Integration Of Behavioral Health Care Research Articles

Patient perspectives on primary care behavioral health integration in an urban mental health professional shortage area: Benefits, facilitators, and barriers.

While studies have described the benefits of integrating behavioral health (BH) into primary care (PC), few have examined patients' perspectives, especially in large, urban health systems. In 2015, the University of Chicago Medicine launched the Primary Care Behavioral Health Integration Program, located in a mental health professional shortage area. In 2021, semistructured interviews were conducted with adult patients who had discussed their depression symptoms with their primary care clinician (PCC). Participants were asked about their experiences of being screened for depression, discussing BH, and being referred to behavioral health clinicians (BHCs). Interviews were analyzed using thematic analysis and constant comparison, and they were conducted until theme saturation was achieved. Fifteen participants were interviewed, the majority of whom were women and African American/Black, with an average age of 52. Participants expressed that PC-BH integration helps patients recognize BH problems and navigate the BH care system, emphasizes the connection between physical and mental health, and eases conversations through familiar setting and established trust. Patients enumerated barriers to integration, including barriers to BH care in the PC setting, barriers to BH conversations with PCCs/BHCs, and barriers to referrals to psychiatry/external therapy. Patients highlighted facilitators of integration, including trust with their PCC, collaboration between PCCs and BHCs, and population-level screening. These perspectives affirm the core strength of PC-BH integration: making BH more accessible and destigmatizing, especially for underserved communities. They also emphasize the importance of collaboration between PCCs and BHCs, shared identities, and actively involving patients in program design and quality improvement interventions. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Supplemental Material for Patient Perspectives on Primary Care Behavioral Health Integration in an Urban Mental Health Professional Shortage Area: Benefits, Facilitators, and Barriers

Supplemental Material for Patient Perspectives on Primary Care Behavioral Health Integration in an Urban Mental Health Professional Shortage Area: Benefits, Facilitators, and Barriers

A Qualitative Investigation of Characteristics Impacting Clinical Decision-Making in Integrated Behavioral Health Care

To support implementation of integrated behavioral health care (IBHC) models in local settings, providers may benefit from clinical decision-making support. The present analysis examines perspectives on patient characteristics appropriate or inappropriate for, and currently managed within, IBHC at a large medical center to inform recommendations for provider decision-making. Twenty-four participants (n = 13 primary care providers; n = 6 behavioral health providers; n = 5 administrators) in an IBHC setting were interviewed. Thematic analysis was conducted with acceptable interrater reliability (κ = 0.75). Responses indicated behavioral health symptom and patient characteristics that impact perceptions of appropriateness for management in IBHC, with high variability between providers. Many patients with characteristics identified as inappropriate for IBHC were nonetheless currently managed in IBHC. Interactions between patient ability to engage in care and provider ability to manage patient needs guided decisions to refer a patient to IBHC or specialty care. A heuristic representing this dimensional approach to clinical decision-making is presented to suggest provider decision-making guidance informed by both patient and provider ability.

Factors influencing virtual collaborative care outcomes for depression and anxiety.

In the United States, access to evidence-based behavioral health treatment remains limited, contributing to inadequate treatment for individuals with depression and anxiety disorders. The Collaborative care model (CoCM), the integration of behavioral healthcare into primary care, has been shown to be effective in addressing this issue, particularly when delivered virtually through telehealth platforms. While collaborative care has been shown to be effective, little has been studied to understand the impact of patient treatment factors on patient improvement. This study aims to analyze factors associated with patient improvement, measured by PHQ-9 and GAD-7 score changes, in patients with depression and anxiety disorders from Concert Health, a national behavioral medical group offering collaborative care across 18 states. Stepwise logistic regression models were utilized to identify factors influencing patient improvement in standardized symptom screener scores (PHQ-9 and GAD-7). Relevant patient-level data, including demographics, clinical engagement, insurance type, clinical touchpoints, and other variables, were analyzed. Results are presented as odds ratios (ORs). We find that increased clinical touchpoints were associated with improved outcomes in both depression (PHQ-9) and anxiety (GAD-7) populations. Commercial insurance was linked to a greater likelihood of improvement relative to Medicaid, and the use of C-SSRS suicide screeners had varied effects on patient outcomes depending on the diagnosis. The duration of time spent in appointments showed a nuanced impact, suggesting an optimal length for touchpoints. Psychiatric consults also impact patient outcomes in both populations. This study sheds light on factors influencing patient outcomes in virtual collaborative care for depression and anxiety disorders, which may be used to inform and motivate further research and allow providers to better optimize and understand the impacts of treatment choices in collaborative care settings.

Psychologists and Integrated Behavioral Health Simulation Training: A Survey of Medical Educators and Perspectives of Directors of Clinical Training.

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.

Integrated Behavioral Healthcare: Paving the Future of Mental Health in India

This research paper explores the concept of integrated behavioral healthcare (IBHC) and its potential as a transformative approach to the future of mental health services in India. This paper explores how integrated care can bridge the gap between physical and mental health, enhance access to services, and improve outcomes by recognizing the unique challenges and opportunities in the Indian healthcare landscape. This paper presents a comprehensive overview of the subject and discusses policy implications for the Indian context towards improving mental health outcomes and healthcare delivery.

Medical provider satisfaction with integrated care in a pediatric gastroenterology clinic.

Benefits of behavioral health (BH) integrated care (IC) in pediatric primary care have been demonstrated (Asarnow et al., 2015). Pediatric subspecialty care treats patients with high levels of medical and psychosocial vulnerability and complexity (Samsel et al., 2017), underscoring the need for increased IC. Medical provider satisfaction (MPS) with IC is highly relevant for the utilization and expansion of these services. The purpose of this preliminary study was to examine MPS related to BH IC services in a pediatric gastroenterology clinic. Eight pediatric gastroenterology providers working in an outpatient clinic completed a 32-item survey (adapted from Corso et al., 2016) assessing their satisfaction with integrated BH care services. Descriptive statistics were utilized to examine and summarize provider satisfaction data. Pediatric gastroenterology medical providers reported high levels of satisfaction with existing IC services and a preference for embedded versus colocated IC. They perceived provider-related and clinical benefits of IC, felt that addressing BH issues is important, and believed IC is a valued service. Medical providers expressed that they wanted expanded IC services, including an embedded psychologist at more locations, BH screenings for younger patients, and an electronic psychosocial screening process. The results of this study align with research findings regarding high medical provider satisfaction with IC in primary care and a preference for embedded BH services (Asarnow et al., 2015). While this preliminary study is small in scale, it is an important initial step to better understand MPS with IC in pediatric subspecialty care. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Interventions to Reduce Repeat Presentations to Hospital Emergency Departments for Mental Health Concerns: A Scoping Review of the Literature.

The number of readmissions to the emergency department (ED) for mental health services each year is significant, which increases healthcare costs and negatively affects the morale and quality of life of patients and their families. This scoping review aimed to establish a better understanding of interventions that have been implemented to reduce psychiatric patient readmission and ED use within the ED, to identify areas for improvement, and therefore to assist in the development of more effective actions in the future. The scoping review was conducted on several bibliographic databases to identify relevant studies. Two researchers independently screened and reviewed titles, abstracts, and full-text articles that met the inclusion criteria. Using Covidence software, 26 out of 6951 studies were eligible for inclusion in this scoping review based on the PRISMA checklist. Data were extracted, collated, summarized, presented, and discussed. This review identified 26 studies which examined interventions aimed to reduce ED visits, such as the High Alert Program (HAP), the Patient-Centered Medical Home (PCMH), the Primary Behavioral Health Care Integration (PBHCI), and the Collaborative Care (CC) Program, etc. Twenty-three of the studies were conducted in North America, while the rest were conducted in Europe and Australia. A total of 16 studies examined interventions directed to any mental health conditions, while the rest addressed specific health conditions, such as substance use disorders, schizophrenia, anxiety, depression. Interventions involved comprehensive and multidisciplinary services, incorporation of evidence-based behavioral and pharmacological strategies, and emphasized the case management that was found to be effective. Additionally, there was a marked consideration for diverse mental health groups, such as those with substance use disorder and of young age. Most interventions showed a positive effect on reducing psychiatric ED visits. Various initiatives have been implemented worldwide to reduce the number of emergency department visits and the associated burden on healthcare systems. This review highlights the greater need for developing more accessible interventions, as well as setting up a comprehensive community health care system aiming to reduce frequent ED presentations.

The Challenge of Integrating Behavioral Health Care in Assisted Living Facilities

Residents of Assisted Living Facilities (ALFs) often experience a range of psychiatric disorders and behavioral symptoms, the usual care for which is marked by fragmentation from medical care, overreliance on Emergency Department visits and psychiatric hospitalizations, and variable collaboration between clinical and facility staff. Given the high and increasing burden of mental illness and cognitive disorders among ALF residents and the growth of Assisted Living industry, there is a considerable need for the integration of high-quality behavioral health care into Assisted Living and Memory Care facility settings. Geriatric mental health workforce shortages demand innovative solutions in order to embed and scale this clinical expertise in communities whose design may lack clinical infrastructure. Existing attempts to address these challenges are marked by heterogeneity and a lack of high-quality evidence.This presentation will describe two different models of the integration of behavioral health care into Assisted Living Facilities and the strategic planning approaches to their development. First, we will present the development and implementation of a Behavioral Health program for ALF-residing patients of ConcertoCare, an innovative risk-bearing in-home and virtual healthcare provider offering interdisciplinary care to geriatric patients across the US. Next, we will discuss a model of embedding a geriatric psychiatrist and neuropsychologist from an academic medical center into a for-profit memory care facility, including the process of forming the business and care models. Both presentations will address challenges and strategies of approaches to clinical care, management of staff, patients, and families, and implementation of behavioral assessments and interventions. Also discussed will be future opportunities including scalability and need for further research into best practices.

Pay-for-Performance in the Massachusetts Medicaid Delivery System Transformation Initiative.

Pay-for-performance (P4P) is among the alternative payment models (APMs) that are designed to incentivize enhancements to healthcare efficiency and quality. Massachusetts' Office of Medicaid implemented a delivery system transformation initiative (DSTI) through an 1115(a) Demonstration Waiver to support and incentivize seven safety net hospitals to implement clinical care changes and transition to risk-based APMs. Comparative case study design was used to describe achievement of hospital-specific clinical and operational measures. Qualifying hospitals implemented 47 projects across three categories: (1) development of a fully integrated delivery system, (2) health outcomes and quality, and (3) ability to respond to statewide transformation to value-based purchasing and to accept alternatives to fee-for-service payments that promote system sustainability. Projects commonly focused on care transitions improvements, physical and behavioral healthcare integration, and chronic disease care management interventions. Collectively, the hospitals met all or most of 60 population-focused improvement measures and 10 common measures' targets, indicative of the progress. Some hospitals achieved substantial positive gains; however, missed targets suggest substantial organizational and workflow changes over a longer timeframe as well as consistent patient engagement may be necessary. Overall, the P4P structure of DSTI was effective in encouraging organizational change and supporting the transition of these hospitals towards APMs.

Implementation of a Novel Pediatric Behavioral Health Integration Initiative.

This study explores healthcare professionals' perspectives about the impact of behavioral health integration (BHI) on pediatric primary care delivery in community health centers (CHCs). A concurrent, qualitative-dominant mixed methods empirical study design was utilized, applying semi-structured interviews with healthcare professionals at the end of the implementation phase of a 3-year co-development, implementation, and evaluation process. Surveys were also administered at three time points. Via thematic analysis, emergent qualitative themes were mapped onto the Relational Coordination (RC) conceptual framework to triangulate and complement final qualitative results with quantitative results. Interview findings reveal five emergent themes aligning with RC domains. Survey results show that healthcare professionals reported increased behavioral healthcare integration into clinic practice (p = 0.0002) and increased clinic readiness to address behavioral health needs (p = 0.0010). Effective pediatric BHI and care delivery at CHCs may rely on strong professional relationships and communication. Additional research from the patient/caregiver perspective is needed.

Preparing residents to practice integrated behavioral health care: Multi-site feasibility study of a competency-based curriculum.

Workforce development is essential for the dissemination of team-based integrated behavioral healthcare. There is limited literature on training family medicine residents to function within an integrated behavioral health (IBH) system. The purpose of this pilot study was to assess the feasibility and value of an IBH competency-based curriculum for family medicine residents across multiple programs. Residency programs were recruited using professional listservs and networks to test a competency-based, multi-modal curriculum for preparing residents to practice IBH in primary care. Faculty instructors who led the workshop were invited to complete semi-structured interviews to examine the feasibility and appropriateness of the curriculum. Interview data were analyzed using thematic analysis to identify, analyze, and report patterns. Residents completed a survey of perceived IBH skill and knowledge before and after training. A paired-sample t-test was used to determine significant differences pre- and post-training. All five instructors completed interviews. Results suggest IBH training is valuable. Instructors gave specific feedback on online modules, implementation flexibility, and adjusting faculty development to differing levels of experience. Nineteen of forty residents (48%) completed anonymous pre-, post-, and retrospective-training surveys. Residents reported an increase in competence after training. The results of this pilot suggest that IBH training implementation is feasible, desirable, timely, and may improve resident ability to work on an IBH team. Training should accommodate variations in program structure and faculty expertise.

Role Distinctions and Role Overlap Among Behavioral Health Providers.

Integrated behavioral health care (IBHC) models are a growing trend for health care delivery, particularly in the primary setting. Clinicians working within IBHC contexts provide a spectrum of behavioral health services, including screening, prevention and health promotion, assessment, and treatment services. Integration of behavioral health providers into primary and specialty medical settings addresses the significant need for behavioral health services, improves care quality, improves patient experience, and reduces costs of care, access issues, and delays in service provision. While benefits are clear, what type of model to implement and which behavioral health care providers to include in that model remain elusive. This is partly due to the failure of IBHC models to include all behavioral health providers in their design, a lack of clarity of the expertise of each provider, and how providers work together. IBHC models are also complicated by contextual issues such as the relative availability of each profession, population health needs in different clinic populations, and financial factors. The purpose of this manuscript is to the clarify roles and responsibilities of different behavioral health professions including similarities and differences in their training, areas of unique expertise (role distinctions), shared responsibilities (role overlap), and relative cost and availability in the United States.

Integrating Pediatric Universal Behavioral Health Care at Federally Qualified Health Centers.

Research supports integrated pediatric behavioral health (BH), but evidence gaps remain in ensuring equitable care for children of all ages. In response, an interdisciplinary team codeveloped a stepped care model that expands BH services at 3 federally qualified health centers (FQHCs). FQHCs reported monthly electronic medical record data regarding detection of BH issues, receipt of services, and psychotropic medications. Study staff reviewed charts of children with attention-deficit/hyperactivity disorder (ADHD) before and after implementation. Across 47 437 well-child visits, >80% included a complete BH screen, significantly higher than the state's long-term average (67.5%; P < .001). Primary care providers identified >30% of children as having BH issues. Of these, 11.2% of children <5 years, 53.8% of 5-12 years, and 74.6% >12 years were referred for care. Children seen by BH staff on the day of referral (ie, "warm hand-off") were more likely to complete an additional BH visit than children seen later (hazard ratio = 1.37; P < .0001). There was no change in the proportion of children prescribed psychotropic medications, but polypharmacy declined (from 9.5% to 5.7%; P < .001). After implementation, diagnostic rates for ADHD more than doubled compared with baseline, follow-up with a clinician within 30 days of diagnosis increased (62.9% before vs 78.3% after; P = .03) and prescriptions for psychotropic medication decreased (61.4% before vs 43.9% after; P = .03). Adding to a growing literature, results demonstrate that integrated BH care can improve services for children of all ages in FQHCs that predominantly serve marginalized populations.

Primary Care Behavioral Health Integration and Care Utilization: Implications for Patient Outcome and Healthcare Resource Use.

Behavioral health (BH) integration in primary care (PC) can potentially improve outcomes and reduce cost of care. While different models of integration exist, evidence from real-world examples is needed to demonstrate the effectiveness and value of integration. This study aimed to evaluate the outcomes of six PC practice sites located in Western New York that implemented a primary care behavioral health (PCBH) integration model. To assess the impact of PCBH on all-cause healthcare utilization rates. A retrospective observational study based on historical multi-payer health insurance claims data. Claims data were aggregated on a per-member-per-month basis to compare utilization rates among the patients in the PC practice sites that had implemented PCBH to those in the sites that had not yet done so. The sample included 6768 unique adult health plan members between October 2015 and June 2017 with at least one BH diagnosis code who were attributed to one of the six newly integrated PC practice sites. Under the PCBH integration model, BH specialists were embedded in PC practice sites to treat a wide range of BH conditions. Rates of all-cause ED visits and hospital admissions, along with rates of PC provider and BH provider visits. PCBH implementation was associated with reductions in the rates of outpatient ED visits (14.2%; p < 0.001) and PC provider visits (12.0%; p < 0.001), as well as with an increased rate of BH provider visits (7.5%; p = 0.018). PCBH integration appears to alter the treatment patterns among patients with BH conditions by shifting patient visits away from ED and PC providers toward BH providers who specialize in treatment of such patients.

Medical Family Therapy in Rural Community Health: A Longitudinal "Peek" into Integrated Care Successes.

Integrated behavioral health care (IBHC) continues to grow as an evidence-based service delivery model adopted by healthcare systems all over the world to better care for the holistic needs of patients and their families. Medical family therapy (MedFT), as a field, has offered innovation to IBHC models by delivering biopsychosocial-spiritual (BPS-S), relational, and family-oriented care across a variety of healthcare contexts. This article details a longitudinal review of a program, spanning 16 years, that grew from no behavioral health services to one that is highly integrated, and embeds MedFTs in a number of rural community health centers. This model highlights the importance of interdisciplinary teams, including Peek’s clinical, operational, financial, and training worlds, as well as decision-making metrics for systems that predominately care for underserved and minoritized populations. The authors illustrate a framework for how the levels of primary care/behavioral healthcare collaboration relate to the work and practice of MedFTs as conceptualized through the MedFT Health Care Continuum and meet the BPS-S needs of diverse populations seeking pediatric, adult, and dental healthcare services. Also described are shifts made in the model over time based on (a) growth in cultural humility, (b) relationally-oriented practice, operations, finance, and training data, and (c) research informed decisions. Recommendations include ways MedFTs can facilitate provider and administrative buy-in, assess model fidelity, and strive for quality outcomes for patients.

Transforming Primary Care in New York Through Patient-Centered Medical Homes: Findings From Qualitative Research.

Background:The patient-centered medical home (PCMH) model, an important component of healthcare transformation in the United States, is an approach to primary care delivery with the goal of improving population health and the patient care experience while reducing costs. PCMH research most often focuses on system level indicators including healthcare use and cost; descriptions of patient and provider experience with PCMH are relatively sparse and commonly limited in scope. This study, part of a mixed-methods evaluation of a multi-year New York State initiative to refine and expand the PCMH model, describes patient and provider experience with New York State PCMH and its key components.Methods:The qualitative component of the evaluation included focus groups with patients of PCMH practices in 5 New York State counties (n = 9 groups and 67 participants) and interviews with providers and practice administrators at New York State PCMH practices (n = 9 interviews with 10 participants). Through these focus groups and interviews, we elicited first-person descriptions of experiences with, as well as perspectives on, key components of the New York State PCMH model, including accessibility, expanded use of electronic health records, integration of behavioral health care, and care coordination.Results:There was evident progress and some satisfaction with the PCMH model, particularly regarding integrated behavioral health and, to some extent, expanded use of electronic health records. There was less evident progress with respect to improved access and reasonable wait times, which caused patients to continue to use urgent care or the emergency department as substitutes for primary care.Conclusions:It is critical to understand the strengths and limitations of the PCMH model, so as to continue to improve upon and promote it. Strengths of the model were evident to participants in this study; however, challenges were also described. It is important to note that these challenges are difficult to separate from wider healthcare system issues, including inadequate incentives for value-based care, and carry implications for PCMH and other models of healthcare delivery.

Responding to COVID-19 through an integrated primary care/behavioral health program.

Background and Implementation: Novel coronavirus disease 2019 (COVID-19) has presented unique challenges for patients and health care systems, including a surge in behavioral health (BH) needs. A community teaching public hospital system in Massachusetts (MA) whose 13 primary care (PC) clinics serve a diverse patient population, has developed a model for Primary Care Behavioral Health Integration (PCBHI) to provide brief, evidence-based interventions to patients in PC. In response to COVID-19, the system developed an intensive community management strategy to care for patients with COVID-19 outside of the hospital, and its PCBHI program adapted alongside this strategy to provide rapid support to patients in emotional distress. Over a 13-week period, 78 patients were specifically referred to the PCBHI COVID clinic and received rapid therapeutic support and/or care navigation. Recommendations: This article will discuss the development and implementation of the PCBHI COVID clinic, common presenting issues and clinical interventions used, and lessons that informed our adaptation of clinic operations and that can serve as recommendations to other health systems in establishing similar services. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Collaborative Care Expands Reach to Racial/Ethnic Minority Patients

Collaborative Care Expands Reach to Racial/Ethnic Minority Patients

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

This report details ongoing efforts to improve integration in the 2 years following implementation of the Primary Care Behavioral Health model at a general internal medicine clinic of an urban academic medical center. Efforts were informed by a modified version of the validated Level of Integration Measure, sent to all faculty and staff annually. At baseline, results indicated that the domains of systems integration, training, and integrated clinical practices had the greatest need for improvement. Over the 2 years, the authors increased availability of behavioral medicine appointments, improved depression screening processes, offered behavioral health training for providers, disseminated clinical decision support tools, and provided updates about integration progress during clinic meetings. Follow-up survey results demonstrated that physicians and staff perceived improvements in integration overall and in targeted domains. However, the main ongoing barrier to integration was insufficient behavioral health staff to meet patient demand for behavioral health services.