Behavioral health referrals and treatment initiation rates in integrated primary care: a Collaborative Care Research Network study

"They really trust us!": Medical Interpreter's Roles and Experiences in an Integrated Primary Care Clinic

This study describes medical interpreters' experiences with behavioral health (BH) services in a primary care clinic. Focus group data with medical interpreters representing multiple languages was analyzed using hybrid inductive-deductive thematic analysis. Themes related to interpreter roles were: (1) case management, (2) patient-interpreter relationship, and (3) patient-provider liaison. Themes related to barriers and facilitators to interpreter-mediated BH care were: (1) cultural factors, (2) patient-provider interactions, (3) BH-specific considerations, and (4) clinic factors. Results illustrate ways that interpreters directly (e.g., interpreter-mediated services) and indirectly (e.g., relationship building) support care. The interpreter-patient relationship reportedly helped improve patient attitudes and buy-in for BH.

Impact of Primary Care-Mental Health Care Integration on Mental Health Care Engagement Across Racial and Ethnic Groups

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.

Supporting Quality Integrated Care for Adolescent Depression in Primary Care: A Learning System Approach

Background

Quality integrated care, which involves primary care and mental health clinicians working together, can help identify and treat adolescent depression early. We explored systemic barriers to quality integrated care at the provincial level in Ontario, Canada using a learning system approach.

Methods

Two Ontario Health Teams (OHTs), regional networks designed to support integrated care, completed the Practice Integration Profile (PIP) and participated in focus groups.

Results

The OHTs had a median PIP score of 69 out of 100. Among the PIP domains, the lowest median score was case identification (50), and the highest one was workspace (100). The focus groups generated 180 statements mapped to the PIP domains. Workflow had the highest number of coded statements (59, 32.8%).

Discussion

While the primary care practices included mental health clinicians on-site, the findings highlighted systemic barriers with adhering to the integrated care pathway for adolescent depression. These include limited access to mental health expertise for assessment and diagnosis, long wait times for treatment, and shortages of clinicians trained in evidence-based behavioral therapies. These challenges contributed to the reliance on antidepressants as the first line of treatment due to their accessibility rather than evidence-based guidelines.

Conclusion

Primary care practices, within regional networks such as OHTs, can form learning systems to continuously identify the strategies needed to support quality integrated care for adolescent depression based on real-world data.

Lessening the Impact of Opioid Misuse at a Federally Qualified Health Center in New York: Outcomes of an Integrated Workforce Training Program

The COVID-19 pandemic has placed an unprecedented burden on patients, health care providers, and communities and has been particularly challenging for medically underserved populations impacted by the social determinants of health, as well as people with co-occurring mental health and substance use risks. This case study examines outcomes and lessons learned from a multisite low-threshold medication-assisted treatment (MAT) program at a federally qualified health center in partnership with a large suburban public university in New York to integrate and train Health Resources & Services Administration Behavioral Health Workforce Education and Training-funded graduate student trainees in social work and nursing in screening, brief intervention, and referral to treatment and patient care coordination, including social determinants of health and medical and behavioral comorbidities. The MAT program for the treatment of opioid use disorder has a low threshold for entry that is accessible and affordable, reduces barriers to care, and uses a harm reduction approach. Outcome data showed an average 70% retention rate in the MAT program and reductions in substance use. And, while more than 73% of patients reported being somewhat or definitely impacted by the pandemic, most patients endorsed the effectiveness of telemedicine and telebehavioral health, such that 86% indicated the pandemic did not affect the quality of their health care. The main implementation lessons learned were the importance of increasing the capacity of primary care and health care centers to deliver integrated care, using cross-disciplinary practicum experiences to enhance trainee competencies, and addressing the social determinants of health among populations with social vulnerabilities and chronic medical conditions.

Characterizing modifications to a comparative effectiveness research study: the OPTIMIZE trial-using the Framework for Reporting Adaptations and Modifications to Evidence-based Interventions (FRAME)

BACKGROUND

The OPTIMIZE trial is a multi-site, comparative effectiveness research (CER) study that uses a Sequential Multiple Assessment Randomized Trial (SMART) designed to examine the effectiveness of complex health interventions (cognitive behavioral therapy, physical therapy, and mindfulness) for adults with chronic low back pain. Modifications are anticipated when implementing complex interventions in CER. Disruptions due to COVID have created unanticipated challenges also requiring modifications. Recent methodologic standards for CER studies emphasize that fully characterizing modifications made is necessary to interpret and implement trial results. The purpose of this paper is to outline the modifications made to the OPTIMIZE trial using the Framework for Reporting Adaptations and Modifications to Evidence-Based Interventions (FRAME) to characterize modifications to the OPTIMIZE trial in response to the COVID pandemic and other challenges encountered.

METHODS

The FRAME outlines a strategy to identify and report modifications to evidence-based interventions or implementation strategies, whether planned or unplanned. We use the FRAME to characterize the process used to modify the aspects of the OPTIMIZE trial. Modifications were made to improve lower-than-anticipated rates of treatment initiation and COVID-related restrictions. Contextual modifications were made to permit telehealth delivery of treatments originally designed for in-person delivery. Training modifications were made with study personnel to provide more detailed information to potential participants, use motivational interviewing communication techniques to clarify potential participants' motivation and possible barriers to initiating treatment, and provide greater assistance with scheduling of assigned treatments.

RESULTS

Modifications were developed with input from the trial's patient and stakeholder advisory panels. The goals of the modifications were to improve trial feasibility without compromising the interventions' core functions. Modifications were approved by the study funder and the trial steering committee.

CONCLUSIONS

Full and transparent reporting of modifications to clinical trials, whether planned or unplanned, is critical for interpreting the trial's eventual results and considering future implementation efforts.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03859713. Registered on March 1, 2019.

The Association Between Depression and Substance Use Among Primary Care Patients With Comorbid Medical and Behavioral Health Conditions

INTRODUCTION

The scope of primary care increasingly encompasses patient behavioral health problems, manifest typically through depression screening and treatment. Although substance use is highly comorbid with depression, it is not commonly identified and addressed in the primary care context. This study aimed to examine the association between the likelihood of substance use disorder and increased depression severity, both cross-sectionally and longitudinally, among a sample of 2409 patients from 41 geographically dispersed and diverse primary care clinics across the US.

METHODS

This is secondary analysis of data obtained from a multi-site parent study of integrated behavioral health in primary care, among patients with both chronic medical and behavioral health conditions. Patient reported outcome surveys were gathered from patients at 3 time points. The primary care practices were blind to which of their patients completed surveys. Included were standardized measures of depression severity (Patient Health Questionnaire-9) [PHQ-9] and substance use disorder likelihood (Global Appraisal of Individual Needs-Short Screener [GSS]).

RESULTS

Four percent of the study population screened positive for substance use disorder. PHQ-9 scores indicated depression among 43% of all patients. There was a significant association between the likelihood of substance use disorder and depression initially, at a 9-month follow-up, and over time. These associations remained significant after adjusting for age, gender, race, ethnicity, education, income, and other patient and contextual characteristics.

CONCLUSIONS

The findings suggest that substance use disorder is associated with depression severity cross-sectionally and over time. Primary care clinics and health systems might consider implementing substance use screening in addition to the more common screening strategies for depression. Especially for patients with severe depression or those who do not respond to frontline depression treatments, the undermining presence of a substance use disorder should be explored.

Designing and Implementing an Electronic Health Record-Embedded Card Study in Primary Care: Methods and Considerations

Card studies-short surveys about the circumstances within which patients receive care-are traditionally completed on physical cards. We report on the development of an electronic health record (EHR)-embedded card study intended to decrease logistical challenges inherent to paper-based approaches, including distributing, tracking, and transferring the physical cards, as well as data entry and respondent prompts, while simultaneously decreasing the complexity for participants and facilitating rich analyses by linking to clinical and demographic data found in the EHR. Developing the EHR-based programming and data extraction was time consuming, required specialized expertise, and necessitated iteration to rectify issues encountered during implementation. Nonetheless, future EHR-embedded card studies will be able to replicate many of the same processes as informed by these results. Once built, the EHR-embedded card study simplified survey implementation for both the research team and clinic staff, resulting in research-quality data, the ability to link survey responses to relevant EHR data, and a 79% response rate. This detailed accounting of the development and implementation process, including issues encountered and addressed, might guide others in conducting EHR-embedded card studies.

Integrated Behavioral Health Care: Reflections of the Past

Humans have long sought to be provided with optimal health care, and the research continues in the twenty-first century. In the spirit of Galen from 19 centuries ago, empowering the patient's physician remains an important approach in health care. There is an emphasis on primary care and integration of behavioral consultation services in primary care. It remains a work in progress with help from the past and realistic hope for the future.

Integrating Behavioral Health and Primary Care (IBH-PC) to improve patient-centered outcomes in adults with multiple chronic medical and behavioral health conditions: study protocol for a pragmatic cluster-randomized control trial

BACKGROUND

Chronic diseases that drive morbidity, mortality, and health care costs are largely influenced by human behavior. Behavioral health conditions such as anxiety, depression, and substance use disorders can often be effectively managed. The majority of patients in need of behavioral health care are seen in primary care, which often has difficulty responding. Some primary care practices are providing integrated behavioral health care (IBH), where primary care and behavioral health providers work together, in one location, using a team-based approach. Research suggests there may be an association between IBH and improved patient outcomes. However, it is often difficult for practices to achieve high levels of integration. The Integrating Behavioral Health and Primary Care study responds to this need by testing the effectiveness of a comprehensive practice-level intervention designed to improve outcomes in patients with multiple chronic medical and behavioral health conditions by increasing the practice's degree of behavioral health integration.

METHODS

Forty-five primary care practices, with existing onsite behavioral health care, will be recruited for this study. Forty-three practices will be randomized to the intervention or usual care arm, while 2 practices will be considered "Vanguard" (pilot) practices for developing the intervention. The intervention is a 24-month supported practice change process including an online curriculum, a practice redesign and implementation workbook, remote quality improvement coaching services, and an online learning community. Each practice's degree of behavioral health integration will be measured using the Practice Integration Profile. Approximately 75 patients with both chronic medical and behavioral health conditions from each practice will be asked to complete a series of surveys to measure patient-centered outcomes. Change in practice degree of behavioral health integration and patient-centered outcomes will be compared between the two groups. Practice-level case studies will be conducted to better understand the contextual factors influencing integration.

DISCUSSION

As primary care practices are encouraged to provide IBH services, evidence-based interventions to increase practice integration will be needed. This study will demonstrate the effectiveness of one such intervention in a pragmatic, real-world setting.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02868983 . Registered on August 16, 2016.

Screening Isn't Enough: A Call to Integrate Behavioral Health Providers in Women's Health and Perinatal Care Settings

This paper aims to enhance the current understanding of integrated mental health services in the United States and how they can be better incorporated in perinatal and women's health specialty care from the perspective of a behavioral health provider. While much is known about gender disparities of mental health and low recognition and treatment rates for mental health disorders in women's health and perinatal care, few changes are being implemented to embed mental health specialists where they are needed most to close gaps in care. This paper demonstrates the value creation of integrated behavioral health in a midwife practice in the State of Arizona. Clinical and operational workflows can easily be adapted to include a behavioral health service to address mental and behavioral health needs that, when untreated, lead to long-term adverse outcomes in women and their families. Financial barriers that may hinder success of the integrated model are highlighted and discussed.

Program Evaluation of an Integrated Behavioral Health Clinic in an Outpatient Women's Health Clinic: Challenges and Considerations

Many women receive their regular check-ups and preventive care through a women's health clinic, including their behavioral health needs. Most of these clinics have not yet developed the capacity to adequately manage behavioral health concerns. We describe our clinical experience integrating behavioral health services into a women's health clinic. In one year, 108 women (54% White, M_age= 35) were referred for behavioral health treatment 47% were identified using a screening questionnaire, 51% were referred by their women's health provider and 2% were self-referred. The most common presenting concerns were anxiety (52%) and depressive symptoms (48%). Sixty-one (56%) patients completed an intake assessment, of whom 33 (54%) engaged in follow-up treatment (M = 3.7 treatment sessions, SD = 3.0). Behavioral health screening and treatment appears to be feasible and effective within a women's health setting. Further research is needed to overcome barriers to referrals and treatment engagement in this population.

Patient and System Characteristics Associated with Performance on the HEDIS Measures of Alcohol and Other Drug Treatment Initiation and Engagement

OBJECTIVES

Understand patient and system characteristics associated with performance on the Healthcare Effectiveness Data and Information Set (HEDIS) Alcohol and Other Drug (AOD) Initiation and Engagement of Treatment (IET) measures.

METHODS

This mixed-methods study linked patient and health system data from four Kaiser Permanente regions to HEDIS performance measure data for 44,320 commercially or Medicare-insured adults with HEDIS-eligible AOD diagnoses in 2012. Characteristics associated with IET were examined using multilevel logistic regression models. Key informant interviews (n = 18) focused on opportunities to improve initiation and engagement.

RESULTS

Non-white race/ethnicity, alcohol abuse, or nonopioid drug abuse diagnoses were associated with lower odds of treatment initiation among commercially insured. For both insurance groups, those diagnosed in healthcare departments other than specialty AOD treatment were less likely to initiate or engage in treatment. Being diagnosed in facilities with co-located AOD/primary care clinics, and those with medications for addiction treatment available, was each associated with higher odds of initiation and engagement for both commercially and Medicare-insured. Having behavioral medicine specialists or clinical health educators in primary care increased initiation and engagement odds among commercially insured. Key informants recommended were as follows: patient-centered care; increased treatment choices; cross-departmental patient identification, engagement, and coordination; provider education; and use of informatics/technology.

CONCLUSIONS

Tailoring treatment, enhancing treatment motivation among individuals with lower severity diagnoses, offering medication treatment of addiction, clinician education, care coordination, co-located AOD and primary care departments, and behavioral medicine specialists in primary care may improve rates of initiation and engagement in AOD treatment.

A Primary Care Prevention System for Behavioral Health: The Behavioral Health Annual Wellness Checkup

Behavioral health problems are involved in the majority of primary care visits. These behavior disorders (e.g., depression, anxiety, smoking, insomnia, etc.) are costly, burdensome to both the patient and the healthcare system, and result in greater medical utilization/cost and poorer future health outcomes. Integrated behavioral healthcare has been proposed as a model for more efficiently addressing the burden of behavioral health problems. While this model has demonstrated some promise in the treatment of behavioral health problems, as well as in the reduction in costs and improvement in healthcare outcomes, the primary prevention of behavioral health problems in this delivery model has been relatively neglected. The present paper discusses the potential value of incorporating the prevention of behavioral health problems into the annual physical/wellness checkup and proposes a detailed system for how this might be accomplished. Limitations, future research, and costs associated with increased prevention in a primary care context are discussed.

Chronic care coordination by integrating care through a team-based, population-driven approach: a case study

Patients with chronic conditions frequently experience behavioral comorbidities to which primary care cannot easily respond. This study observed a Vermont family medicine practice with integrated medical and behavioral health services that use a structured approach to implement a chronic care management system with Lean. The practice chose to pilot a population-based approach to improve outcomes for patients with poorly controlled Type 2 diabetes using a stepped-care model with an interprofessional team including a community health nurse. This case study observed the team's use of Lean, with which it designed and piloted a clinical algorithm composed of patient self-assessment, endorsement of behavioral goals, shared documentation of goals and plans, and follow-up. The team redesigned workflows and measured reach (patients who engaged to the end of the pilot), outcomes (HbA1c results), and process (days between HbA1c tests). The researchers evaluated practice member self-reports about the use of Lean and facilitators and barriers to move from pilot to larger scale applications. Of 20 eligible patients recruited over 3 months, 10 agreed to participate and 9 engaged fully (45%); 106 patients were controls. Relative to controls, outcomes and process measures improved but lacked significance. Practice members identified barriers that prevented implementation of all changes needed but were in agreement that the pilot produced useful outcomes. A systematized, population-based, chronic care management service is feasible in a busy primary care practice. To test at scale, practice leadership will need to allocate staffing, invest in shared documentation, and standardize workflows to streamline office practice responsibilities.

Leadership Perspectives on Integrating Psychologists into Specialty Care Clinics: An Evolving Paradigm

Integration of health psychologists into specialty care is a shift in the tertiary care construct that addresses all aspects of a patient's presentation, including psychiatric/social history, psychological well-being, and behavioral contributions to the disease process, assuring both optimal health outcomes and cost-effectiveness in a financially challenging healthcare environment. In this paper, we discuss leadership perspectives (physician and psychologists) on the factors involved in integrating a health psychologist into a busy tertiary care environment. Ultimately, we hope that this information provides a primer on how to frame a proposal for an integrated health psychologist emphasizing the elements important to senior medical leadership and administration. First, we briefly discuss the current payer framework, providing support for integration emphasizing costs and other metrics. Second, we introduce organizational structure models and strategies for integration. Lastly, we will discuss the unique skillset psychologists possess, and additional skills necessary, to be effective in the changing landscape of healthcare. We think this information is important both for leaders attempting to integrate a health psychologist into specialty care and for the early career health psychologist embarking on his/her first senior staff position.

Preparing the workforce for integrated healthcare: A systematic review

Integrated healthcare is recommended to deliver care to individuals with co-occurring medical and mental health conditions. This literature review was conducted to identify the knowledge and skills required for behavioral health consultants in integrated settings. A review from 1999 to 2015 identified 68 articles. Eligible studies examined care to the U.S. adult population at the highest level of integration. The results provide evidence of specific knowledge of medical and mental health diagnoses, screening instruments, and intervention skills in integrated primary care, specialty medical, and specialty mental health. Further research is required to identify methods to develop knowledge/skills in the workforce.

Development and use of a clinical decision support tool for behavioral health screening in primary care clinics

OBJECTIVE

Screening, brief intervention, and referral for treatment (SBIRT) for behavioral health (BH) is a key clinical process. SBIRT tools in electronic health records (EHR) are infrequent and rarely studied. Our goals were 1) to design and implement SBIRT using clinical decision support (CDS) in a commercial EHR; and 2) to conduct a pragmatic evaluation of the impact of the tools on clinical outcomes.

METHODS

A multidisciplinary team designed SBIRT workflows and CDS tools. We analyzed the outcomes using a retrospective descriptive convenience cohort with age-matched comparison group. Data extracted from the EHR were evaluated using descriptive statistics.

RESULTS

There were 2 outcomes studied: 1) development and use of new BH screening tools and workflows; and 2) the results of use of those tools by a convenience sample of 866 encounters. The EHR tools developed included a flowsheet for documenting screens for 3 domains (depression, alcohol use, and prescription misuse); and 5 alerts with clinical recommendations based on screening; and reminders for annual screening. Positive screen rate was 21% (≥1 domain) with 60% of those positive for depression. Screening was rarely positive in 2 domains (11%), and never positive in 3 domains. Positive and negative screens led to higher rates of documentation of brief intervention (BI) compared with a matched sample who did not receive screening, including changes in psychotropic medications, updated BH terms on the problem list, or referral for BH intervention. Clinical process outcomes changed even when screening was negative.

CONCLUSIONS

Modified workflows for BH screening and CDS tools with clinical recommendations can be deployed in the EHR. Using SBIRT tools changed clinical process metrics even when screening was negative, perhaps due to conversations about BH not captured in the screening flowsheet. Although there are limitations to the study, results support ongoing investigation.

Variations in Mental Health Diagnosis and Prescribing Across Pediatric Primary Care Practices

BACKGROUND

Primary care pediatricians increasingly care for children's mental health problems, but little is known about practice-level variation in diagnosis and psychotropic medication prescribing practices.

METHODS

This retrospective review of electronic heath records from 43 US primary care practices included children aged 4 to 18 years with ≥1 office visit from January 1, 2009, to June 30, 2014. We examined variability in diagnosis and psychotropic prescribing across practices using logistic regression with practice fixed effects and evaluated associations of the availability of colocated or community-based mental health providers or the proportion of children in foster care with diagnosis and prescribing using generalized linear mixed models.

RESULTS

Among 294 748 children, 40 932 (15%) received a mental health diagnosis and 39 695 (14%) were prescribed psychotropic medication. Attention deficit/hyperactivity disorder was most commonly diagnosed (1%-16% per practice). The proportion of children receiving any psychotropic medication (4%-26%) and the proportion receiving ≥2 medication classes (1%-12%) varied across practices. Prescribing of specific medication classes also varied (stimulants, 3%-18%; antidepressants, 1%-12%; α-agonists, 0%-8%; second-generation antipsychotics, 0%-5%). Variability was partially explained by community availability of psychiatrists (significantly higher odds of a diagnosis or prescription when not available) but not by colocation of mental health professionals or percentage of children in foster care.

CONCLUSIONS

The prevalence of mental health diagnosis and psychotropic medication prescribing varies substantially across practices and is only partially explained by psychiatrist availability. Research is needed to better define the causes of variable practice-level diagnosis and prescribing and implications for child mental health outcomes.

Integrating Behavioral Health in Primary Care Using Lean Workflow Analysis: A Case Study

BACKGROUND

Primary care offices are integrating behavioral health (BH) clinicians into their practices. Implementing such a change is complex, difficult, and time consuming. Lean workflow analysis may be an efficient, effective, and acceptable method for use during integration. The objectives of this study were to observe BH integration into primary care and to measure its impact.

METHODS

This was a prospective, mixed-methods case study in a primary care practice that served 8,426 patients over a 17-month period, with 652 patients referred to BH services. Secondary measures included primary care visits resulting in BH referrals, referrals resulting in scheduled appointments, time from referral to the scheduled appointment, and time from the referral to the first visit. Providers and staff were surveyed on the Lean method.

RESULTS

Referrals increased from 23 to 37 per 1000 visits (P < .001). Referrals resulted in more scheduled (60% to 74%; P < .001) and arrived visits (44% to 53%; P = .025). Time from referral to the first scheduled visit decreased (hazard ratio, 1.60; 95% confidence interval, 1.37-1.88) as did time to first arrived visit (hazard ratio, 1.36; 95% confidence interval, 1.14-1.62). Survey responses and comments were positive.

CONCLUSIONS

This pilot integration of BH showed significant improvements in treatment initiation and other measures. Strengths of Lean analysis included workflow improvement, system perspective, and project success. Further evaluation is indicated.

Effect of Pediatric Behavioral Health Screening and Colocated Services on Ambulatory and Inpatient Utilization

OBJECTIVE

The study sought to determine the impact of a pediatric behavioral health screening and colocation model on utilization of behavioral health care.

METHODS

In 2003, Cambridge Health Alliance, a Massachusetts public health system, introduced behavioral health screening and colocation of social workers sequentially within its pediatric practices. An interrupted time-series study was conducted to determine the impact on behavioral health care utilization in the 30 months after model implementation compared with the 18 months prior. Specifically, the change in trends of ambulatory, emergency, and inpatient behavioral health utilization was examined. Utilization data for 11,223 children ages ≥4 years 9 months to <18 years 3 months seen from 2003 to 2008 contributed to the study.

RESULTS

In the 30 months after implementation of pediatric behavioral health screening and colocation, there was a 20.4% cumulative increase in specialty behavioral health visit rates (trend of .013% per month, p=.049) and a 67.7% cumulative increase in behavioral health primary care visit rates (trend of .019% per month, p<.001) compared with the expected rates predicted by the 18-month preintervention trend. In addition, behavioral health emergency department visit rates increased 245% compared with the expected rate (trend .01% per month, p=.002).

CONCLUSIONS

After the implementation of a behavioral health screening and colocation model, more children received behavioral health treatment. Contrary to expectations, behavioral health emergency department visits also increased. Further study is needed to determine whether this is an effect of how care was organized for children newly engaged in behavioral health care or a reflection of secular trends in behavioral health utilization or both.

Under Construction: One State's Approach to Creating Health Homes for Individuals with Serious Mental Illness

Changes to the health care market associated with the Patient Protection and Affordable Care Act (ACA) are creating both need and opportunity for states, health plans, and providers to improve quality, outcomes, and satisfaction through better integration of traditionally separate health care delivery systems. Applications of the term "integrated care" vary widely and include, but are not limited to, the integration of care for Medicare-Medicaid dually enrolled beneficiaries, the integration of mental health and substance abuse (also known as behavioral health), and the integration of mental health and substance abuse with medical care, most commonly primary care. In this article, integrated care refers to well-coordinated physical health and behavioral health care. Medicaid Health Homes are emerging as a promising practice, with sixteen states having adopted the Health Home model through approved State Plan Amendments. This article describes one state's journey towards establishing Health Homes with a behavioral health focus. We discuss a partnership model between the relevant state organizations, the contracted providers, and the behavioral health managed care organization responsible for many of the supportive administrative functions. We highlight successes and operational challenges and offer recommendations for future Health Home development efforts.

Newcomers to Al-Anon family groups: Who stays and who drops out?

Al-Anon Family Groups (Al-Anon), a 12-step mutual-help program for people concerned about another's drinking, is the most widely used form of help for concerned others (COs) in the US. This study assessed the prevalence of dropout, and predictors of dropout, in the six months following newcomers' initial attendance at Al-Anon meetings. Al-Anon's World Service Office mailed a random sample of groups, which subsequently yielded a sample of 251 newcomers who completed surveys at baseline and 6 months later. At the 6-month follow-up, 57% of newcomers at baseline had dropped out (had not attended any Al-Anon meetings during the past month). At baseline, individuals who later dropped out of Al-Anon were less likely to have been referred to Al-Anon by their drinker's health care provider, and reported less severe problems than individuals who continued to attend, but dropouts were more often concerned about their drinker's psychological health; newcomers with these concerns may have found them incompatible with Al-Anon's philosophy. Dropouts reported high rates of problems, suggesting that COs who drop out of Al-Anon would benefit from ongoing help and support.

Mental health collaborative care and its role in primary care settings

Collaborative care models (CCMs) provide a pragmatic strategy to deliver integrated mental health and medical care for persons with mental health conditions served in primary care settings. CCMs are team-based intervention to enact system-level redesign by improving patient care through organizational leadership support, provider decision support, and clinical information systems, as well as engaging patients in their care through self-management support and linkages to community resources. The model is also a cost-efficient strategy for primary care practices to improve outcomes for a range of mental health conditions across populations and settings. CCMs can help achieve integrated care aims underhealth care reform yet organizational and financial issues may affect adoption into routine primary care. Notably, successful implementation of CCMs in routine care will require alignment of financial incentives to support systems redesign investments, reimbursements for mental health providers, and adaptation across different practice settings and infrastructure to offer all CCM components.