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As we continue to move through historic change in our healthcare and criminal justice systems, the research on integration seems to have slowed down a bit. That said, we still have some important developments helping to move the field of integrated care forward. As always, I collect and review the latest research on integration. Links and abstracts are available below.

In the last Research Review post, I mentioned a review article suggesting the field has focused too much on the structural aspects of integration, and not the patient experience. A new article in this post looks at the provider viewpoint of integration and reports challenges with cultural differences, information flow, and payment models. The authors confirm what many already knew: any effort to integrate care services should be tailored to the resources and needs of the organization.

I also recommend reading a report on an employer-sponsored comprehensive primary care model associated with higher primary care and lower specialist utilization (and, consequently, lower overall costs). Large employers may want to consider making integrated primary care easily accessible to their employees workplace.

IMPLEMENTATION RESEARCH

Factors Influencing Physician Practices’ Adoption of Behavioral Health Integration in the United States

Behavioral health integration is uncommon among U.S. physician practices despite recent policy changes that may encourage its adoption. The purpose of this paper is to describe factors influencing physician practices’ implementation of behavioral health integration. We completed semi structured interviews with 47 physician practice leaders and clinicians from 30 physician practices that adopted behavioral health integration, supplemented by contextual interviews with 20 experts and 5 vendors in behavioral health integration.

We found four overarching factors affecting physician practices’ implementation of behavioral health integration were identified. First, practices’ motivations for integrating behavioral health care included expanding access to behavioral health services, improving other clinicians’ abilities to respond to patients’ behavioral health needs, and enhancing practice reputation. Second, practices tailored their implementation of behavioral health integration to local resources, financial incentives, and patient populations. Third, barriers to behavioral health integration included cultural differences and incomplete information flow between behavioral and nonbehavioral health clinicians and billing difficulties. Fourth, practices described the advantages and disadvantages of both fee-for-service and alternative payment models, and few reported positive financial returns.

Practices currently using behavioral health integration face cultural, informational, and financial barriers to implementing and sustaining behavioral health integration. Tailored, context-specific technical support to guide practices’ implementation and payment models that improve the business case for practices may enhance the dissemination and long-term sustainability of behavioral health integration.

EFFECTIVENESS RESEARCH

Utilization and Cost of an Employer-Sponsored Comprehensive Primary Care Delivery Model

What are the utilization rates and costs of service of a comprehensive primary care model that incorporates employer-sponsored on-site, near-site, and virtual primary care? In this cohort study of 23 518 commercially insured employees, the employer-sponsored services cost a mean (SD) of $87 ($32) per member per month after accounting for infrastructure and service costs, with members using the model clinics for most of their primary care having higher primary care costs but lower total health care costs in a matched cohort analysis controlling for demographics, diagnoses, and risk. The findings suggest that lower total health care costs per person and higher primary care costs may be associated with preferential use by lower-risk persons and/or with the use of comprehensive primary care.

Retrospective cohort study of a novel acceptance and commitment therapy group intervention for adolescents implemented in integrated primary care

To address limited access to behavioral health services in primary care, we conducted a preliminary effectiveness study of a novel acceptance and commitment therapy group treatment implemented within pediatric integrated primary care (ACT-IPC) using a retrospective cohort study design. Participants included 110 youth referred after psychological evaluation between 2015 and 2019. ACT-IPC was implemented in nine sessions; participants had a variety of primary psychiatric diagnoses and were predominantly White (93%) and female (81%) with an average age of 15.1 (SD = 1.5). Anxiety (d = −0.71) and depression (d = −0.54) symptoms improved significantly, as did psychological inflexibility (d = −0.52). Additionally, up to three individualized treatment goals were established and tracked weekly. These outcomes also improved significantly (d = −.69 to d = −1.42), and the first two goals evidenced the majority of improvement within approximately the first half of treatment. Reliable and clinically significant change was promising on all outcomes, and few iatrogenic effects were observed. Of note, concurrent individual therapy and psychotropic medication were prevalent within the sample and were not associated with improved outcomes. Overall, findings provide preliminary transdiagnostic effectiveness and feasibility of ACT-IPC and represent a positive example of a reticulated contextual behavioral science approach to treatment development.

Embedding Social Workers In Veterans Health Administration Primary Care Teams Reduces Emergency Department Visits

While an emerging body of evidence suggests that medical homes may yield more benefits than traditional care models do, the role of social workers within medical homes has yet to be evaluated separately. We assessed the impact of an initiative to add social workers to rural primary care teams in the Veterans Health Administration on patients’ use of social work services, hospital admissions, and emergency department visits. We found that introducing a social worker increased social work encounters by 33 percent among all veterans who received care. Among high-risk patients, we observed a 4.4 percent decrease in the number of veterans who had any acute hospital admission and a 3.0 percent decrease in veterans who had any emergency department visit, after the introduction of a social worker. Investing in social workers is a key strategy for addressing the social determinants of health and managing care coordination for high-risk, high-need populations.

SPECIAL POPULATIONS

The Feasibility and Impact of a Suicide Risk Screening Program in Rural Adult Primary Care: A Pilot Test of the Ask Suicide-Screening Questions Toolkit

Suicide risk screening was feasible and well-accepted by adult patients in rural primary care and has potential to improve suicide risk detection in this setting.

WORKFORCE DEVELOPMENT

Improvement in behavioral health symptoms and functioning among rural patients cared for by primary care teams using the extension for community health care outcomes model

Rural communities disproportionately experience behavioral health care shortages. This study examines outcomes among the patients of rural primary care teams trained and supported to deliver behavioral health care. Patients (n = 243) completed 5 iterations of the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5) Self-Rated Level 1 Cross-Cutting Symptom Measures (American Psychiatric Association, 2013) and the World Health Organization Disability Assessment Schedule 2.0 (World Health Organization, 2012). Survey data were used in multiple linear regressions to assess health changes. Patients who received treatment from teams experienced less anxiety, sleep problems, and cognition problems over time. This exploratory research shows supporting primary care teams to deliver behavioral health care is associated with improved behavioral health and functioning among rural patient populations. (PsycINFO Database Record (c) 2019 APA, all rights reserved)

POLICY

Addressing social determinants of noncommunicable diseases in primary care: a systematic review

The purpose of this study was to explore how primary care organizations assess and subsequently act upon the social determinants of noncommunicable diseases in their local populations. We identified 666 studies of which 17 were included in the review. All studies used descriptive study designs. Clinic-based and household surveys and interviews were more commonly used to assess local social determinants than population-level data. We found no examples of organizations that assessed sociopolitical drivers of noncommunicable diseases; all focused on sociodemographic factors or circumstances of daily living. Our findings may help policy-makers to consider suitable approaches for assessing and addressing social determinants of health in their domestic context. More rigorous observational and experimental evidence is needed to ascertain whether measuring social determinants leads to interventions which mitigate unmet social needs and reduce health disparities.