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If you’re looking for a break from election and pandemic news, you came to the right place. This post covers the best research in integrated behavioral healthcare over the past 4-6 months. First, check out the recent special issue on pediatrics and collaborative care in the Pediatrics Annal journal. You will find several articles from the special issue below.
Next, I found an interesting article on a taxonomy that defines patient populations with complex needs in practice. The authors reviewed 90 unique complex population definitions and concluded three general approaches: stratification, segmentation, and targeting. Patients with health complexity may benefit from collaborative care more than any other patient group. Check that article out!
I am also seeing more implementation research articles in the collaborative care field. For example, these authors found that the level of behavioral health integration in primary care was not significantly related to depression screening rates, but components like evidence-based practice, funding access, organizational leadership, and links to community resources were related.
There are two articles on warm handoffs under the Effectiveness Research category below. The first study found that handoffs were associated with some short-term benefits (patient engagement, care utilization), suggesting that integrated care may be more beneficial than co-located care. The second study reports evidence that engagement activities can work, including shorter average duration between follow-up sessions.
Finally, I found a couple of articles showing how quality improvement techniques can be used to examine barriers and patient concerns with integrated behavioral healthcare. Quality improvement articles are typically uncommon because they are a little harder to publish than traditional research articles. If you’re interested in learning more about QI and LSS, check them out below!
Pediatricians are increasingly asked to address the mental health care needs of their patients, despite lack of formal mental health training. Pediatricians who wish to expand their scope of practice to include mental health care may benefit from didactic training as well as ongoing consultative or collaborative relationships with mental health specialists. Consultative and collaborative relationships between mental health and primary care have evolved in various models across the country. We outline models of mental health consultation and collaboration, address some considerations for pediatricians prior to adopting a model, and list key collaborative care resources.
Interventions to support patients with complex needs are proliferating. However, little attention has been paid to methods for identifying complex patients. This study aims to summarize approaches used to define populations with complex needs in practice, by cataloging specific population criteria and organizing them into a taxonomy. The authors conducted a pragmatic review of literature published January 2000-December 2018 using PubMed. Search results were limited to English-language studies of adults that specified a set of objective criteria to identify a population with complex needs. The authors abstracted data from each article on population parameters, and conducted thematic analysis guided by deductive coding. The review identified 70 studies reflecting 90 unique complex population definitions. Complex populations criteria reflected 3 approaches: stratification, segmentation, and targeting. Six domains of population criteria were found within, including age-based criteria (59 populations); income (12); health care costs (45); health care utilization (39); health conditions (35); and subjective criteria (15). Criteria from multiple domains were frequently used in combination, and exact specifications were highly variable within each domain. Overall, 83% of the 90 population definitions included at least 1 cost- or utilization-based criterion. Nearly every study in the review presented a unique approach to identifying patients with complex needs but a limited number of “schools of thought” were found. Variability in definitions and inconsistent terminology are potential sources of ambiguity between stakeholders. Greater specificity and transparency in complex population definition would be a substantial contribution to the emerging field of complex care.
Adverse childhood experiences (ACEs) are linked with negatively impacting child and adult health outcomes. Clinicians are integral in identifying childhood adversities and offering supportive measures to minimize negative effects. This systematic literature review included 13 ACE studies that examined the acceptability, feasibility, and implementation of ACE screenings from the perspectives of clinicians and patients. The findings of this review can assist clinicians in considering the appropriateness of ACE screenings for their patients and the ethical and practical issues that must be addressed for effective screening implementation.
The authors adapted the established Child-Adult Relationship Enhancement (CARE) interaction model for use in integrated behavioral health clinics. CARE was modified for delivery in the examination room, during routine primary care visits. Adopting a real-world implementation approach, clinical social workers were trained in the new model—IntegratedCARE—and provided the brief, 3-session treatment to 30 different parent-child dyads. Measurements included the Parental Stress Index–4 Short Form (PSI 4-SF), the Eyberg Childhood Behavior Inventory (ECBI), and the Therapy Attitude Inventory (TAI). There was a statistically significant mean score decrease on the both subscales of the ECBI at pre- and posttreatment. Scores on the TAI indicated that participants were satisfied with the treatment. Attrition rates were somewhat lower than similar studies. Findings indicate the IntegratedCARE model is feasible for sustainable delivery by trained behavioral health professionals in primary care.
Patients with somatic symptom disorders (SSD) are prevalent in primary care, urgent care, and emergency rooms and present with reduced quality of life, increased disability, and suicidality . Criteria for SSD include (1) somatic symptoms that cause distress and disrupt life; (2) concurrent physical illness with thoughts and feelings that are disproportionate to the seriousness of the illness; and (3) distress which is persistent and causes suffering. The frequency of SSD in the general population is 5% to 7%; however, in primary care, it is 5% to 35% . Because patients present with anxiety, depression, and/or pain, providers are flummoxed when diagnostic findings do not match symptom intensity.
Objective: Adolescent depression is a serious behavioral health concern often seen in primary care clinics. The purpose of this study was to examine the relationship between successful implementation of integrated behavioral health (IBH) services in primary care settings and clinics’ rates of screening adolescents for depression. Method: We examined clinic-level data, with screening rates obtained from a statewide reporting agency and IBH data obtained through an implementation collaborative. Using the Site Self-Assessment, we first examined global IBH integration using a simple regression, then examined specific components of integration using 2 multiple regressions. Results: While an overall level of behavioral health integration was not significantly related to screening rates, several specific components were. These included positive relationships of adolescent depression screening rates with evidence-based practice and provider/staff integrated care training; and negative relationships of adolescent depression screening rates with funding access and integration, organizational leadership for integrated care, and linking to community resources. Conclusions: Clinical implications include the importance of training providers and staff in behavioral health care and regular use and reinforcement of evidence-based practices to facilitate adolescent depression screening. In addition, clinic personnel may perceive less support for IBH implementation from organizational leadership and less financial integration between behavioral and medical services, when clinics have high screening rates. While more research is needed to examine this unexpected finding, it may be that in clinics with high screening rates a culture of valuing behavioral health care leads to a desire for more organizational support for IBH.
Objective: Evidence demonstrates the importance of providing anticipatory guidance in interdisciplinary pediatric primary care to promote optimal social–emotional development of young children. However, there is a paucity of research available regarding the development and implementation of such programs within large refugee or immigrant populations. Our goal was to develop a culturally sensitive universal anticipatory guidance program delivered by an integrated behavioral health consultant that would be feasible and acceptable in a busy pediatric primary care clinic (PPCC). Method: Participants were caregivers of children (0 to 36 months), primary care providers, and nursing staff in an urban PPCC. Program development and evaluation followed the Plan-Do-Study-Act quality improvement methodology. A needs assessment was developed and administered to primary care staff and families to identify barriers and value-based program targets to aid in culturally sensitive program development. Feasibility and acceptability were measured by satisfaction surveys. Results: All stakeholders identified the need for this type of programming in the clinic. Space, time, and workflow impact were the most reported perceived barriers. Stakeholders varied in their recommendation of preferred ages for behavioral health consultant (BHC) involvement. Results of the satisfaction surveys revealed that the program was feasible and acceptable. Approximately 20% of patients who presented for the identified well child check visits met with the BHC. Conclusions: Results highlight how stakeholder engagement can be used to support the development and implementation of a culturally sensitive universal early childhood education program in a busy pediatric primary care setting.
Implementation science (IS) has developed as a field to assess effective ways to implement and disseminate evidence-based practices. Although the size and rigor of the field has improved, the economic evaluation of implementation strategies has lagged behind other areas of IS (Roberts, Healey, & Sevdalis, 2019). Beyond demonstrating the effectiveness of implementation strategies, there needs to be evidence that investments in these strategies are efficient or financially sustainable. Many cost-effectiveness studies in public health and medicine ignore the costs of implementation and scale-up (Salomon, 2019). Two recent reviews on the use of economic evaluation in implementation studies noted a limited number of studies that have used an economic evaluation (only two in primary care settings) and the few that did have a high variance in methodological quality (Reeves, Edmunds, Searles, & Wiggers, 2019; Roberts et al., 2019). Thus, there are many opportunities for IS and economics to collaborate. In this editorial, we lay out conceptual challenges in applying economic evaluation to IS and the implications for conducting economic analyses in integrated primary care research.
Objective: Referrals initiated via the “warm handoff” (HO) common to consultation-based models of integrated primary care are theorized to add value for patient outcomes relative to referral as usual (RAU) processes often used in colocated service models. The current evaluation tested this assumption in terms of impact on patient engagement, medical system utilization, and behavioral health system utilization. Method: Short-term longitudinal data were extracted for 175 integrated behavioral health referrals across urban pediatric primary care patients. A retrospective cohort design was used to assess differences between patients exposed to an HO immediately following referral versus RAU (control). Results: Analyses revealed significant differences for patients referred via HO at different time points, including fewer primary care provider appointment no-show/same-day cancellations, greater total behavioral health encounters, and fewer days from referral to any scheduled or completed follow-up behavioral health encounter. Conclusions: Consultation via HOs was associated with some short-term benefits on patient engagement and systems utilization for urban pediatric primary care patients compared to RAU. Preliminary findings may help stakeholders leverage the need for integrated (vs. colocated) models of pediatric integrated primary care to help inform economic- or value-based decisions on program development and promote care approaches that increase the likelihood of families staying engaged in care.
Objective: Investigation into models of integrated behavioral health primary care and innovative adaptations of these models can help address challenges associated with behavioral health service delivery. To date, few studies have examined access to pediatric behavioral health treatment in primary care, and no known studies have investigated access for pediatric patients in a hub-extension model. In this model, behavioral health providers receive referrals from both hub clinics (integrated sites in which behavioral health providers treat patients) and extension clinics (coordinated off-sites without behavioral health providers). Method: This study investigated differences in latency between referrals and intakes, scheduling rates, and intake show rates between patients from extension versus hub clinics using retrospective electronic medical record data from pediatric patients referred for behavioral health in primary care over an 8-month period. Results: During the time frame, 766 patient referrals were placed from 3 hub clinics and 6 extension clinics (483 hub; 283 extension). Of those referred, 98 patients never scheduled (36 hub; 62 extension). Patients were more likely to schedule intakes following referrals from hub clinics (92.3%) than extension clinics (78.1%). In addition, hub patients (M = 14.2, SD = 12.4) scheduled for sooner initial appointments than extension patients (M = 25.0, SD = 19.8). Hub clinic patients were 2.4 times more likely to cancel and 2.2 times more likely to not show than extension clinic patients. Conclusions: Although additional research on the hub-extension model of behavioral health implementation is needed, this study provides a preliminary examination into the innovative alteration of integrated care models.
Objective: This study assessed parent engagement and satisfaction with an evidence-based parenting intervention delivered within a pediatric primary care clinic serving families at-risk for toxic stress. Method: Ten pilot study parent participants (all female; 80% African American; mean age = 26.1 years) completed sociodemographic, adverse childhood experiences (ACEs) history, depression, social support, and session satisfaction measures to assess parent characteristics and intervention satisfaction. Parent attendance was assessed and thematic analysis of session notes was conducted to assess parent engagement in intervention sessions. Results: Sixty percent of respondents had elevated ACE scores (Total Score ≥4), and 27% of respondents had elevated Edinburgh (Total Score ≥10). Attendance in intervention sessions was inconsistent. Thematic analysis indicated that parents demonstrated several engagement behaviors during sessions they attended, including sharing opinions/disclosing information and providing one’s point of view. Follow-through with activities recommended during intervention sessions was more likely when linked to parents’ personal strengths or concerns. Parents reported all session content as “helpful or “very helpful” and would recommend the program to others. Conclusions: Parents experiencing risk factors for toxic stress may face challenges in consistently attending integrated care parenting intervention sessions but engage in sessions they attend. Strategies for engaging parents at risk for toxic stress in a primary care-based parenting program include building from parent strengths, addressing identified parent concerns, offering proactive support including parent mental health promotion, and building trusting relationships.
The reduction of mental health stigma (MHS) was an expected benefit of integrating behavioral health in primary care (IPC). However, unlike other barriers discussed in agency reports on IPC, discussions of MHS lack research support. To fill this gap, the authors conducted a literature review identifying seven studies. Given the dearth of research, we also examine general IPC research on probable indicators of MHS reduction in IPC, as well as, facets of IPC potentially influencing MHS related factors negatively associated with help-seeking. Using the data from these three types of research, the evidence suggests the potential of IPC to reduce MHS impact on care utilization, but indicates it is premature to draw firm conclusions. Given the possible benefits of primary care and the known benefits of decreased MHS, this review highlights the importance of further research examining this question and provides specific research and program development recommendations.
Objective: Integrated primary care (IPC) is intended to address the gap in access to behavioral health care. This may be particularly true in urban settings; however, there is a paucity of research on treatment engagement in urban IPC. This study explored factors associated with treatment engagement. Method: Data were collected via retrospective chart review for 410 patients of diverse backgrounds who received an IPC referral in an urban primary care site. Patient-related factors included having multiple types of referral concerns, patient primary care show rate, and number of visits with referring clinician. Service-related factors included referral type (warm handoff/electronic), number of days between referral and intake, and average number of days between IPC treatment sessions. Engagement outcomes included attendance at IPC intake, total IPC sessions attended, overall IPC show rate, and IPC treatment attrition. Results: Of referred patients, 348 (84.9%) were encouraged to or scheduled an intake. Of those, 289 (83.1%) scheduled and 57.2% attended; the average number of sessions attended was 1.73. Patients who had more primary care office visits and higher primary care show rates were more likely to attend an IPC intake. Shorter average duration between follow-up sessions was associated with higher overall IPC show rates for those who initiated IPC follow-up care. Conclusions: Supporting engagement in primary care broadly and building scheduling capacity for IPC treatment may increase IPC service engagement in an urban primary care context.
Burnout among primary care clinicians (PCPs) is associated with negative health and productivity consequences. The Veterans Health Administration (VA) embedded mental health specialists and care managers in primary care to manage common psychiatric diseases. While challenging to implement, mental health integration is a team-based care model thought to improve clinician well-being.
The number of older adults in the United States and much of the world is rapidly increasing as individuals continue to live longer, healthier lives, and is expected to continue growing over the next several decades. As a result, healthcare settings are constantly adapting to meet the specialized needs of this aging population. One major adaptation in the delivery of healthcare services is a shift toward integrated healthcare settings wherein older adults can seek services for a variety of physical and mental health needs within a single system. This article addresses several pertinent issues unique to working with older adults within integrated care settings to prepare practitioners for effectively serving older adult patients. We begin with an overview of key demographics of aging in the United States and of professional geropsychology. This is followed by a discussion of key issues relevant to serving older adults in integrated care settings, such as the roles of behavioral health professionals, common comorbidities among older adults, intervention effectiveness, and standards for professional competency. We conclude with a discussion of evidence-based psychological and cognitive assessment of older adults, highlighting measures that may be considered for use in integrated care settings.
Primary care has been on the front line of mental health, but with the increase in patient demands, many primary care providers (PCPs) have relied on prescribed medication to address these needs. About twenty years ago the Integrated Behavioral Health (IBH) and Primary Care Behavioral Health (PCBH) models were formed which have Behavioral Health Consultants (BHCs) work alongside PCPs as a team to improve patient care and success when dealing with a mental health diagnosis. PCPs not only include physicians but also mid-level providers as well, with this paper focusing on physician assistants (PAs), who make up a significant portion of the PCP workforce. Three commonly used databases were used to find literature and/ or studies on IBH or PCBH and PA training or education, however no articles were found that met criteria. The results of no studies being found provides PAs with an opportunity to work towards eliminating this important gap.
Objective: Pediatric Integrated Primary Care (IPC) plays a unique and foundational role in prevention of behavioral health disorders and promotion of healthy development and positive health behaviors across the life span. Early intervention can mitigate the impact of social determinants of health (including adverse childhood experiences) and promote health equity. Yet to realize this potential for health promotion and prevention, it will be necessary for pediatric integrated primary care to shift focus upstream—ensuring a 2-generation approach (e.g., parenting programs, screening for maternal depression) and enabling effective collaboration with other sectors in communities that impact children and families (e.g., home visiting programs, schools). This will pose challenges for sharing desired outcomes and data and reconceptualizing returns on investment across sectors. Other policy changes will also be necessary, including payment reforms (e.g., value-based payment models), interprofessional training, and increased funding for IPC research in pediatrics. It will be necessary to educate policymakers that health promotion and prevention in pediatric IPC results in improved health and savings into adulthood. Conclusion: Pediatric psychology can play a leadership role in realizing the potential for pediatric IPC.
This commentary discusses the journey to integrated behavioral health and primary care in the state of Colorado. The authors discuss integrated care, and the lessons learned by early adopters can help those just getting started. They argue integration is possible in practice settings of all types despite the barriers that exist – but these barriers must continue to be broken down for further scaling and long-term sustainability. While adequate payment, workforce, and data-sharing infrastructure and policy are necessary for scaling and sustainability, they are not sufficient: practice transformation support is crucial for a change this fundamental. Finally, scaling and sustaining integration takes a village; diverse stakeholders across sectors, including payers, clinicians, patients, public health, philanthropy, and policymakers, all have a role to play.
Objective: To use quality improvement tools to optimize pediatric behavioral health (BH) integration, a promising approach to increasing access to behavioral health care services for children. Method: As part of the practice transformation efforts of a pediatric BH integration initiative implemented in three community health centers, we used Failure Modes and Effects Analysis (FMEA), a quality improvement tool, to examine barriers in implementing 2 core BH integration workflows: universal screening to identify developmental and behavioral concerns and implementation of real-time “warm” hand-offs. Results: Failure modes fell broadly into 2 categories across both workflows: (a) parental/caregiver characteristics and receptivity to the new workflow and (b) consistent implementation of the workflow by health center staff. Failures related to parental/caregiver characteristics included low literacy, language incongruence, and feeling burdened, intimidated, or offended by the screening process. Failures related to implementation of the workflow involved difficulties in administration of the correct age-appropriate screening form and incomplete hand-offs between primary care providers and behavioral health clinicians. Improvement strategies were identified to address both workflow failures, including making changes to electronic medical record functionality, modifying behavioral health clinician scheduling template, and retraining staff. Conclusions: Pediatric primary care practices planning for, or in the early stages of, BH integration may consider using the FMEA tool to support successful implementation.
Patients with physical injuries or chronic conditions may be impacted by mental health conditions, which significantly affect their participation and progress in treatment. The Patient Health Questionnaire-2 (PHQ-2) depression screening can identify patients who are at greatest risk for depression to provide better whole-person care. The quality improvement project objective was to identify and design a process that would result in the PHQ-2 depression screening for admitted trauma patients with a minimum 75% completion rate. Lean Six Sigma (LSS) process design methodology, DMADV (define, measure, analyze, design, and verify), drove process improvement. Medical records from before (December 2018 through February 2019) and after (March 2019 through May 2019) the intervention were evaluated using frequencies, percentages, χ2, and multivariable logistic regression to determine the effectiveness of the intervention. PHQ-2 document location was imperative to successful compliance, which increased from 60.74% (78 of 128) to 80.56% (87 of 108). Specifically, weekend compliance increased from 42.9% (18 of 42) to 82.8% (24 of 29). LSS DMADV methodology helped health care professionals design a process to facilitate compliance with the PHQ-2 depression screening protocol in trauma patients. Adherence with this screening can help increase the number of behavioral health consultations, which in turn improves the treatment of traumatic injury survivors.