15 minute read
If you’re looking for the hottest research, then swipe right here. This serial post covers several categories of research in integrated behavioral healthcare over the past 4-6 months. As always, I include the titles and abstracts below each research category. Click on the titles to access the full article.
The top article on my list today is a systematic review and meta-analysis on interprofessional collaborative practice reporting collaborative care is associated with improved outcomes for diabetes and hypertension. This is a good reference for anyone writing a manuscript or grant application for integrated care.
Another article that got my attention was a multi-site RCT examining four-sessions of behavioral activation, a low-intensity behavioral medicine treatment. Results show improved outcomes at 12 weeks compared to treatment as usual. I really like some of the research that has appeared over the past few years supporting behavioral activation and other similar treatments. There are many team members (medical assistant, paraprofessional, health coach, physician) who can learn to deliver these effective and accessible interventions.
Third is an article reporting results from a large survey of medical clinicians. The findings suggest that clinicians have reservations for social risk screening without proper training and resources. In some instances, screening practices may need to be de-implemented.
Finally, a large, updated secondary data analysis confirms knowledge that certain groups are less likely to seek mental health treatment than others. These findings further support the need for expanding integrated care to reduce disparities and provide greater accessibility.
The literature on integrated care and behavioral medicine are huge! Be sure to check again for the next round of research review.
EFFECTIVENESS RESEARCH
In this systematic review and meta-analysis of 39 comparative studies that evaluated interprofessional team care involving 3 or more professions in primary care for adult patients with diabetes and/or hypertension, ICP was associated with improved hemoglobin A1C (HbA1c), systolic blood pressure, and diastolic blood pressure levels. Primary care ICP was associated with reductions in HbA1c regardless of baseline levels, but the greatest reductions were found with HbA1c levels of 9 or higher.
The current study tested whether a brief version of Behavioral Activation (two 30-minute appointments, 2 boosters) designed for primary care (BA-PC) was more effective than primary care behavioral health treatment-as-usual (TAU) in reducing depressive symptoms and improving quality of life and functioning. Parallel-arm, multi-site randomized controlled trial. 140 Veterans were randomized to BA-PC or TAU and completed assessments at baseline, 6 weeks, 12 weeks, and 24 weeks. Reductions in depressive symptoms were observed in both groups between baseline and 3-weeks prior to any treatment, with continued reductions among those in the BA-PC condition through 12-weeks. However, there was no significant condition X time interaction at 12-weeks. Quality of life and mental health functioning were significantly improved for those in the BA-PC condition, compared to TAU, at 12 weeks. Generalizability to a broader population may be limited as this sample consisted of veterans. Although engagement in TAU matched other prior work, it was lower than engagement in BA-PC, which also may compromise results. Although this study found that both TAU and BA-PC participants showed a decline in depressive symptoms, improvements in functioning and quality of life within those assigned to BA-PC, strong treatment retention and feasibility of BA-PC, and significant reductions in depressive symptoms among those with more severe baseline depressive symptoms are encouraging and support continued research on BA-PC.
The integrated health home, the Hope Health and Wellness Clinic, provides comprehensive primary and behavioral health services to adult clients of a Community Mental Health Center in Aurora, Colorado. A program evaluation of the effectiveness of this clinic was conducted over a 4 year period. Physical health data (Body Mass Index BMI, HbA1c, cholesterol, blood pressure, and waist circumference measurements) and self-report data (social connectedness, everyday functioning, psychological distress, perceived health, satisfaction with services) were tracked across time. Individuals enrolled (N = 534) experienced significant improvements over time in LDL and total cholesterol, as well as self-reported social connectedness, everyday functioning, perceived health, and psychological distress. At risk individuals demonstrated significant improvements in HDL cholesterol, triglycerides, blood pressure, tobacco and alcohol use. Individuals with serious mental illness show improvements in physical health and self-reported health after being involved in bidirectional integrated care.
CONCEPTUAL DEVELOPMENT
Ethics in integrated health care: social workers’ perspective
The proliferation of integrated health care in which a holistic approach of physical and behavioral health is addressed by multiple providers is quickly evolving to be the standard of care in the United States. Social workers are well-suited to be key members of these interdisciplinary teams. As a reference point for professional conduct, social workers are guided by a set of ethical standards. Given the nature of integrated healthcare settings, social workers may encounter unprecedented ethical challenges. This study provides an exploratory examination of the ethical situations among social workers in integrated health care.
CLINICAL PRACTICE
Factors related to providers screening children for behavioral health risks in primary care settings
Participants were a sample of physicians (n=319) and nurse practitioners (n=292) from across the U.S. who completed a confidential online survey about screening practices through a computer-assisted self-interview. Findings suggest a great amount of diversity in how providers screen for behavioral health risks. There is reluctance to screen when options for addressing the problems are limited. Research is needed to better guide healthcare providers in determining the right context and methods for screening social risks. Protocols for screening adverse childhood events (ACES) and other social risk factors should be accompanied by adequate training and efforts to improve community resource and support networks.
Despite strong extant support for exposure-based therapy for anxiety disorders, the use of exposure to treat anxiety in PC settings is low. Although barriers to exposure therapy (ET) may be exacerbated in PC settings, many anxiety presentations in PC warrant an exposure-based approach to treatment. Thus, exploration of feasibility and efficacy of ET in PC represents a critical area for advancing evidence-based treatment of anxiety symptoms. The current article addresses this gap through the presentation of two case examples of ET conducted in PCBH. Theoretical and practical information regarding the implementation of exposure using a brief (≤ 30 min), time-limited (4–6 visit) approached are presented. Results from the case examples demonstrate feasibility of conducting exposure in a brief format consistent with a PCBH approach. Additionally, patient outcomes presented suggest that ET conducted in PCBH reduces anxiety symptoms and may facilitate referral to specialty care settings.
A Stepped Care Model of Patient Navigation to Enhance Engagement with Perinatal Mental Health Care
During the perinatal period, women are at increased risk for developing perinatal mood and anxiety disorders (PMADs). As perinatal mental health screening efforts increase, significantly more women will be identified who require mental health services. Evidence-based treatments exist, yet many women do not receive adequate care. Patient navigation (PN) offers a promising patient-centered approach to improve treatment attendance and engagement. The purpose of this study is to describe the development of a stepped care PN service at an intensive outpatient program for women with PMADs. Our experience incorporating this model of PN revealed significant features that may guide other treatment care facilities to adopt this service to increase identification and connection to care.
IMPLEMENTATION RESEARCH
Primary care practices are in great need of practical guidance on the steps they can take to build behavioral health integration (BHI) capacities, particularly for smaller practice settings with fewer resources. 11 small primary care sites (≤ 5 providers) throughout New York State utilized a continuum framework of core components of BHI in combination with technical assistance. Surveys were collected at baseline, 6-months, and 12-months. Semi-structured interviews and focus groups were conducted during site visits, and a stakeholder roundtable was facilitated to address broader themes. Data were analyzed using qualitative thematic analysis. Practices reported successful engagement with the framework and actively participated in planning and advancing BHI operations. Greater success was observed in practices with existing on-site BHI services, identified champions for BHI, early and sustained training and involvement of providers and administrators, use of collaborative agreements with external behavioral health providers, and capacity to successfully receive reimbursements for BHI services. Advancing health information technologies was a challenge across sites. Financing and policy factors were viewed as critically important to advance integration efforts.
Definitions of “behavioral health integration” vary across disciplines and organizations, and little is known about how integrated behavioral health care is actually implemented in most pediatric settings. In addition, program evaluation activities have not included a thorough examination of long-term outcomes. This article provides detailed information on the implementation planning and evaluation activities for an integrated behavioral health program in pediatric primary care. This work has been guided by a logic model, an important implementation science tool to guide the development and evaluation of new programs and promote replication. The logic model and measurement plan we developed provides a guide for policy makers, researchers, and clinicians seeking to develop and evaluate similar programs in other systems and community settings. This work will enable greater adoption, implementation, and sustainment of integrated care models and increase access to high-quality care.
SPECIAL POPULATIONS
Even when diagnosed with a mental health disorder, Hispanics and Blacks were less likely to seek mental health treatment than Whites, highlighting the continuing disparity. Future research should focus on understanding how and what aspects of integrated care models and other mental health delivery models that reduce disparities and provide greater accessibility.
This review demonstrates that research on prenatal PTSD symptoms, diagnosis, and treatment is extremely limited despite a clear link between prenatal PTSD and perinatal complications. Early evidence supports further scientific inquiry into psychoeducation, psychotherapy treatments (e.g., exposure therapy), integrated prenatal care approaches, and community‐based approaches.
There is limited evidence of multi-level and multi-sector integration of services for older adults with multimorbidity in an English context. The literature increasingly acknowledges wider determinants of population health that are likely to require integration beyond primary care and social services. Improving clinical care in one or two sectors may not be as effective as simultaneously improving the organization or design across services as one single system of provision. This may take time to establish and will require local input.
WORKFORCE DEVELOPMENT
POLICY
Health care policies that increase funding to adopt integrated health services at community Hispanic-Serving Organizations may help decrease inequities in mental health access for Hispanics in the United States.
Mental health facilities are an integral piece of the behavioral health safety net and need to respond to changes in service needs. Findings suggest that mental health facilities have not shifted their services mix to address the ongoing suicide epidemic.
There is a need for a paradigm shift across mental health in primary care to improve the lives of millions of Europeans. To contribute to this paradigm shift, the European Forum for Primary Care (EFPC-MH) working group for Mental Health, produced a Position Paper for Primary Care Mental Health outlining 14 themes that needed prioritizing. These themes were developed and discussed interactively during the EFPC conferences between 2012 and 2019. The Position Paper on Mental Health gives direction to the necessary improvements over the next ten years. The themes vary from preferable healthcare model to the social determinants highlighting issues such as inequalities. The Statement of Mental Health in Primary Care will be established in cooperation with fellow organizations.
QUALITY IMPROVEMENT
Improving Access to Integrated Behavioral Health in a Nurse-Led Federally Qualified Health Center
For psychiatric nurse practitioners, this quality improvement effort provides evidence that a consultative role can be effective in supporting primary care providers. Through providing education, establishing patient tiers, and establishing an effective workflow, more patients may have access to psychiatric services.
Leave a Reply