Patient Perspectives of Integrated Behavioral Health in Primary Care: A Mixed Methods Analysis

Integrated and collaborative care models, in which mental/behavioral health providers work closely with primary care providers within a primary care setting, help support the quadruple aim of improved health outcomes, patient satisfaction, provider experience, and lower cost. In this paper, we describe patients' general perspectives of integrated care and their unique experiences accessing this care within one health system. Qualitative (interviews with patients) and quantitative (surveys with patients) methods were used to collect and analyze these results separately and together. The results highlight important features to the provision of integrated care from the perspective of patients using integrated care. They include the importance and experience of access, whole-person care and a team-based approach, the availability and use of telehealth when appropriate, having high quality mental health providers, scheduling and service usage suggestions, and means to connect with longer-term services for ongoing mental health care when needed.

Person-centered care for common mental disorders in Ontario's primary care patient-centered medical homes: a qualitative study of provider perspectives

BACKGROUND

For more than a decade, the Patient-Centered Medical Home model has been a guiding vision for the modernization of primary care systems. In Canada, Ontario's Family Health Teams (FHTs) were designed in the mid-2000s with the medical home model in mind. These primary care clinics aim to provide accessible, comprehensive, and person-centered primary care services to communities across Ontario. Their services typically include mental health care for people experiencing common mental disorders, such as depression and anxiety disorders. It remains unclear, however, whether the mental health care delivered within FHTs is consistent with person-centered care approaches. In the current study, we aimed to explore the perspectives of FHT providers on the care delivered to people with common mental disorders to determine whether, and to what extent, they believed this care was person-centered.

METHODS

We conducted a qualitative grounded theory study involving interviews with 65 health professionals and administrators from 18 FHTs across Ontario. Transcripts were coded using a three-step process of initial, focused, and axial coding that mixed inductive and deductive approaches informed by sensitizing concepts on person-centeredness.

RESULTS

Practices and challenges associated with the delivery of mental health care in a person-centered way were captured by several themes regrouped into five domains: (1) patient as unique person, (2) patient-provider relationship, (3) sharing power and responsibility, (4) connecting to family and community, and (5) creating person-centered care environments. FHT providers perceived that they delivered person-centered care by delivering mental health care that was responsive, flexible, and consistent with biopsychosocial approaches. They emphasized the importance of creating long-lasting relationships with patients grounded in empathy and trust. Their challenges included being able to ensure continuity of care, adequately prioritizing patients' mental health issues, and meaningfully engaging patients and families as partners in care.

CONCLUSIONS

Our findings suggest that FHT providers have adopted a range of person-centered practices for people with common mental disorders. However, greater attention to practices such as shared decision making, supporting self-management, and involving families in care would strengthen person-centeredness and bring teams closer to the Patient-Centered Medical Home vision.

Patients' experiences of and roles in interprofessional collaborative practice in primary care: a constructivist grounded theory study

AIM

This constructivist grounded theory study aimed to (1) explore patients' experiences of and roles in interprofessional collaborative practice for chronic conditions in primary care and (2) consider the relevance and alignment of an existing theoretical framework on patients' roles and based on the experiences of patient advocates.

BACKGROUND

High-quality management of chronic conditions requires an interprofessional collaborative practice model of care considering an individual's mental, physical, and social health situation. Patients' experiences of this model in the primary care setting are relatively unknown.

METHODS

A constructivist grounded theory approach was taken. Interview data were collected from primary care patients with chronic conditions across Australia in August 2020 - February 2022. Interviews were recorded, transcribed verbatim, and thematically analysed by (1) initial line-by-line coding, (2) focused coding, (3) memo writing, (4) categorisation, and (5) theme and sub-theme development. Themes and sub-themes were mapped against an existing theoretical framework to expand and confirm the results from a previous study with a similar research aim.

FINDINGS

Twenty adults with chronic conditions spanning physical disability, diabetes, heart disease, cancer, autoimmune, and mental health conditions participated. Two themes were developed: (1) Adapting to Change with two sub-themes describing how patients adapt to interprofessional team care and (2) Shifting across the spectrum of roles, with five sub-themes outlining the roles patients enact while receiving care. The findings suggest that patients' roles are highly variable and fluid in interprofessional collaborative practice, and further work is recommended to develop a resource to support greater patient engagement in interprofessional collaborative practice.

Evaluation of collaborative mental health services in Latin America: Theoretical and methodological basis

OBJECTIVES

Approaches to collaborative mental health care (CMHC) have been implemented in many countries to strengthen the accessibility and delivery of mental health services in primary care. However, there are not well-defined frameworks to evaluate CMHC models. The purpose of this article is to identify, contextualize and discuss relevant health services research approaches, theory, and evaluation models for the development of an appropriate evaluation framework in order to foster effective CMHC in Latin America.

METHODS

A comprehensive literature review informed a critical analysis of relevant theories and alternative methods to be considered in the development of the framework.

RESULTS

Specific health services research frameworks are discussed in the context of evaluating CMHC. Two theoretical perspectives - collaboration theory and systems theory - and three evaluation models- realistic, developmental and collaborative - are analyzed in terms of their relevance. Methodological implications are identified.

CONCLUSION

An appropriate evaluation framework for CMHC in Latin America needs to reflect theoretical and contextual considerations and relevant evaluation approaches and methods, including key dimensions and attributes/variables, core indicators, and recommendations for implementation.

Social workers are key to addressing social determinants of health in integrated care settings

Social workers play an important role in assessing social determinants of health (SDH) and providing behavioral health services in integrated care settings. Evidence suggests that integrated care interventions improve quality of life and other patient outcomes. However, the ambiguous role of social workers on the interdisciplinary team, the lack of protocol in SDH screening and intervention, and restrictions due to healthcare reimbursement limit social workers' ability to intervene. Future directions include standardizing integrated care models, evaluating integrated care's efficacy to address SDH, incorporating SDH into interprofessional training including role clarification and reimbursing for SDH assessment and intervention.

What do patients experience? Interprofessional collaborative practice for chronic conditions in primary care: an integrative review

BACKGROUND

Improving the patient experience is one of the quadruple aims of healthcare. Therefore, understanding patient experiences and perceptions of healthcare interactions is paramount to quality improvement. This integrative review aimed to explore how patients with chronic conditions experience Interprofessional Collaborative Practice in primary care.

METHODS

An integrative review was conducted to comprehensively synthesize primary studies that used qualitative, quantitative, and mixed methods. Databases searched were Medline, Embase, CINAHL and Web of Science on June 1st, 2021. Eligible studies were empirical full-text studies in primary care that reported experiences or perceptions of Interprofessional Collaborative Practice by adult patients with a chronic condition, in any language published in any year. Quality appraisal was conducted on included studies using the Mixed Method Appraisal Tool. Data on patients' experiences and perceptions of Interprofessional Collaborative Practice in primary care were extracted, and findings were thematically analyzed through a meta-synthesis.

RESULTS

Forty-eight (n = 48) studies met the inclusion criteria with a total of n = 3803 participants. Study quality of individual studies was limited by study design, incomplete reporting, and the potential for positive publication bias. Three themes and their sub-themes were developed inductively: (1) Interacting with Healthcare Teams, subthemes: widening the network, connecting with professionals, looking beyond the condition, and overcoming chronic condition collectively; (2) Valuing Convenient Healthcare, subthemes: sharing space and time, care planning creates structure, coordinating care, valuing the general practitioner role, and affording healthcare; (3) Engaging Self-care, subthemes: engaging passively is circumstantial, and, engaging actively and leading care.

CONCLUSIONS

Patients overwhelmingly had positive experiences of Interprofessional Collaborative Practice, signaling it is appropriate for chronic condition management in primary care. The patient role in managing their chronic condition was closely linked to their experience. Future studies should investigate how the patient role impacts the experience of patients, carers, and health professionals in this context.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42020156536.

Mental health care integration and primary care patient experience in the Veterans Health Administration

BACKGROUND

Mental health specialists and care managers facilitate comprehensive care provision within medical homes. Despite implementation challenges, mental health integration is thought to improve patient-centered primary care.

OBJECTIVES

To examine the relationship between primary care patient experience and mental health integration.

RESEARCH DESIGN

Cross-sectional surveys from 168 primary care clinicians (PCPs) (n = 226) matched with assigned patients' surveys (n = 1734) in one Veterans Health Administration (VA) region, fiscal years 2012-2013. Multilevel regression models examined patient experience and mental health integration, adjusting for patient and PCP characteristics.

MEASURES

Patient experience outcomes were (1) experience with PCP and (2) receipt of comprehensive care, such as talked about "stress". Independent variables represented mental health integration- (1) PCP-rated communication with mental health and (2) proportion of clinic patients who saw integrated specialists.

RESULTS

50% and 43% of patients rated their PCPs 10/10 and reported receiving comprehensive care, respectively. Neither patient experience or receipt of comprehensive care was significantly associated with PCP's ratings of communication with mental health, nor with proportion of clinic patients who saw integrated specialists. Among a subsample of patients who rated their mental health as poor/fair, however, we detected an association between proportion of clinic patients who saw integrated specialists and patient experience (odds ratio = 1.05, 95% confidence interval = 1.01-1.09, p = .01).

CONCLUSIONS

No association was observed between mental health integration and primary care patients' reported care experiences, but a significant association existed among patients who reported poor/fair mental health. More research is needed to understand patient experiences with regard to care model implementation.

What Are Patient Preferences for Integrated Behavioral Health in Primary Care?

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.

Five-Phase Replication of Behavioral Health Integration in Pediatric Primary Care

BACKGROUND AND OBJECTIVES

Because of severe and protracted shortages of pediatric behavioral health (BH) specialists, collaboration between pediatric primary care practitioners (PCPs) and BH specialists has the potential to increase access to BH services by expanding the BH workforce. In a previous study, we demonstrated that phase 1 of a behavioral health integration program (BHIP) enrolling 13 independently owned, community-based pediatric practices was associated with increased access to BH services while averting substantial cost increases and achieving high provider self-efficacy and professional satisfaction. The current study was undertaken to assess whether the initial access findings were replicated over 4 subsequent implementation phases and to explore the practicality of broad dissemination of the BHIP model.

METHODS

After phase 1, BHIP was extended over 4 subsequent phases in a stepped-wedge design to 46 additional pediatric practices, for a total cohort of 59 practices (354 PCPs serving >300 000 patients). Program components comprised BH education and consultation and support for integrated practice transformation; these components facilitated on-site BH services by an interprofessional BH team. Outcomes were assessed quarterly, preprogram and postprogram launch.

RESULTS

Across combined phases 1 to 5, BHIP was associated with increased primary care access to BH services (screening, psychotherapy, PCP BH visits, psychotropic prescribing) and performed well across 7 standard implementation outcome domains (acceptability, appropriateness, feasibility, fidelity, adoption, penetration, and sustainability). Emergency BH visits and attention-deficit/hyperactivity disorder prescribing were unchanged.

CONCLUSIONS

These findings provide further support for the potential of integrated care to increase access to BH services in pediatric primary care.

'I Accelerate' model: A grounded theory on conceptual framework of patient experience with nursing care in China

AIM

To develop a conceptual framework of patient experience with nursing care.

BACKGROUND

Patient experience includes several aspects of health care delivery that patients value highly when they seek and receive care and is now increasingly used to evaluate the quality of care. Nurses are the backbone of the health care system, and patient experience with nursing care significantly influences the overall patient satisfaction and hospital performance. However, the conceptual framework of patient experience with nursing care is not clear.

METHOD

This grounded theory study employed in-depth interviews with 37 inpatients between March and May 2020.

RESULTS

An explanatory theoretical framework of the patient experience with nursing care emerged and was termed the 'I Accelerate' model; 'I Accelerate' stands for information and interpretation, appropriate attitude, close monitoring of progress, continuity of care, education, linking of the medical team, emotional support, responding to requests promptly, admission and discharge coordination, technical skills, and environment management, highlighting professional, emotional and coordinating functions of nurses.

CONCLUSIONS

This study resulted in a holistic nursing care model based on patients' views, values and preferences.

IMPLICATIONS FOR NURSING MANAGEMENT

To create a more therapeutic nurse-patient relationship and a more patient-centred health care system, hospital administrators, nursing managers and nursing practitioners should understand what patients desire and expect. Efforts should be made to explore the barriers and facilitators of using patient experience for quality improvement and to further determine how these patient-perceived attributes of nursing care can be rooted in the daily practice through organisational changes, culture shaping and staff education. There should be recognition of the potential need for psychological and emotional support, as well as of the importance of meeting communication and information needs.

Patient and provider perception of appropriateness, acceptability, and feasibility of behavioral health home (BHH) core components based on program implementation in an urban, safety-net health system

Background

This manuscript evaluates patient and provider perspectives on the core components of a Behavioral Health Home (BHH) implemented in an urban, safety-net health system. The BHH integrated primary care and wellness services (e.g., on-site Nurse Practitioner and Care Manager, wellness groups and tools, population health management) into an existing outpatient clinic for people with serious mental illness (SMI).

Methods

As the qualitative component of a Hybrid Type I effectiveness-implementation study, semi-structured interviews were conducted with providers and patients 6 months after program implementation, and responses were analyzed using thematic analysis. Valence coding (i.e., positive vs. negative acceptability) was also used to rate interviewees' transcriptions with respect to their feedback of the appropriateness, acceptability, and feasibility/sustainability of 9 well-described and desirable Integrated Behavioral Health Core components (seven from prior literature and two additional components developed for this intervention). Themes from the thematic analysis were then mapped and organized by each of the 9 components and the degree to which these themes explain valence ratings by component.

Results

Responses about the team-based approach and universal screening for health conditions had the most positive valence across appropriateness, acceptability, and feasibility/sustainability by both providers and patients. Areas of especially high mismatch between perceived provider appropriateness and measures of acceptability and feasibility/sustainability included population health management and use of evidence-based clinical models to improve physical wellness where patient engagement in specific activities and tools varied. Social and peer support was highly valued by patients while incorporating patient voice was also found to be challenging.

Conclusions

Findings reveal component-specific challenges regarding the acceptability, feasibility, and sustainability of specific components. These findings may partly explain mixed results from BHH models studied thus far in the peer-reviewed literature and may help provide concrete data for providers to improve BHH program implementation in clinical settings.

Plain language abstract

Many people with serious mental illness also have medical problems, which are made worse by lack of access to primary care. The Behavioral Health Home (BHH) model seeks to address this by adding primary care access into existing interdisciplinary mental health clinics. As these models are implemented with increasing frequency nationwide and a growing body of research continues to assess their health impacts, it is crucial to examine patient and provider experiences of BHH implementation to understand how implementation factors may contribute to clinical effectiveness. This study examines provider and patient perspectives of acceptability, appropriateness, and feasibility/sustainability of BHH model components at 6-7 months after program implementation at an urban, safety-net health system. The team-based approach of the BHH was perceived to be highly acceptable and appropriate. Although providers found certain BHH components to be highly appropriate in theory (e.g., population-level health management), their acceptability of these approaches as implemented in practice was not as high, and their feedback provides suggestions for model improvements at this and other health systems. Similarly, social and peer support was found to be highly appropriate by both providers and patients, but in practice, at months 6-7, the BHH studied had not yet developed a process of engaging patients in ongoing program operations that was highly acceptable by providers and patients alike. We provide these data on each specific BHH model component, which will be useful to improving implementation in clinical settings of BHH programs that share some or all of these program components.

Patient Views of Behavioral Health Providers in Primary Care: A Qualitative Study of 2 Southeastern Clinics

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.

Effectiveness of Suicide-Focused Psychosocial Interventions in Psychosis: A Systematic Review and Meta-Analysis

OBJECTIVE

Suicide ideation, plan, attempt, and death are significant and prevalent concerns among individuals with psychosis. Previous studies have focused on risk factors, but few have systematically evaluated the effect of psychosocial interventions on these experiences among individuals with psychosis. This study evaluated the effectiveness of psychosocial interventions in reducing suicide ideation, plan, attempt, and death among individuals with psychotic symptoms.

METHODS

Eight electronic databases were systematically searched from inception until June 30, 2019. Identified studies included both randomized controlled trials and controlled trials without randomization that examined psychosocial interventions for suicide ideation, plan, attempt, and death among individuals with psychotic symptoms. A random-effects model was used to pool the effect sizes for synthesis.

RESULTS

Eleven studies with 14 effect sizes (N=4,829 participants) were analyzed. The average age of participants ranged from 21 to 51, and most participants identified as male and non-Hispanic Caucasian or Chinese and were in an early or first-episode stage of illness. On average, participants who received psychosocial interventions were less likely than their counterparts in the control group to report suicide ideation, plan, and attempt and die by suicide (odds ratio [OR]=0.57, 95% confidence interval [CI]=0.41-0.78). Subgroup analyses further revealed significant reductions in suicide ideation (OR=0.73, 95% CI=0.55-0.97) and suicide death (OR=0.45, 95% CI=0.30-0.68) among intervention participants.

CONCLUSIONS

Preliminary evidence indicated that psychosocial interventions are effective in reducing suicide ideation, plan, attempt, and death among individuals with psychotic symptoms. Intervention characteristics, however, varied across studies, which suggests a lack of consensus on best clinical practices.

Policy brief on climate change and mental health/well-being

Climate change has a significant global impact on individuals' mental health and well-being. However, global health systems are inadequately prepared to address this issue. Studies indicate that climate events such as floods, droughts, tornados, earthquakes, and fires not only exacerbate chronic mental illness, but also impact well-being causing anxiety, stress, and in the worst case, suicide. The World Health Organization estimates that 12.6 million preventable deaths per year can be attributed to environmental factors, all of which are exacerbated by climate change, and an additional 250,000 deaths per year are projected between 2030 and 2050. Nurses must advocate for research, education, and policies that support disaster-resilient infrastructure and human services that allow communities across the globe to effectively mitigate the impact of climate change on human health.

Mapping Evidence of Patients' Experiences in Integrated Care: A Scoping Review

OBJECTIVES

Despite the established clinical and cost-effectiveness of integrated care (IC) models for patients with comorbid mental and physical illness, little is known about whether these models facilitate a better care experience from the patient's perspective. The authors conducted a scoping review of the literature to explore how IC influences patients' care experiences.

METHODS

MEDLINE, EMBASE, PSYC INFO CINAHL, AMED, the Cochrane Library, and grey literature were searched to identify relevant articles. Eligible studies were systematically reviewed and analyzed, using thematic analysis approach, to identify patterns, trends, and variation in patient experience within IC settings.

RESULTS

Search results yielded 5250 unique resources of which 21 primary studies met our eligibility criteria for analysis. Findings from this scoping review revealed variation in patients' experiences in IC settings. IC models enhanced patients' experience by creating theraputic spaces: improving patient access to care, developing collaborative relationships, and personalizing patient care to address individual needs.

CONCLUSION

Productive interactions with care team were key to improve patient engagement and experience of centeredness in IC settings. Successful implementation of IC demanded purposeful alignment of IC structural components and care processes to create therapeutic spaces that address patient care needs and preferences.

Five-Year Outcomes of Behavioral Health Integration in Pediatric Primary Care

BACKGROUND AND OBJECTIVES

In the context of protracted shortages of pediatric behavioral health (BH) specialists, BH integration in pediatric primary care can increase access to BH services. The objectives of this study were to assess the structure and process of pediatric BH integration and outcomes in patient experience (access and quality), cost, and provider satisfaction.

METHODS

In 2013, we launched a multicomponent, transdiagnostic integrated BH model (Behavioral Health Integration Program [BHIP]) in a large pediatric primary care network in Massachusetts. Study participants comprised the first 13 practices to enroll in BHIP (Phase-1). Phase-1 practices are distributed across Greater Boston, with ∼105 primary care practitioners serving ∼114 000 patients. Intervention components comprised in-depth BH education, on-demand psychiatric consultation, operational support for integrated practice transformation, and on-site clinical BH service.

RESULTS

Over 5 years, BHIP was associated with increased practice-level BH integration (P < .001), psychotherapy (P < .001), and medical (P = .04) BH visits and guideline-congruent medication prescriptions for anxiety and depression (P = .05) and attention-deficit/hyperactivity disorder (P = .05). Total ambulatory BH spending increased by 8% in constant dollars over 5 years, mainly attributable to task-shifting from specialty to primary care. Although an initial decline in emergency BH visits from BHIP practices was not sustained, total emergency BH spending decreased by 19%. BHIP providers reported high BH self-efficacy and professional satisfaction from BHIP participation.

CONCLUSIONS

Findings from this study suggest that integrating BH in the pediatric setting can increase access to quality BH services while engendering provider confidence and satisfaction and averting substantial increases in cost.

Clinical Workflows and the Associated Tasks and Behaviors to Support Delivery of Integrated Behavioral Health and Primary Care

Integrating primary care and behavioral health is an important focus of health system transformation. Cross-case comparative analysis of 19 practices in the United States describing integrated care clinical workflows. Surveys, observation visits, and key informant interviews analyzed using immersion-crystallization. Staff performed tasks and behaviors-guided by protocols or scripts-to support 4 workflow phases: (1) identifying; (2) engaging/transitioning; (3) providing treatment; and (4) monitoring/adjusting care. Shared electronic health records and accessible staffing/scheduling facilitated workflows. Stakeholders should consider these workflow phases, address structural features, and utilize a developmental approach as they operationalize integrated care delivery.