby health care is provided by a multidisciplinary team working collaboratively. This article describes such a model, including information about its development, structure and organization, and programs. It concludes with a discussion of lessons learned and remaining challenges. (PsycINFO Database Record (c) 2020 APA, all rights reserved)
Integrated Behavioral Health Curriculum in Counseling Psychology Training Programs
Effective training in integrated behavioral health requires systematic, interprofessional education that is anchored in competencies. We describe core learning objectives, competencies, and strategies for assessing counseling psychology trainees in integrated health care settings. Two programs that have transformed their training to emphasize interprofessional and primary care competencies of psychological practice are presented, along with their training goals and didactic and experiential curricular activities. We describe the assessment of student learning, accompanied by program adjustments implemented to improve student outcomes. We conclude with a call for counseling psychologists to ensure student competency development as members of the interprofessional health care workforce.
The Primary Care First Model Is Flawed: CMS Can Fix It With Stronger Support For Behavioral Health Integration
By incorporating specific tools to advance Behavioral Health Integration, the Primary Care First model can achieve its goals of reducing Medicare spending while improving quality and access of care. Offering support to smaller, less advanced primary care practices, including direct incentives, and eliminating disincentives for BHI will enable more primary care practices to deliver high-quality, integrated care.
Accelerating the Adoption of Value-Based Payment in Medicaid by Linking Delivery System Reform to Managed Care Payment
This brief examines how 10 states are seeking to accelerate the use of VBP—and sustain the delivery system reforms achieved through Medicaid section 1115 demonstrations—by setting requirements or targets for managed care plans (MCPs) to contract with network providers using VBP arrangements. We compare how states design the interaction and sequencing of provider delivery reforms with VBP goals for MCPs. We also assess the extent to which state policies align the incentives to increase the use of VBP for both providers that receive delivery reform funding and MCPs.
Challenges in turning a great idea into great health policy: the case of integrated care
We argue that the organization of health care and integrated care is of public concern, and should thus be of crucial interest to policy-makers. We highlight three challenges or limitations likely to be encountered by policy-makers in integrated care. These are: (1) conceptual challenges; (2) empirical/methodological challenges; and (3) resource challenges. We will argue that it is still unclear what integrated care means and how we should measure it. ‘Integrated care’ is a single label that can refer to a great number of different processes. It can describe the integration of care for individual patients, the integration of services aimed at particular patient groups or particular conditions, or it can refer to institution-wide collaborations between different health care providers. We subsequently argue that health reform inevitably possesses a political context that should be taken into account. We also show how evidence supporting integrated care may not guarantee success in every context. Finally, we will discuss how promoting collaboration and integration might actually demand more resources. In the final section, we look at three different paradigmatic examples of integrated care policy: Norway, the UK’s NHS, and Belgium.
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