Evaluation of integrated psychological services in a university-based primary care clinic

Exploring Staff Perspectives and Experiences from a Nurse Practitioner-Led Behavioral Health Integration Project in North Carolina Multi-Site Federally Qualified Health Center: A Qualitative Descriptive Study

PURPOSE

As primary care (PC) clinics seek to integrate behavioral health (BH) services into patient care, it is crucial to understand the experiences of the clinic team and the impact on workflow and well-being. This study was designed to identify perspectives and experiences of nurse practitioner-led PC teams as they implemented a behavioral health integration (BHI) model into their Federally Qualified Health Center PC practices.

METHODS

We conducted in-depth qualitative interviews with staff members at three clinic sites that implemented BHI. Interviewees were asked questions about the benefits and challenges encountered in the new BHI workflow, the dynamics of the warm hand-off, the tools and resources they used and desired, and the changes they would like to see to promote efficient workflows.

RESULTS

We interviewed 21 staff members during May and June of 2020. An analysis of the qualitative data showed the most frequently reported experiences and attitudes focused on (a) the availability of behavioral health consultants (BHC); (b) procedural uses of the warm hand-off; (c) the organization's productivity goals; and (d) desired tools and resources that are generally unavailable to the clinicians but could make a difference to patient care.

CONCLUSION

Our results can assist FQHCs and similar organizations to achieve both BHI and the Quintuple aim. Integrating BH services into PC clinics is valuable and may mitigate clinician-staff burnout. However, PC organizations desiring to integrate new sustainable care models should consider involving staff in every phase of the transitional process phase to increase staff buy-in and staff rapport.

Utilizing primary care to engage underserved patients in a psychological intervention for chronic pain

BACKGROUND

Although psychological interventions can be used to improve chronic pain management, underserved individuals (i.e., racially minoritized and socioeconomically disadvantaged) may be less likely to engage in such services. The purpose of this study was to examine whether offering a psychological intervention for chronic pain in a primary care clinic could be a method in which to successfully engage underserved patients.

METHODS

There were 220 patients with chronic pain in a primary care clinic located in a socioeconomically and racially diverse city who were approached to discuss enrolment in a pilot randomized controlled trial of a five-session psychological intervention for chronic pain. Patients were introduced to the study by their primary care provider using the warm handoff model. We compared whether there were sociodemographic differences between those who enrolled in the study and those who declined to enrol.

RESULTS

There were no differences between those who enrolled and those who declined enrolment with regard to race, age, insurance type, and household income. However, females were more likely to enrol in the study compared to males.

CONCLUSIONS

Recruiting patients to participate in a trial of a psychological intervention for chronic pain in a primary care clinic appeared to be effective for engaging Black patients, patients with lower income, and those with government insurance. Thus, offering a psychological intervention for chronic pain in a primary care clinic may encourage engagement among racially minoritized individuals and those with lower socioeconomic status.

Primary Care Behavioral Health in Sweden - a protocol of a cluster randomized trial evaluating outcomes related to implementation, organization, and patients (KAIROS)

BACKGROUND

Providing comprehensive and continuous care for patients whose conditions have mental or behavioral components is a central challenge in primary care and an important part of improving universal health coverage. There is a great need for high and routine availability of psychological interventions, but traditional methods for delivering psychotherapy often result in low reach and long wait times. Primary Care Behavioral Health (PCBH) is a method for organizing primary care in which behavioral health staff provide brief, flexible interventions to a large part of the population in active collaboration with other providers. While PCBH holds promise in addressing important challenges, it has not yet been thoroughly evaluated.

METHODS

This cluster randomized trial will assess 17 primary care centers (PCCs) that are starting a PCBH implementation process. The PCCs will be divided into two groups, with one starting immediate implementation and the other acting as a control, implementing six months later. The purpose of the study is to strengthen the evidence base for PCBH regarding implementation-, organization-, and patient-level outcomes, taking into consideration that there is a partially dependent relationship between the three levels. Patient outcomes (such as increased daily functioning and reduction of symptoms) may be dependent on organizational changes (such as availability of treatment, waiting times and interprofessional teamwork), which in turn requires change in implementation outcomes (most notably, model fidelity). In addition to the main analysis, five secondary analyses will compare groups based on different combinations of randomization and time periods, specifically before and after each center achieves sufficient PCBH fidelity.

DISCUSSION

A randomized comparison of PCBH and traditional primary care has, to our knowledge, not been made before. While the naturalistic setting and the intricacies of implementation pose certain challenges, we have designed this study in an effort to evaluate the causal effects of PCBH despite these complex aspects. The results of this project will be helpful in guiding decisions on how to organize the delivery of behavioral interventions and psychological treatment within the context of primary care in Sweden and elsewhere.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05335382. Retrospectively registered on March 13th, 2022.

Anxiety interventions delivered in primary care behavioral health routine clinical practice

INTRODUCTION

Although anxiety is highly prevalent in primary care and a top reason for referral to primary care behavioral health (PCBH) services, there are limited data on which anxiety interventions are used in routine PCBH practice. The objective of this study was to identify interventions delivered when treating anxiety in PCBH practice.

METHOD

We conducted an online survey of PCBH providers regarding their clinical practice with patients who present for treatment of anxiety symptoms. The final sample comprised 209 PCBH providers recruited from e-mail listservs of national professional organizations (59.3% psychologists, 23.4% social workers, 12.4% counselors, 4.8% other). Providers reported on use (yes/no) of 17 interventions in their most recent session with their most recent adult patient presenting with a primary concern of non-trauma-related anxiety.

RESULTS

On average, patients were reported to be 42.2 (14.73) years old, White (73.7%), and male (56.5%) with anxiety symptoms of moderate severity (65.6%). Most reportedly had comorbid sleep difficulties (63.6%), depressive symptoms (58.4%), and/or stress/adjustment (56.0%). Providers reported delivering an average of 5.77 (2.05, range: 1-15) interventions, with psychoeducation (94.7%), relaxation training (64.1%), and supportive therapy (60.8%) being most common. Several highly efficacious evidence-based interventions for anxiety, including cognitive therapy (45.0%) and exposure (21.1%), were less common.

DISCUSSION

While PCBH providers delivered numerous brief interventions for anxiety, cognitive therapy and exposure were underutilized. Furthermore, PCBH patients with anxiety symptoms were complex, with significant severity and comorbidity. These results suggest implications for research, clinical training, intervention design, and future implementation efforts. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

The Primary Care Behavioral Health (PCBH) Model: An Overview and Operational Definition

The Primary Care Behavioral Health (PCBH) model is a prominent approach to the integration of behavioral health services into primary care settings. Implementation of the PCBH model has grown over the past two decades, yet research and training efforts have been slowed by inconsistent terminology and lack of a concise, operationalized definition of the model and its key components. This article provides the first concise operationalized definition of the PCBH model, developed from examination of multiple published resources and consultation with nationally recognized PCBH model experts. The definition frames the model as a team-based approach to managing biopsychosocial issues that present in primary care, with the over-arching goal of improving primary care in general. The article provides a description of the key components and strategies used in the model, the rationale for those strategies, a brief comparison of this model to other integration approaches, a focused summary of PCBH model outcomes, and an overview of common challenges to implementing the model.

Rationale and study design of the MyHEART study: A young adult hypertension self-management randomized controlled trial

Young adults (18-39 year-olds) with hypertension have a higher lifetime risk for cardiovascular disease. However, less than 50% of young adults achieve hypertension control in the United States. Hypertension self-management programs are recommended to improve control, but have been targeted to middle-aged and older populations. Young adults need hypertension self-management programs (i.e., home blood pressure monitoring and lifestyle modifications) tailored to their unique needs to lower blood pressure and reduce the risks and medication burden they may face over a lifetime. To address the unmet need in hypertensive care for young adults, we developed MyHEART (My Hypertension Education And Reaching Target), a multi-component, theoretically-based intervention designed to achieve self-management among young adults with uncontrolled hypertension. MyHEART is a patient-centered program, based upon the Self-Determination Theory, that uses evidence-based health behavior approaches to lower blood pressure. Therefore, the objective of this study is to evaluate MyHEART's impact on changes in systolic and diastolic blood pressure compared to usual care after 6 and 12 months in 310 geographically and racially/ethnically diverse young adults with uncontrolled hypertension. Secondary outcomes include MyHEART's impact on behavioral outcomes at 6 and 12 months, compared to usual clinical care (increased physical activity, decreased sodium intake) and to examine whether MyHEART's effects on self-management behavior are mediated through variables of perceived competence, autonomy, motivation, and activation (mediation outcomes). MyHEART is one of the first multicenter, randomized controlled hypertension trials tailored to young adults with primary care. The design and methodology will maximize the generalizability of this study. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03158051.

Patient outcomes associated with primary care behavioral health services: A systematic review

OBJECTIVE

This systematic review focused on Primary Care Behavioral Health (PCBH) services delivered under normal clinic conditions that included the patient outcomes of: 1) access/utilization of behavioral health services, 2) health status, and 3) satisfaction.

METHOD

Following PRISMA guidelines, comprehensive database searches and rigorous coding procedures rendered 36 articles meeting inclusion criteria. The principle summary measures of odd ratios or Cohen's d effect sizes were reported.

RESULTS

Due to significant limitations in the methodological rigor of reviewed studies, robust findings only emerged for healthcare utilization: PCBH is associated with shorter wait-times for treatment, higher likelihood of engaging in care, and attending a greater number of visits. Several small, uncontrolled studies report emerging evidence that functioning, depression, and anxiety improve overtime. There was no evidence of greater improvement in patient health status when PCBH was compared to other active treatments. The limited available evidence supports that patient satisfaction with PCBH services is high.

CONCLUSIONS

The implementation of PCBH services is ahead of the science supporting the usefulness of these services. Patient outcomes for PCBH are weaker than outcomes for Collaborative Care. More rigorous investigations of patient outcomes associated with PCBH are needed to allow for optimization of services.

Legislative and Policy Developments and Imperatives for Advancing the Primary Care Behavioral Health (PCBH) Model

The Primary Care Behavioral Health (PCBH) practice model continues to gain converts among primary care and behavioral health professionals as the evidence supporting its effectiveness continues to accumulate. Despite a growing number of practices and organizations using the model effectively, widespread implementation has been hampered by outmoded policies and regulatory barriers. As policymakers and legislators begin to recognize the contributions that PCBH model services make to the care of complex patients and the expansion of access to those in need of behavioral health interventions, some encouraging policy initiatives are emerging and the policy environment is becoming more favorable to implementation of the PCBH model. This article outlines the necessity for policy change, exposing the policy issues and barriers that serve to limit the practice of the PCBH model; highlights innovative approaches some states are taking to foster integrated practice; and discusses the compatibility of the PCBH model with the nation's health care reform agenda. Psychologists have emerged as leaders in the design and implementation of PCBH model integration and are encouraged to continue to advance the model through the demonstration of efficient and effective clinical practice, participation in the expansion of an appropriately trained workforce, and advocacy for the inclusion of this practice model in emerging healthcare systems and value-based payment methodologies.

Preparing the workforce for integrated healthcare: A systematic review

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

Measuring Perceived Level of Integration During the Process of Primary Care Behavioral Health Implementation

Provider- and staff-perceived levels of integration were measured during implementation of a primary care behavioral health clinic; these data were used to tailor and evaluate quality improvement strategies. Providers and staff at an urban, academic, adult primary care clinic completed the 32-item Level of Integration Measure (LIM) at baseline and 7 months. The LIM assesses 6 domains of integrated care. Overall and domain scores were calibrated from 0 to 100, with ≥80 representing a highly integrated clinic. Response rate was 79% (N = 46/58) at baseline and 83% (N = 52/63) at follow-up. Overall, LIM score increased from 64.5 to 70.1, P = .001. The lowest scoring domains at baseline were targeted for quality improvement and increased significantly: integrated clinical practice, 60.0 versus 68.4, P < .001; systems integration, 57.0 versus 63.8, P = .001; and training, 56.7 versus 65.3, P = .001. Ongoing quality improvement, including organizational and financial strategies, is needed to achieve higher levels of integration.

Cumulative Risk and Physiological Stress Responses in African American Adolescents

OBJECTIVE

To investigate associations between components of cumulative risk (CR) and physiological stress responses in African American adolescents and evaluate emotion regulation as a mediator and sex as a moderator of these associations.

METHODS

Cortisol and salivary alpha amylase (sAA) were collected in adolescents ( N = 205; 55% female; 12.1 ± 1.6 years at baseline) as part of a longitudinal study of stress and adjustment in families. CR was assessed at baseline and emotion regulation was assessed at baseline and 2 years later at Wave 3 (W3) using caregiver and adolescent reports. Cortisol and sAA responses to the social competence interview were assessed at W3.

RESULTS

Repeated-measures analyses of variance predicting cortisol and controlling for time of day, adolescent age, medication usage, and pubertal status revealed significant interactions of time with both psychosocial and sociodemographic risk. In both analyses, youths with higher levels of risk showed a steeper decline in cortisol than youths with lower levels of risk. In parallel analyses predicting sAA, time interacted with psychosocial but not with sociodemographic risk. There were no interactions with sex in any of the analyses. Although CR was associated with changes in emotion regulation, there was no evidence that these changes accounted for the observed CR-stress response associations.

CONCLUSIONS

These findings illustrate the potential importance of disentangling CR and suggest that additional work is needed to help explicate why and how CR is associated with specific physiological responses to stress.

Initial and Follow-Up Evaluations of Integrated Psychological Services for Anxiety and Depression in a Safety Net Primary Care Clinic

OBJECTIVE

Despite the recognized importance of integrated behavioral health, particularly in safety net primary care, its effectiveness in real world settings has not been extensively evaluated. This article presents 2 successive studies examining the effectiveness of integrated behavioral care in a safety net setting.

METHOD

Study 1 compared the depression and anxiety scores of predominately low-income and minority patients who underwent brief interventions (N = 147) to those of patients from a demographically similar comparison clinic without integrated psychological services, matched on baseline levels of anxiety and depression and length of time between assessments (N = 139). Study 2 did not include a control group but served as a long-term follow-up assessment of anxiety and depression for a subset of 47 patients who finished treatment and could be reached by telephone within 6-18 months of their last session.

RESULTS

Study 1 found that patients from the clinic with integrated psychology services experienced greater decreases in depression and anxiety scores than patients in the control clinic. These effects did not differ as a function of age, gender, or race. Study 2 found that patients continued to decline in depression and anxiety over time, with lower scores at the last session and even lower scores after longer-term follow-up ranging from 6 to18 months. These improvements remained significant when controlling for other interim mental health treatments.

CONCLUSION

These results support the short- and long-term treatment effects of brief primary care behavioral interventions, further strengthening the case for integrated behavioral healthcare in safety net settings.

The Impact of Integrated Psychological Services in a Safety Net Primary Care Clinic on Medical Utilization

OBJECTIVE

The integration of psychological and behavioral health services into safety net primary care clinics has been viewed as a step toward reducing disparities in mental health treatment and addressing behavioral factors in chronic diseases. Though it is posited that integrated behavioral health (IBH) reduces preventable medical costs, this premise has yet to be tested in a safety net primary care clinic.

METHOD

Retrospective pre- and posttreatment analysis with quasi-experimental control group was constructed using propensity score matching. Participants included 1,440 adult patients at a safety net primary care clinic, 720 of whom received IBH services, and 720 of whom received medical treatment only.

RESULTS

Analysis showed that rates of preventable inpatient utilization decreased significantly among IBH-treated patients compared to no change among control patients.

CONCLUSION

IBH was associated with decreased rates of preventable inpatient visits. IBH may present opportunities to deliver improved holistic patient care while reducing unnecessary inpatient medical utilization.

Comparing Cognitive Failures and Metacognitive Beliefs in Mild Traumatic Brain Injured Patients and Normal Controls in Kashan

BACKGROUND

Head trauma is associated with multiple destructive cognitive symptoms and cognitive failure. Cognitive failures include problems with memory, attention and operation. Cognitive failures are considered as a process associated with metacognition.

OBJECTIVES

This study aimed to compare cognitive failures and metacognitive beliefs in mild Traumatic Brain Injured (TBI) patients and normal controls in Kashan.

PATIENTS AND METHODS

The study was performed on 40 TBI patients referred to the Shahid Beheshti Hospital of Kashan city and 40 normal controls in Kashan. Traumatic brain injured patients and normal controls were selected by convenience sampling. Two groups filled out the demographic sheet, Cognitive Failures Questionnaire (CFQ) and Meta-Cognitions Questionnaire 30 (MCQ-30). The data were analyzed by the SPSS-19 software with multivariate analysis of variance.

RESULTS

The results of this study showed that there were no significant differences between TBI and controls in total scores and subscales of CFQ and MCQ (F = 0.801, P = 0.61).

CONCLUSIONS

Based on these findings, it seems that mild brain injuries don't make significant metacognitive problems and cognitive failures.