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Beaudin J, Chouinard MC, Hudon É, Hudon C. Integrated self-management support provided by primary care nurses to persons with chronic diseases and common mental disorders: a qualitative study. BMC PRIMARY CARE 2024; 25:212. [PMID: 38867162 PMCID: PMC11167744 DOI: 10.1186/s12875-024-02464-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 06/03/2024] [Indexed: 06/14/2024]
Abstract
BACKGROUND More and more people suffer from concomitant chronic physical diseases and common mental disorders, calling for integrated self-management support in primary care. However, self-management support of chronic physical diseases and common mental disorders is not clearly operationalized by guidelines and is still conducted in silos by primary care nurses, especially in favour of chronic diseases. This study aims to better understand primary care nurses' experience of integrated self-management support for people with physical chronic diseases and common mental disorders. METHODS An interpretive descriptive qualitative approach was conducted with 23 primary care nurses from family medicine groups in Quebec (Canada). They were selected through purposive and snowball sampling methods to participate in an individual interview. Data were analysed using an iterative inductive and deductive analysis (Rainbow Model of Integrated Care and the Practical Reviews in Self-Management Support (PRISMS) taxonomy). RESULTS Nurses' experience of integrated self-management support for people with CD and CMD was structured around: (1) elements of the approach; (2) clinical integration through prevention and health promotion; and (3) operationalization of integrated self-management support. Several elements deemed essential to integrated self-management support were identified. Nurses offered integrated self-management support through prevention of risk factors and promotion of a healthy lifestyle for physical chronic diseases and common mental disorders. Nurses' self-management support activities included education, action plans, monitoring, and many practical, psychological, and social support strategies. A model of integrated self-management support for primary care nursing is proposed to better understand its clinical integration. CONCLUSION This study presents clinical integration of self-management support and activities for people with physical chronic diseases and common mental disorders in primary care settings. Understanding integrated self-management support will help implement future interventions.
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Affiliation(s)
- Jérémie Beaudin
- Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, 3001, 12e Avenue Nord, Sherbrooke, Québec, J1H 5N4, Canada.
- Module des sciences infirmières, Université du Québec à Chicoutimi, 555 Bd de l'Université, Chicoutimi, Québec, G7H 2B1, Canada.
| | - Maud-Christine Chouinard
- Faculté des sciences infirmières, Université de Montréal, Pavillon Marguerite-d'Youville, C.P. 6128 succ. Centre-ville, Montréal, Québec, Canada, H3C 3J7
| | - Émilie Hudon
- Module des sciences infirmières, Université du Québec à Chicoutimi, 555 Bd de l'Université, Chicoutimi, Québec, G7H 2B1, Canada
| | - Catherine Hudon
- Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, 3001, 12e Avenue Nord, Sherbrooke, Québec, J1H 5N4, Canada
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Matthews EB, Lushin V, Macneal E, Marcus SC. The Impact of Structural Integration on Clinical Outcomes among Individuals with Serious Mental Illness and Chronic Illness. Community Ment Health J 2024:10.1007/s10597-024-01293-4. [PMID: 38850504 DOI: 10.1007/s10597-024-01293-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 05/10/2024] [Indexed: 06/10/2024]
Abstract
Though considered a best practice, there is substantial variation in how integrated behavioral health (IBH) services are structured. This study examined the impact of IBH structure on health outcomes among individuals with serious mental illness (SMI) and chronic disease receiving care in community health centers (CHCs). Data from the ADVANCE network identified 8,548 individuals with co-occurring SMI diabetes and 16,600 with an SMI and hypertension. Logistic regression tested whether IBH type impacted disease specific health outcomes among these populations. Among those with diabetes or hypertension, colocated care was associated with better health outcomes related to HbA1c, blood pressure control, and BMI compared to less coordinated and unintegrated care, though there was significant variation in this relationship across SMI diagnoses. Results reflect that colocation of primary care and behavioral health may improve outcomes for individuals with bipolar disorder or major depression and chronic disease, but that CHC-based integrated care may not be optimized for individuals with schizophrenia.
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Affiliation(s)
- Elizabeth B Matthews
- Graduate School of Social Service, Fordham University, 113 W. 60th St, New York, NY, 10023, USA.
| | - Viktor Lushin
- National Institutes of Mental Health, 6001 Executive Boulevard, MSC 9663, Bethesda, MD, 20892-9663, USA
| | - Eliza Macneal
- Center for Mental Health, University of Pennsylvania, 3535 Market St, Philadelphia, PA, 19104, USA
| | - Steve C Marcus
- Center for Mental Health, University of Pennsylvania, 3535 Market St, Philadelphia, PA, 19104, USA
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Pereira LM, Mallela JL, Carroll AJ, Washburn JJ, Robiner WN. Psychologists and Integrated Behavioral Health Simulation Training: A Survey of Medical Educators and Perspectives of Directors of Clinical Training. J Clin Psychol Med Settings 2024; 31:304-315. [PMID: 38615281 DOI: 10.1007/s10880-024-10015-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2024] [Indexed: 04/15/2024]
Abstract
It is well established that the integration of behavioral healthcare into the medical home model improves patient outcomes, reduces costs, and increases resident learning. As academic health centers increasingly integrate behavioral healthcare, targeted training for interprofessional collaboration around behavioral healthcare is needed. Simulation educational approaches potentially can provide this training. Health service psychologists are well-poised to support this because of their specialized training in integrated healthcare. The present exploratory study aimed to evaluate existing simulation programs and develop recommendations for integrated behavioral health training and evaluation. Directors of ACGME accredited residency programs that are high utilizers of the medical home model (Pediatrics, Internal Medicine, Medicine/Pediatrics, Family Medicine) as well as Psychiatry residencies and medical schools with membership in the Society for Simulation in Healthcare were recruited to complete a 26-item survey to assess program usage of psychologists as part of simulation training for integrated behavioral healthcare services. Of 79 participants who completed initial items describing their training program, only 32 programs completed the entire survey. While many academic health centers offered integrated team and behavioral health simulations, few utilized psychology faculty in design, implementation, and evaluation. Other behavioral health providers (psychiatrists, social workers) were often involved in medical school and pediatric residency simulations. Few institutions use standardized evaluation. Qualitative feedback and faculty-written questionnaires were often used to evaluate efficacy. Survey responses suggest that psychologists play limited roles in integrated behavioral healthcare simulation despite their expertise in interdisciplinary training, integrated behavioral healthcare, and program evaluation.
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Affiliation(s)
- Lila M Pereira
- Division of Hematology/Oncology/SCT, Department of Pediatrics, New York Medical College, 19 Skyline Dr, Rm1NH12, Valhalla, NY, 10595, USA.
| | - Jaya L Mallela
- Division of Hematology/Oncology/SCT, Department of Pediatrics, New York Medical College, 19 Skyline Dr, Rm1NH12, Valhalla, NY, 10595, USA
| | - Allison J Carroll
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jason J Washburn
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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4
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Shepardson RL, Weisberg RB, Wade M, Maisto SA, Funderburk JS. Brief modular anxiety intervention for primary care: Hybrid I pilot randomized controlled trial of feasibility, acceptability, effectiveness, and implementation potential. J Affect Disord 2024; 361:497-507. [PMID: 38810782 DOI: 10.1016/j.jad.2024.05.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 04/30/2024] [Accepted: 05/21/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND Anxiety is highly prevalent, but undertreated, in primary care. Brief, non-pharmacological interventions are needed. Modular Anxiety Skills Training (MAST), a cognitive-behavioral anxiety intervention, was developed for primary care and tailored for a Veteran sample (MAST-V). The purpose of this mixed methods pilot study was to evaluate MAST-V's feasibility, acceptability, and implementation potential, and preliminarily examine its effectiveness compared to Primary Care Behavioral Health (PCBH) usual care. METHODS This hybrid I randomized controlled trial (conducted 2019-2021) assigned 35 primary care patients (Mage = 47, 17 % female, 27 % racial/ethnic minority) with clinically significant anxiety symptoms to receive MAST-V or PCBH usual care. Participants completed validated measures of anxiety symptoms and functional impairment at 0, 4, 8, 12, and 16 weeks. RESULTS Participants attended more sessions in MAST-V than usual care. After necessary adjustments to reduce session duration, MAST-V will likely fit within PCBH practice parameters. Participants in both conditions valued treatment, but treatment satisfaction, credibility, and therapeutic alliance were higher for MAST-V. Study therapists achieved high treatment fidelity and rated MAST-V as highly feasible, acceptable, and appropriate for PCBH. They identified ways to address potential barriers to implementation. MAST-V was more effective than usual care in reducing anxiety symptoms and impairment. LIMITATIONS This was a small pilot study at a single site using study therapists. Results should be considered preliminary until replicated in a full-scale clinical trial. CONCLUSIONS This brief modular anxiety intervention, which was designed with implementation in mind, may help to address the anxiety treatment gap in primary care.
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Affiliation(s)
- Robyn L Shepardson
- Center for Integrated Healthcare, Syracuse VA Medical Center. USA; Department of Psychology, Syracuse University. USA.
| | - Risa B Weisberg
- VA, Boston Healthcare System. USA; Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine. USA; Department of Family Medicine, Alpert Medical School, Brown University. USA
| | - Michael Wade
- Center for Integrated Healthcare, Syracuse VA Medical Center. USA
| | - Stephen A Maisto
- Center for Integrated Healthcare, Syracuse VA Medical Center. USA; Department of Psychology, Syracuse University. USA
| | - Jennifer S Funderburk
- Center for Integrated Healthcare, Syracuse VA Medical Center. USA; Department of Psychology, Syracuse University. USA; Department of Psychiatry, University of Rochester. USA
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Woodward EN, Cornwell BL, Wray LO, Pomerantz AS, Kirchner JE, McCarthy JF, Kearney LK. Impact of Primary Care-Mental Health Care Integration on Mental Health Care Engagement Across Racial and Ethnic Groups. Psychiatr Serv 2024; 75:369-377. [PMID: 38321918 DOI: 10.1176/appi.ps.20220631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
OBJECTIVE Receiving mental health services as part of primary care in the Veterans Health Administration (VHA) might increase engagement in specialty mental health care. The authors reexamined the association between primary care-mental health integration (PCMHI) and continued engagement in specialty mental health care for VHA patients and assessed differences by race and ethnicity. METHODS The study included 437,051 primary care patients with a first in-person specialty mental health encounter in 2015-2016 (no specialty mental health encounters in prior 12 months), including 46,417 patients with new PCMHI encounters in the year before the first specialty mental health encounter. Multivariable logistic regression assessed odds of follow-up specialty mental health care within 3 months of the first specialty mental health encounter. The dependent variable was care engagement (attending a second specialty mental health appointment); independent variables were whether patients were seen by PCMHI on the same day as the primary care appointment ("same-day access"), the time between PCMHI and first specialty mental health appointments, and race and ethnicity. RESULTS PCMHI was associated with increased engagement in specialty mental health care for all patients, with a greater likelihood of engagement among non-Hispanic White patients. Same-day access to PCMHI was positively associated with care engagement, with no significant differences by race or ethnicity. PCMHI care within 3 months before a first specialty mental health encounter was associated with greater care engagement. CONCLUSIONS PCMHI, especially same-day access to PCMHI care, may boost engagement in mental health care, although the study design precluded conclusions regarding causal relationships.
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Affiliation(s)
- Eva N Woodward
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, U.S. Department of Veterans Affairs (VA), and Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Woodward); Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health and Suicide Prevention, Veterans Health Administration, Ann Arbor (Cornwell); VA Center for Integrated Healthcare and Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo (Wray); Office of Mental Health and Suicide Prevention, Veterans Health Administration, Washington, D.C., and Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire (Pomerantz); VA Behavioral Health Quality Enhancement Research Initiative, Central Arkansas Veterans Healthcare System, North Little Rock, and Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Kirchner); Center for Clinical Management Research, VA, and Department of Psychiatry, University of Michigan, Ann Arbor (McCarthy); Office of Mental Health and Suicide Prevention, VA, Washington, D.C., and University of Texas Health Science Center at San Antonio, San Antonio, Texas (Kearney)
| | - Brittany L Cornwell
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, U.S. Department of Veterans Affairs (VA), and Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Woodward); Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health and Suicide Prevention, Veterans Health Administration, Ann Arbor (Cornwell); VA Center for Integrated Healthcare and Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo (Wray); Office of Mental Health and Suicide Prevention, Veterans Health Administration, Washington, D.C., and Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire (Pomerantz); VA Behavioral Health Quality Enhancement Research Initiative, Central Arkansas Veterans Healthcare System, North Little Rock, and Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Kirchner); Center for Clinical Management Research, VA, and Department of Psychiatry, University of Michigan, Ann Arbor (McCarthy); Office of Mental Health and Suicide Prevention, VA, Washington, D.C., and University of Texas Health Science Center at San Antonio, San Antonio, Texas (Kearney)
| | - Laura O Wray
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, U.S. Department of Veterans Affairs (VA), and Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Woodward); Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health and Suicide Prevention, Veterans Health Administration, Ann Arbor (Cornwell); VA Center for Integrated Healthcare and Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo (Wray); Office of Mental Health and Suicide Prevention, Veterans Health Administration, Washington, D.C., and Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire (Pomerantz); VA Behavioral Health Quality Enhancement Research Initiative, Central Arkansas Veterans Healthcare System, North Little Rock, and Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Kirchner); Center for Clinical Management Research, VA, and Department of Psychiatry, University of Michigan, Ann Arbor (McCarthy); Office of Mental Health and Suicide Prevention, VA, Washington, D.C., and University of Texas Health Science Center at San Antonio, San Antonio, Texas (Kearney)
| | - Andrew S Pomerantz
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, U.S. Department of Veterans Affairs (VA), and Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Woodward); Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health and Suicide Prevention, Veterans Health Administration, Ann Arbor (Cornwell); VA Center for Integrated Healthcare and Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo (Wray); Office of Mental Health and Suicide Prevention, Veterans Health Administration, Washington, D.C., and Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire (Pomerantz); VA Behavioral Health Quality Enhancement Research Initiative, Central Arkansas Veterans Healthcare System, North Little Rock, and Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Kirchner); Center for Clinical Management Research, VA, and Department of Psychiatry, University of Michigan, Ann Arbor (McCarthy); Office of Mental Health and Suicide Prevention, VA, Washington, D.C., and University of Texas Health Science Center at San Antonio, San Antonio, Texas (Kearney)
| | - JoAnn E Kirchner
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, U.S. Department of Veterans Affairs (VA), and Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Woodward); Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health and Suicide Prevention, Veterans Health Administration, Ann Arbor (Cornwell); VA Center for Integrated Healthcare and Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo (Wray); Office of Mental Health and Suicide Prevention, Veterans Health Administration, Washington, D.C., and Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire (Pomerantz); VA Behavioral Health Quality Enhancement Research Initiative, Central Arkansas Veterans Healthcare System, North Little Rock, and Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Kirchner); Center for Clinical Management Research, VA, and Department of Psychiatry, University of Michigan, Ann Arbor (McCarthy); Office of Mental Health and Suicide Prevention, VA, Washington, D.C., and University of Texas Health Science Center at San Antonio, San Antonio, Texas (Kearney)
| | - John F McCarthy
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, U.S. Department of Veterans Affairs (VA), and Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Woodward); Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health and Suicide Prevention, Veterans Health Administration, Ann Arbor (Cornwell); VA Center for Integrated Healthcare and Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo (Wray); Office of Mental Health and Suicide Prevention, Veterans Health Administration, Washington, D.C., and Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire (Pomerantz); VA Behavioral Health Quality Enhancement Research Initiative, Central Arkansas Veterans Healthcare System, North Little Rock, and Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Kirchner); Center for Clinical Management Research, VA, and Department of Psychiatry, University of Michigan, Ann Arbor (McCarthy); Office of Mental Health and Suicide Prevention, VA, Washington, D.C., and University of Texas Health Science Center at San Antonio, San Antonio, Texas (Kearney)
| | - Lisa K Kearney
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, U.S. Department of Veterans Affairs (VA), and Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Woodward); Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health and Suicide Prevention, Veterans Health Administration, Ann Arbor (Cornwell); VA Center for Integrated Healthcare and Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo (Wray); Office of Mental Health and Suicide Prevention, Veterans Health Administration, Washington, D.C., and Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire (Pomerantz); VA Behavioral Health Quality Enhancement Research Initiative, Central Arkansas Veterans Healthcare System, North Little Rock, and Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock (Kirchner); Center for Clinical Management Research, VA, and Department of Psychiatry, University of Michigan, Ann Arbor (McCarthy); Office of Mental Health and Suicide Prevention, VA, Washington, D.C., and University of Texas Health Science Center at San Antonio, San Antonio, Texas (Kearney)
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Falgas-Bague I, Melero-Dominguez M, de Vernisy-Romero D, Tembo T, Chembe M, Lubozha T, Paul R, Parkerson D, Rockers PC, Sikazwe D, Fink G. Testing the feasibility, acceptability, and exploring trends on efficacy of the problem management plus for moms: Protocol of a pilot randomized control trial. PLoS One 2024; 19:e0287269. [PMID: 38181004 PMCID: PMC10769019 DOI: 10.1371/journal.pone.0287269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 11/24/2023] [Indexed: 01/07/2024] Open
Abstract
Mental health disorders are one of the most common causes that limit the ability of mothers to care for themselves and for their children. Recent data suggest high rates of distress among women in charge of young children in Zambia. Nevertheless, Zambia's public healthcare offers very limited treatment for common mental health distress. To address this treatment gap, this study aims to test the feasibility, acceptability, and potential efficacy of a context-adapted psychosocial intervention. A total of 265 mothers with mental health needs (defined as SRQ-20 scores above 7) were randomly assigned with equal probability to the intervention or control group. The intervention group will receive a locally adapted version of the Problem-Management Plus and "Thinking Healthy" interventions developed by the World Health Organization (WHO), combined with specific parts of the Strong Minds-Strong Communities intervention. Trained and closely supervised wellbeing-community health workers will provide the psychosocial intervention. Mental health distress and attendance to the intervention will be assessed at enrollment and 6 months after the intervention. We will estimate the impact of the intervention on mental health distress using an intention-to-treat approach. We previously found that there is a large necessity for interventions that aim to address mother anxiety/depression problems. In this study, we tested the feasibility and efficacy of an innovative intervention, demonstrating that implementing these mental health treatments in low-income settings, such as Zambia, is viable with an adequate support system. If successful, larger studies will be needed to test the effectiveness of the intervention with increased precision. Trial registration: This study is registered at clinicaltrials.gov as NCT05627206.
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Affiliation(s)
- Irene Falgas-Bague
- Department of Epidemiology and Public Health. Swiss Tropical and Public Health Institute, Basel, Switzerland
- Faculty of Economics, University of Basel, Basel, Switzerland
- Disparities Research Unit, Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Department of Medicine. Harvard Medical School, Boston, Massachusetts, United States of America
| | - Maria Melero-Dominguez
- Department of Epidemiology and Public Health. Swiss Tropical and Public Health Institute, Basel, Switzerland
- Disparities Research Unit, Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Daniela de Vernisy-Romero
- Department of Epidemiology and Public Health. Swiss Tropical and Public Health Institute, Basel, Switzerland
- Department of Global Health. Boston University School of Public Health, Boston, Massachusetts, United States of America
| | | | - Mpela Chembe
- Innovations for Poverty Action, New York, New York, New York, United States of America
| | - Theresa Lubozha
- Innovations for Poverty Action, New York, New York, New York, United States of America
| | - Ravi Paul
- Department of Psychiatry, University of Zambia, Lusaka, Zambia
| | - Doug Parkerson
- Innovations for Poverty Action, New York, New York, New York, United States of America
| | - Peter C. Rockers
- Department of Global Health. Boston University School of Public Health, Boston, Massachusetts, United States of America
| | | | - Günther Fink
- Department of Epidemiology and Public Health. Swiss Tropical and Public Health Institute, Basel, Switzerland
- Faculty of Economics, University of Basel, Basel, Switzerland
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Nyman SJ, Vogel ME, Heller GM, Hella JR, Illes RA, Kirkpatrick HA. Development and Evaluation of a Health Behavior Change Clinic in Primary Care: An Interdisciplinary Partnership. J Clin Psychol Med Settings 2023; 30:909-923. [PMID: 36869987 PMCID: PMC9985097 DOI: 10.1007/s10880-023-09945-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2023] [Indexed: 03/05/2023]
Abstract
Providing effective healthy behavior change interventions within primary care presents numerous challenges. Obesity, tobacco use, and sedentary lifestyle negatively impact the health quality of numerous medical patients, particularly in underserved patient populations with limited resources. Primary Care Behavioral Health (PCBH) models, which incorporate a Behavioral Health Consultant (BHC), can offer point-of-contact psychological consultation, treatment, and also provide opportunities for interdisciplinary psychologist-physician clinical partnerships to pair a BHC's health behavior change expertise with the physician's medical care. Such models can also enhance medical training programs by providing resident physicians with live, case-based learning opportunities when partnered with a BHC to address patient health behaviors. We will describe the development, implementation, and preliminary outcomes of a PCBH psychologist-physician interdisciplinary health behavior change clinic within a Family Medicine residency program. Patient outcomes revealed significant reductions (p < .01) in weight, BMI, and tobacco use. Implications and future directions are discussed.
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Affiliation(s)
- Scott J. Nyman
- Department of Clinical Health Psychology, Ascension Genesys Hospital, Grand Blanc, MI USA
- Departments of Family Medicine and Psychiatry, Michigan State University College of Human Medicine, Lansing, MI USA
- Department of Psychology, Ascension Genesys Family Health Center, 1460 N. Center Rd, Burton, MI 48509 USA
| | - Mark E. Vogel
- Department of Clinical Health Psychology, Ascension Genesys Hospital, Grand Blanc, MI USA
- Departments of Family Medicine and Psychiatry, Michigan State University College of Human Medicine, Lansing, MI USA
| | - Grant M. Heller
- Spectrum Health Lakeland, Saint Joseph, MI USA
- Department of Psychiatry, Michigan State University College of Osteopathic Medicine, Lansing, MI USA
| | - Jennifer R. Hella
- Department of Research, Ascension Genesys Hospital, Grand Blanc, MI USA
| | - Rose A. Illes
- Florida State University Family Medicine Residency Program at Lee Health, Fort Myers, FL USA
| | - Heather A. Kirkpatrick
- Department of Clinical Health Psychology, Ascension Genesys Hospital, Grand Blanc, MI USA
- Departments of Family Medicine and Psychiatry, Michigan State University College of Human Medicine, Lansing, MI USA
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Kerrissey M, Jamakandi S, Alcusky M, Himmelstein J, Rosenthal M. Integration on the Frontlines of Medicaid Accountable Care Organizations and Associations With Perceived Care Quality, Health Equity, and Satisfaction. Med Care Res Rev 2023; 80:519-529. [PMID: 37232171 DOI: 10.1177/10775587231173474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Amid enthusiasm about accountable care organizations (ACOs) in Medicaid, little is known about the primary care practices engaging in them. We leverage a survey of administrators within a random sample (stratified by ACO) of 225 practices joining Massachusetts Medicaid ACOs (64% response rate; 225 responses). We measure the integration of processes with distinct entities: consulting clinicians, eye specialists for diabetes care, mental/behavioral care providers, and long-term and social services agencies. Using multivariable regression, we examine organizational correlates of integration and assess integration's relationships with care quality improvement, health equity, and satisfaction with the ACO. Integration varied across practices. Clinical integration was positively associated with perceived care quality improvement; social service integration was positively associated with addressing equity; and mental/behavioral and long-term service integration were positively associated with ACO satisfaction (all p < .05). Understanding differences in integration at the practice level is vital for sharpening policy, setting expectations, and supporting improvement in Medicaid ACOs.
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Affiliation(s)
| | | | - Matthew Alcusky
- University of Massachusetts Chan Medical School, Worcester, USA
| | - Jay Himmelstein
- University of Massachusetts Chan Medical School, Worcester, USA
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Shepardson RL, Funderburk JS, Weisberg RB, Maisto SA. Brief, modular, transdiagnostic, cognitive-behavioral intervention for anxiety in veteran primary care: Development, provider feedback, and open trial. Psychol Serv 2023; 20:622-635. [PMID: 35099230 PMCID: PMC10166236 DOI: 10.1037/ser0000622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Anxiety is undertreated in primary care, and most treatment provided is pharmacological rather than behavioral. Integrating behavioral health providers (BHPs) using the Primary Care Behavioral Health (PCBH) model can help address this treatment gap, but brief interventions suitable for use in PCBH practice are needed. We developed a modular, cognitive-behavioral anxiety intervention, Modular Anxiety Skills Training (MAST), that is evidence-based, transdiagnostic, feasible for PCBH, and patient-centered. MAST comprises up to six 30-min sessions emphasizing skills training. This article describes the rationale for and development of MAST as well as pilot work in the Veterans Health Administration (VA) to tailor and refine MAST for delivery to Veterans in VA primary care (MAST-V) to improve feasibility for VA BHPs and acceptability to Veterans. We used a convergent mixed-methods design with concurrent data collection. In phase one, we interviewed five BHPs to obtain feedback on the treatment manual. BHPs assessed MAST-V to be highly compatible with PCBH and provided suggestions to enhance feasibility. In phase two, we conducted an open trial in which six Veterans experiencing clinically significant anxiety received and provided feedback on all nine possible modules; we also assessed changes in mental health symptoms and functioning as well as treatment satisfaction and credibility. Veterans found MAST-V to be highly acceptable, and pre-post clinical outcomes were very promising with large effect sizes. Findings from this initial pilot provide preliminary support for the feasibility, acceptability, and efficacy of MAST-V and suggest further research with a randomized clinical trial is warranted. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
- Robyn L. Shepardson
- Center for Integrated Healthcare, Syracuse VA Medical Center
- Department of Psychology, Syracuse University
| | - Jennifer S. Funderburk
- Center for Integrated Healthcare, Syracuse VA Medical Center
- Department of Psychology, Syracuse University
- Department of Psychiatry, University of Rochester
| | - Risa B. Weisberg
- VA Boston Healthcare System
- Department of Psychiatry, Boston University School of Medicine
- Department of Family Medicine, Alpert Medical School, Brown University
| | - Stephen A. Maisto
- Center for Integrated Healthcare, Syracuse VA Medical Center
- Department of Psychology, Syracuse University
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10
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Leffler JM, Romanowicz M, Brennan E, Elmaghraby R, Caflisch S, Lange H, Kirtley AT. Integrated Case Presentation Seminar: Bridging Parallel Fields to Improve Psychiatry and Psychology Learner Experience. Child Psychiatry Hum Dev 2023:10.1007/s10578-023-01522-z. [PMID: 36869965 PMCID: PMC9984746 DOI: 10.1007/s10578-023-01522-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/26/2023] [Indexed: 03/05/2023]
Abstract
Daily clinical practice of mental health professionals often requires interaction between providers from diverse training and professional backgrounds. Efforts to engage mental health trainees across disciplines are necessary and have had varied outcomes. The current study reviews the development and implementation of a monthly one-hour integrated case presentation seminar (ICPS) as part of independent psychology and psychiatry two-year fellowships at a Midwestern teaching hospital. The training integrated a semi-structured seminar to facilitate case presentation within a group setting. The focus of the seminar was to allow for exposure to conceptualization, diagnostic, and treatment strategies and skills, as well as science-based practice techniques for trainees. Learner survey results and the sustained offering of the seminar suggest the format and goals of the seminar are feasible and acceptable. Based on the current preliminary findings, similar training programs may find benefit in strategies to enhance integrated training opportunities for psychiatry and psychology trainees.
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Affiliation(s)
- Jarrod M Leffler
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First Street SW, Rochester, MN, USA.
| | - Magdalena Romanowicz
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Elle Brennan
- Division of NeuroBehavioral Health, Akron Children's Hospital, 215 W. Bowery St, Akron, OH, 44308, USA
| | - Rana Elmaghraby
- Department of Psychiatry, University of Washington, Seattle, WA, USA
- Behavioral Health Services, Sea Mar Community Center, Washington Sea Mar Community Health Centers, 14508 NE 20th Ave. Suite #305, Vancouver, WA, 98686, USA
| | - Sara Caflisch
- University of Wisconsin-Eau Claire, Eau Claire, WI, USA
| | - Hadley Lange
- Minnesota Epilepsy Group, 225 Smith Ave N #201, St. Paul, MN, USA
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11
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Funderburk JS, Gass JC, Wray JM, Shepardson RL. Prevalence and predictors of team-based care activities between primary care providers and embedded behavioral health providers: a national survey. J Interprof Care 2023; 37:58-65. [PMID: 34979874 DOI: 10.1080/13561820.2021.2004098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Primary care (PC) settings increasingly use team-based care activities with embedded behavioral health providers (BHPs) to enhance patient care via group medical visits, conjoint appointments, team huddles, and warm handoffs. Aim 1 was to describe the variation of team-based care activities within integrated PC clinics. Aim 2 was to explore whether factors associated with the BHP (e.g., gender, training, and experience) and the PC setting (e.g., perceived teamwork) predict engagement in team-based activities. A national sample of eligible BHPs (n = 345; 14.2% response rate) completed an anonymous survey assessing the presence/intensity of team-based care activities. 90% of BHPs reported regularly engaging in team-based care activities with PC teams. Most engagement occurred when providing feedback to PC providers (90.4% at least daily) and during warm handoffs (90.4% at least once daily). Engagement in team-based care was predicted by the level of teamwork occurring within the PC clinic (βs = .41-.47; ps < .001) and BHP characteristics, such as the number of years spent in PC (βs = .24-.26, ps < .001). Although these data are promising, with many BHPs reportedly engaging in team-based activities with PC teams, there is significant variation. Researchers should continue to explore whether the engagement in these team-based care activities enhances patient care.
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Affiliation(s)
- Jennifer S Funderburk
- VA Center for Integrated Healthcare, Syracuse VA Medical Center, Syracuse, NY, USA.,Department of Psychology, Syracuse University, Syracuse, NY, USA.,Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA
| | - Julie C Gass
- Va Center for Integrated Healthcare, Western New York Va Healthcare System, Buffalo, NY, USA.,Department of Psychology, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Jennifer M Wray
- VA Center for Integrated Healthcare, Syracuse VA Medical Center, Syracuse, NY, USA.,Department of Psychology, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Robyn L Shepardson
- VA Center for Integrated Healthcare, Syracuse VA Medical Center, Syracuse, NY, USA.,Department of Psychology, Syracuse University, Syracuse, NY, USA
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12
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Social Factors Predict Treatment Engagement in Veterans with PTSD or SUD. J Behav Health Serv Res 2022; 50:286-300. [PMID: 36456866 DOI: 10.1007/s11414-022-09823-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2022] [Indexed: 12/03/2022]
Abstract
Veterans with PTSD and SUDs often fail to initiate, or prematurely discontinue, mental health treatment in Veteran Affairs Medical Centers (VAMC). While much is known about clinical characteristics and demographic factors impacting treatment engagement in this population, less is known about the role of social factors. This retrospective study examines primary care-based screening assessment and specialty mental healthcare appointment data in a VAMC, to test whether social factors predict treatment initiation and appointment attendance. Findings reveal veterans were more likely to initiate treatment when (a) those with SUDs (n = 235) reported more frequent negative exchanges with others and (b) those with PTSD (n = 2107) reported more perceived support or being partnered. Those with PTSD who were partnered had higher appointment attendance rates. Findings suggest social factors are relevant to treatment initiation among veterans with PTSD and SUDs and that close others may be helpful in facilitating referrals.
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13
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Pardes A, Rene R, Chun P, Cherson M. Technology-enabled Behavioral Health Integration Decreases Emergency Department Utilization. Clin Pract Epidemiol Ment Health 2022; 18:e174501792208150. [PMID: 37274856 PMCID: PMC10158075 DOI: 10.2174/17450179-v18-e2208150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 06/09/2022] [Accepted: 06/15/2022] [Indexed: 06/07/2023]
Abstract
Background Behavioral health integration allows for patient-centered care, leads to higher levels of provider-patient engagement, and is key to improving patient outcomes. However, behavioral health integration is administratively burdensome and therefore is often not adopted. Technology presents opportunities to increase care team efficiency and improve patient outcomes. The goal of this study was to retrospectively compare clinical outcomes and emergency department utilization in patients using a technology platform compared to patients receiving treatment as usual. Methods The technology platform, NeuroFlow, was deployed to deliver technology-enabled behavioral health integration in 30 clinics, and 598 electronic health records were analyzed. Results In the six-month period following technology-enabled behavioral health integration implementation, emergency department utilization decreased by 34% in the treatment group (n=259), while increasing by 58% in the treatment as usual group (n=339). Additionally, statistically significant (p < .01) decreases in PHQ-9 (-17.3%) and GAD-7 (-12.4%) scores were only observed in the treatment group. Conclusion Findings from this study support use of a technology-enabled behavioral health tool to decrease emergency department use and highlight the importance of measurement-based care. Future research will be key to enhancing behavioral health technology and integration to further improve patient outcomes and reduce emergency department utilization.
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Affiliation(s)
- Adam Pardes
- NeuroFlow, Inc., Philadelphia, PA, United States
| | - Rachelle Rene
- Jefferson Health, Thomas Jefferson University, Philadelphia, PA 19144, United States
| | - Phansy Chun
- Jefferson Health, Thomas Jefferson University, Philadelphia, PA 19144, United States
| | - Mollie Cherson
- Jefferson Health, Thomas Jefferson University, Philadelphia, PA 19144, United States
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14
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Staab EM, Wan W, Campbell A, Gedeon S, Schaefer C, Quinn MT, Laiteerapong N. Elements of Integrated Behavioral Health Associated with Primary Care Provider Confidence in Managing Depression at Community Health Centers. J Gen Intern Med 2022; 37:2931-2940. [PMID: 34981360 PMCID: PMC9485335 DOI: 10.1007/s11606-021-07294-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 11/23/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Depression is most often treated by primary care providers (PCPs), but low self-efficacy in caring for depression may impede adequate management. We aimed to identify which elements of integrated behavioral health (BH) were associated with greater confidence among PCPs in identifying and managing depression. DESIGN Mailed cross-sectional surveys in 2016. PARTICIPANTS BH leaders and PCPs caring for adult patients at community health centers (CHCs) in 10 midwestern states. MAIN MEASURES Survey items asked about depression screening, systems to support care, availability and integration of BH, and PCP attitudes and experiences. PCPs rated their confidence in diagnosing, assessing severity, providing counseling, and prescribing medication for depression on a 5-point scale. An overall confidence score was calculated (range 4 (low) to 20 (high)). Multilevel linear mixed models were used to identify factors associated with confidence. KEY RESULTS Response rates were 60% (N=77/128) and 52% (N=538/1039) for BH leaders and PCPs, respectively. Mean overall confidence score was 15.25±2.36. Confidence was higher among PCPs who were satisfied with the accuracy of depression screening (0.38, p=0.01), worked at CHCs with depression tracking systems (0.48, p=0.045), had access to patients' BH treatment plans (1.59, p=0.002), and cared for more patients with depression (0.29, p=0.003). PCPs who reported their CHC had a sufficient number of psychiatrists were more confident diagnosing depression (0.20, p=0.02) and assessing severity (0.24, p=0.03). Confidence in prescribing was lower at CHCs with more patients living below poverty (-0.66, p<0.001). Confidence in diagnosing was lower at CHCs with more Black/African American patients (-0.20, p=0.03). CONCLUSIONS PCPs who had access to BH treatment plans, a system for tracking patients with depression, screening protocols, and a sufficient number of psychiatrists were more confident identifying and managing depression. Efforts are needed to address disparities and support PCPs caring for vulnerable patients with depression.
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Affiliation(s)
| | - Wen Wan
- University of Chicago, Chicago, IL, USA
| | | | - Stacey Gedeon
- Mid-Michigan Community Health Services, Houghton Lake, MI, USA
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15
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Martin MP, Bridges AJ, Cos T. Measuring Productivity in Primary Care Behavioral Health: A Delphi Study. J Clin Psychol Med Settings 2022; 29:616-623. [PMID: 34420120 DOI: 10.1007/s10880-021-09814-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2021] [Indexed: 10/20/2022]
Abstract
High productivity by behavioral health consultants (BHC) is a defining aspect of the primary care behavioral health (PCBH) model to maximize access to care and is often measured by patient volume. Studies of productivity in health care settings suggest a single productivity target may not be optimal. We used a Delphi method to obtain expert consensus on an operational definition of high productivity by BHCs in the PCBH model. Clinicians, managers, and researchers in PCBH were recruited to participate in a multi-round survey using a modified Delphi technique and develop consensus on PCBH productivity metrics. Ten participants completed all three survey rounds and rated 28 metrics. After three rounds, two direct metrics (average number of billable BHC visits each day; number of patients seen per day) received at least 80% consensus as "Essential", two received at least 50%, and five received less than 50%. One influencer (level of integration at the practice) received at least 80% consensus as "Very Much" influential, 19 received at least 50%, and eight items received less than 50%. Several themes arose from participant comments. PCBH productivity can be interpreted as being high volume. Numerous practice factors influence how productive a BHC may be. Future studies should determine the feasibility of our metrics in clinical practice, establish productivity expectations based on patient needs and clinic resources, and identify patient-, clinician-, or practice-level moderators of productivity.
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Affiliation(s)
- Matthew P Martin
- College of Health Solutions, Arizona State University, 550 N. 3rd St Phoenix, Phoenix, AZ, 85004, USA.
| | - Ana J Bridges
- Department of Psychological Science, University of Arkansas, Fayetteville, AR, USA
| | - Travis Cos
- Health Federation of Philadelphia, Philadelphia, PA, USA
- Department of Psychology, La Salle University, Philadelphia, PA, USA
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16
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Bodenheimer T. Revitalizing Primary Care, Part 2: Hopes for the Future. Ann Fam Med 2022; 20:469-478. [PMID: 36228059 PMCID: PMC9512544 DOI: 10.1370/afm.2859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 05/16/2022] [Accepted: 05/27/2022] [Indexed: 11/09/2022] Open
Abstract
Part 1 of this essay argued that the root causes of primary care's problems lie in (1) the low percent of national health expenditures dedicated to primary care and (2) overly large patient panels that clinicians without a team are unable to manage, leading to widespread burnout and poor patient access. Part 2 explores policies and practice changes that could solve or mitigate these primary care problems.Initiatives attempting to improve primary care are discussed. Diffuse multi-component initiatives-patient-centered medical homes (PCMHs), accountable care organizations (ACOs), and Comprehensive Primary Care Plus (CPC+)-have had limited success in addressing primary care's core problems. More focused initiatives-care management, open access, and telehealth-offer more promise.To truly revitalize primary care, 2 fundamental changes are needed: (1) a substantially greater percent of health expenditures dedicated to primary care, and (2) the building of powerful teams that add capacity to care for large panels while reducing burnout.Part 2 of the essay reviews 3 approaches to increasing primary care spending: state-level legislation, eliminating Medicare's disparity between primary care and procedural specialty reimbursement, and efforts by health systems. The final section of Part 2 addresses the building of powerful core and interprofessional teams.
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Affiliation(s)
- Thomas Bodenheimer
- Department of Family and Community Medicine, University of California, San Francisco, San Francisco, California
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17
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Nakamura JS, Kim ES, Rentscher KE, Bower JE, Kuhlman KR. Early-life stress, depressive symptoms, and inflammation: the role of social factors. Aging Ment Health 2022; 26:843-851. [PMID: 33502257 PMCID: PMC8313624 DOI: 10.1080/13607863.2021.1876636] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To identify modifiable, social factors that moderate the relationship between early-life stress (ELS) and health outcomes as measured by depressive symptoms and inflammation. METHODS Data were from 3,416 adults (58.28% female), ages 36 - 97 (Mage = 68.41; SDage = 10.24) who participated in the 2006 wave of the Health and Retirement Study, a nationally representative sample of older adults in the United States. This study used hierarchical regression analyses to first test the main effects of ELS on depressive symptoms and inflammation (high-sensitivity C-reactive protein). Four social factors (perceived support, frequency of social contact, network size, and volunteer activity) were assessed as moderators of the ELS-depression and ELS-inflammation relationships. RESULTS There was a small, positive association between ELS and depressive symptoms (B = 0.17, SE = 0.05, p = .002), which was moderated by social contact and perceived support. Specifically, ELS was only associated with elevated depressive symptoms for participants with limited social contact (B = 0.24, SE = 0.07, p < .001) and low perceived support (B = 0.24, SE = 0.07, p < .001). These associations remained after accounting for potential confounds (age, body-mass index, adulthood stress, and marital status). CONCLUSIONS Increased social contact and perceived support may be protective for individuals at a higher risk of developing depressive symptoms as a result of ELS. Future interventions may benefit from leveraging these social factors to improve quality of life in adults with ELS.
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Affiliation(s)
- Julia S. Nakamura
- Department of Psychology, University of California, Los Angeles, Los Angeles, CA, USA,Department of Psychology, University of British Columbia, Vancouver, Canada
| | - Eric S. Kim
- Department of Psychology, University of British Columbia, Vancouver, Canada
| | - Kelly E. Rentscher
- Cousins Center for Psychoneuroimmunology, Semel Institute for Neuroscience & Human Behavior, University of California, Los Angeles, Los Angeles, CA, USA
| | - Julienne E. Bower
- Department of Psychology, University of California, Los Angeles, Los Angeles, CA, USA,Cousins Center for Psychoneuroimmunology, Semel Institute for Neuroscience & Human Behavior, University of California, Los Angeles, Los Angeles, CA, USA
| | - Kate R. Kuhlman
- Cousins Center for Psychoneuroimmunology, Semel Institute for Neuroscience & Human Behavior, University of California, Los Angeles, Los Angeles, CA, USA,Department of Psychological Science, University of California, Irvine, Irvine, CA, USA,Institute for Interdisciplinary Salivary Bioscience, University of California, Irvine, Irvine, CA, USA
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18
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Cost Analysis of Integrated Behavioral Health in a Large Primary Care Practice. J Clin Psychol Med Settings 2022; 29:446-452. [PMID: 35325350 DOI: 10.1007/s10880-022-09866-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/26/2022] [Indexed: 10/18/2022]
Abstract
A residency-based Family Medicine outpatient clinic chose to implement an integrated behavioral health care program in a large primary care clinic in the Southeast to improve patient access to behavioral health care. We hypothesized that embedding a BHP in a primary care setting would be a cost neutral intervention. We implemented a prospective cohort design and included expenses from both inpatient and outpatient visits. We implemented a mixed effects linear regression model to evaluate pre- and post-BHP exposure costs. A total of 1256 patients were identified in the post-BHP exposure period that had more than one-year post-exposure. After applying exclusion criteria, there were 926 patients included in analysis. These patient had an average total cost during the one-year pre-BHP exposure period of $5113 (SD = 7712) and one-year post-BHP exposure period of $5462 (SD = 7813). Our analysis shows a relatively cost neutral impact following the introduction of BHPs in a primary care setting. The results of this study provide a gauge for future planning of services.
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19
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Buchanan GJR, Piehler T, Berge J, Hansen A, Stephens KA. Integrated Behavioral Health Implementation Patterns in Primary Care Using the Cross-Model Framework: A Latent Class Analysis. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2022; 49:312-325. [PMID: 34529202 PMCID: PMC8854330 DOI: 10.1007/s10488-021-01165-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2021] [Indexed: 12/20/2022]
Abstract
Primary care has increasingly adopted integrated behavioral health (IBH) practices to enhance overall care. The IBH Cross-Model Framework clarifies the core processes and structures of IBH, but little is known about how practices vary in the implementation of these processes and structures. This study aimed to describe clusters of clinics using the IBH Cross-Model Framework for a large sample of primary care clinics, as well as contextual variables associated with differences in implementation. Primary care clinics (N = 102) in Minnesota reported their level of implementation across 18 different components of IBH via the site self-assessment (SSA). The components were mapped to all five principles and four of the nine structures of the IBH Cross-Model Framework. latent class analysis was used to identify unique clusters of IBH components from the SSA across the IBH Cross-Model Framework's processes and structures. Latent classes were then regressed onto context variables. A four-class model was determined to be the best fit: Low IBH (39.6%), Structural IBH (7.9%), Partial IBH (29.4%), and Strong IBH (23.1%). Partial IBH clinics were more urban than the other three classes, lower in SES risk than Structural IBH clinics, and located in smaller organizations than Strong IBH clinics. There were no differences between classes in race/ethnicity of the clinic area or practice size. Four groups of IBH implementation were identified representing unique profiles of integration. These clusters may represent patterns of community-based implementation of IBH that indicate easier and more challenging aspects of IBH implementation.
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Affiliation(s)
| | - Timothy Piehler
- Department of Family Social Science, University of Minnesota, Minneapolis, MN, USA
| | - Jerica Berge
- Department of Family Medicine and Community Health, University of Minnesota, Minneapolis, MN, USA
| | - Audrey Hansen
- Institute for Clinical Systems Improvement, Bloomington, MN, USA
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20
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Alessi EJ, Caldwell B, Zazzarino AS, Greenfield B, Findley PA. 'You just really have to assert yourself:' social work, nursing, and rehabilitation counseling student experiences of providing integrated behavioral health services before and after the immediate start of COVID-19. BMC Health Serv Res 2022; 22:88. [PMID: 35042482 PMCID: PMC8765676 DOI: 10.1186/s12913-022-07465-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 12/24/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Educators who train healthcare students to provide behavioral health services in primary care settings frequently encounter challenges as they work to ensure that students acquire the knowledge and skills to effectively function on interprofessional practice teams. This has become increasingly important during COVID-19, as interprofessional collaborative practice is needed more than ever to address the interrelated health, mental health, and social structural issues linked to the pandemic. METHODS We used qualitative focus groups to understand the experiences of 6 interprofessional teams (comprised of graduate social work, nursing, and rehabilitation counseling students; n = 19) providing behavioral health services in primary care settings before and after the immediate start of COVID-19. To triangulate data and enrich findings, one focus group with students' faculty supervisors was also conducted; n = 5). Data were analyzed using thematic analysis. RESULTS Four themes highlighted student participants' need to assert themselves at the beginning of their educational experience, to communicate and learn from one another to develop positive team dynamics, to contend with role confusion and missed opportunities for collaboration, and to manage the emotional impact of COVID-19 on learning. CONCLUSION Findings indicate that educators should work with clinical faculty and agency supervisors to orient students to ensure they have role clarity within the agency. Graduate students providing behavioral health services should also learn to work collaboratively within their scopes of practice to serve patients virtually, especially in preparation for public health emergencies.
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Affiliation(s)
- Edward J Alessi
- School of Social Work, Rutgers, The State University of New Jersey, 390 George Street, FL 6 - Room 607A, New Brunswick, NJ, 08901, USA.
| | - Barbara Caldwell
- School of Nursing, Division of Advanced Nursing Practice, Rutgers, The State University of New Jersey, Newark, NJ, USA
| | - Anthony S Zazzarino
- School of Health Professions, Rutgers, The State University of New Jersey, Scotch Plains, NJ, USA
| | - Brett Greenfield
- School of Social Work, Rutgers, The State University of New Jersey, 390 George Street, FL 6 - Room 607A, New Brunswick, NJ, 08901, USA
| | - Patricia A Findley
- School of Social Work, Rutgers, The State University of New Jersey, 390 George Street, FL 6 - Room 607A, New Brunswick, NJ, 08901, USA
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21
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Hiefner AR, Villareal A. A Multidisciplinary, Family-Oriented Approach to Caring for Parents After Miscarriage: The Integrated Behavioral Health Model of Care. Front Public Health 2021; 9:725762. [PMID: 34917568 PMCID: PMC8669268 DOI: 10.3389/fpubh.2021.725762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 11/08/2021] [Indexed: 11/19/2022] Open
Abstract
Miscarriage is increasingly gaining recognition, both in scientific literature and media outlets, as a loss that has significant and lasting effects on parents, though often disenfranchised and overlooked by both personal support networks and healthcare providers. For both men and women, miscarriage can usher in intense grief, despair, and difficulty coping, and for women in particular, there is evidence of increased prevalence of depression, anxiety, and post-traumatic stress. Additionally, miscarriage can contribute to decreased relationship satisfaction and increased risk of separation, all while stigma and disenfranchisement create a sense of isolation. Despite this increased need for support, research indicates that many parents experience their healthcare providers as dismissive of the significance of the loss and as primarily focusing only on the physical elements of care. Research exploring the barriers to providers engaging in more biopsychosocial-oriented care has identified time constraints, lack of resources, lack of training in addressing loss, and compassion fatigue as key areas for intervention. This paper will review the biopsychosocial elements of miscarriage and discuss a multidisciplinary, family-oriented approach that can be implemented in healthcare settings to ensure a high quality and holistic level of care for individuals, couples, and families experiencing pregnancy loss.
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Affiliation(s)
- Angela R Hiefner
- Family and Community Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Astrud Villareal
- Family and Community Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
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22
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Cognitive behavioral therapy for depressive disorders: Outcomes from a multi-state, multi-site primary care practice. J Affect Disord 2021; 294:745-752. [PMID: 34375199 DOI: 10.1016/j.jad.2021.07.061] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 07/08/2021] [Accepted: 07/12/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Individuals with depressive disorders often present to and seek treatment in primary care. Integrated behavioral health services within this setting can improve access to evidence-based cognitive behavioral therapy (CBT). However, limited information exists on the effectiveness of CBT for depression in primary care. METHODS 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. A psychotherapy tracking database was used to collect relevant data, which included demographics, clinical characteristics, treatment outcomes, and CBT intervention use. RESULTS Participants with moderate to severe depression who participated in CBT reported a significant decrease in depression and anxiety symptoms at the end of treatment (p ≤ .001, d = 0.52-0.78). Rates of reliable change, response, and remission and types of CBT interventions used differed between major and persistent depressive disorders. LIMITATIONS Multiple limitations must be noted, which are related to the naturalistic study design, inclusion and exclusion criteria, sample operationalization, symptomatic measurement, time-limited and focused assessment, data collection strategies, and psychological services. Together, these temper the conclusions that can be drawn. CONCLUSION Significant reductions in depression and anxiety symptoms were reported by participants with depressive disorders who engaged in short-term CBT within primary care. 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.
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23
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Dunn JA, Chokron Garneau H, Filipowicz H, Mahoney M, Seay-Morrison T, Dent K, McGovern M. What Are Patient Preferences for Integrated Behavioral Health in Primary Care? J Prim Care Community Health 2021; 12:21501327211049053. [PMID: 34670441 PMCID: PMC8543553 DOI: 10.1177/21501327211049053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Behavioral health services, integrated into primary care practices, have become increasingly implemented. Although patient satisfaction has been studied, limited information exists about patient preferences for integrated behavioral health in primary care and how perceptions may vary. Objective: To determine patient preferences for integrated behavioral health within primary care and explore differences across patient groups. Methods: A self-report survey was distributed within a quality improvement initiative in an academic health system. A brief 8-item self-report questionnaire of perceptions and preferences for integrated behavioral health was administered to 752 primary care patients presenting before their visits at two primary care clinics. Participation was voluntary, responses were anonymous, and all patients presenting during a three-week timeframe were eligible. Results: In general, patients preferred to have behavioral health concerns addressed within primary care (n = 301; 41%) rather than referral to a specialist (7.5%; n = 55). There was no evidence of variation in preferences by demographic characteristics. Comfort levels to receive behavioral health services (P < .001) and perceived needs being met were significantly associated with preferences for receiving IBHPC (P < .001). Conclusion: This project provided valuable data to support the implementation of integrated behavioral health services in primary care clinics. In general, patients prefer to have behavioral health issues addressed within their primary care experience rather than being referred to specialty mental health care. This study adds to an expanding pool of studies exploring patient preferences for integrated behavioral health in primary care.
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Affiliation(s)
| | | | | | - Megan Mahoney
- Stanford University School of Medicine, Palo Alto, CA, USA
| | | | - Kaitlin Dent
- University of Northern Colorado, Greeley, CO, USA
| | - Mark McGovern
- Stanford University School of Medicine, Palo Alto, CA, USA
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Monaghan K, Cos T. Integrating physical and mental healthcare: Facilitators and barriers to success. MEDICINE ACCESS @ POINT OF CARE 2021; 5:23992026211050615. [PMID: 36204502 PMCID: PMC9413608 DOI: 10.1177/23992026211050615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 09/16/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction: Effective and appropriate provision of mental healthcare has long been a
struggle globally, resulting in significant disparity between prevalence of
mental illness and access to care. One attempt to address such disparity was
the Patient Protection and Affordable Care Act (PPACA), 2010, mandate in the
United States to integrate physical and mental healthcare in Federally
Qualified Health Centers (FQHCs). The notion of integration is attractive,
as it has demonstrated the potential to improve both access to mental
healthcare and healthcare outcomes. However, while the PPACA mandate set
this requirement for FQHCs, no clear process as to how these centers should
achieve successful integration was identified. Methods: This research employed case study methods to examine the implementation of
this policy in two FQHCs in New England. Data were obtained from in-depth
interviews with leadership, management, and frontline staff at two case
study sites. Results: Study findings include multiple definitions of and approaches for integrating
physical and mental healthcare, mental healthcare being subsumed into,
rather than integrated with, the medical model and multiple facilitators of
and barriers to integration. Conclusion: This study asked questions about what integration means, how it occurs, and
what factors facilitate or pose barriers to integration. Integration is
facilitated by co-location of providers within the same department, a warm
hand-off, collaborative collegial relationships, strong leadership support,
and a shared electronic health record. However, interdisciplinary conflict,
power differentials, job insecurity, communication challenges, and the
subsumption of mental health into the medical model pose barriers to
successful integration.
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Affiliation(s)
| | - Travis Cos
- School of Arts and Sciences, La Salle University, Philadelphia, PA, USA
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25
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Wilfong KM, Goodie JL, Curry JC, Hunter CL, Kroke PC. The Impact of Brief Interventions on Functioning Among those Demonstrating Anxiety, Depressive, and Adjustment Disorder Symptoms in Primary Care: The Effectiveness of the Primary Care Behavioral Health (PCBH) Model. J Clin Psychol Med Settings 2021; 29:318-331. [PMID: 34626278 DOI: 10.1007/s10880-021-09826-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2021] [Indexed: 10/20/2022]
Abstract
Limited scalability combined with limited opportunities for patients to receive evidence-based interventions in traditional behavioral health treatment models for anxiety and depression creates a gap in access to adequate care. Primary Care Behavioral Health (PCBH) is one model of treatment in which behavioral health consultants (BHC) work directly within primary care settings, but there is limited evidence regarding the effectiveness of this model of care. The functional outcomes and appointment characteristics of Beneficiaries (N = 5402) within the military healthcare system were assessed. The study sample was predominately Caucasian, female, military dependents seen for 2 to 4 appointments. A reliable change index revealed that 17.2% showed reliable improvement and 2.4% showed reliable deterioration (p < .05). Of individuals with a severe Behavioral Health Measure-20 score at baseline, 81.5% showed some improvement at their final appointment, with 33% demonstrating reliable improvement. A mixed model analysis was used to determine the predictive value of appointment characteristics. All relations were significant (p < .001), except the between-subjects effect of appointment duration. Appointment duration revealed individuals reported worse functioning at the start of atypically long appointments. Individuals with generally longer intervals between appointments reported worse functioning, but an atypically long interval predicted better functioning at the following appointment. As it relates to number of appointments, individuals with more total appointments reported worse functioning outcomes, with generally better functioning across appointments. Overall, these data support the effectiveness of time-limited care provided through the PCBH model.
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Affiliation(s)
- Kevin M Wilfong
- Uniformed Service University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD, 20814, USA.
| | - Jeffrey L Goodie
- Uniformed Service University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD, 20814, USA
| | - Justin C Curry
- Defense Health Agency, Clinical Support Division, Patient Centered Medical Home Branch, 7700 Arlington Boulevard, Suite 5101, Falls Church, VA, 22042, USA
| | - Christopher L Hunter
- Defense Health Agency, Clinical Support Division, Patient Centered Medical Home Branch, 7700 Arlington Boulevard, Suite 5101, Falls Church, VA, 22042, USA
| | - Phillip C Kroke
- Uniformed Service University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD, 20814, USA
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26
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Bonilla AG, Pourat N, Chuang E, Ettner S, Zima B, Chen X, Lu C, Hoang H, Hair BY, Bolton J, Sripipatana A. Mental Health Staffing at HRSA-Funded Health Centers May Improve Access to Care. Psychiatr Serv 2021; 72:1018-1025. [PMID: 34074146 PMCID: PMC8410613 DOI: 10.1176/appi.ps.202000337] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The study objective was to examine the association between mental health staffing at health centers funded by the Health Resources and Services Administration (HRSA) and patients' receipt of mental health treatment. METHODS Data were from the 2014 HRSA-funded Health Center Patient Survey and the 2013 Uniform Data System. Colocation of any mental health staff, including psychiatrists, psychologists, and other licensed staff, was examined. The outcomes of interest were whether a patient received any mental treatment and received any such treatment on site (at the health center). Analyses were conducted with multilevel generalized structural equation logistic regression models for 4,575 patients ages 18-64. RESULTS Patients attending health centers with at least one mental health full-time equivalent (FTE) per 2,000 patients had a higher predicted probability of receiving mental health treatment (32%) compared with those attending centers with fewer than one such FTE (24%) or no such staffing (22%). Among patients who received this treatment, those at health centers with no staffing had a significantly lower predicted probability of receiving such treatment on site (28%), compared with patients at health centers with fewer than one such FTE (49%) and with at least one such FTE (65%). The predicted probability of receiving such treatment on site was significantly higher if there was a colocated psychiatrist versus no psychiatrist (58% versus 40%). CONCLUSIONS Colocating mental health staff at health centers increases the probability of patients' access to such treatment on site as well as from off-site providers.
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Affiliation(s)
- Amy G Bonilla
- Department of Health Policy and Management, Fielding School of Public Health (Bonilla, Pourat, Chuang, Ettner); Center for Health Policy Research (Pourat, Chen, Lu); Center for Health Services and Society, Semel Institute for Neuroscience and Human Behavior (Zima); Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine (Ettner); Department of Psychiatry and Behavioral Sciences, David Geffen School of Medicine (Zima), all at University of California, Los Angeles, Los Angeles; Office of Quality Improvement, Bureau of Primary Health Care, Health Resources and Services Administration, U.S. Department of Health and Human Services (Hoang, Hair, Bolton, Sripipatana)
| | - Nadereh Pourat
- Department of Health Policy and Management, Fielding School of Public Health (Bonilla, Pourat, Chuang, Ettner); Center for Health Policy Research (Pourat, Chen, Lu); Center for Health Services and Society, Semel Institute for Neuroscience and Human Behavior (Zima); Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine (Ettner); Department of Psychiatry and Behavioral Sciences, David Geffen School of Medicine (Zima), all at University of California, Los Angeles, Los Angeles; Office of Quality Improvement, Bureau of Primary Health Care, Health Resources and Services Administration, U.S. Department of Health and Human Services (Hoang, Hair, Bolton, Sripipatana)
| | - Emmeline Chuang
- Department of Health Policy and Management, Fielding School of Public Health (Bonilla, Pourat, Chuang, Ettner); Center for Health Policy Research (Pourat, Chen, Lu); Center for Health Services and Society, Semel Institute for Neuroscience and Human Behavior (Zima); Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine (Ettner); Department of Psychiatry and Behavioral Sciences, David Geffen School of Medicine (Zima), all at University of California, Los Angeles, Los Angeles; Office of Quality Improvement, Bureau of Primary Health Care, Health Resources and Services Administration, U.S. Department of Health and Human Services (Hoang, Hair, Bolton, Sripipatana)
| | - Susan Ettner
- Department of Health Policy and Management, Fielding School of Public Health (Bonilla, Pourat, Chuang, Ettner); Center for Health Policy Research (Pourat, Chen, Lu); Center for Health Services and Society, Semel Institute for Neuroscience and Human Behavior (Zima); Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine (Ettner); Department of Psychiatry and Behavioral Sciences, David Geffen School of Medicine (Zima), all at University of California, Los Angeles, Los Angeles; Office of Quality Improvement, Bureau of Primary Health Care, Health Resources and Services Administration, U.S. Department of Health and Human Services (Hoang, Hair, Bolton, Sripipatana)
| | - Bonnie Zima
- Department of Health Policy and Management, Fielding School of Public Health (Bonilla, Pourat, Chuang, Ettner); Center for Health Policy Research (Pourat, Chen, Lu); Center for Health Services and Society, Semel Institute for Neuroscience and Human Behavior (Zima); Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine (Ettner); Department of Psychiatry and Behavioral Sciences, David Geffen School of Medicine (Zima), all at University of California, Los Angeles, Los Angeles; Office of Quality Improvement, Bureau of Primary Health Care, Health Resources and Services Administration, U.S. Department of Health and Human Services (Hoang, Hair, Bolton, Sripipatana)
| | - Xiao Chen
- Department of Health Policy and Management, Fielding School of Public Health (Bonilla, Pourat, Chuang, Ettner); Center for Health Policy Research (Pourat, Chen, Lu); Center for Health Services and Society, Semel Institute for Neuroscience and Human Behavior (Zima); Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine (Ettner); Department of Psychiatry and Behavioral Sciences, David Geffen School of Medicine (Zima), all at University of California, Los Angeles, Los Angeles; Office of Quality Improvement, Bureau of Primary Health Care, Health Resources and Services Administration, U.S. Department of Health and Human Services (Hoang, Hair, Bolton, Sripipatana)
| | - Connie Lu
- Department of Health Policy and Management, Fielding School of Public Health (Bonilla, Pourat, Chuang, Ettner); Center for Health Policy Research (Pourat, Chen, Lu); Center for Health Services and Society, Semel Institute for Neuroscience and Human Behavior (Zima); Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine (Ettner); Department of Psychiatry and Behavioral Sciences, David Geffen School of Medicine (Zima), all at University of California, Los Angeles, Los Angeles; Office of Quality Improvement, Bureau of Primary Health Care, Health Resources and Services Administration, U.S. Department of Health and Human Services (Hoang, Hair, Bolton, Sripipatana)
| | - Hank Hoang
- Department of Health Policy and Management, Fielding School of Public Health (Bonilla, Pourat, Chuang, Ettner); Center for Health Policy Research (Pourat, Chen, Lu); Center for Health Services and Society, Semel Institute for Neuroscience and Human Behavior (Zima); Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine (Ettner); Department of Psychiatry and Behavioral Sciences, David Geffen School of Medicine (Zima), all at University of California, Los Angeles, Los Angeles; Office of Quality Improvement, Bureau of Primary Health Care, Health Resources and Services Administration, U.S. Department of Health and Human Services (Hoang, Hair, Bolton, Sripipatana)
| | - Brionna Y Hair
- Department of Health Policy and Management, Fielding School of Public Health (Bonilla, Pourat, Chuang, Ettner); Center for Health Policy Research (Pourat, Chen, Lu); Center for Health Services and Society, Semel Institute for Neuroscience and Human Behavior (Zima); Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine (Ettner); Department of Psychiatry and Behavioral Sciences, David Geffen School of Medicine (Zima), all at University of California, Los Angeles, Los Angeles; Office of Quality Improvement, Bureau of Primary Health Care, Health Resources and Services Administration, U.S. Department of Health and Human Services (Hoang, Hair, Bolton, Sripipatana)
| | - Joshua Bolton
- Department of Health Policy and Management, Fielding School of Public Health (Bonilla, Pourat, Chuang, Ettner); Center for Health Policy Research (Pourat, Chen, Lu); Center for Health Services and Society, Semel Institute for Neuroscience and Human Behavior (Zima); Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine (Ettner); Department of Psychiatry and Behavioral Sciences, David Geffen School of Medicine (Zima), all at University of California, Los Angeles, Los Angeles; Office of Quality Improvement, Bureau of Primary Health Care, Health Resources and Services Administration, U.S. Department of Health and Human Services (Hoang, Hair, Bolton, Sripipatana)
| | - Alek Sripipatana
- Department of Health Policy and Management, Fielding School of Public Health (Bonilla, Pourat, Chuang, Ettner); Center for Health Policy Research (Pourat, Chen, Lu); Center for Health Services and Society, Semel Institute for Neuroscience and Human Behavior (Zima); Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine (Ettner); Department of Psychiatry and Behavioral Sciences, David Geffen School of Medicine (Zima), all at University of California, Los Angeles, Los Angeles; Office of Quality Improvement, Bureau of Primary Health Care, Health Resources and Services Administration, U.S. Department of Health and Human Services (Hoang, Hair, Bolton, Sripipatana)
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27
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Teo DCL, Yan S, Tan MSQ, Tirtajana I, Lim HK, Saffari SE, Peh ALH. Impact of an integrated care programme on patient-reported outcomes for mild to moderate mental health conditions in Singapore: a pilot study. Singapore Med J 2021; 62:230-234. [PMID: 34409472 DOI: 10.11622/smedj.2021062] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
| | - Shi Yan
- Singapore Health Services, Singapore
| | | | - Irene Tirtajana
- Department of Psychiatry, Ng Teng Fong General Hospital, Singapore
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28
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Kanzler KE, McGeary DD, McGeary C, Blankenship AE, Young-McCaughan S, Peterson AL, Buhrer JC, Cobos BA, Dobmeyer AC, Hunter CL, Bhagwat A, Star JAB, Goodie JL. Conducting a Pragmatic Trial in Integrated Primary Care: Key Decision Points and Considerations. J Clin Psychol Med Settings 2021; 29:185-194. [PMID: 34100153 PMCID: PMC8184053 DOI: 10.1007/s10880-021-09790-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2021] [Indexed: 11/30/2022]
Abstract
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. Formal pragmatic trials conducted in integrated primary care settings are uncommon, making it difficult for researchers to anticipate the potential pitfalls associated with balancing scientific rigor with the demands of routine clinical practice. This paper is based on our experience conducting the first phase of a large, multisite, pragmatic clinical trial evaluating the implementation and effectiveness of behavioral health consultants treating patients with chronic pain using a manualized intervention, brief cognitive behavioral therapy for chronic pain (BCBT-CP). 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.
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Affiliation(s)
- Kathryn E Kanzler
- Research to Advance Community Health (ReACH) Center, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, Mail Code 7768, San Antonio, TX, 78229, USA. .,Psychiatry & Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA. .,Family & Community Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
| | - Donald D McGeary
- Psychiatry & Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.,Rehabilitation Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.,South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Cindy McGeary
- Psychiatry & Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Abby E Blankenship
- Psychiatry & Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Stacey Young-McCaughan
- Psychiatry & Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Alan L Peterson
- Psychiatry & Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.,South Texas Veterans Health Care System, San Antonio, TX, USA.,Department of Psychology, University of Texas at San Antonio, San Antonio, TX, USA
| | | | - Briana A Cobos
- Psychiatry & Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Anne C Dobmeyer
- Psychological Health Center of Excellence J-9/Defense Health Agency, Falls Church, VA, USA
| | - Christopher L Hunter
- J3 Medical Affairs-Clinical Support Division/Defense Health Agency, Falls Church, VA, USA
| | - Aditya Bhagwat
- J3 Medical Affairs-Clinical Support Division/Defense Health Agency, Falls Church, VA, USA
| | - John A Blue Star
- 59 Medical Operations Squadron, Wilford Hall Ambulatory Medical Center, JBSA-Lackland, San Antonio, TX, USA
| | - Jeffrey L Goodie
- Department of Medical & Clinical Psychology, Uniformed Services University, Bethesda, MD, USA
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Integration of Diabetes and Depression Care Is Associated with Glucose Control in Midwestern Federally Qualified Health Centers. J Gen Intern Med 2021; 36:978-984. [PMID: 33492584 PMCID: PMC8042086 DOI: 10.1007/s11606-020-06585-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 12/30/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND The 2016 American Diabetes Association position statement emphasized that psychosocial and medical care should be integrated and provided to all people with diabetes. OBJECTIVE To determine whether better integration of diabetes and depression care is associated with better glycemic control. DESIGN Cross-sectional surveys of Midwestern federally qualified health center (FQHC) leaders and primary care providers (PCPs) in 2016. Responses were linked to FQHC-level data on the percentage of patients with uncontrolled diabetes (glycated hemoglobin ≥ 9%; 75 mmol/mol). PARTICIPANTS Midwest Clinicians' Network-affiliated FQHC leaders, and PCPs at the FQHCs. MAIN MEASURES Multilevel models were used to determine associations between the percentage of patients with uncontrolled diabetes and FQHC and PCP characteristics; presence of diabetes and behavioral health care services; and PCPs' perception of the stage of integration between diabetes and depression care services based on the transtheoretical model (i.e., pre-contemplation, contemplation, preparation, action, or maintenance). KEY RESULTS Response rates were 60% for the FQHC survey (N = 77) and 55% for the PCP survey (N = 538). In adjusted models, FQHCs in which PCPs perceived a higher stage of integration between diabetes and depression care had 3% fewer patients with uncontrolled diabetes per 1-level increase in integration stage (p = 0.01); on-site diabetes self-management education was associated with 7% fewer patients with uncontrolled diabetes (p < 0.01). CONCLUSIONS At Midwestern FQHCs, a higher stage of perceived integration of diabetes and depression care was associated with better FQHC-level glycemic control. Future studies are needed to elucidate what defines integration of diabetes and depression care services.
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Bogucki OE, Mattson AB, Leasure WB, Berg SL, Mulholland HL, Sawchuk CN. Adaptations of an Integrated Behavioral Health Program During COVID-19. COGNITIVE AND BEHAVIORAL PRACTICE 2021; 28:481-491. [PMID: 33776398 PMCID: PMC7983459 DOI: 10.1016/j.cbpra.2021.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 01/18/2021] [Indexed: 11/28/2022]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has consistently been described as an “unprecedented” global health crisis. While the focus has been primarily on the medical and economic impact of the pandemic, psychological sequelae are anticipated. Primary care is the main point of access for mental health care in the United States, making it the ideal locale to provide psychological services for a larger proportion of the population than traditional mental health care settings. The aim of this paper is to describe how our multi-state, multi-site integrated primary care program adapted and applied cognitive behavioral therapy in the context of COVID-19. Access to mental health care was disrupted despite burgeoning mental health concerns, necessitating novel approaches to providing care. A stepped-care approach was implemented within our primary care practice, which consisted of a combination of low-intensity, high-yield stress management and resiliency building resources and cognitive behavioral therapy that were delivered flexibly based on patient preference, technological capabilities, state ordinances, insurance coverage, and institutional policies. The lessons learned from this experience can inform other integrated primary care clinics in responding to the current and future pandemics.
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Affiliation(s)
- Olivia E Bogucki
- Division of Integrated Behavioral Health, Mayo Clinic, Rochester, MN
| | - Angela B Mattson
- Division of Integrated Behavioral Health, Mayo Clinic, Rochester, MN
| | - William B Leasure
- Division of Integrated Behavioral Health, Mayo Clinic, Rochester, MN
| | - Summer L Berg
- Division of Integrated Behavioral Health, Mayo Clinic, Rochester, MN
| | | | - Craig N Sawchuk
- Division of Integrated Behavioral Health, Mayo Clinic, Rochester, MN
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31
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Baker JG, Doxbeck DR, Washington ME, Horton A, Dunning A. Substance use identification and follow-up rates among commercial and Medicare health insurance members in primary care and other settings. BMC FAMILY PRACTICE 2020; 21:223. [PMID: 33131488 PMCID: PMC7604972 DOI: 10.1186/s12875-020-01286-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 10/15/2020] [Indexed: 12/05/2022]
Abstract
Background The objective of this study was to investigate factors associated with substance use disorder identification and follow-up rates among samples of members of a private health insurance plan. Methods In an observational study, samples of claims data for 2017 for Commercial and Medicare members from a private health insurer were accessed and analyzed using descriptive statistics, decision tree analysis, and linear regression models. Results Commercial and Medicare members differed in age. Medicare members had higher rates of inclusion in a measure of substance use disorder than Commercial members, lower rates of initial short term follow-up, more opioid prescriptions from primary care provides, fewer prescriptions for opioid treatment, and higher rates of selected comorbid conditions. Mental health diagnoses and substance use disorder co-occurred frequently and to a greater extent in the Medicare sample. Among commercial members, there were primarily alcohol problems that increased with age, while opioid problems at about 10% peaked in the mid-twenties. More males were included among all substance types. The overall rate for an initial short term follow-up visit indicating initiation of treatment was 30%. There were large differences in the follow-up rates across settings with a very low rate (4.6% for alcohol and 6.9% for opioid) in primary care settings. Conclusions These results suggest that increased attention in primary care to young adult males and to older adults, may help to reduce substance use disorder rates, especially alcohol use disorders.
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32
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Koehler AN, Trejo G, Sandberg JC, Swain BH, Marion GS, Kirk JK. Patient Views of Behavioral Health Providers in Primary Care: A Qualitative Study of 2 Southeastern Clinics. J Patient Exp 2020; 7:527-533. [PMID: 33062874 PMCID: PMC7534134 DOI: 10.1177/2374373519860357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background: Limited research is available around patient experience of integrated behavioral health care in primary care settings. Objective: We sought to identify the major themes through which patients described their integrated behavioral health care experiences as a means of informing and improving clinic processes of integrated health care delivery. Methods: We captured viewpoints from 16 patients who experienced an integrated behavioral health care model from 2 primary care clinics and completed at least 3 visits with a behavioral health provider (BHP). Using grounded theory analyses, we coded and analyzed transcriptions for emergent themes. Analysis: The interview process yielded 3 major themes related to the BHP including (a) the BHPs’ clinic presence made behavioral health care more convenient and accessible, (b) BHPs worked within time and program limitations, and (c) BHPs helped with coping, wellness, and patient-care team communication. Conclusion: The BHPs serving in a large primary care practice and a Federally Qualified Health Center played an important role in connecting patients with behavioral health care and improving care team collaboration, both in terms of communication within the team and between the team and the patient/family.
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Affiliation(s)
- Aubry N Koehler
- Department of Family and Community Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Grisel Trejo
- Department of Family and Community Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Joanne C Sandberg
- Department of Family and Community Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Brittany H Swain
- Department of Family and Community Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Gail S Marion
- Department of Family and Community Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Julienne K Kirk
- Department of Family and Community Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
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33
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Stephens KA, van Eeghen C, Mollis B, Au M, Brennhofer SA, Martin M, Clifton J, Witwer E, Hansen A, Monkman J, Buchanan G, Kessler R. Defining and measuring core processes and structures in integrated behavioral health in primary care: a cross-model framework. Transl Behav Med 2020; 10:527-538. [PMID: 32766871 PMCID: PMC8128511 DOI: 10.1093/tbm/ibz163] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
A movement towards integrated behavioral health (IBH) in primary care continues to grow, among an accumulating evidence base for its effectiveness for improving care. However, healthcare organizations struggle to navigate where to target their limited resources for improving integration. We evaluated a cross-model framework of IBH core processes and structures. We used a mixed-methods approach for evaluation of the framework, which included (a) an evaluation survey of national experts and stakeholders, (b) crosswalks with common IBH measures, and (c) a real-world usability test. Five core IBH principles, mapping to 25 processes, and nine clinic structures were defined. Survey responses from 29 IBH domain and policy experts and stakeholders resulted in uniformly high ratings of importance and variable levels of feasibility for measurement, particularly with respect to electronic health record (EHR) systems. A real-world usability test resulted in good uptake and use of the framework across a state-wide effort. An IBH Cross-Model Framework of core principles, processes, and structures generated good acceptability and showed good real-world utility in a state-wide effort to improve IBH across disparate levels of integration in diverse primary care settings. Findings identify feasible areas of measurement, particularly with EHR systems. Next steps include testing the relationship between the individual framework components and patient outcomes to help guide clinics towards prioritizing efforts focused on improving integration.
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Affiliation(s)
- Kari A Stephens
- Department of Family Medicine, University of Washington, Seattle, WA, USA.,Psychiatry and Behavioral Sciences, University of Washington, Burlington, VT, USA
| | - Constance van Eeghen
- Department of Medicine, Division of General Internal Medicine Research, University of Vermont, Seattle, WA, USA
| | - Brenda Mollis
- Department of Family Medicine, University of Washington, Seattle, WA, USA
| | - Margaret Au
- Psychiatry and Behavioral Sciences, University of Washington, Burlington, VT, USA
| | - Stephanie A Brennhofer
- Integrated Behavioral Health Program, College of Health Solutions, Arizona State University, Phoenix, AZ, USA
| | - Matthew Martin
- Integrated Behavioral Health Program, College of Health Solutions, Arizona State University, Phoenix, AZ, USA
| | - Jessica Clifton
- Department of Medicine, Division of General Internal Medicine Research, University of Vermont, Seattle, WA, USA
| | - Elizabeth Witwer
- Department of Family Medicine, University of Washington, Seattle, WA, USA
| | | | - Jeyn Monkman
- MN Health Collaborative, ICSI, Minneapolis, MN, USA
| | - Gretchen Buchanan
- Family Social Science, University of Minnesota, Minneapolis, MN, USA
| | - Rodger Kessler
- Integrated Behavioral Health Program, College of Health Solutions, Arizona State University, Phoenix, AZ, USA
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Shepardson RL, Minnick MR, Funderburk JS. Anxiety interventions delivered in primary care behavioral health routine clinical practice. FAMILIES, SYSTEMS & HEALTH : THE JOURNAL OF COLLABORATIVE FAMILY HEALTHCARE 2020; 38:193-199. [PMID: 32525354 PMCID: PMC8314503 DOI: 10.1037/fsh0000493] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
INTRODUCTION Although anxiety is highly prevalent in primary care and a top reason for referral to primary care behavioral health (PCBH) services, there are limited data on which anxiety interventions are used in routine PCBH practice. The objective of this study was to identify interventions delivered when treating anxiety in PCBH practice. METHOD We conducted an online survey of PCBH providers regarding their clinical practice with patients who present for treatment of anxiety symptoms. The final sample comprised 209 PCBH providers recruited from e-mail listservs of national professional organizations (59.3% psychologists, 23.4% social workers, 12.4% counselors, 4.8% other). Providers reported on use (yes/no) of 17 interventions in their most recent session with their most recent adult patient presenting with a primary concern of non-trauma-related anxiety. RESULTS On average, patients were reported to be 42.2 (14.73) years old, White (73.7%), and male (56.5%) with anxiety symptoms of moderate severity (65.6%). Most reportedly had comorbid sleep difficulties (63.6%), depressive symptoms (58.4%), and/or stress/adjustment (56.0%). Providers reported delivering an average of 5.77 (2.05, range: 1-15) interventions, with psychoeducation (94.7%), relaxation training (64.1%), and supportive therapy (60.8%) being most common. Several highly efficacious evidence-based interventions for anxiety, including cognitive therapy (45.0%) and exposure (21.1%), were less common. DISCUSSION While PCBH providers delivered numerous brief interventions for anxiety, cognitive therapy and exposure were underutilized. Furthermore, PCBH patients with anxiety symptoms were complex, with significant severity and comorbidity. These results suggest implications for research, clinical training, intervention design, and future implementation efforts. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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Chen R, Fussell C, Austin JP, May SE, Wang Q. How Therapists Should Work with Infertile Couples: A Literature Review. JOURNAL OF COUPLE & RELATIONSHIP THERAPY 2020. [DOI: 10.1080/15332691.2020.1757545] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Ruoxi Chen
- College of Health Sciences, University of Louisiana at Monroe, Monroe, Louisiana, USA
| | - Cierra Fussell
- College of Health Sciences, University of Louisiana at Monroe, Monroe, Louisiana, USA
| | - Jason P. Austin
- College of Health Sciences, University of Louisiana at Monroe, Monroe, Louisiana, USA
| | - Stephen E. May
- College of Health Sciences, University of Louisiana at Monroe, Monroe, Louisiana, USA
| | - Qilin Wang
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
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Integrating Neuropsychology Services in a Multidisciplinary Concussion Clinic. J Head Trauma Rehabil 2019; 34:419-424. [DOI: 10.1097/htr.0000000000000541] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ward-Ciesielski EF, Rizvi SL. Finding mental health providers in the United States: a national survey and implications for policy and practice. J Ment Health 2019; 30:578-584. [PMID: 31647364 DOI: 10.1080/09638237.2019.1677867] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Research suggests that a major barrier to mental health treatment is not knowing where to go for services, yet little is known about the specific steps people take to find treatment. AIMS To (1) understand the process people would undertake if they decided they needed mental health treatment and (2) examine how well the process that current non-treatment-seeking individuals describe matches that used by individuals currently in treatment. METHODS Adults recruited online via Amazon's Mechanical Turk (N = 669) answered questions about finding a mental health provider. Participants who had (N = 167) and had not (N = 502) seen a mental health provider in the past month were compared. RESULTS Both groups indicated they would rely on Internet searches and recommendations of family, friends and physicians to find mental health providers. The order in which participants indicated they would use each step was similar across groups as was participants' confidence these steps would help them find a provider. Differences emerged in the factors each group indicated were important to their selection of a provider. CONCLUSIONS Results can inform mental health providers and policy makers regarding the importance of clear and informative online mental health information, including thorough information about appropriate mental health providers.
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Affiliation(s)
| | - Shireen L Rizvi
- Graduate School of Applied and Professional Psychology, Rutgers University, Piscataway, NJ, USA
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Beiser DG, Ward CE, Vu M, Laiteerapong N, Gibbons RD. Depression in Emergency Department Patients and Association With Health Care Utilization. Acad Emerg Med 2019; 26:878-888. [PMID: 30884035 PMCID: PMC6690783 DOI: 10.1111/acem.13726] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 03/07/2019] [Accepted: 03/12/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND Depression is one of the most common illnesses in the United States, with increased prevalence among people with lower socioeconomic status and chronic mental illness who often seek care in the emergency department (ED). We sought to estimate the rate and severity of major depressive disorder (MDD) in a nonpsychiatric ED population and its association with subsequent ED visits and hospitalizations. METHODS This prospective cohort study enrolled a convenience sample of English-speaking adults presenting to an urban academic medical center ED without psychiatric complaints between January 1, 2015, and September 21, 2015. Patients completed a computerized adaptive depression diagnostic screen (CAD-MDD) and dimensional depression severity measurement test (CAT-DI) via tablet computer. Primary outcomes included number of ED visits and hospitalizations assessed from index visit until January 1, 2016. Negative binomial regression modeling was performed to assess associations between depression, depression severity, clinical covariates, and utilization outcomes. RESULTS Of 999 enrolled patients, 27% screened positive for MDD. The presence of MDD conveyed a 61% increase in the rate of ED visits (incidence rate ratio [IRR] = 1.61, 95% confidence interval [CI] = 1.27 to 2.03) and a 49% increase in the rate of hospitalizations (IRR = 1.49, 95% CI = 1.06-2.09). For each 10% increase in MDD severity, there was a 10% increase in the relative rate of subsequent ED visits (IRR = 1.10, 95% CI = 1.04 to 1.16) and hospitalizations (IRR = 1.10, 95% CI = 1.02 to 1.18). Across the range of the severity scale there was over a 2.5-fold increase in the rate of ED visits and hospitalization rates. CONCLUSIONS Rates of depression were high among a convenience sample of English-speaking adult ED patients presenting with nonpsychiatric complaints and independently associated with increased risk of subsequent ED utilization and hospitalization. Standardized assessment tools that provide rapid, accurate, and precise classification of MDD severity have the potential to play an important role in identifying ED patients in need of urgent psychiatric resource referral.
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Affiliation(s)
- David G. Beiser
- Section of Emergency Medicine, University of Chicago, Chicago, IL
| | - Charlotte E. Ward
- Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Milkie Vu
- Section of Emergency Medicine, Departments of Medicine, University of Chicago, Chicago, IL, presently at Rollins School of Public Health, Emory University, Atlanta, GA
| | - Neda Laiteerapong
- Section of General Internal Medicine, University of Chicago, Chicago, IL
| | - Robert D. Gibbons
- Center for Health Statistics, Departments of Medicine and Public Health Sciences, University of Chicago, Chicago, IL
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Brandt CP, Deavers F, Hundt NE, Fletcher TL, Cully JA. The Impact of Integrating Physical Health into a Brief CBT Approach for Medically Ill Veterans. J Clin Psychol Med Settings 2019; 27:285-294. [PMID: 31201653 DOI: 10.1007/s10880-019-09634-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
The current study explored the use and preliminary outcomes of physical health treatment elements integrated into a traditional brief cognitive behavioral therapy (bCBT) approach for medically ill veterans with depression and/or anxiety. Data were collected as part of a pragmatic randomized trial examining patient outcomes of bCBT versus an enhanced usual care condition. bCBT was delivered to participants by Veterans Health Administration (VA) mental health providers in the primary care setting. Using a skill-based approach, providers and participants selected modules from a list of intervention strategies. Modules included Taking Control of Your Physical Health, Using Thoughts to Improve Wellness, Increasing Pleasant Activities, and Learning How to Relax. Skill module use and impact on treatment completion and clinical outcomes were explored for participants randomized to bCBT who received at least one skill module (n = 127). Utilization data showed that participants and providers most commonly selected the physical health module for the first skill session. Receiving the "physical health" and "thoughts" modules earlier in treatment were associated with a higher likelihood of treatment completion (defined as four or more sessions). Preliminary outcome data suggest that the physical health skill module was equally effective or superior to other bCBT skill modules. Results suggest that incorporating physical health elements with a bCBT approach hold the potential to positively impact treatment engagement/completion and may result in improved outcomes for medically ill patient populations.
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Affiliation(s)
- Charles P Brandt
- The Houston OCD Program, 708 E. 19th Street, Houston, TX, 77008, USA.,Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, One Baylor Plaza, Houston, TX, 77030, USA
| | - Frances Deavers
- Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Blvd. (152), Houston, TX, 77030, USA
| | - Natalie E Hundt
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, One Baylor Plaza, Houston, TX, 77030, USA.,Houston VA HSR &D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center (MEDVAMC 152), 2002 Holcombe Blvd., Houston, TX, 77030, USA.,VA South Central Mental Illness Research, Education and Clinical Center (A Virtual Center), Houston, TX, USA
| | - Terri L Fletcher
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, One Baylor Plaza, Houston, TX, 77030, USA.,Houston VA HSR &D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center (MEDVAMC 152), 2002 Holcombe Blvd., Houston, TX, 77030, USA.,VA South Central Mental Illness Research, Education and Clinical Center (A Virtual Center), Houston, TX, USA
| | - Jeffrey A Cully
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, One Baylor Plaza, Houston, TX, 77030, USA. .,Houston VA HSR &D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center (MEDVAMC 152), 2002 Holcombe Blvd., Houston, TX, 77030, USA. .,VA South Central Mental Illness Research, Education and Clinical Center (A Virtual Center), Houston, TX, USA.
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Possemato K, Shepardson RL, Funderburk JS. The Role of Integrated Primary Care in Increasing Access to Effective Psychotherapies in the Veterans Health Administration. FOCUS: JOURNAL OF LIFE LONG LEARNING IN PSYCHIATRY 2018; 16:384-392. [PMID: 31975930 DOI: 10.1176/appi.focus.20180024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
American military veterans have higher rates of psychiatric disorders, and timely access to high-quality mental health treatment in the Veterans Health Administration (VHA) is a persistent challenge. Integrated primary care (IPC) is one of many strategies implemented by VHA to increase access to care. IPC, including collaborative care and primary care behavioral health services, successfully increases access to initial behavioral health services in primary care (e.g., brief psychotherapies, pharmacotherapy) and continued engagement in specialty mental health services. IPC components that drive increased access include population-based care, response to patient preferences, and team-based care. The state of the evidence for IPC interventions for common behavioral health concerns in primary care (depression, anxiety, posttraumatic stress disorder, alcohol use, tobacco use, and insomnia) is reviewed, with areas for future research and implementation discussed, including how technology can assist IPC services and the importance of incorporating evidence-based psychotherapies into IPC.
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Affiliation(s)
- Kyle Possemato
- Drs. Possemato, Shepardson, and Funderburk are with the Veterans Administration Center for Integrated Healthcare, New York/New Jersey Veterans Administration Healthcare System, and the Department of Psychology, Syracuse University, New York
| | - Robyn L Shepardson
- Drs. Possemato, Shepardson, and Funderburk are with the Veterans Administration Center for Integrated Healthcare, New York/New Jersey Veterans Administration Healthcare System, and the Department of Psychology, Syracuse University, New York
| | - Jennifer S Funderburk
- Drs. Possemato, Shepardson, and Funderburk are with the Veterans Administration Center for Integrated Healthcare, New York/New Jersey Veterans Administration Healthcare System, and the Department of Psychology, Syracuse University, New York
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Benjenk I, Chen J. Effective mental health interventions to reduce hospital readmission rates: a systematic review. JOURNAL OF HOSPITAL MANAGEMENT AND HEALTH POLICY 2018; 2:45. [PMID: 30283917 PMCID: PMC6167018 DOI: 10.21037/jhmhp.2018.08.05] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Hospitals in the United States are financially penalized for having a higher than expected thirty-day readmission ratio among patients initially hospitalized for heart failure, acute myocardial infarction (AMI), pneumonia, chronic obstructive pulmonary disease (COPD), coronary artery bypass graft (CABG) surgery, or hip and knee replacement. Patients hospitalized for these conditions that have comorbid mental health diagnoses or symptoms are at high risk for readmission. METHODS We conducted a systematic review to determine if interventions, that are specifically designed to assess or treat mental health symptoms, can effectively reduce risk of readmission following hospitalization for physical health conditions. We searched on PubMed and Google Scholar for peer-reviewed articles published between January 2010 and June 2018 that examined the impact of mental-health interventions on readmissions for physical conditions. RESULTS After screening 81 full text articles, we found eleven intervention studies, one meta-analysis, and one cross-sectional study that met our inclusion criteria. Only three of the intervention studies found significant differences in readmission rates between intervention and comparison groups. Each of these interventions targeted patients after discharge from the hospital. One of the interventions was a physical health telemonitoring and individual psychotherapy intervention for patients that were initially admitted for heart failure. The second intervention was individual and group psychotherapy sessions for patients who were initially admitted for AMI. The third intervention was a nurse-driven depression care management protocol for home care patients with depressive symptoms who were initially admitted for any physical health condition. The cross-sectional study showed that communities with a stronger, social-based public mental health infrastructure had significantly lower physical health readmission rates. CONCLUSIONS The literature identified in this review, appears to provide support for the use of mental health interventions after discharge as a mechanism for reducing physical health condition readmissions. Future research is needed to determine if these interventions can specifically reduce thirty-day readmissions for the six conditions linked to financial penalties.
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Affiliation(s)
- Ivy Benjenk
- Department of Health Services Administration, University of Maryland School of Public Health, College Park, MD, USA
| | - Jie Chen
- Department of Health Services Administration, University of Maryland School of Public Health, College Park, MD, USA
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A Qualitative Study on Primary Care Integration into an Asian Immigrant-specific Behavioural Health Setting in the United States. Int J Integr Care 2018; 18:2. [PMID: 30214389 PMCID: PMC6133215 DOI: 10.5334/ijic.3719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Introduction Integrating primary care and behavioural health services improves access to services and health outcomes among individuals with serious mental illness. Integrated care is particularly promising for racial and ethnic minority individuals given higher rates of chronic illnesses and poorer access to and quality of care compared to Whites. However, little is known about integrated care implementation in non-White populations. The aim of this study is to identify facilitators and barriers to successful implementation of primary care-behavioural health integration in a multilingual behavioural healthcare setting. Methods Seven focus groups and five semi-structured interviews were conducted with 41 patients and 5 providers participating in integrated care in a community mental health clinic in California serving Asian immigrants. Results Themes generated from constant comparative analysis suggest limited system-level preconditions and cross-organisational dynamics challenged integrated care. At the same time, changing organisational culture and practice, improving patient-provider and provider-provider communication, and increasing patient involvement enhanced clinical outcomes and facilitated successful implementation. Discussion and conclusions Findings highlight the importance of patient involvement, peer services and interdisciplinary communication to successfully implement integrated care in the face of linguistic and operational challenges in settings serving multilingual and multicultural patients.
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Possemato K, Johnson EM, Beehler GP, Shepardson RL, King P, Vair CL, Funderburk JS, Maisto SA, Wray LO. Patient outcomes associated with primary care behavioral health services: A systematic review. Gen Hosp Psychiatry 2018; 53:1-11. [PMID: 29698902 DOI: 10.1016/j.genhosppsych.2018.04.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 04/13/2018] [Accepted: 04/15/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE This systematic review focused on Primary Care Behavioral Health (PCBH) services delivered under normal clinic conditions that included the patient outcomes of: 1) access/utilization of behavioral health services, 2) health status, and 3) satisfaction. METHOD Following PRISMA guidelines, comprehensive database searches and rigorous coding procedures rendered 36 articles meeting inclusion criteria. The principle summary measures of odd ratios or Cohen's d effect sizes were reported. RESULTS Due to significant limitations in the methodological rigor of reviewed studies, robust findings only emerged for healthcare utilization: PCBH is associated with shorter wait-times for treatment, higher likelihood of engaging in care, and attending a greater number of visits. Several small, uncontrolled studies report emerging evidence that functioning, depression, and anxiety improve overtime. There was no evidence of greater improvement in patient health status when PCBH was compared to other active treatments. The limited available evidence supports that patient satisfaction with PCBH services is high. CONCLUSIONS The implementation of PCBH services is ahead of the science supporting the usefulness of these services. Patient outcomes for PCBH are weaker than outcomes for Collaborative Care. More rigorous investigations of patient outcomes associated with PCBH are needed to allow for optimization of services.
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Affiliation(s)
- Kyle Possemato
- VA Center for Integrated Healthcare, New York/New Jersey VA Healthcare System, United States; Department of Psychology, Syracuse University, Syracuse, NY, United States.
| | - Emily M Johnson
- VA Center for Integrated Healthcare, New York/New Jersey VA Healthcare System, United States
| | - Gregory P Beehler
- VA Center for Integrated Healthcare, New York/New Jersey VA Healthcare System, United States; Community Health and Health Behavior, University at Buffalo, Buffalo, NY, United States
| | - Robyn L Shepardson
- VA Center for Integrated Healthcare, New York/New Jersey VA Healthcare System, United States; Department of Psychology, Syracuse University, Syracuse, NY, United States
| | - Paul King
- VA Center for Integrated Healthcare, New York/New Jersey VA Healthcare System, United States; Department of Counseling, School, and Educational Psychology, University at Buffalo, Buffalo, NY, United States
| | | | - Jennifer S Funderburk
- VA Center for Integrated Healthcare, New York/New Jersey VA Healthcare System, United States; Department of Psychology, Syracuse University, Syracuse, NY, United States; Department of Psychiatry, University of Rochester, Rochester, NY, United States
| | - Stephen A Maisto
- VA Center for Integrated Healthcare, New York/New Jersey VA Healthcare System, United States; Department of Psychology, Syracuse University, Syracuse, NY, United States
| | - Laura O Wray
- VA Center for Integrated Healthcare, New York/New Jersey VA Healthcare System, United States; Division of Geriatrics/Palliative Care, Jacobs School of Medicine, University at Buffalo, Buffalo, NY, United States
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Landoll RR, Nielsen MK, Waggoner KK, Najera E. Innovations in primary care behavioral health: a pilot study across the U.S. Air Force. Transl Behav Med 2018; 9:266-273. [DOI: 10.1093/tbm/iby046] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Ryan R Landoll
- Department of Family Medicine, Uniformed Services University, Bethesda, MD, USA
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Shepardson RL, Buchholz LJ, Weisberg RB, Funderburk JS. Psychological interventions for anxiety in adult primary care patients: A review and recommendations for future research. J Anxiety Disord 2018; 54:71-86. [PMID: 29427898 PMCID: PMC7909724 DOI: 10.1016/j.janxdis.2017.12.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 11/07/2017] [Accepted: 12/23/2017] [Indexed: 10/18/2022]
Abstract
Anxiety symptoms are prevalent in primary care, yet treatment rates are low. The integration of behavioral health providers into primary care via the Primary Care Behavioral Health (PCBH) model offers a promising way to improve treatment options by adding a team member with the necessary skillset to deliver evidence-based psychological interventions for anxiety. We conducted a narrative review of psychological interventions for anxiety applied within adult primary care settings (k = 44) to update the literature and evaluate the fit of existing interventions with the PCBH model. The majority of studies were randomized controlled trials (RCTs; 70.5%). Most interventions utilized cognitive-behavioral therapy (68.2%) and were delivered individually, face-to-face (52.3%). Overall, 65.9% of interventions (58.6% of RCTs, 91.7% of pre-post) were effective in reducing anxiety symptoms, and 83.3% maintained the gains at follow-up. Although it is encouraging that most interventions significantly reduced anxiety, their longer formats (i.e., number and duration of sessions) and narrow symptom targets make translation into practice difficult. Methodological limitations of the research included homogenous samples, failure to report key procedural details, pre-post designs, and restrictive eligibility criteria. We offer recommendations to guide future research to improve the likelihood of successful translation of anxiety interventions into clinical practice.
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Affiliation(s)
- Robyn L Shepardson
- Center for Integrated Healthcare, Syracuse VA Medical Center, Syracuse, NY, United States; Department of Psychology, Syracuse University, Syracuse, NY, United States.
| | - Laura J Buchholz
- Center for Integrated Healthcare, VA Western New York Healthcare System at Buffalo, Buffalo, NY, United States; Department of Psychology, University at Buffalo/State University of New York, Buffalo, NY, United States; Department of Psychology, University of Tampa, Tampa, FL, United States.
| | - Risa B Weisberg
- VA Boston Healthcare System, Boston, MA, United States; Boston University School of Medicine, Boston, MA, United States; Alpert Medical School of Brown University, Providence, RI, United States.
| | - Jennifer S Funderburk
- Center for Integrated Healthcare, Syracuse VA Medical Center, Syracuse, NY, United States; Department of Psychology, Syracuse University, Syracuse, NY, United States; Department of Psychiatry, University of Rochester School of Medicine, Rochester, NY, United States.
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Staab EM, Terras M, Dave P, Beckman N, Shah S, Vinci LM, Yohanna D, Laiteerapong N. Measuring Perceived Level of Integration During the Process of Primary Care Behavioral Health Implementation. Am J Med Qual 2017; 33:253-261. [PMID: 29072487 DOI: 10.1177/1062860617736607] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Provider- and staff-perceived levels of integration were measured during implementation of a primary care behavioral health clinic; these data were used to tailor and evaluate quality improvement strategies. Providers and staff at an urban, academic, adult primary care clinic completed the 32-item Level of Integration Measure (LIM) at baseline and 7 months. The LIM assesses 6 domains of integrated care. Overall and domain scores were calibrated from 0 to 100, with ≥80 representing a highly integrated clinic. Response rate was 79% (N = 46/58) at baseline and 83% (N = 52/63) at follow-up. Overall, LIM score increased from 64.5 to 70.1, P = .001. The lowest scoring domains at baseline were targeted for quality improvement and increased significantly: integrated clinical practice, 60.0 versus 68.4, P < .001; systems integration, 57.0 versus 63.8, P = .001; and training, 56.7 versus 65.3, P = .001. Ongoing quality improvement, including organizational and financial strategies, is needed to achieve higher levels of integration.
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Abstract
A multidisciplinary team approach to care and robust care coordination services are primary components of almost all integrated care delivery systems. Given that these services have limited reimbursement in fee-for-service payment arrangements, integrating care in a fee-for-service environment is almost impossible. Capitated payment models hold promise for supporting integrated behavioral and physical health services. There are multiple national examples of integrated care delivery systems supported by capitated payment arrangements.
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Affiliation(s)
- Katherine Hobbs Knutson
- Department of Psychiatry, Duke University School of Medicine, 2608 Erwin Road, Suite 300, Durham, NC 27705, USA.
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Nigg CR, Jake-Schoffman DE, Janke EA. Motivating future directions of behavioral medicine. J Behav Med 2016; 40:1-5. [PMID: 28028656 DOI: 10.1007/s10865-016-9817-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 12/09/2016] [Indexed: 12/19/2022]
Affiliation(s)
- Claudio R Nigg
- Office of Public Health Studies, University of Hawaii, 1960 East-West Road, Honolulu, HI, 96822, USA.
| | - Danielle E Jake-Schoffman
- Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - E Amy Janke
- Department of Behavioral and Social Sciences, University of the Sciences, Philadelphia, PA, USA
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