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 6-7 months.
The top article on my list today is a report of strategies for integrating social care practices into primary care, an example of the expanding role of primary care. A related article is a systematic review of publications that describe care coordination between healthcare and social services. Results show there are common program elements, but limited details and study rigor. It seems we can do more to better understand best practices for linking healthcare delivery with social services.
A third article that got my attention is a claims-based retrospective analysis of the long-term effects of bundled payments on healthcare expenditures, showing an increase for those with multimorbidity. I have become more interested recently in how healthcare systems can decrease costs for our really sick patients.
Finally, a large retrospective analysis of completed referrals shows that patients with unstable finances were more likely to miss first appointments with a specialty behavioral health provider after referral from primary care. Authors did not observe other previously reported disparities (e.g., race, ethnicity, illness severity). This suggests integrated care programs should target patients with certain financial situations.
EFFECTIVENESS RESEARCH
Conducting a Pragmatic Trial in Integrated Primary Care: Key Decision Points and Considerations
Pragmatic trials testing the effectiveness of interventions under “real world” conditions help bridge the research-to-practice gap. Such trial designs are optimal for studying the impact of implementation efforts, such as the effectiveness of integrated behavioral health clinicians in primary care settings. The paper highlights key choice points using the PRagmatic-Explanatory Continuum Indicator Summary (PRECIS-2) tool. We discuss the dilemmas of pragmatic research that we faced and offer recommendations for aspiring integrated primary care pragmatic trialists.
Of the 1,302 participants with a primary depressive disorder referred by their primary care provider, 435 endorsed moderate to severe depression at baseline and engaged in at least one CBT session. This study indicates that CBT can be implemented within primary care and suggests that primary care patients with depression can benefit from integrated psychological services, supporting population-based models of care.
Medical Assistant Protocol Improves Disparities in Depression Screening Rates
This quasi-experimental study examines the impacts of a medical assistant screening protocol on the rates of depression screening, overall and by sociodemographic groups, in a primary care setting. A total of 45,157 visits by 21,377 unique patients were included. Overall, screening increased from 18% (physician-only screening) to 57% (medical assistant protocol) (p<0.0001). Screening increased for all measured demographics. With physician screening, depression screening was less likely to occur at visits by women (than at visits by men; OR=0.91, 95% CI=0.85, 0.98) and at visits by Black/African American patients (than at visits by White; OR=0.91, 95% CI=0.84, 0.99). Implementation of a medical assistant protocol in a primary care setting may significantly increase depression screening rates while mitigating or removing sociodemographic disparities.
CONCEPTUAL DEVELOPMENT
In this paper, we introduce a model of integrated behavioral health (IBH) in a primary care practice for adults with childhood onset medical and developmental conditions. Our discussion includes the role of IBH providers (i.e., psychologists, psychiatrists, and social workers) as members of the integrated team, patient engagement and response to treatment, and innovative ways we strive to meet patient needs. Our review of electronic health records of patients seen at the UR Medicine Complex Care Center suggest that IBH is feasible and highly utilized, with 216 patients (40%) having had contact with an IBH provider on the team at least once.
CLINICAL PRACTICE
The objective of our study was to describe the impact of the COVID-19 pandemic on primary care teams’ delivery of mental health care. A qualitative study using focus groups conducted with primary care teams in Ontario, Canada. Focus group data was analyzed using thematic analysis. We conducted 11 focus groups with 10 primary care teams and a total of 48 participants. From the outset of the COVID-19 pandemic, primary care quickly responded to the rising mental health care demands of their patients. Despite the numerous challenges they faced with the rapid transition to virtual care, primary care teams have persevered. It is essential that policy and decision-makers take note of the toll that these demands have placed on providers. There is an immediate need to enhance primary care’s capacity for mental health care for the duration of the pandemic and beyond.
IMPLEMENTATION RESEARCH
While behavioral health integration has been shown to lead to better patient outcomes and decreased costs, and while this practice is growing in popularity, still very few healthcare systems are utilizing this model. No dissemination and implementation study has developed a strategy for integration across a large healthcare system.
Applying Lessons from Behavioral Health Integration to Social Care Integration in Primary Care
Lessons learned from more than 2 decades of research on behavioral health integration could be applied to efforts to integrate social care into primary care. In this article, we synthesize learnings from primary care and behavioral health care integration, and translate them into organizing principles with the goal of advancing social care integration practices to improve the health of both patients and communities.
This study examined the transition to telehealth services during the COVID-19 pandemic in terms of attendance rates, the provision of evidence-based interventions, and clinical outcomes. Attendance significantly improved after the transition to telehealth, as indicated by fewer cancellations and more appointments attended. Patients showed significant improvement and decreases in symptoms. The quality of care was maintained, as indicated by consistent evidence-based intervention use over time.
In the context of a Colorado State Innovation Model (SIM) effort, we examined stakeholder readiness to advance and sustain partnerships for behavioral health integration beyond the period of grant funding. RCP analyses indicated a moderate level of readiness among Colorado stakeholders for partnering to continue the work of behavioral health integration initiated by SIM. Stakeholders indicated their highest readiness levels for general capacity and lowest for innovation-specific capacity.
An electronic search of the PubMed database identified 25 articles that met inclusion criteria. On average, studies utilized approximately six implementation strategies to facilitate implementation, with education (96%), quality management (64%), and planning (56%) strategies the most frequently reported. Promising evidence exists that patients and providers are accepting of BAI implementation efforts and implementation efforts are helpful in expanding the reach of BAIs.
SPECIAL POPULATIONS
The purpose of this paper is to examine the challenge of integrating care in this context using evidence from an evaluation of English hospital discharge services for people experiencing homelessness. The paper undertakes secondary analysis of qualitative data from a mixed methods evaluation of hospital discharge schemes and uses an established framework for understanding integrated care, the Rainbow Model of Integrated Care (RMIC), to help examine the complexities of integration in this area. The RMIC provided a strong framework for exploring the concept of integration, demonstrating how intertwined the elements of the framework are and, hence, that solutions need to be holistically organized across the RMIC.
This study examined whether documented disparities in access to behavioral health specialty care persisted in a novel integrated primary care model situated in a large health system when triage and referral management supports were provided by a centralized resource center for patients with behavioral health needs. Patients triaged and referred to specialty behavioral health care who did or did not attend a specialty care visit (N=1,450) were compared in terms of various demographic and clinical characteristics by using binary logistic regression. Among patients with attendance data, financially unstable individuals were more likely than financially stable counterparts to miss their first appointment with a specialty behavioral health provider after referral from primary care. Previously documented attendance disparities based on race, ethnicity, and illness severity were not observed. These findings can inform targeted strategies to increase attendance among patients with financial insecurity and reduce disparities in outpatient behavioral health services.
This article outlines the barriers to providing comprehensive and high-quality care to this pediatric population and describes a trauma-informed, integrated primary care medical home model as a promising strategy to address these barriers.
We conducted a systematic review of peer-reviewed publications that document the coordination of health care and social services in the United States. Results indicate that patient needs assessment, in-person patient contact, and standardized care coordination protocols are common across programs that bridge health care and social services. Publications discussing these programs often provide limited detail on other key elements of care coordination, especially the nature of referrals and care coordinator caseload.
Thirteen family practice physicians in rural locations participated in in-depth semi-structured interviews. Physicians described a lack of quality behavioral health services and challenges for integrating and collaborating with those that do exist. Participants also described the changing role of stigma, service delivery strategies that are currently working, and the unique role primary care plays in rural behavioral health care.
Rural versus urban primary care patients’ behavioral health needs and service utilization.
This study compared behavioral health needs, service utilization, and functional improvement of adult patients receiving behavioral health services at rural (n = 116) and urban (n = 77) primary care clinics, both part of a large federally qualified health center. Contrary to our hypotheses, rural patients did not evince higher medical or behavioral health symptoms than did urban patients. A larger proportion of patients from the rural clinic utilized behavioral health services and were more likely to reside in cities that were not in the same location as the clinic as compared to urban patients. Rural and urban patients attended a similar number of behavioral health sessions.
A retrospective file audit was conducted for all patients accepted into the service over a 6-month period in 2018. At admission, the three most common presentations were depression/anxiety, trauma and stress related, and psychotic disorders. During their time in the service, young people displayed a statistically significant improvement in functioning, reduction in self-harm in those 18 years and under, and a trend to reduction in distress scores. hEIT delivered a broad range of services covering social, occupational, educational, medical and mental health care, and the service was experienced positively by the patient cohort.
LGBTQ-Affirmative Behavioral Health Services in Primary Care
LGBTQ-affirming behavioral health providers in primary care can offer a unique service by conducting tailored evaluations and interventions targeting the sexual and gender minority stress influences that perpetuate psychological distress in LGBTQ patients.
WORKFORCE DEVELOPMENT
This commentary provides an overview of the process by which an integrated primary healthcare workforce planning toolkit was co-developed by university-based researchers with the Canadian Health Workforce Network and partners within a major urban regional health authority. The co-development process was guided by a conceptual framework emphasizing the key principles of sound health workforce planning: that it (1) be informed by evidence both quantitative and qualitative in nature; (2) be driven by population health needs and achieve population, worker and system outcomes; (3) recognize that deployment is geographically based and interprofessionally bound within a complex adaptive system; and (4) be embedded in a cyclical process of aligning evolving population health needs and workforce capacity.
POLICY
All Hands on Deck: Addressing Adolescent Depression in Pediatric Primary Care
This study examines prevalence rates of elevated depression symptoms utilizing the Patient Health Questionnaire-9 Item Modified for Adolescents (PHQ-9A), characterizes recommendations and interventions by primary care providers (PCPs) and behavioral health clinicians (BHCs) in response to elevated PHQ-9As, and identifies factors associated with improved PHQ-9A scores at follow-up pediatric primary care visits.
Slow Progress in Mental and Behavioral Health, but Far More Is Needed
NEJM Catalyst Insights Council members say the range of mental and behavioral health services offered by their organizations has grown, but many barriers remain, even as the Covid-19 pandemic has taken a major toll.
We aimed to assess the long-term effects of bundled payments on healthcare expenditure. We used health insurance claims data from 2008 to 2015 to compare the healthcare expenditure between everyone who was included in bundled payments and a control group. We performed a difference-in-difference analysis in combination with propensity score matching and found that bundled payments consistently increased health care expenditure over seven years. The increase was higher for those with multimorbidity compared to those without multimorbidity. This suggests that the expectations of the bundled payments are yet to be fulfilled.
QUALITY IMPROVEMENT
This report details ongoing efforts to improve integration in the 2 years following implementation of the Primary Care Behavioral Health model at a general internal medicine clinic of an urban academic medical center. Main ongoing barrier to integration was insufficient behavioral health staff to meet patient demand for behavioral health services.
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