Improving Primary Care Behavioral Health Integration in an Academic Internal Medicine Practice: 2-Year Follow-Up

Pragmatic Clinical Trial of Population Health, Portal-Based Depression Screening: the PORTAL-Depression Study

BACKGROUND

A population health approach to depression screening using patient portals may be a promising strategy to proactively engage and identify patients with depression.

OBJECTIVE

To determine whether a population health approach to depression screening is more effective than screening during clinic appointments alone for identifying patients with depression.

DESIGN

A pragmatic clinical trial at an adult outpatient internal medicine clinic at an urban, academic, tertiary care center.

PATIENTS

Eligible patients (n = 2713) were adults due for depression screening with active portal accounts. Patients with documented depression or bipolar disorder and those who had been screened in the year prior to the study were excluded.

INTERVENTION

Patients were randomly assigned to usual (n = 1372) or population healthcare (n = 1341). For usual care, patients were screened by medical assistants during clinic appointments. Population healthcare patients were sent letters through the portal inviting them to fill out an online screener regardless of whether they had a scheduled appointment. The same screening tool, the Computerized Adaptive Test for Mental Health (CAT-MH™), was used for clinic- and portal-based screening.

MAIN MEASURES

The primary outcome was the depression screening rate.

KEY RESULTS

The depression screening rate in the population healthcare arm was higher than that in the usual care arm (43% (n = 578) vs. 33% (n = 459), p < 0.0001). The rate of positive screens was also higher in the population healthcare arm compared to that in the usual care (10% (n = 58) vs. 4% (n = 17), p < 0.001).

CONCLUSION

Findings suggest depression screening via a portal as part of a population health approach can increase screening and case identification, compared to usual care.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03832283.

Measuring Behavioral Health Integration in Primary Care

Behavioral health integration (BHI) within primary care settings is shown to improve outcomes. However, achieving BHI requires identifying best practices and a reliable tool that can be used to measure existing levels and progress toward BHI. The objective of this study was to develop and apply a conceptual framework to measure BHI, test the approach, and examine challenges to achieving BHI. Surveys and interviews were conducted with key informants within 17 designated public hospitals in California at the midpoint of participating in a 5-year project to establish BHI. A framework and coding methodology were developed to assess BHI best practices at each hospital. BHI status was assessed in the domains of infrastructure and process. Each domain included 5 themes such as electronic health record integration and functionality (infrastructure) and interprovider communication (process). Themes were assessed using a 6-point scale for various activities under a theme and associated weights. Theme-specific values were standardized from 0% to 100% to compare BHI scores between hospitals. Overall progress toward BHI ranged from scores of 52% to 83% (mean 63%) and indicated greater contribution of infrastructure versus process implementation. Within the infrastructure domain, scores were higher for having institutional and provider support, but lagged in establishing provider proximity. Within the process domain, scores were highest for implementation of behavioral health screening, but were frequently lower for other themes such as use of care coordination and referral processes. Further research is needed to test the robustness of this approach in other settings.