Barriers to physical and mental condition integrated service delivery

Removing Obstacles To Eliminating Racial And Ethnic Disparities In Behavioral Health Care

Despite decades of research, racial and ethnic disparities in behavioral health care persist. The Affordable Care Act expanded access to behavioral health care, but many reform initiatives fail to consider research about racial/ethnic minorities. Mistaken assumptions that underlie the expansion of behavioral health care run the risk of replicating existing service disparities. Based on a review of relevant literature and numerous observational and field studies with minority populations, we identified the following three mistaken assumptions: Improvement in health care access alone will reduce disparities, current service planning addresses minority patients' preferences, and evidence-based interventions are readily available for diverse populations. We propose tailoring the provision of care to remove obstacles that minority patients face in accessing treatment, promoting innovative services that respond to patients' needs and preferences, and allowing flexibility in evidence-based practice and the expansion of the behavioral health workforce. These proposals should help meet the health care needs of a growing racial/ethnic minority population.

Effectiveness of Cognitive Behavioural Self-Help for the Treatment of Depression and Anxiety in People with Long-Term Physical Health Conditions: a Systematic Review and Meta-Analysis of Randomised Controlled Trials

BACKGROUND

Depression and anxiety are prevalent comorbidities in people with long-term physical health conditions; however, there is limited access to evidence-based treatments for comorbid mental health difficulties.

PURPOSE

This study is a meta-analysis examining the effectiveness of cognitive behavioural self-help for physical symptoms, depression and anxiety in people with long-term conditions.

METHODS

This study involves a systematic search of electronic databases supplemented by expert contact, reference and citation checking and grey literature.

RESULTS

The meta-analysis yielded a small effect size for 11 studies reporting primary outcomes of depression (g = -0.20) and 8 studies anxiety (g = -0.21) with a large effect size (g = -1.14) for 1 study examining physical health symptoms. There were no significant moderators of the main effect.

CONCLUSIONS

Limited evidence supports cognitive behavioural self-help for depression, anxiety and physical symptoms in people with long-term conditions. Small effect sizes for depression and anxiety may result from failure to recruit participants with clinical levels of these difficulties at baseline.

Barriers to Self-management of Serious Mental Illness and Diabetes

OBJECTIVES

Individuals with serious mental illness (SMI) (major depressive disorder, bipolar disorder, schizophrenia), and diabetes (DM), face significant challenges in managing their physical and mental health. The objective of this study was to assess perceived barriers to self-management among patients with both SMI and DM in order to inform healthcare delivery practices.

METHODS

We conducted 20 in-depth interviews with persons who had diagnoses of both SMI and DM. All interviews were audiotaped, transcribed verbatim, and analyzed using content analysis with an emphasis on dominant themes.

RESULTS

Transcript-based analysis generated 3 major domains of barriers to disease self-management among patients with both DM and SMI: (1) personal level barriers (stress, isolation, stigma); (2) family and community level barriers (lack of support from family and friends); and (3) provider and health care system level barriers (poor relationships and communication with providers, fragmentation of care).

CONCLUSIONS

Care approaches that provide social support, help in managing stress, optimize communication with providers, and reduce compartmentalization of medical and psychiatric care are needed to help these vulnerable individuals avoid health complications and premature mortality.

Collaborative Depression Care in a Safety Net Medical Home: Facilitators and Barriers to Quality Improvement

Little is known about how to integrate primary care with mental/behavioral services outside of clinical trials. The authors implemented a collaborative care model (CCM) for depression in a safety net patient-centered medical home. The model focused on universal screening for symptoms, risk stratification based on symptom severity, care management for intensive follow-up, and psychiatry consultation. CCM increased rates of primary care physician encounters, timely follow-up for monitoring symptoms of depression, and documentation of treatment response. Contextual factors that facilitated or hindered practice redesign included clinic leadership, quality improvement culture, staffing, technology infrastructure, and external incentives/disincentives for organizational change.

The Rate of Depression Screening at a Federally Qualified Community Health Center

Purpose:

The purpose of this study is to examine the rate of depression screening among patients, aged 19 and older, seen at a community health center, while referencing to US Preventive Services Task Force (USPSTF) screening recommendations.

Methods:

A random sample of 500 patients, aged 19 and older, were extracted from the total number of patients seen at the community health center, between December 1, 2013, and April 30, 2014. The rate of depression screening was calculated by analyzing the completed standardized screening questionnaires (Patient Health Questionnaire 2).

Results:

On analysis, it was found that 14.6% of patients were screened for depression. The rate of screening for males was 8.4% and for females it was 17.5%. The race with the highest rate of screening was Asian at 23.2%, and the lowest rate was white at 12.8%.

Conclusion:

The studied community health center had a suboptimal rate of depression screening at 14.6%. The USPSTF recommends depression screening on all adults. Addressing barriers to screening including patient education, provider education, system practices, and provision of resources may help improve the rate of depression screening, leading to early treatment and better health outcomes.

Pilot feasibility study of a brief, tailored mobile health intervention for depression among patients with chronic pain

This pilot feasibility study investigated a brief, tailored mobile health intervention to provide brief treatment and motivate further depression treatment seeking among patients with comorbid chronic pain. The computer tablet intervention was delivered in a hospital clinic using a blended motivational interviewing and cognitive behavioral therapy approach. Individuals were at least age 18, and screened positive for depression during a visit for chronic pain. Participants completed assessments before the intervention and at two-week follow-up. The 64 participants were most often over 50 years old, female, and Caucasian. Participant ratings demonstrated an increase in interest to seek depression treatment and willingness to make life changes to mitigate symptoms. A significant reduction in mean depression score and non-significant reductions on both measures of disability were observed. This intervention was feasible and acceptable, demonstrated promise in reducing depression and increasing treatment interest, and should be tested in a trial.

Preparing the Workforce for Behavioral Health and Primary Care Integration

PURPOSE

To identify how organizations prepare clinicians to work together to integrate behavioral health and primary care.

METHODS

Observational cross-case comparison study of 19 U.S. practices, 11 participating in Advancing Care Together, and 8 from the Integration Workforce Study. Practices varied in size, ownership, geographic location, and experience delivering integrated care. Multidisciplinary teams collected data (field notes from direct practice observations, semistructured interviews, and online diaries as reported by practice leaders) and then analyzed the data using a grounded theory approach.

RESULTS

Organizations had difficulty finding clinicians possessing the skills and experience necessary for working in an integrated practice. Practices newer to integration underestimated the time and resources needed to train and organizationally socialize (onboard) new clinicians. Through trial and error, practices learned that clinicians needed relevant training to work effectively as integrated care teams. Training efforts exclusively targeting behavioral health clinicians (BHCs) and new employees were incomplete if primary care clinicians (PCCs) and others in the practice also lacked experience working with BHCs and delivering integrated care. Organizations' methods for addressing employees' need for additional preparation included hiring a consultant to provide training, sending employees to external training programs, hosting residency or practicum training programs, or creating their own internal training program. Onboarding new employees through the development of training manuals; extensive shadowing processes; and protecting time for ongoing education, mentoring, and support opportunities for new and established clinicians and staff were featured in these internal training programs.

CONCLUSION

Insufficient training capacity and practical experience opportunities continue to be major barriers to supplying the workforce needed for effective behavioral health and primary care integration. Until the training capacity grows to meet the demand, practices must put forth considerable effort and resources to train their own employees.

The medical home and integrated behavioral health: advancing the policy agenda

There has been a considerable expansion of the patient-centered medical home model of primary care delivery, in an effort to reduce health care costs and to improve patient experience and population health. To attain these goals, it is essential to integrate behavioral health services into the patient-centered medical home, because behavioral health problems often first present in the primary care setting, and they significantly affect physical health. At the 2013 Patient-Centered Medical Home Research Conference, an expert workgroup convened to determine policy recommendations to promote the integration of primary care and behavioral health. In this article we present these recommendations: Build demonstration projects to test existing approaches of integration, develop interdisciplinary training programs to support members of the integrated care team, implement population-based strategies to improve behavioral health, eliminate behavioral health carve-outs and test innovative payment models, and develop population-based measures to evaluate integration.

Care coordination of multimorbidity: a scoping study

BACKGROUND

A key challenge in healthcare systems worldwide is the large number of patients who suffer from multimorbidity; despite this, most systems are organized within a single-disease framework.

OBJECTIVE

The present study addresses two issues: the characteristics and preconditions of care coordination for patients with multimorbidity; and the factors that promote or inhibit care coordination at the levels of provider organizations and healthcare professionals.

DESIGN

The analysis is based on a scoping study, which combines a systematic literature search with a qualitative thematic analysis. The search was conducted in November 2013 and included the PubMed, CINAHL, and Web of Science databases, as well as the Cochrane Library, websites of relevant organizations and a hand-search of reference lists. The analysis included studies with a wide range of designs, from industrialized countries, in English, German and the Scandinavian languages, which focused on both multimorbidity/comorbidity and coordination of integrated care.

RESULTS

The analysis included 47 of the 226 identified studies. The central theme emerging was complexity. This related to both specific medical conditions of patients with multimorbidity (case complexity) and the organization of care delivery at the levels of provider organizations and healthcare professionals (care complexity).

CONCLUSIONS

In terms of how to approach care coordination, one approach is to reduce complexity and the other is to embrace complexity. Either way, future research must take a more explicit stance on complexity and also gain a better understanding of the role of professionals as a prerequisite for the development of new care coordination interventions.

Implementation of integrated services networks in Quebec and nursing practice transformation: convergence or divergence?

BACKGROUND

Even though nurses are expected to play a key role in implementing integrated services networks, up to now their practice in this regard has received very little research attention. The aim of this study is to describe the extent to which the evolution of nursing practice in Quebec in recent years has converged with the requirements and efforts involved in services integration.

METHODS

This descriptive study was carried out with 107 nurses working an integrated network of healthcare services in Quebec in four different care pathways: chronic obstructive pulmonary disease, autonomy support for the elderly, palliative oncology care, and mental health. Development model for integrated care (DMIC) was used, first, to examine the prevalence in each pathway of integrative activities, grouped into nine practice dimensions, and then to position each pathway in relation to the four phases of development for any integration process, as defined by the DMIC.

RESULTS

Only one pathway had reached Phase 3, which involves expansion and monitoring of integration, whereas the others were still in the preliminary Phases 1 and 2 characterized by initiative and experimentation. Only two dimensions out of nine ('quality of care' and 'interprofessional teamwork') were prevalent in all the pathways; two others ('transparent entrepreneurship' and 'performance management') were in none of the pathways, and the remaining five ('patient-family centered care', 'result-focused learning', 'delivery system', 'commitment', 'roles and tasks') were present to varying degrees.

CONCLUSIONS

These results suggest that particular efforts should be made to bridge the significant gap between the pace of nursing practice transformation and the objectives of service integration. These efforts should focus, among other things, on the deployment of organizational, clinical, human, and material resources to support practice renewal and continuing education for nurses to prepare them for the requirements of integration.

Associations between level of services integration and nurses' workplace well-being

BACKGROUND

To respond better to population needs, in recent years Quebec has invested in improving the integration of services and care pathways. Nurses are on the front lines of these transformation processes, which require them to adopt new clinical practices. This updating of practices can be a source of both satisfaction and stress. The aim of this study was to gain a better understanding of the relationship between the transformation processes underlying services integration and nurses' workplace well-being.

METHOD

This study was based on a descriptive cross-sectional correlational design. The target population included all nurses working in four care pathways in a Quebec healthcare establishment: palliative oncology services, mental health services, autonomy support for the elderly, and chronic obstructive pulmonary disease. In all, 107 nurses took part in the study and completed a questionnaire sent to them. Hierarchical linear regression analyses were used to examine the relationship between level of integration, measured using the Development Model for Integrated Care; nurses' perceptions of organizational change, measured on four dimensions (challenge, responsibility, threat, control); and nurses' workplace well-being, measured on three dimensions (negative stress, positive stress, satisfaction), as defined by the Flexihealth model.

RESULTS

Nurses in the palliative oncology care pathway, which was at a more advanced level of integration, presented a lower negative stress level and a higher positive stress level than did nurses in other care pathways. Their mean satisfaction score was also higher. More advanced integration was associated with nurses' feeling less threatened, as well as improved workplace well-being. The perception of threat appeared to be a significant mediating variable in the relationship between level of integration and well-being.

CONCLUSION

The association observed between level of services integration and workplace well-being contributes to a better understanding of nurses' experiences in such situations. These results provide new perspectives on interventions that could be implemented to remedy the potential negative consequences of these types of transformations.

Using electronic health records to improve the physical healthcare of people with serious mental illnesses: a view from the front lines

Individuals with serious mental illnesses (SMI) treated in the public mental health sector die decades younger than the general population. Poor quality and fragmentation of care are risk factors underlying the poor health of this population. Integrated electronic health records (EHR) can play a vital role in efforts to improve quality and outcomes of care in patients with SMI. The objective of this paper is to describe the current state of efforts to integrate and improve the mental and physical care of individuals with SMI in the public sector, with an emphasis on the use of electronic health records (EHR). While a range of encouraging initiatives exists throughout the country, technological and medico-legal challenges are providing significant barriers for the successful integration of care and EHRs for many partnering organizations. Furthermore, there is a lack of rigorous research studying the effectiveness and sustainability of these programmes. Recommendations are made for the alleviation of policy barriers and future areas of inquiry.

System-level intersectoral linkages between the mental health and non-clinical support sectors: a qualitative systematic review

OBJECTIVES

Concerns about fragmented mental health service delivery persist, particularly for people with severe and persistent mental illness. The objective was to review evidence regarding outcomes attributed to system-level intersectoral linkages involving mental health services and non-clinical support services, and to identify barriers and facilitators to the intersectoral linkage process.

METHODS

A systematic, qualitative review of studies describing attempts to coordinate the activities of multiple service agencies at the policy, program or organisational level was conducted. Electronic databases Medline, PsycINFO and EMBASE were searched via OVID from inception to July 2012.

RESULTS

Of 1593 studies identified, 40 were included in the review - 26 in adult and 14 in vulnerable youth populations. Identified mechanisms to promote positive system-level outcomes included: interagency coordinating committees or intersectoral/interface workers engaged in joint service planning; formalised interagency collaborative agreements; a single care plan in which the responsibilities of all agencies are described; cross-training of staff to ensure staff culture, attitudes, knowledge and skills are complementary; service co-location; and blended funding initiatives to ensure funding aligns with program integration. Identified barriers included: adequacy of funding and technology; ensuring realistic workloads; overcoming 'turf issues' between service providers and disagreements regarding areas of responsibility; ensuring integration strategies are implemented as planned; and maintaining stakeholder enthusiasm.

CONCLUSIONS

System-level intersectoral linkages can be achieved in various ways and are associated with positive clinical and non-clinical outcomes for services and clients. Some linkage mechanisms present greater implementation challenges than others (e.g. major technology upgrades or co-location in geographically remote areas). In some instances (e.g. co-location) alternative options may achieve equivalent benefits. Publication bias could not be discounted, and studies using high-quality research designs are scarce. The limited information base applicable to system-level integration argues strongly for the evaluation of the models that evolve in the rollout of the national Partners in Recovery initiative.

Significance and costs of complex biopsychosocial health care needs in elderly people: results of a population-based study

OBJECTIVE

To improve health care for the elderly, a consideration of biopsychosocial health care needs may be of particular importance-especially because of the prevalence of multiple conditions, mental disorders, and social challenges facing elderly people. The aim of the study was to investigate significance and costs of biopsychosocial health care needs in elderly people.

METHODS

Data were derived from the 8-year follow-up of the ESTHER study-a German epidemiological study in the elderly population. A total of 3124 participants aged 57 to 84 years were visited at home by trained medical doctors. Biopsychosocial health care needs were assessed using the INTERMED for the Elderly (IM-E) interview. Health-related quality of life (HRQOL) was measured by the 12-Item Short-Form Health Survey, and psychosomatic burden was measured by the Patient Health Questionnaire.

RESULTS

The IM-E correlated with decreased mental (mental component score: r = -0.38, p < .0001) and physical HRQOL (physical component score: r = -0.45, p < .0001), increased depression severity (r = 0.53, p < .0001), and costs (R = 0.41, p < .0001). The proportion of the participants who had an IM-E score of at least 21 was 8.2%; according to previous studies, they were classified as complex patients (having complex biopsychosocial health care needs). Complex patients showed a highly reduced HRQOL compared with participants without complex health care needs (mental component score: 37.0 [10.8] versus 48.7 [8.8]; physical component score: 33.0 [9.1] versus 41.6 [9.5]). Mean health care costs per 3 months of complex patients were strongly increased (1651.1 &OV0556; [3192.2] versus 764.5 &OV0556; [1868.4]).

CONCLUSIONS

Complex biopsychosocial health care needs are strongly associated with adverse health outcomes in elderly people. It should be evaluated if interdisciplinary treatment plans would improve the health outcomes for complex patients.

Primary care: mental and behavioral health and persons with intellectual and developmental disabilities

Introduction: There are multiple ways to address the mental and behavioral health needs of people with intellectual and developmental disabilities (IDD).

Method: In this paper, we do not argue for a particular approach or set of approaches, but instead review the benefits of integrating mental and behavioral health supports with primary healthcare based primarily on our experience in and understanding of healthcare systems in the United States. It is estimated that between 35 and 40% of people with IDD also live with psychiatric disorders. NADD, an association for persons with developmental disabilities and mental health needs in the US holds that coexisting IDD and a psychiatric disorder interferes with a person’s education and job readiness, and disrupts family and peer relationships. Historically, the presence of such disorders among people with IDD was not well understood or was discounted altogether.

Conclusion: Over the past 15 years, however, greater attention is being paid to these comorbidities and their treatment, including the need to integrate mental and behavioral health treatments into primary care. Healthcare must account for multiple domains of quality of life, going beyond yearly physicals, and acute care visits, for example, to assess individuals’ healthcare goals and support them in achieving those goals. While integrated healthcare delivery systems can be difficult to find and access for people with IDD, such approaches are more responsive to the comprehensive needs and desires of people with IDD.

Innovative strategies for closing the mental health treatment gap globally

PURPOSE OF REVIEW

In the field of global mental health, an enormous gap between what we know and what we do exists in the delivery of clinical care. Creative and effective strategies that surmount the barriers to provision of mental healthcare are essential to improve the lives of millions affected by mental illness. This article provides a review of three classes of innovative strategies currently being developed and implemented to diminish the mental health treatment gap globally.

RECENT FINDINGS

This review provides recent evidence related to the feasibility of implementation and efficacy for the following three classes of innovation that show promise for building clinical capacity and expanding mental health coverage: integration of mental health services into primary care; expansion of human capacity through task sharing and training of nonspecialists; and innovative use of technological platforms to enhance access, cut costs, and reduce stigma.

SUMMARY

The strategies outlined in this review hold great potential for enhancing mental health treatment services, and address some of the major barriers globally to accessing mental healthcare, such as scarcity of resources (infrastructure, capacity, and funding) and stigma. Despite much evidence supporting the efficacy of these models, thorough studies that test their feasibility, acceptability, utility, and effectiveness in various contexts, including low-income and middle-income countries, are required. Moreover, these innovations require social support and political will in order to be successfully implemented and scaled-up such that they have a meaningful impact on the burden of disease associated with mental illness worldwide.

Value-based financially sustainable behavioral health components in patient-centered medical homes

Because a high percentage of primary care patients have behavioral problems, patient-centered medical homes (PCMHs) that wish to attain true comprehensive whole-person care will find ways to integrate behavioral health services into their structure. Yet in today's health care environment, the incorporation of behavioral services into primary care is exceptional rather than usual practice. In this article, we discuss the components considered necessary to provide sustainable, value-added integrated behavioral health care in the PCMH. These components are to: (1) combine medical and behavioral benefits into one payment pool; (2) target complex patients for priority behavioral health care; (3) use proactive onsite behavioral "teams;" (4) match behavioral professional expertise to the need for treatment escalation inherent in stepped care; (5) define, measure, and systematically pursue desired outcomes; (6) apply evidence-based behavioral treatments; and (7) use cross-disciplinary care managers in assisting the most complicated and vulnerable. By adopting these 7 components, PCHMs will augment their ability to achieve improved health in their patients at lower cost in a setting that enhances ease of access to commonly needed services.

Effectiveness of a psychosomatic day hospital treatment for the elderly: a naturalistic longitudinal study with waiting time before treatment as control condition

OBJECTIVE

In 2006 the psychosomatic day hospital for the treatment of acute mental illness of elderly people opened as the first clinic of its kind in Germany. The aim of this study was to determine treatment effectiveness and identify possible effects on health care utilization.

METHODS

Designed as a naturalistic study with waiting time before admission as a control condition, the primary outcome was the level of depressive symptoms as measured by the hospital anxiety and depression scale. Secondary outcomes were depressive and somatoform symptoms and syndromes as measured with the patient health questionnaire, patient perception of interpersonal problems and health care use before and after treatment.

RESULTS

After treatment significant improvement (p<0.01) with moderate effect sizes (ES) was found in all variables from admission to discharge (ES from 0.3 to 0.8) and also to follow-up (ES from 0.2 to 0.6). Improvement remained stable at follow-up. Furthermore, after psychosomatic treatment a reduction in medical service usage was visible. Number of consultations (pre: 13, post: 9), number and length of hospital stays (pre: 1, 7 weeks, post: 0, 3 weeks) were both significantly (p<0.001) reduced six months after treatment as compared to the period six months prior to treatment.

CONCLUSION

Results indicate that the psychosomatic day hospital treatment of the elderly is successful. Reduced usage of health care and the lower costs for day hospital treatment compared to inpatient treatment point to a positive cost-effect-ratio. Expanding this psychosomatic intervention would be useful in reducing the current gap in mental health care for the elderly.

Primary care clinicians' recognition and management of depression: a model of depression care in real-world primary care practice

BACKGROUND

Depression is prevalent in primary care (PC) practices and poses a considerable public health burden in the United States. Despite nearly four decades of efforts to improve depression care quality in PC practices, a gap remains between desired treatment outcomes and the reality of how depression care is delivered.

OBJECTIVE

This article presents a real-world PC practice model of depression care, elucidating the processes and their influencing conditions.

DESIGN

Grounded theory methodology was used for the data collection and analysis to develop a depression care model. Data were collected from 70 individual interviews (60 to 70 min each), three focus group interviews (n = 24, 2 h each), two surveys per clinician, and investigators' field notes on practice environments. Interviews were audiotaped and transcribed for analysis. Surveys and field notes complemented interview data.

PARTICIPANTS

Seventy primary care clinicians from 52 PC offices in the Midwest: 28 general internists, 28 family physicians, and 14 nurse practitioners.

KEY RESULTS

A depression care model was developed that illustrates how real-world conditions infuse complexity into each step of the depression care process. Depression care in PC settings is mediated through clinicians' interactions with patients, practice, and the local community. A clinician's interactional familiarity ("familiarity capital") was a powerful facilitator for depression care. For the recognition of depression, three previously reported processes and three conditions were confirmed. For the management of depression, 13 processes and 11 conditions were identified. Empowering the patient was a parallel process to the management of depression.

CONCLUSIONS

The clinician's ability to develop and utilize interactional relationships and resources needed to recognize and treat a person with depression is key to depression care in primary care settings. The interactional context of depression care makes empowering the patient central to depression care delivery.

Implementation strategies for collaborative primary care-mental health models

PURPOSE OF REVIEW

Extensive research exists that collaborative primary care-mental health models can improve care and outcomes for patients. These programs are currently being implemented throughout the United States and beyond. The purpose of this study is to review the literature and to generate an overview of strategies currently used to implement such models in daily practice.

RECENT FINDINGS

Six overlapping strategies to implement collaborative primary care-mental health models were described in 18 selected studies. We identified interactive educational strategies, quality improvement change processes, technological support tools, stakeholder engagement in the design and execution of implementation plans, organizational changes in terms of expanding the task of nurses and financial strategies such as additional collaboration fees and pay for performance incentives.

SUMMARY

Considering the overwhelming evidence about the effectiveness of primary care-mental health models, there is a lack of good studies focusing on their implementation strategies. In practice, these strategies are multifaceted and locally defined, as a result of intensive and required stakeholder engagement. Although many barriers still exist, the implementation of collaborative models could have a chance to succeed in the United States, where new service delivery and payment models, such as the Patient-Centered Medical Home, the Health Home and the Accountable Care Organization, are being promoted.

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.

Quality and equity of primary care with patient-centered medical homes: results from a national survey

BACKGROUND

The patient-centered medical home (PCMH) model has gained support, but the impact of this model on the quality and equity of care merits further evaluation.

OBJECTIVE

To determine if PCMHs are associated with improved quality and equity in pediatric primary care.

RESEARCH DESIGN

Using the 2007/2008 National Survey of Children's Health, a nationally representative survey of parents/guardians of children (age, 0-17 y), we evaluated the association of PCMHs with 10 quality-of-care measures using multivariable regression models, adjusting for demographic and socioeconomic covariates. For quality indicators that were significantly associated with medical homes, we determined if this association differed by race/ethnicity.

RESULTS

Compared with children without medical homes, those with medical homes had significantly better adjusted rates for 6 of 10 quality measures (all P≤0.02), such as obtaining a developmental history [adjusted rates % (SE): 41.7 (1.3) vs. 52.0 (1.1), P<0.001]. Having a medical home was associated with better adjusted rates of receiving a developmental history exam for both white and black children, but the disparity between these groups was not significantly narrowed [difference in risk differences (SE): 0.9 (4.3) for whites vs. blacks; P=0.83].

CONCLUSIONS

Our results underscore the benefits of the medical home model for children while highlighting areas for improvement, such as narrowing disparities. Our findings also emphasize the key role of patient experience measures in the evaluation of medical homes.

Patient-centered medical home: how it affects psychosocial outcomes for diabetes

Fragmentation of the current U.S. health care system and the increased prevalence of chronic diseases in the U.S. have led to the recognition that new models of care are needed. Chronic disease management, including diabetes, is often accompanied by a myriad of associated psychosocial issues that need to be addressed as part of a comprehensive treatment plan. Diabetes care should be aligned with comprehensive whole-person health care. The patient-centered medical home (PCMH) has emerged as a model for enhanced primary care that focuses on comprehensive integrated care. PCMH demonstration projects have shown improvements in quality of care, patient experience, care coordination, access to care, and quality measures for diabetes. Key PCMH transformative features associated with psychosocial issues related to diabetes reviewed in this article include integration of mental and behavioral health, care management/coordination, payment reform, advanced access, and putting the patient at the center of health care. This article also reviews the evidence supporting comprehensive and integrated care for addressing psychosocial issues associated with diabetes in the medical home.

Behavioral health integration: an essential element of population-based healthcare redesign

The fundamental aim of healthcare reform is twofold: to provide health insurance coverage for most of the citizens currently uninsured, thereby granting them access to healthcare; and to redesign the overall healthcare system to provide better care and achieve the triple aim (better health for the population, better healthcare for individuals, and at less cost). The foundation for this improved system will rest on a redesigned (i.e., sufficiently comprehensive and integrated) system of primary care, with which all other providers, services, and sites of care are associated. The Patient-Centered Medical Home (PCMH) and its congeners are the best current examples of the kind of primary care that can achieve the triple aim, if they can become sufficiently comprehensive and can adequately integrate services. This means fully integrating behavioral healthcare into the PCMH, a difficult task under the most favorable circumstances. Creating functioning accountable care organizations is an even more daunting task: this requires new principles of collaborating and financing and the current prototypes have generally failed to incorporate behavioral healthcare sufficient to meet even the basic needs of the target population. This paper will discuss (1) the case for and the difficulties associated with integrating behavioral healthcare into primary care at three levels: the practice, the state, and the nation; and (2) how this looks clinically, operationally, and financially.

Effective group training for patients with unexplained physical symptoms: a randomized controlled trial with a non-randomized one-year follow-up

BACKGROUND

Although cognitive-behavioral therapy for Unexplained Physical Symptoms (UPS) is effective in secondary care, studies done in primary care produced implementation problems and conflicting results. We evaluated the effectiveness of a cognitive-behavioral group training tailored to primary care patients and provided by a secondary community mental-health service reaching out into primary care.

METHODOLOGY/PRINCIPAL FINDINGS

The effectiveness of this training was explored in a randomized controlled trial. In this trial, 162 patients with UPS classified as undifferentiated somatoform disorder or as chronic pain disorder were randomized either to the training or a waiting list. Both lasted 13 weeks. The preservation of the training's effect was analyzed in non-randomized follow-ups, for which the waiting group started the training after the waiting period. All patients attended the training were followed-up after three months and again after one year. The primary outcomes were the physical and the mental summary scales of the SF-36. Secondary outcomes were the other SF-36-scales and the SCL-90-R. The courses of the training's effects in the randomized controlled trial and the follow-ups were analyzed with linear mixed modeling. In the randomized controlled trial, the training had a significantly positive effect on the quality of life in the physical domain (Cohen's d = 0.38;p = .002), but this overall effect was not found in the mental domain. Regarding the secondary outcomes, the training resulted in reporting an improved physical (Cohen's d = 0.43;p = 0.01), emotional (Cohen's d = 0.44;p = 0.01), and social (Cohen's d = 0.36;p = 0.01) functioning, less pain and better functioning despite pain (Cohen's d = 0.51;p = <0.001), less physical symptoms (Cohen's d = -.23;p = 0.05) and less sleep difficulties (Cohen's d = -0.25;p = 0.04) than time in the waiting group. During the non-randomized follow-ups, there were no relapses.

CONCLUSIONS/SIGNIFICANCE

The cognitive-behavioral group training tailored for UPS in primary care and provided by an outreaching secondary mental-health service appears to be effective and to broaden the accessibility of treatment for UPS.

TRIAL REGISTRATION

TrialRegister.nl NTR1609

Strategies to improve the management of depression in primary care

Effective management of depression in the primary care setting requires a systematic, population-based approach, which entails systematic case finding and diagnosis, patient engagement and education, use of evidence-based treatments, including medications and/or psychotherapy, close follow-up to ensure patients are improving, and a commitment to adjust treatments or consult with mental health specialists until depression is significantly improved. Programs in which primary care providers and mental health specialists collaborate effectively using principles of measurement-based stepped care and treatment to target can substantially improve patients' health and functioning while reducing overall health care costs.

A Qualitative Comparative Analysis of factors associated with trends in narrowing health inequalities in England

This study explores why progress with tackling health inequalities has varied among a group of local authority areas in England that were set targets to narrow important health outcomes compared to national averages. It focuses on premature deaths from cancers and cardiovascular disease (CVD) and whether the local authority gap for these outcomes narrowed. Survey and secondary data were used to create dichotomised conditions describing each area. For cancers, ten conditions were found to be associated with whether or not narrowing occurred: presence/absence of a working culture of individual commitment and champions; spending on cancer programmes; aspirational or comfortable/complacent organisational cultures; deprivation; crime; assessments of strategic partnership working, commissioning and the public health workforce; frequency of progress reviews; and performance rating of the local Primary Care Trust (PCT). For CVD, six conditions were associated with whether or not narrowing occurred: a PCT budget closer or further away from target; assessments of primary care services, smoking cessation services and local leadership; presence/absence of a few major programmes; and population turnover. The method of Qualitative Comparative Analysis was used to find configurations of these conditions with either the narrowing or not narrowing outcomes. Narrowing cancer gaps were associated with three configurations in which individual commitment and champions was a necessary condition, and not narrowing was associated with a group of conditions that had in common a high level of bureaucratic-type work. Narrowing CVD gaps were associated with three configurations in which a high assessment of either primary care or smoking cessation services was a necessary condition, and not narrowing was associated with two configurations that both included an absence of major programmes. The article considers substantive and theoretical arguments for these configurations being causal and as pointing to ways of improving progress with tackling health inequalities.