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Stein NR, Stolzmann KL, Abel EA, Burgess CM, Franz A, Connolly SL, Meshberg N, Bailey HM, Osser DN, Smith EG, Bauer MS, Godleski L, Miller CJ. Ten Years of Bipolar Telehealth: Program Evaluation of a Team-Based Telemental Health Clinic. Telemed J E Health 2025; 31:269-278. [PMID: 39421937 DOI: 10.1089/tmj.2024.0411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2024] Open
Abstract
Objectives: Telemental health via videoconferencing (TMH-V) can overcome many of the barriers to accessing quality mental health care. Toward this end, in 2011, the U.S. Department of Veterans Affairs (VA) established the National Bipolar Disorders TeleHealth (BDTH) Program to provide expert mental health consultation and treatment to Veterans with bipolar spectrum disorders. Methods: Initial analyses of BDTH services suggested that participants had positive changes in quality-of-care indices and clinical outcomes; however, that evaluation was based on a limited sample of both participants and VA medical centers. We were able to confirm and expand upon those early results by using nearly eight times the number of participants and more than twice as many medical centers. Results: For the 2,456 Veterans who completed the intake to our program, there were significant improvements in some of the quality metrics (e.g., lithium use) and a 54% reduction in positive suicide screens (p < 0.05). The Veterans who completed the initial and postprogram assessments (n = 815) reported a 16.6% reduction in manic symptoms (p < 0.001), a 29.3% reduction in depressive symptoms (p < 0.001), and a 21.2% reduction in mood episodes (p < 0.001). Additionally, these Veterans demonstrated significant improvements (p < 0.001) in mental health-related quality of life between the two assessments. Conclusions: These analyses provide further support for the general effectiveness and safety of telemental health via videoconferencing. Future research should examine the generalizability of these findings across various subgroups (e.g., minority patients, patients in rural areas), populations, and health care systems.
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Affiliation(s)
- Nathan R Stein
- VA Boston Healthcare System, Brockton, Massachusetts, USA
- VA National Expert Consultation & Specialized Services, West Haven, Connecticut, USA
| | - Kelly L Stolzmann
- VA Boston Healthcare System, Center for Health Optimization and Implementation Research (CHOIR), Boston, Massachusetts, USA
| | - Erica A Abel
- VA National Expert Consultation & Specialized Services, West Haven, Connecticut, USA
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Yale School of Medicine, New Haven, Connecticut, USA
| | - Claire M Burgess
- VA Boston Healthcare System, Brockton, Massachusetts, USA
- VA National Expert Consultation & Specialized Services, West Haven, Connecticut, USA
- Harvard Medical School, Department of Psychiatry, Boston, Massachusetts, USA
| | - Aleda Franz
- VA National Expert Consultation & Specialized Services, West Haven, Connecticut, USA
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Yale School of Medicine, New Haven, Connecticut, USA
| | - Samantha L Connolly
- VA Boston Healthcare System, Center for Health Optimization and Implementation Research (CHOIR), Boston, Massachusetts, USA
- Harvard Medical School, Department of Psychiatry, Boston, Massachusetts, USA
| | - Nathaniel Meshberg
- Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Hannah M Bailey
- VA Boston Healthcare System, Center for Health Optimization and Implementation Research (CHOIR), Boston, Massachusetts, USA
| | - David N Osser
- VA Boston Healthcare System, Brockton, Massachusetts, USA
- VA National Expert Consultation & Specialized Services, West Haven, Connecticut, USA
- Harvard Medical School, Department of Psychiatry, Boston, Massachusetts, USA
| | - Eric G Smith
- VA National Expert Consultation & Specialized Services, West Haven, Connecticut, USA
- VA Bedford Healthcare System, Center for Health Optimization and Implementation Research (CHOIR), Bedford, Massachusetts, USA
- University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Mark S Bauer
- Harvard Medical School, Department of Psychiatry, Boston, Massachusetts, USA
| | - Linda Godleski
- Yale School of Medicine, New Haven, Connecticut, USA
- VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Christopher J Miller
- VA National Expert Consultation & Specialized Services, West Haven, Connecticut, USA
- VA Boston Healthcare System, Center for Health Optimization and Implementation Research (CHOIR), Boston, Massachusetts, USA
- Harvard Medical School, Department of Psychiatry, Boston, Massachusetts, USA
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Sepúlveda-Muñoz J, Quemada González C, Hurtado Lara MM, Gutiérrez García ÁM, Martí-García C, García-Herrera Pérez-Bryan JM, Morales-Asencio JM. Management of Psychosis and Schizophrenia by Primary Care GPs: A Cross-Sectional Study in Spain. J Prim Care Community Health 2025; 16:21501319241306177. [PMID: 39883456 PMCID: PMC11783486 DOI: 10.1177/21501319241306177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2024] [Revised: 11/12/2024] [Accepted: 11/18/2024] [Indexed: 01/31/2025] Open
Abstract
AIM To investigate the detection and initial management of first psychotic episodes, as well as established schizophrenia, within the primary care of the Andalusian Health System. BACKGROUND Delay in detecting and treating psychosis is associated with slower recovery, higher relapse risk, and poorer long-term outcomes. Often, psychotic episodes go unnoticed for years before a diagnosis is established. Primary care physicians are crucial for early recognition of psychosis and schizophrenia, especially in Spain, where primary care is the main entry point to healthcare services. METHODS Cross-sectional exploratory study. All active primary care physicians in the Malaga Guadalhorce Health District were invited to participate. Due to the COVID-19 pandemic, the survey was conducted online. The survey, adapted and validated for the local context, included 22 items and 5 sociodemographic questions covering early detection, treatment options, physical health monitoring, and management challenges. Descriptive and bivariate analyses summarized the data and explored correlations between key variables. FINDINGS The study included 142 primary care physicians (response rate 35.5%), with 28.9% men and 71.1% women, primarily from urban areas (83.1%). Most had completed residency training (86.6%), with 79.6% receiving psychiatric training. However, only 5.6% had participated in training sessions in the last 5 years, with all such sessions lasting less than 30 h. Physicians typically managed 0-10 patients with diagnosed schizophrenia and saw these patients 2 to 3 times annually. They often felt capable of managing these patients, especially with mental health consultancy support. Physical health monitoring was common, though some relied on mental health services to do this. Collaboration with mental health services was moderate, with high utility perceived for having a list of patients with severe mental disorders in their care panel. CONCLUSIONS Family physicians are generally confident in managing psychosis and schizophrenia but lack recent specialized training. Mental health consultancy services are valued, but collaboration with these services needs improvement. Clear guidelines and enhanced training are essential to ensure comprehensive care, addressing both mental and physical health needs of these patients.
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Affiliation(s)
- Jesús Sepúlveda-Muñoz
- Health District Málaga-Guadalhorce, Málaga, Spain
- Unidad Docente de Málaga, Málaga, Spain
| | - Casta Quemada González
- Regional University Hospital, Málaga, Spain
- Instituto de Investigación Biomédica de Málaga, Málaga, Spain
- Universidad de Málaga, Málaga, Spain
| | - María M. Hurtado Lara
- Regional University Hospital, Málaga, Spain
- Instituto de Investigación Biomédica de Málaga, Málaga, Spain
- Universidad de Málaga, Málaga, Spain
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Jamieson M, Juda M, Lavergne MR, Kurdyak P, Laporte A, Rudoler D. Demographic and temporal trends in mental health and substance use services provided by primary care physicians in British Columbia, Canada. BMC PRIMARY CARE 2024; 25:335. [PMID: 39256641 PMCID: PMC11384687 DOI: 10.1186/s12875-024-02587-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 08/28/2024] [Indexed: 09/12/2024]
Abstract
BACKGROUND As the demand for mental health and substance use (MHSU) services increases, there will be an even greater need for health human resources to deliver this care. This study investigates how family physicians' (FP) contact volume, and more specifically, MHSU contact volume, is shaped by demographic trends among FPs in British Columbia, Canada. METHODS We used annual physician-level administrative billing data and demographic information on FPs in British Columbia between 1996 and 2017. This study analyzes trends in primary care service provision among graduating cohorts of FPs, FPs of different ages (as measured by years since graduation), and FPs practicing during different time periods. Additionally, analyses are stratified by FP sex to account for potential differences in labour supply patterns between male and female FPs. RESULTS Our results show that while FPs' overall contacts with patients decreased between 1996 and 2017, their annual number of MHSU contacts increased, which was largely driven by an increase in substance use visits. Demographically, the proportion of female FPs in the labour force rose over time. Observed trends were similar, though not identical in male and female FPs, as males tended to have higher overall contact volume (both total contacts and MHSU), but also steeper declines in contact volume in later careers. The number of contacts (both total and MHSU) changed across career stage - rising steadily from start to mid-career, peaking at 20-30 years in practice, and decreasing steadily thereafter. This was evident for all cohorts and consistent over the 21-year study period but flattened in amplitude over time. Our findings also point to potential cohort effects on labour supply. The inverse U-shaped career trend extended to MHSU contacts, but its peak seems to have shifted to a later career stage (peaking at 30-40 years of practice) over time. CONCLUSIONS Our study shows changing dynamics in MHSU service delivery among FPs over time, across the life span and between FP sexes that are likely to influence access to care beyond simply the number of FPs. Given the healthcare needs of the population, these findings point to potential future changes in provision of MHSU services.
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Affiliation(s)
- Margaret Jamieson
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Suite 425, Toronto, ON, M5T 3M6, Canada.
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), 250 College Street, Toronto, M5T 1R8, Canada.
- Canadian Centre for Health Economics, 155 College Street, Suite 425, Toronto, M5T 3M6, Canada.
| | - Myriam Juda
- Department of Psychology, Simon Fraser University, Robert C. Brown Hall 5246, 8888 University Drive, Burnaby, V5A 1S6, Canada
- Telfer School of Management, University of Ottawa, 5105-55 Laurier Avenue East, Ottawa, K1N 6N5, Canada
| | - M Ruth Lavergne
- Department of Family Medicine, Dalhousie University, 5909 Veterans Memorial Lane, Halifax, B3H 2E2, Canada
| | - Paul Kurdyak
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), 250 College Street, Toronto, M5T 1R8, Canada
- ICES, Toronto, Canada
- Department of Psychiatry, University of Toronto, 250 College Street, 8th Floor, Toronto, M5T 1R8, Canada
| | - Audrey Laporte
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Suite 425, Toronto, ON, M5T 3M6, Canada
- Canadian Centre for Health Economics, 155 College Street, Suite 425, Toronto, M5T 3M6, Canada
| | - David Rudoler
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Suite 425, Toronto, ON, M5T 3M6, Canada
- Faculty of Health Sciences, University of Ontario Institute of Technology, 2000 Simcoe Street North, Oshawa, L1H 7K4, Canada
- Ontario Shores Centre for Mental Health Sciences, 700 Gordon Street, Whitby, L1N 5S9, Canada
- Canadian Centre for Health Economics, 155 College Street, Suite 425, Toronto, M5T 3M6, Canada
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Miller CJ, Bailey HM, Abel EA, Burgess CM, Connolly SL, Franz A, Smith E, Bauer MS. Efficacy of life goals collaborative care for bipolar disorder: A systematic review. J Affect Disord 2024; 359:356-363. [PMID: 38754598 DOI: 10.1016/j.jad.2024.05.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 04/17/2024] [Accepted: 05/12/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND Bipolar disorder remains a disabling mental health condition despite the availability of effective treatments. Collaborative chronic care models (CCMs) represent an evidence-based way to structure care for conditions like bipolar disorder. Life Goals Collaborative Care (LGCC) was designed specifically for bipolar disorder, featuring psychoeducation alongside collaborative components (e.g. nurse care management or expert psychiatric consultation). Despite the use of Life Goals across health systems, a systematic review summarizing its effectiveness has never been conducted. METHODS We conducted a systematic review of randomized controlled trials (RCTs) of LGCC through December 2023 to help guide the field in treating bipolar disorder (PROSPERO: #404581). We evaluated study quality and outcomes in several symptom and quality of life domains. RESULTS Ten articles describing eight studies met inclusion criteria. All studies featured group-based LGCC; most were compared to treatment as usual (TAU). Three of eight studies found LGCC to be associated with statistically significant effects for the prevention of manic episodes. Most studies finding positive effects featured additional collaborative care components beyond psychoeducation and were conducted in capitated healthcare systems. LIMITATIONS Limitations include: several types of potential bias in included studies; exclusion of observational studies of LGCC; lack of generalizability to pediatric populations; insufficient studies to conduct subgroup analyses; and low confidence in the quality of the evidence. CONCLUSIONS In this systematic review, group-based LGCC demonstrated some positive effects for reducing mania recurrence; results for other outcome domains were equivocal. Future studies should investigate one-on-one LGCC, both in person and virtually, to enhance well-being for people with bipolar disorder.
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Affiliation(s)
- Christopher J Miller
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 S. Huntington Ave (152M), Boston, MA, USA; Department of Psychiatry, Harvard Medical School, 401 Park Drive, Boston, MA, USA; National Expert Consultation & Specialized Services - Mental Health (NEXCSS-MH), US Department of Veterans Affairs, Washington, DC, USA.
| | - Hannah M Bailey
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 S. Huntington Ave (152M), Boston, MA, USA
| | - Erica A Abel
- National Expert Consultation & Specialized Services - Mental Health (NEXCSS-MH), US Department of Veterans Affairs, Washington, DC, USA; Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, USA; VA Connecticut Healthcare System, West Haven, CT, USA; Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Claire M Burgess
- Department of Psychiatry, Harvard Medical School, 401 Park Drive, Boston, MA, USA; National Expert Consultation & Specialized Services - Mental Health (NEXCSS-MH), US Department of Veterans Affairs, Washington, DC, USA; Department of Mental Health, VA Boston Healthcare System, Boston, MA, USA
| | - Samantha L Connolly
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 S. Huntington Ave (152M), Boston, MA, USA; Department of Psychiatry, Harvard Medical School, 401 Park Drive, Boston, MA, USA
| | - Aleda Franz
- National Expert Consultation & Specialized Services - Mental Health (NEXCSS-MH), US Department of Veterans Affairs, Washington, DC, USA; VA Connecticut Healthcare System, West Haven, CT, USA; Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Eric Smith
- VA Bedford Healthcare System, Bedford, MA, USA; Departments of Psychiatry and Population and Quantitative Health Sciences, U Mass Chan Medical School, Worcester, MA, USA
| | - Mark S Bauer
- Department of Psychiatry, Harvard Medical School, 401 Park Drive, Boston, MA, USA
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Khazanov GK, Wolk CB, Lorenc E, Candon M, Pieri MF, Oslin DW, Press MJ, Anderson E, Famiglio E, Jager-Hyman S. Change in suicidal ideation, depression, and anxiety following collaborative care in the community. BMC PRIMARY CARE 2024; 25:241. [PMID: 38970006 PMCID: PMC11225270 DOI: 10.1186/s12875-024-02494-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 06/26/2024] [Indexed: 07/07/2024]
Abstract
BACKGROUND The Collaborative Care Model (CoCM) increases access to mental health treatment and improves outcomes among patients with mild to moderate psychopathology; however, it is unclear how effective CoCM is for patients with elevated suicide risk. METHODS We examined data from the Penn Integrated Care program, a CoCM program including an intake and referral management center plus traditional CoCM services implemented in primary care clinics within a large, diverse academic medical system. In this community setting, we examined: (1) characteristics of patients with and without suicidal ideation who initiated CoCM, (2) changes in suicidal ideation (Patient Health Questionnaire-9 [PHQ-9] item 9), depression (PHQ-9 total scores), and anxiety (Generalized Anxiety Disorder Scale-7 scores) from the first to last CoCM visit overall and across demographic subgroups, and (3) the relationship between amount of CoCM services provided and degree of symptom reduction. RESULTS From 2018 to 2022, 3,487 patients were referred to CoCM, initiated treatment for at least 15 days, and had completed symptom measures at the first and last visit. Patients were 74% female, 45% Black/African American, and 45% White. The percentage of patients reporting suicidal ideation declined 11%-7% from the first to last visit. Suicidal ideation severity typically improved, and very rarely worsened, during CoCM. Depression and anxiety declined significantly among patients with and without suicidal ideation and across demographic subgroups; however, the magnitude of these declines differed across race, ethnicity, and age. Patients with suicidal ideation at the start of CoCM had higher depression scores than patients without suicidal ideation at the start and end of treatment. Longer CoCM episodes were associated with greater reductions in depression severity. CONCLUSIONS Suicidal ideation, depression, and anxiety declined following CoCM among individuals with suicidal ideation in a community setting. Findings are consistent with emerging evidence from clinical trials suggesting CoCM's potential for increasing access to mental healthcare and improving outcomes among patients at risk for suicide.
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Affiliation(s)
- Gabriela Kattan Khazanov
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Center of Excellence for Substance Addiction Treatment and Education, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Avenue, Philadelphia, PA, 19104, USA.
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - Courtney Benjamin Wolk
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Emily Lorenc
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Molly Candon
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Matteo F Pieri
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA
| | - David W Oslin
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Mental Illness Research Education and Clinical Center, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Matthew J Press
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Eleanor Anderson
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Emilie Famiglio
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Shari Jager-Hyman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Fanali A, Giorgi F, Tramonti F. Thick description and systems thinking: Reiterating the importance of a biopsychosocial approach to mental health. J Eval Clin Pract 2024; 30:309-315. [PMID: 36444133 DOI: 10.1111/jep.13800] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 11/10/2022] [Accepted: 11/20/2022] [Indexed: 11/30/2022]
Abstract
STUDY AIMS The article aims at reiterating the importance of a biopsychosocial approach to mental health, taking stock of the critiques that have been raised and moving forward throughout a reconsideration of the theoretical background of systems thinking and emphasizing the relevance of the concept of thick description for the promotion of an adequate reflection on methodology and case formulation. LITERATURE REVIEW It is our opinion that the biopsychosocial approach is still a powerful framework for making sense of the growing data collected in the different fields related to mental health and for designing proper treatment plans. A crucial challenge for mental health is that of surpassing the dichotomies and ideological disputes that still contaminate the field with detrimental effects on the advancement of knowledge and on the integration and continuity of different kind of interventions. CONCLUSIONS The time is ripe for building bridges among neuroscience, humanities and social sciences, and this can only happen within the umbrella of a biopsychosocial perspective reinstated into its systems thinking background.
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Affiliation(s)
| | - Franco Giorgi
- Department of Neuroscience, University of Pisa, Pisa, Italy
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Meredith LS, Wong EC, Marx BP, Han B, Korn AR, Tobin JN, Cassells A, Williamson S, Franco M, Overa CC, Holder T, Lin TJ, Sloan DM. Design of a hybrid implementation effectiveness cluster randomized controlled trial of delivering written exposure therapy for PTSD in underserved primary care settings. Contemp Clin Trials 2024; 138:107435. [PMID: 38211725 PMCID: PMC11146292 DOI: 10.1016/j.cct.2024.107435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 12/28/2023] [Accepted: 01/07/2024] [Indexed: 01/13/2024]
Abstract
INTRODUCTION Posttraumatic stress disorder (PTSD) results in substantial costs to society. Prevalence of PTSD among adults is high, especially among those presenting to primary care settings. Evidence-based psychotherapies (EBPs) for PTSD are available but dissemination and implementation within primary care settings is challenging. Building Experience for Treating Trauma and Enhancing Resilience (BETTER) examines the effectiveness of integrating Written Exposure Therapy (WET) within primary care collaborative care management (CoCM). WET is a brief exposure-based treatment that has the potential to address many challenges of delivering PTSD EBPs within primary care settings. METHODS The study is a hybrid implementation effectiveness cluster-randomized controlled trial in which 12 Federally Qualified Health Centers (FQHCs) will be randomized to either CoCM plus WET (CoCM+WET) or CoCM only with 60 patients within each FQHC. The primary aim is to evaluate the effectiveness of CoCM+WET to improve PTSD and depression symptom severity. Secondary treatment outcomes are mental and physical health functioning. The second study aim is to examine implementation of WET within FQHCs using FQHC process data and staff interviews pre- and post-intervention. Exploratory aims are to examine potential moderators and mediators of the intervention. Assessments occur at baseline, and 3- and 12-month follow-up. CONCLUSION The study has the potential to impact practice and improve clinical and public health outcomes. By establishing the effectiveness and feasibility of delivering a brief trauma-focused EBP embedded within CoCM in primary care, the study aims to improve PTSD outcomes for underserved patients. TRIAL REGISTRATION (Clinicaltrials.govNCT05330442).
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Affiliation(s)
- Lisa S Meredith
- RAND Corporation, Santa Monica, CA, United States of America; VA HSR&D Center for Healthcare Innovation, Implementation & Policy, Sepulveda, CA, United States of America.
| | - Eunice C Wong
- RAND Corporation, Santa Monica, CA, United States of America
| | - Brian P Marx
- National Center for PTSD, Behavioral Science Division at VA Boston Healthcare, Boston, MA, United States of America; Boston University Chobanian & Avedisian School of Medicine, Boston, MA, United States of America
| | - Bing Han
- Kaiser Permanente Southern California, Department of Research & Evaluation, Pasadena, CA, United States of America
| | - Ariella R Korn
- RAND Corporation, Boston, MA 02116, United States of America
| | - Jonathan N Tobin
- Clinical Directors Network (CDN), New York, NY, United States of America; The Rockefeller University Center for Clinical and Translational Science, New York, NY, United States of America
| | - Andrea Cassells
- Clinical Directors Network (CDN), New York, NY, United States of America
| | | | - Meghan Franco
- Pardee RAND Graduate School, Santa Monica, CA, United States of America
| | - Cleo Clarize Overa
- Clinical Directors Network (CDN), New York, NY, United States of America
| | - Tameir Holder
- Clinical Directors Network (CDN), New York, NY, United States of America
| | - T J Lin
- Clinical Directors Network (CDN), New York, NY, United States of America
| | - Denise M Sloan
- National Center for PTSD, Behavioral Science Division at VA Boston Healthcare, Boston, MA, United States of America; Boston University Chobanian & Avedisian School of Medicine, Boston, MA, United States of America
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Kim HK, Melamed OC, Sloan M, Husain MI, Rodie DJ, Perivolaris A, Kurdyak P, Oslin DW, Geist R, Selby P, Mulsant BH. A computer-assisted telephone collaborative care intervention provided by lay providers for the treatment of comorbid depression and at-risk drinking: Analysis of a randomized controlled trial. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 157:209207. [PMID: 37939903 DOI: 10.1016/j.josat.2023.209207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 06/08/2023] [Accepted: 10/24/2023] [Indexed: 11/10/2023]
Abstract
INTRODUCTION Virtual collaborative care for people with comorbid depression and at-risk drinking lacks strong evidence. Our aim was to assess the impact of 12 months of telephone collaborative care (tCC) versus enhanced usual care (eUC) on depression and drinking. METHODS We performed a secondary analysis of the Primary care Assessment and Research of a Telephone intervention for Neuropsychiatric conditions with Education and Resources study (PARTNERs), a blinded randomized controlled trial. We examined 144 participants with comorbid depression and at-risk drinking, of which 129 were from the original sample whose data have been published, and 15 were studied since the original report had been published. PARTNERs compared eUC consisting of usual care plus assessment of symptoms at baseline, and 4, 8, and 12 months later vs. tCC consisting of eUC plus telephone-based coaching and symptom monitoring provided by a lay mental health technician to patients supervised by a psychiatrist. The study assessed depression response and remission using logistic regression; we assessed trajectory of drinking using Generalized-estimating equations (GEE). Baseline factors associated with likelihood of not exceeding number of drinks at 12 months were identified using decision trees. RESULTS tCC produced a faster decline in the number of drinks than eUC (Wald Χ2 = 9.47, p = 0.02). However, drinking and depression outcomes did not differ significantly between the two groups at the end of treatment. Higher alcohol consumption at baseline (≥18 standard drinks per week in the tCC group and ≥11 standard drinks per week in the eUC group) was associated with a higher likelihood of having at-risk drinking after 12 months of treatment. CONCLUSIONS Our findings suggest that, compared to eUC, tCC may accelerate drinking reductions in patients with comorbid depression and at-risk drinking. Both treatments were equally effective at the end of treatment for both depression and drinking outcomes.
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Affiliation(s)
- Helena K Kim
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Osnat C Melamed
- Department of Family and community Medicine, University of Toronto, Toronto, ON, Canada; Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada; Department of Pharmacology & Toxicology, University of Toronto, Toronto, Ontario, Canada; Department of Psychological Clinical Science, University of Toronto Scarborough, Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Matthew Sloan
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada; Department of Pharmacology & Toxicology, University of Toronto, Toronto, Ontario, Canada; Department of Psychological Clinical Science, University of Toronto Scarborough, Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - M Ishrat Husain
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
| | - David J Rodie
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
| | | | - Paul Kurdyak
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
| | - David W Oslin
- University of Pennsylvania and the Department of Veteran Affairs, Philadelphia, PA, USA
| | - Rose Geist
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Peter Selby
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Department of Family and community Medicine, University of Toronto, Toronto, ON, Canada; Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Canada
| | - Benoit H Mulsant
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada.
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Kroenke K, Corrigan JD, Ralston RK, Zafonte R, Brunner RC, Giacino JT, Hoffman JM, Esterov D, Cifu DX, Mellick DC, Bell K, Scott SG, Sander AM, Hammond FM. Effectiveness of care models for chronic disease management: A scoping review of systematic reviews. PM R 2024; 16:174-189. [PMID: 37329557 DOI: 10.1002/pmrj.13027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 05/14/2023] [Accepted: 05/31/2023] [Indexed: 06/19/2023]
Abstract
OBJECTIVE To conduct a scoping review of models of care for chronic disease management to identify potentially effective components for management of chronic traumatic brain injury (TBI). METHODS Information sources: Systematic searches of three databases (Ovid MEDLINE, Embase, and Cochrane Database of Systematic Reviews) from January 2010 to May 2021. ELIGIBILITY CRITERIA Systematic reviews and meta-analyses reporting on the effectiveness of the Chronic Care Model (CCM), collaborative/integrated care, and other chronic disease management models. DATA Target diseases, model components used (n = 11), and six outcomes (disease-specific, generic health-related quality of life and functioning, adherence, health knowledge, patient satisfaction, and cost/health care use). SYNTHESIS Narrative synthesis, including proportion of reviews documenting outcome benefits. RESULTS More than half (55%) of the 186 eligible reviews focused on collaborative/integrated care models, with 25% focusing on CCM and 20% focusing on other chronic disease management models. The most common health conditions were diabetes (n = 22), depression (n = 16), heart disease (n = 12), aging (n = 11), and kidney disease (n = 8). Other single medical conditions were the focus of 22 reviews, multiple medical conditions of 59 reviews, and other or mixed mental health/behavioral conditions of 20 reviews. Some type of quality rating for individual studies was conducted in 126 (68%) of the reviews. Of reviews that assessed particular outcomes, 80% reported disease-specific benefits, and 57% to 72% reported benefits for the other five types of outcomes. Outcomes did not differ by the model category, number or type of components, or target disease. CONCLUSIONS Although there is a paucity of evidence for TBI per se, care model components proven effective for other chronic diseases may be adaptable for chronic TBI care.
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Affiliation(s)
- Kurt Kroenke
- Department of Medicine, Indiana School of Medicine and Regenstrief Institute, Indianapolis, Indiana, USA
| | - John D Corrigan
- Department of Physical Medicine & Rehabilitation, The Ohio State University, Columbus, Ohio, USA
| | - Rick K Ralston
- Ruth Lilly Medical Library, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Ross Zafonte
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, and Spaulding Rehabilitation Hospital, Boston, Massachusetts, USA
| | - Robert C Brunner
- Department of Physical Medicine and Rehabilitation, University of Alabama, Birmingham, Alabama, USA
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, and Spaulding Rehabilitation Hospital, Boston, Massachusetts, USA
| | - Jeanne M Hoffman
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Dmitry Esterov
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota, USA
| | - David X Cifu
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, Virginia, USA
- U.S. Department of Veterans Affairs, Washington, DC, USA
| | | | - Kathleen Bell
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern, Dallas, Texas, USA
| | - Steven G Scott
- Center of Innovation on Disability & Rehab Research (CINDRR), James A Haley Veterans' Hospital, Tampa, Florida, USA
| | - Angelle M Sander
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, and Brain Injury Research Center, TIRR Memorial Hermann, Houston, Texas, USA
| | - Flora M Hammond
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, Indiana, USA
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10
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Miller CJ, Sullivan JL, Connolly SL, Richardson EJ, Stolzmann KL, Brown M, Bailey HM, Weaver K, Sippel L, Kim B. Adaptation for sustainability in an implementation trial of team-based collaborative care. IMPLEMENTATION RESEARCH AND PRACTICE 2024; 5:26334895231226197. [PMID: 38322803 PMCID: PMC10807389 DOI: 10.1177/26334895231226197] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024] Open
Abstract
Background Sustaining healthcare interventions once they have been implemented is a pivotal public health endeavor. Achieving sustainability requires context-sensitive adaptations to evidence-based practices (EBPs) or the implementation strategies used to ensure their adoption. For replicability of adaptations beyond the specific setting in question, the underlying logic needs to be clearly described, and adaptations themselves need to be plainly documented. The goal of this project was to describe the process by which implementation facilitation was adapted to improve the uptake of clinical care practices that are consistent with the collaborative chronic care model (CCM). Method Quantitative and qualitative data from a prior implementation trial found that CCM-consistent care practices were not fully sustained within outpatient general mental health teams that had received 1 year of implementation facilitation to support uptake. We undertook a multistep consensus process to identify adaptations to implementation facilitation based on these results, with the goal of enhancing the sustainability of CCM-based care in a subsequent trial. The logic for these adaptations, and the resulting adaptations themselves, were documented using two adaptation-oriented implementation frameworks (the iterative decision-making for evaluation of adaptations [IDEA] and the framework for reporting adaptations and modifications to evidence-based implementation strategies [FRAME-IS], respectively). Results Three adaptations emerged from this process and were documented using the FRAME-IS: (a) increasing the scope of implementation facilitation within the medical center, (b) having the internal facilitator take a greater role in the implementation process, and (c) shortening the implementation timeframe from 12 to 8 months, while increasing the intensity of facilitation support during that time. Conclusions EBP sustainability may require careful adaptation of EBPs or the implementation strategies used to get them into routine practice. Recently developed frameworks such as the IDEA and FRAME-IS may be used to guide decision-making and document resulting adaptations themselves. An ongoing funded study is investigating the utility of the resulting adaptations for improving healthcare.
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Affiliation(s)
- Christopher J. Miller
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Jennifer L. Sullivan
- Center of Innovation in Long Term Services and Supports (LTSS COIN), VA Providence Healthcare System Capt. Jonathan H. Harwood Jr. Center for Research, Providence, RI, USA
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, RI, USA
| | - Samantha L. Connolly
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Eric J. Richardson
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Kelly L. Stolzmann
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA
| | - Madisen Brown
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA
| | - Hannah M. Bailey
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA
| | - Kendra Weaver
- U.S. Department of Veterans Affairs Office of Mental Health and Suicide Prevention, Washington, DC, USA
| | - Lauren Sippel
- U.S. Department of Veterans Affairs Office of Mental Health and Suicide Prevention, Washington, DC, USA
- Department of Veterans Affairs Northeast Program Evaluation Center, West Haven, Connecticut, USA
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Bo Kim
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
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11
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McConnell KJ, Edelstein S, Hall J, Levy A, Danna M, Cohen DJ, Unützer J, Zhu JM, Lindner S. Access, Utilization, and Quality of Behavioral Health Integration in Medicaid Managed Care. JAMA HEALTH FORUM 2023; 4:e234593. [PMID: 38153809 PMCID: PMC10755612 DOI: 10.1001/jamahealthforum.2023.4593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 10/25/2023] [Indexed: 12/30/2023] Open
Abstract
Importance Many states have moved from models that carve out to those that carve in or integrate behavioral health in their Medicaid managed care organizations (MCOs), but little evidence exists about the effect of this change. Objective To assess the association of the transition to integrated managed care (IMC) in Washington Medicaid with health services use, quality, health-related outcomes, and measures associated with social determinants of health. Design, Setting, and Participants This cohort study used difference-in-differences analyses of Washington State's 2014 to 2019 staggered rollout of IMC on claims-based measures for enrollees in Washington's Medicaid MCO. It was supplemented with interviews of 24 behavioral health agency leaders, managed care administrators, and individuals who were participating in the IMC transition. The data were analyzed between February 1, 2023, and September 30, 2023. Main Outcomes and Measures Claims-based measures of utilization (including specialty mental health visits and primary care visits); health-related outcomes (including self-harm events); rates of arrests, employment, and homelessness; and additional quality measures. Results This cohort study included 1 454 185 individuals ages 13 to 64 years (743 668 female [51.1%]; 14 306 American Indian and Alaska Native [1.0%], 132 804 Asian American and Pacific Islander [9.1%], 112 442 Black [7.7%], 258 389 Hispanic [17.8%], and 810 304 White [55.7%] individuals). Financial integration was not associated with changes in claims-based measures of utilization and quality. Most claims-based measures of outcomes were also unchanged, although enrollees with mild or moderate mental illness experienced a slight decrease in cardiac events (-0.8%; 95% CI, -1.4 to -0.2), while enrollees with serious mental illness experienced small decreases in employment (-1.2%; 95% CI -1.9 to -0.5) and small increases in arrests (0.5%; 95% CI, 0.1 to 1.0). Interviews with key informants suggested that financial integration was perceived as an administrative change and did not have substantial implications for how practices delivered care; behavioral health agencies lacked guidance on how to integrate care in behavioral health settings and struggled with new contracts and regulatory policies that may have inhibited the ability to provide integrated care. Conclusions and Relevance The results of this cohort study suggest that financial integration at the MCO level was not associated with significant changes in most measures of utilization, quality, outcomes, and social determinants of health. Additional support, including monitoring, training, and funding, may be necessary to drive delivery system changes to improve access, quality, and outcomes.
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Affiliation(s)
- K. John McConnell
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland
| | - Sara Edelstein
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland
| | - Jennifer Hall
- Department of Family Medicine, Oregon Health & Science University, Portland
| | - Anna Levy
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland
| | - Maria Danna
- Department of Family Medicine, Oregon Health & Science University, Portland
| | - Deborah J. Cohen
- Department of Family Medicine, Oregon Health & Science University, Portland
| | - Jürgen Unützer
- Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle
| | - Jane M. Zhu
- Division of General Internal Medicine, Oregon Health & Science University, Portland
| | - Stephan Lindner
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland
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12
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Mavandadi S, Loebach Wetherell J, Barker MD, Steadman-Wood PL, Harrington PJ, Karel MJ. Home-based primary care-mental health integration in the Veterans Health Administration: An updated evaluation of practice patterns. Psychol Serv 2023; 20:723-733. [PMID: 36136832 PMCID: PMC10327407 DOI: 10.1037/ser0000710] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Starting in 2008, the U.S. Veterans Health Administration required the integration of mental health providers (MH providers) in Home-Based Primary Care (HBPC) programs to promote access to and quality of mental health services for veterans enrolled in HBPC. Surveys were administered in both 2010 and 2019 to HBPC program directors and MH providers to evaluate the status of mental health practice in HBPC programs and inform the continued development of program resources. Findings reported here summarize responses to the 2019 survey and highlight changes compared to 2010 in key areas (e.g., mental health staffing and workload, services provided, training needs, and integration with and impact on the HBPC team). In 2019, approximately half of invited HBPC program directors (n = 66) and MH providers (n = 136) completed the voluntary, anonymous, and confidential surveys. Descriptive and bivariate analyses of quantitative data, and thematic analyses of open-text responses, were conducted. Comparisons of survey responses were made between the 2019 surveys and those collected in 2010 from MH providers (n = 132) and program directors (n = 112), and indicated similar patterns of variability in program staffing and practices across sites, with ongoing behavioral/mental health education and training needs reported for both MH providers and teams. The perceived degree and value of mental health integration in HBPC also remained high. Survey responses suggest integration of mental health services into HBPC continues to be feasible and improves access to key services. Findings may inform the expansion of home-based mental health services for meeting the needs of an aging population. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
- Shahrzad Mavandadi
- VISN4 Mental Illness Research, Education, and Clinical Center (MIRECC), CPL Michael J. Crescenz VA Medical Center; Philadelphia, Pennsylvania, USA
- Department of Psychiatry, Perelman School of Medicine; University of Pennsylvania; Philadelphia, Pennsylvania, USA
| | - Julie Loebach Wetherell
- VA San Diego Healthcare System, San Diego, California, USA
- Department of Psychiatry, University of California, San Diego, California, USA
| | - Marie D. Barker
- Charles George VA Medical Center, Asheville, North Carolina, USA
| | - Pamela L. Steadman-Wood
- Providence VA Medical Center, Providence, Rhode Island, USA
- Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | | | - Michele J. Karel
- US Department of Veterans Affairs, Office of Mental Health and Suicide Prevention, Washington, DC, USA
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13
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Mousavizadeh SN, Jandaghian Bidgoli MA. Recovery-Oriented Practices in Community-based Mental Health Services: A Systematic Review. IRANIAN JOURNAL OF PSYCHIATRY 2023; 18:332-351. [PMID: 37575606 PMCID: PMC10422940 DOI: 10.18502/ijps.v18i3.13013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 04/11/2023] [Accepted: 04/18/2023] [Indexed: 08/15/2023]
Abstract
Objective: New initiatives are needed to manage patients with mental health problems in the community. Among the core principal ideals of any healthcare system is transition from traditional services to community-based practices. The aim of this study was to assess community-based and recovery-oriented practices and interventions for individuals with mental health problems. Method : MESH keywords, including "mental health recovery", "rehabilitation", "aftercare", "community psychiatry", and "mental health service" were searched in scientific databases such as Medline, EMBASE, PsychInfo, CINAHL, and Cochrane up to July 2022. A snowball search was also conducted on eligible studies. The methodological quality of the studies was determined by Kmet standard criteria. Results: The systematic review included 32 studies, all of which demonstrated a moderate to high promising effect for community-based and recovery-oriented practices or programs on patients with severe mental illness. These practices could help patients to find suitable jobs, avoid isolation and stigma, improve communication skills, increase awareness of problems, and foster independence. The study also highlighted the pivotal role of nurses, artistic and sports activities, electronic (E)-mental health, home visits, psychoeducation, and special recovery programs. Conclusion: Community-based and recovery-oriented practices should be used as an effective means of normalizing the lives of psychiatric patients. In essence, by cultivating hope and empowering these patients, many of the concerns of health systems can be eradicated.
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Affiliation(s)
- Seyedeh Narjes Mousavizadeh
- Department of Psychiatric Nursing and Management, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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14
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McConnell KJ, Edelstein S, Hall J, Levy A, Danna M, Cohen DJ, Lindner S, Unützer J, Zhu JM. The effects of behavioral health integration in Medicaid managed care on access to mental health and primary care services-Evidence from early adopters. Health Serv Res 2023; 58:622-633. [PMID: 36635871 PMCID: PMC10154169 DOI: 10.1111/1475-6773.14132] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE To evaluate the impacts of a transition to an "integrated managed care" model, wherein Medicaid managed care organizations moved from a "carve-out" model to a "carve-in" model integrating the financing of behavioral and physical health care. DATA SOURCES/STUDY SETTING Medicaid claims data from Washington State, 2014-2019, supplemented with structured interviews with key stakeholders. STUDY DESIGN This mixed-methods study used difference-in-differences models to compare changes in two counties that transitioned to financial integration in 2016 to 10 comparison counties maintaining carve-out models, combined with qualitative analyses of 15 key informant interviews. Quantitative outcomes included binary measures of access to outpatient mental health care, primary care, the emergency department (ED), and inpatient care for mental health conditions. DATA COLLECTION Medicaid claims were collected administratively, and interviews were recorded, transcribed, and analyzed using a thematic analysis approach. PRINCIPAL FINDINGS The transition to financially integrated care was initially disruptive for behavioral health providers and was associated with a temporary decline in access to outpatient mental health services among enrollees with serious mental illness (SMI), but there were no statistically significant or sustained differences after the first year. Enrollees with SMI also experienced a slight increase in access to primary care (1.8%, 95% CI 1.0%-2.6%), but no sustained statistically significant changes in the use of ED or inpatient services for mental health care. The transition to financially integrated care had relatively little impact on primary care providers, with few changes for enrollees with mild, moderate, or no mental illness. CONCLUSIONS Financial integration of behavioral and physical health in Medicaid managed care did not appear to drive clinical transformation and was disruptive to behavioral health providers. States moving towards "carve-in" models may need to incorporate support for practice transformation or financial incentives to achieve the benefits of coordinated mental and physical health care.
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Affiliation(s)
- K. John McConnell
- Center for Health Systems EffectivenessOregon Health & Science UniversityPortlandOregonUnited States
| | - Sara Edelstein
- Center for Health Systems EffectivenessOregon Health & Science UniversityPortlandOregonUnited States
| | - Jennifer Hall
- Department of Family MedicineOregon Health & Science UniversityPortlandOregonUnited States
| | - Anna Levy
- Center for Health Systems EffectivenessOregon Health & Science UniversityPortlandOregonUnited States
| | - Maria Danna
- Department of Family MedicineOregon Health & Science UniversityPortlandOregonUnited States
| | - Deborah J. Cohen
- Department of Family MedicineOregon Health & Science UniversityPortlandOregonUnited States
| | - Stephan Lindner
- Center for Health Systems EffectivenessOregon Health & Science UniversityPortlandOregonUnited States
| | - Jürgen Unützer
- Department of Psychiatry & Behavioral SciencesUniversity of WashingtonSeattleWAUnited States
| | - Jane M. Zhu
- Division of General Internal MedicineOregon Health & Science UniversityPortlandOregonUnited States
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15
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Kilbourne AM, Geng E, Eshun-Wilson I, Sweeney S, Shelley D, Cohen DJ, Kirchner JE, Fernandez ME, Parchman ML. How does facilitation in healthcare work? Using mechanism mapping to illuminate the black box of a meta-implementation strategy. Implement Sci Commun 2023; 4:53. [PMID: 37194084 PMCID: PMC10190070 DOI: 10.1186/s43058-023-00435-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 05/06/2023] [Indexed: 05/18/2023] Open
Abstract
BACKGROUND Healthcare facilitation, an implementation strategy designed to improve the uptake of effective clinical innovations in routine practice, has produced promising yet mixed results in randomized implementation trials and has not been fully researched across different contexts. OBJECTIVE Using mechanism mapping, which applies directed acyclic graphs that decompose an effect of interest into hypothesized causal steps and mechanisms, we propose a more concrete description of how healthcare facilitation works to inform its further study as a meta-implementation strategy. METHODS Using a modified Delphi consensus process, co-authors developed the mechanistic map based on a three-step process. First, they developed an initial logic model by collectively reviewing the literature and identifying the most relevant studies of healthcare facilitation components and mechanisms to date. Second, they applied the logic model to write vignettes describing how facilitation worked (or did not) based on recent empirical trials that were selected via consensus for inclusion and diversity in contextual settings (US, international sites). Finally, the mechanistic map was created based on the collective findings from the vignettes. FINDINGS Theory-based healthcare facilitation components informing the mechanistic map included staff engagement, role clarification, coalition-building through peer experiences and identifying champions, capacity-building through problem solving barriers, and organizational ownership of the implementation process. Across the vignettes, engagement of leaders and practitioners led to increased socialization of the facilitator's role in the organization. This in turn led to clarifying of roles and responsibilities among practitioners and identifying peer experiences led to increased coherence and sense-making of the value of adopting effective innovations. Increased trust develops across leadership and practitioners through expanded capacity in adoption of the effective innovation by identifying opportunities that mitigated barriers to practice change. Finally, these mechanisms led to eventual normalization and ownership of the effective innovation and healthcare facilitation process. IMPACT Mapping methodology provides a novel perspective of mechanisms of healthcare facilitation, notably how sensemaking, trust, and normalization contribute to quality improvement. This method may also enable more efficient and impactful hypothesis-testing and application of complex implementation strategies, with high relevance for lower-resourced settings, to inform effective innovation uptake.
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Affiliation(s)
- Amy M. Kilbourne
- Health Services Research & Development, VA Office of Research and Development, US Department of Veterans Affairs and University of Michigan, 810 Vermont Ave, NW, Washington, D.C., 20420 USA
| | - Elvin Geng
- Washington University at St. Louis, St. Louis, MO USA
| | | | | | - Donna Shelley
- New York University School of Global Public Health, New York, New York USA
| | | | - JoAnn E. Kirchner
- Central Arkansas VA Healthcare System and University of Arkansas for Medical Sciences, North Little Rock, AR USA
| | - Maria E. Fernandez
- University of Texas Health Science Center at Houston, School of Public Health, Houston, TX USA
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16
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Ng LC, Miller AN, Bowers G, Cheng Y, Brigham R, Him Tai M, Smith AM, Mueser KT, Fortuna LR, Coles M. A pragmatic feasibility trial of the Primary Care Intervention for PTSD: A health service delivery model to reduce health disparities for low-income and BIPOC youth. Behav Res Ther 2023; 165:104310. [PMID: 37040669 DOI: 10.1016/j.brat.2023.104310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 02/27/2023] [Accepted: 03/29/2023] [Indexed: 04/09/2023]
Abstract
OBJECTIVE This study is a non-randomized pragmatic trial to assess the feasibility and acceptability of the Primary Care Intervention for Posttraumatic stress disorder (PCIP) (Srivastava et al., 2021), an Integrated Behavioral Health Care treatment for PTSD in adolescents. METHOD Following routine clinic procedures, youth who were suspected of having trauma-related mental health symptoms were referred by their primary care providers to integrated care social workers for evaluation. The integrated care social workers referred the first 23 youth whom they suspected of having PTSD to the research study. Twenty youth consented to the study and 19 completed the pre-assessment (17 female; mean age = 19.32, SD = 2.11; range 14-22 years). More than 40% identified as Black and a third as Hispanic/Latinx. PCIP mechanisms and clinical outcomes were assessed pre- and post-treatment, and at one-month follow-up. Participants and therapists completed post-treatment qualitative interviews to assess feasibility and acceptability, and treatment sessions were audio recorded to assess fidelity. RESULTS Findings suggest high acceptability, satisfaction, and feasibility of the PCIP delivered in "real-life" safety net pediatric primary care. Integrated care social workers had high treatment fidelity. Despite the small sample size, there was significant improvement in symptom scores of anxiety (g = 0.68, p = 0.02) and substance use (g = 0.36, p = 0.04) from pre to post, and depression symptoms (g = 0.38, p = 0.04) from pre to follow-up. Qualitative data from patients who completed exit interviews and integrated social workers indicated high satisfaction with the treatment, with some participants reporting that the integrated intervention was more acceptable and less stigmatizing than seeking mental health care outside of primary care. CONCLUSIONS The PCIP may improve treatment engagement and access for vulnerable youth. Promising findings of high acceptability, feasibility, and initial clinical effectiveness suggest that PCIP warrants larger-scale study as part of routine care in pediatric integrated care.
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17
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Murphy KA, Daumit GL. Establishing a Care Continuum for Cardiometabolic Conditions for Patients with Serious Mental Illness. Curr Cardiol Rep 2023; 25:193-202. [PMID: 36847991 PMCID: PMC10042919 DOI: 10.1007/s11886-023-01848-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/03/2023] [Indexed: 03/01/2023]
Abstract
PURPOSE OF REVIEW Addressing cardiometabolic risk factors in persons with serious mental illness requires early screening and proactive medical management in both medical and mental health settings. RECENT FINDINGS Cardiovascular disease remains the leading cause of death for persons with serious mental illness (SMI), such as schizophrenia or bipolar disorder, much of which is driven by a high prevalence of metabolic syndrome, diabetes, and tobacco use. We summarize barriers and recent approaches to screening and treatment for metabolic cardiovascular risk factors within physical health and specialty mental health settings. Incorporating system-based and provider-level support within physical health and psychiatric clinical settings should contribute to improvement for screening, diagnosis, and treatment for cardiometabolic conditions for patients with SMI. Targeted education for clinicians and leveraging multi-disciplinary teams are important first steps to recognize and treat populations with SMI at risk of CVD.
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Affiliation(s)
- Karly A. Murphy
- Division of General Internal Medicine, University of California San Francisco School of Medicine, 1701 Divisidero Street, Suite 500, 94117 San Francisco, CA USA
| | - Gail L. Daumit
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD USA
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18
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Kim B, Sullivan JL, Drummond KL, Connolly SL, Miller CJ, Weaver K, Bauer MS. Interdisciplinary behavioral health provider perceptions of implementing the Collaborative Chronic Care Model: an i-PARIHS-guided qualitative study. Implement Sci Commun 2023; 4:35. [PMID: 36998010 DOI: 10.1186/s43058-023-00407-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 03/04/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND The evidence-based Collaborative Chronic Care Model (CCM), developed to help structure care for chronic health conditions, comprises six elements: work role redesign, patient self-management support, provider decision support, clinical information systems, linkages to community resources, and organizational/leadership support. As the CCM is increasingly implemented in real-world settings, there is heightened interest in understanding specific influences upon implementation. Therefore, guided by the Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework, we (i) identified innovation-, recipient-, context-, and facilitation-related influences on CCM implementation and (ii) assessed the influences' relationship to each CCM element's implementation. METHODS Using semi-structured interviews, we examined interdisciplinary behavioral health providers' experiences at nine VA medical centers that implemented the CCM. We used i-PARIHS constructs as a priori codes for directed content analysis, then analyzed the data for cross-coding by CCM element and i-PARIHS construct. RESULTS Participants (31 providers) perceived the CCM innovation as enabling comprehensive care but challenging to coordinate with existing structures/procedures. As recipients, participants recounted not always having the authority to design CCM-consistent care processes. They perceived local leadership support to be indispensable to implementation success and difficult to garner when CCM implementation distracted from other organizational priorities. They found implementation facilitation helpful for keeping implementation on track. We identified key themes at the intersection of i-PARIHS constructs and core CCM elements, including (i) the CCM being an innovation that offers a formal structure to stepping down care intensity for patients to encourage their self-management, (ii) recipients accessing their multidisciplinary colleagues' expertise for provider decision support, (iii) relationships with external services in the community (e.g., homelessness programs) being a helpful context for providing comprehensive care, and (iv) facilitators helping to redesign specific interdisciplinary team member roles. CONCLUSIONS Future CCM implementation would benefit from (i) facilitating strategic development of supportive maintenance plans for patients' self-management, (ii) collocating multidisciplinary staff (on-site or virtually) to enhance provider decision support, (iii) keeping information on available community resources up to date, and (iv) making clearer the explicit CCM-consistent care processes that work roles can be designed around. This work can inform concrete tailoring of implementation efforts to focus on the more challenging CCM elements, which is crucial to better account for multiple influences that vary across diverse care settings in which the CCM is being implemented.
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Affiliation(s)
- Bo Kim
- VA Boston Healthcare System, 150 South Huntington Avenue, Boston, MA, 02130, USA.
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA.
| | - Jennifer L Sullivan
- VA Providence Healthcare System, 385 Niagara Street, Providence, RI, 02907, USA
- Brown University School of Public Health, 121 South Main Street, Providence, RI, 02903, USA
| | - Karen L Drummond
- Central Arkansas Veterans Healthcare System, 4300 West 7th Street, Little Rock, AR, 72205, USA
- University of Arkansas for Medical Sciences, 4301 West Markham Street, Little Rock, AR, 72205, USA
| | - Samantha L Connolly
- VA Boston Healthcare System, 150 South Huntington Avenue, Boston, MA, 02130, USA
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA
| | - Christopher J Miller
- VA Boston Healthcare System, 150 South Huntington Avenue, Boston, MA, 02130, USA
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA
| | - Kendra Weaver
- VA Office of Mental Health and Suicide Prevention, 810 Vermont Avenue NW, Washington, DC, 20420, USA
| | - Mark S Bauer
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA
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19
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Fu E, Carroll AJ, Rosenthal LJ, Rado J, Burnett-Zeigler I, Jordan N, Carlo AD, Ekwonu A, Kust A, Brown CH, Csernansky JG, Smith JD. Implementation Barriers and Experiences of Eligible Patients Who Failed to Enroll in Collaborative Care for Depression and Anxiety. J Gen Intern Med 2023; 38:366-374. [PMID: 35931910 PMCID: PMC9362538 DOI: 10.1007/s11606-022-07750-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 07/20/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND Effective and efficient implementation of the Collaborative Care Model (CoCM) for depression and anxiety is imperative for program success. Studies examining barriers to implementation often omit patient perspectives. OBJECTIVES To explore experiences and attitudes of eligible patients referred to CoCM who declined participation or were unable to be reached, and identify implementation barriers to inform strategies. DESIGN Convergent mixed-methods study with a survey and interview. PARTICIPANTS Primary care patients at an academic medical center who were referred to a CoCM program for anxiety and depression by their primary care clinician (PCC) but declined participation or were unable to be reached by the behavioral health care manager to initiate care (n = 80). Interviews were conducted with 45 survey respondents. MAIN MEASURES Survey of patients' referral experiences and behavioral health preferences as they related to failing to enroll in the program. Interview questions were developed using the Consolidated Framework for Implementation Research version 2.0 (CFIR 2.0) to identify implementation barriers to enrollment. KEY RESULTS Survey results found that patients were uncertain about insurance coverage, did not understand the program, and felt services were not necessary. Referred patients who declined participation were concerned about how their mental health information would be used and preferred treatment without medication. Men agreed more that they did not need services. Qualitative results exhibited a variety of implementation determinants (n = 23) across the five CFIR 2.0 domains. Barriers included mental health stigma, perceiving behavioral health as outside of primary care practice guidelines, short or infrequent primary care appointments, prioritizing physical health over mental health, receiving inaccurate program information, low motivation to engage, and a less established relationship with their PCC. CONCLUSIONS Multiple barriers to enrollment led to failing to link patients to care, which can inform implementation strategies to address the patient-reported experiences and concerns.
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Affiliation(s)
- Emily Fu
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Allison J Carroll
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Lisa J Rosenthal
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Northwestern Medicine, Chicago, IL, USA
| | - Jeffrey Rado
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Northwestern Medicine, Chicago, IL, USA
| | - Inger Burnett-Zeigler
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Neil Jordan
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, Hines, IL, USA
| | - Andrew D Carlo
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Adaora Ekwonu
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Ariella Kust
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - C Hendricks Brown
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - John G Csernansky
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Justin D Smith
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
- Department of Population Health Sciences, Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, UT, USA.
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Miller CJ, Kim B, Connolly SL, Spitzer EG, Brown M, Bailey HM, Weaver K, Sullivan JL. Sustainability of the Collaborative Chronic Care Model in Outpatient Mental Health Teams Three Years Post-Implementation: A Qualitative Analysis. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2023; 50:151-159. [PMID: 36329294 PMCID: PMC9633036 DOI: 10.1007/s10488-022-01231-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2022] [Indexed: 11/06/2022]
Abstract
Our goal was to investigate the sustainability of care practices that are consistent with the collaborative chronic care model (CCM) in nine outpatient mental health teams located within US Department of Veterans Affairs (VA) medical centers, three to four years after the completion of CCM implementation. We conducted qualitative interviews (N = 30) with outpatient mental health staff from each of the nine teams. We based our directed content analysis on the six elements of the CCM. We found variable sustainability of CCM-based care processes across sites. Some care processes, such as delivery of evidence-based psychotherapies (EBPs) and use of measurement-based care (MBC) to guide clinic decision-making, were robustly maintained or even expanded within participating teams. In contrast, other care processes-which had in some cases been developed with considerable effort-had not been sustained. For example, care manager roles were diminished in scope or eliminated completely in response to workload pressures, frontline care needs, or the COVID-19 pandemic. Similarly, processes for engaging Veterans more fully in decision-making had generally been scaled back. Leadership support in the form of adequate team staffing and time to conduct team meetings were seen as crucial for sustaining CCM-consistent care. Given the potential impact of leadership turnover on sustainability in mental health, future efforts to implement CCM-based mental health care should strive to involve multiple leaders in implementation and sustainment efforts, lest one key departure undo years of implementation work. Our results also suggest that implementing CCM processes may best be conceptualized as a partnership across multiple levels of medical center leadership.
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Affiliation(s)
- Christopher J. Miller
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 S. Huntington Ave (152M), Boston, MA USA ,Department of Psychiatry, Harvard Medical School, 25 Shattuck St., Boston, MA USA
| | - Bo Kim
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 S. Huntington Ave (152M), Boston, MA USA ,Department of Psychiatry, Harvard Medical School, 25 Shattuck St., Boston, MA USA
| | - Samantha L. Connolly
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 S. Huntington Ave (152M), Boston, MA USA ,Department of Psychiatry, Harvard Medical School, 25 Shattuck St., Boston, MA USA
| | - Elizabeth G. Spitzer
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 S. Huntington Ave (152M), Boston, MA USA ,Department of Psychiatry, Harvard Medical School, 25 Shattuck St., Boston, MA USA
| | - Madisen Brown
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 S. Huntington Ave (152M), Boston, MA USA
| | - Hannah M. Bailey
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 S. Huntington Ave (152M), Boston, MA USA
| | - Kendra Weaver
- Department of Veterans Affairs Office of Mental Health & Suicide Prevention, 810 Vermont Ave NW, Washington, DC USA
| | - Jennifer L. Sullivan
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 S. Huntington Ave (152M), Boston, MA USA ,Department of Health Law, Policy and Management, Boston University School of Public Health, 715 Albany St, Talbot Building, Boston, MA USA
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21
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Nair P, Walters K, Aw S, Gould R, Kharicha K, Buszewicz MC, Frost R. Self-management of depression and anxiety amongst frail older adults in the United Kingdom: A qualitative study. PLoS One 2022; 17:e0264603. [PMID: 36477180 PMCID: PMC9728861 DOI: 10.1371/journal.pone.0264603] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 11/19/2022] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Depression and anxiety are common in frail older people and are associated with high levels of morbidity and mortality, yet they typically face greater barriers to accessing mental health treatments than younger people and express preferences for self-managing their symptoms. This study aims to explore frail older adults' experiences of self-managing symptoms of depression and/or anxiety. DESIGN Qualitative semi-structured interviews, exploring experiences of depression and/or anxiety, ways participants self-managed these and the contexts within which this took place. Interviews were audio-recorded and transcribed verbatim. PARTICIPANTS 28 frail older adults in the United Kingdom, purposively sampled for neighbourhood, frailty and symptoms of anxiety/depression. ANALYSIS Thematic analysis to inductively derive themes from the data. RESULTS Our findings suggest that frail older adults find maintaining independence, engaging in meaningful activities, and socialising and peer support important for self-managing depression and anxiety. These could all be adapted to the level of frailty experienced. Drawing on life experiences, addressing the perceived cause and faith were helpful in some situations and for some personalities. Distraction and avoidance were helpful for more severe symptoms or where the causes of symptoms could not be resolved. Self-management strategies were less well-established for anxiety symptoms, especially when linked to newer health fears and worries about the future. CONCLUSIONS Developing services and sources of information that support and facilitate key therapeutic components of self-management, which align with older adults' preferred coping styles and take into account levels of frailty, may be a way of supporting frail older people waiting for mental health treatments or those who prefer not to access these. Greater awareness of anxiety and how it can be self-managed in frail older people is needed.
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Affiliation(s)
- Pushpa Nair
- Department of Primary Care and Population Health, University College London Medical School (Royal Free Campus), London, United Kingdom
| | - Kate Walters
- Department of Primary Care and Population Health, University College London Medical School (Royal Free Campus), London, United Kingdom
| | - Su Aw
- National University of Singapore, Saw Swee Hock of Public Health, Singapore, Singapore
| | - Rebecca Gould
- Division of Psychiatry, University College London, London, United Kingdom
| | - Kalpa Kharicha
- NIHR Health & Social care Workforce Research Unit, The Policy Institute, King’s College London, London, United Kingdom
| | - Marta College Buszewicz
- Department of Primary Care and Population Health, University College London Medical School (Royal Free Campus), London, United Kingdom
| | - Rachael Frost
- Department of Primary Care and Population Health, University College London Medical School (Royal Free Campus), London, United Kingdom
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22
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Morgan ER, Rivara FP, Ta M, Grossman DC, Jones K, Rowhani-Rahbar A. Incarceration and subsequent risk of suicide: A statewide cohort study. Suicide Life Threat Behav 2022; 52:467-477. [PMID: 35092087 DOI: 10.1111/sltb.12834] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 10/26/2021] [Accepted: 11/22/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Increasing suicide rates across the United States are disproportionate among populations most impacted by mass incarceration. We sought to determine if incarceration is associated with risk of suicide and firearm suicide after release from prison. METHODS Using a population-based Washington cohort from Department of Corrections and vital statistics administrative records 1990-2017, individuals were compared to the sex-, age-, and race-matched population of Washington using Poisson regression. Among previously incarcerated individuals, we included incarceration history characteristics to calculate sub-hazard ratios using Cox proportional-hazards models. RESULTS Of 140,281 individuals released from prison, 484 died by suicide. Suicide risk was 62% higher among previously incarcerated individuals compared with the general population (RR: 1.62; 95% CI: 1.46-1.79). Suicide risk was higher among individuals convicted of firearm-involved crimes (RR: 2.27; 95% CI: 1.79-2.89). Individuals released prior to age 18 had substantially higher risk of firearm suicide than those whose first release occurred between ages 18-24 (sHR: 11.91; 95% CI: 4.30-32.96). CONCLUSION Our findings highlight the need for improved mental health resources and lethal means safety in this population. Mental health and substance use treatment have been proposed as effective alternatives to incarceration-continuing to study their impacts may reveal additional benefits of reducing suicide.
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Affiliation(s)
- Erin Renee Morgan
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington, USA.,Firearm Injury and Policy Research Program, Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington, USA
| | - Frederick P Rivara
- Firearm Injury and Policy Research Program, Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington, USA.,Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington, USA
| | - Myduc Ta
- Assessment, Policy Development and Evaluation Unit, Public Health - Seattle & King County, Seattle, Washington, USA
| | - David C Grossman
- Kaiser Permanente Health Research Institute, Kaiser Permanente Washington, Seattle, Washington, USA.,Department of Health Services, School of Public Health, University of Washington, Seattle, Washington, USA
| | - Karl Jones
- Washington State Department of Corrections, Tumwater, Washington, USA
| | - Ali Rowhani-Rahbar
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington, USA.,Firearm Injury and Policy Research Program, Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington, USA
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23
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Griauzde DH, Othman A, Dallas C, Oshman L, Gabison J, Markel DS, Richardson CR, Kullgren JT, Piatt G, Heisler M, Kilbourne AM, Kraftson A. Developing weight navigation program to support personalized and effective obesity management in primary care settings: protocol for a quality improvement program with an embedded single-arm pilot study. Prim Health Care Res Dev 2022; 23:e14. [PMID: 35234116 PMCID: PMC8919179 DOI: 10.1017/s1463423621000906] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 11/03/2021] [Accepted: 11/29/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Primary care providers (PCPs) are expected to help patients with obesity to lose weight through behavior change counseling and patient-centered use of available weight management resources. Yet, many PCPs face knowledge gaps and clinical time constraints that hinder their ability to successfully support patients' weight loss. Fortunately, a small and growing number of physicians are now certified in obesity medicine through the American Board of Obesity Medicine (ABOM) and can provide personalized and effective obesity treatment to individual patients. Little is known, however, about how to extend the expertise of ABOM-certified physicians to support PCPs and their many patients with obesity. AIM To develop and pilot test an innovative care model - the Weight Navigation Program (WNP) - to integrate ABOM-certified physicians into primary care settings and to enhance the delivery of personalized, effective obesity care. METHODS Quality improvement program with an embedded, 12-month, single-arm pilot study. Patients with obesity and ≥1 weight-related co-morbidity may be referred to the WNP by PCPs. All patients seen within the WNP during the first 12 months of clinical operations will be compared to a matched cohort of patients from another primary care site. We will recruit a subset of WNP patients (n = 30) to participate in a remote weight monitoring pilot program, which will include surveys at 0, 6, and 12 months, qualitative interviews at 0 and 6 months, and use of an electronic health record (EHR)-based text messaging program for remote weight monitoring. DISCUSSION Obesity is a complex chronic condition that requires evidence-based, personalized, and longitudinal care. To deliver such care in general practice, the WNP leverages the expertise of ABOM-certified physicians, health system and community weight management resources, and EHR-based population health management tools. The WNP is an innovative model with the potential to be implemented, scaled, and sustained in diverse primary care settings.
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Affiliation(s)
- Dina H. Griauzde
- VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan, Medical School, Ann Arbor, MI, USA
- University of Michigan, Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
| | - Amal Othman
- Department of Family Medicine, University of Michigan, Medical School, Ann Arbor, MI, USA
| | - Chris Dallas
- Department of Internal Medicine, University of Michigan, Medical School, Ann Arbor, MI, USA
| | - Lauren Oshman
- Department of Family Medicine, University of Michigan, Medical School, Ann Arbor, MI, USA
| | - Jonathan Gabison
- Department of Family Medicine, University of Michigan, Medical School, Ann Arbor, MI, USA
| | - Dorene S. Markel
- Department of Learning Health Sciences, University of Michigan, Medical School, Ann Arbor, MI, USA
| | - Caroline R. Richardson
- University of Michigan, Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
- Department of Family Medicine, University of Michigan, Medical School, Ann Arbor, MI, USA
| | - Jeffrey T. Kullgren
- VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan, Medical School, Ann Arbor, MI, USA
- University of Michigan, Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
- Department of Health Management and Policy, University of Michigan, School of Public Health, Ann Arbor, MI, USA
| | - Gretchen Piatt
- Department of Learning Health Sciences, University of Michigan, Medical School, Ann Arbor, MI, USA
- Department of Health Behavior and Health Education, University of Michigan, School of Public Health, Ann Arbor, MI, USA
| | - Michele Heisler
- VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan, Medical School, Ann Arbor, MI, USA
- University of Michigan, Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
| | - Amy M. Kilbourne
- VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- University of Michigan, Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
- Department of Learning Health Sciences, University of Michigan, Medical School, Ann Arbor, MI, USA
| | - Andrew Kraftson
- Department of Internal Medicine, University of Michigan, Medical School, Ann Arbor, MI, USA
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24
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Meredith LS, Wong E, Osilla KC, Sanders M, Tebeka MG, Han B, Williamson SL, Carton TW. Trauma-informed Collaborative Care for African American Primary Care Patients in Federally Qualified Health Centers: A Pilot Randomized Trial. Med Care 2022; 60:232-239. [PMID: 35157622 PMCID: PMC8867914 DOI: 10.1097/mlr.0000000000001681] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND African Americans have nearly double the rate of posttraumatic stress disorder (PTSD) compared with other racial/ethnic groups. OBJECTIVE To understand whether trauma-informed collaborative care (TICC) is effective for improving PTSD among African Americans in New Orleans who receive their care in Federally Qualified Health Centers (FQHCs). DESIGN AND METHOD In this pilot randomized controlled trial, we assigned patients within a single site to either TICC or to enhanced usual care (EUC). We performed intent to treat analysis by nonparametric exact tests for small sample sizes. PARTICIPANTS We enrolled 42 patients from October 12, 2018, through July 2, 2019. Patients were eligible if they considered the clinic their usual source of care, had no obvious physical or cognitive obstacles that would prevent participation, were age 18 or over, self-identified as African American, and had a provisional diagnosis of PTSD. MEASURES Our primary outcome measures were PTSD measured as both a symptom score and a provisional diagnosis based on the PTSD Checklist for DSM-5 (PCL-5). KEY RESULTS Nine months following baseline, both PTSD symptom scores and provisional PTSD diagnosis rates decreased substantially more for patients in TICC than in EUC. The decreases were by 26 points in EUC and 36 points in TICC for symptoms (P=0.08) and 33% in EUC and 57% in TICC for diagnosis rates (P=0.27). We found no effects for mediator variables. CONCLUSIONS TICC shows promise for addressing PTSD in this population. A larger-scale trial is needed to fully assess the effectiveness of this approach in these settings.
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Affiliation(s)
- Lisa S. Meredith
- RAND Corporation, 1776 Main Street, Santa Monica, CA, USA
- VA HSR&D Center for Healthcare Innovation, Implementation & Policy, 16111 Plummer St, North Hills, CA, USA
| | - Eunice Wong
- RAND Corporation, 1776 Main Street, Santa Monica, CA, USA
| | | | - Margaret Sanders
- Louisiana Public Health Institute, 1515 Poydras Street, Suite 1200, New Orleans, LA, USA
| | | | - Bing Han
- RAND Corporation, 1776 Main Street, Santa Monica, CA, USA
| | | | - Thomas W. Carton
- Louisiana Public Health Institute, 1515 Poydras Street, Suite 1200, New Orleans, LA, USA
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25
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Campbell DG, Lombardero A, English I, Waltz TJ, Hoggatt KJ, Simon BF, Lanto AB, Simon A, Rubenstein LV, Chaney EF. Depression complexity prevalence and outcomes among veterans affairs patients in integrated primary care. FAMILIES, SYSTEMS & HEALTH : THE JOURNAL OF COLLABORATIVE FAMILY HEALTHCARE 2022; 40:35-45. [PMID: 34735212 PMCID: PMC8940635 DOI: 10.1037/fsh0000637] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
INTRODUCTION The Veterans Health Administration (VA) Primary Care-Mental Health Integration (PC-MHI) initiative targets depression (MDD), anxiety/posttraumatic stress disorder (PTSD) and alcohol misuse (AM) for care improvement. In primary care, case finding often relies on depression screening. Whereas clinical practice guidelines solely inform management of depression, minimal information exists to guide treatment when psychiatric symptom clusters coexist. We provide descriptive clinical information for care planners about VA PC patients with depression alone, depression plus alcohol misuse, and depression with complex psychiatric comorbidities (PTSD and/or probable bipolar disorder). METHOD We examined data from a VA study that used a visit-based sampling procedure to screen 10,929 VA PC patients for depression; 761 patients with probable major depression completed baseline measures of health and care engagement. Follow-up assessments were completed at 7 months. RESULTS At baseline, 53% of patients evidenced mental health conditions in addition to depression; 10% had concurrent AM, and 43% had psychiatrically complex depression (either with or without AM). Compared with patients with depression alone or depression with AM, those with psychiatrically complex depression evinced longer standing and more severe mood disturbance, higher likelihood of suicidal ideation, higher unemployment, and higher levels of polypharmacy. Baseline depression complexity predicted worse mental health status and functioning at follow-up. DISCUSSION A substantial proportion of VA primary care patients with depression presented with high medical multimorbidity and elevated safety concerns. Psychiatrically complex depression predicted lower treatment effectiveness, suggesting that PC-MHI interventions should co-ordinate and individualize care for these patients. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
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Affiliation(s)
| | - Anayansi Lombardero
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Nevada, Reno
| | | | | | - Katherine J. Hoggatt
- VA Health Services Research & Development (HSR&D), Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System
| | - Barbara F. Simon
- VA Health Services Research & Development (HSR&D), Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System
| | - Andrew B. Lanto
- VA Health Services Research & Development (HSR&D), Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System
| | - Alissa Simon
- VA Health Services Research & Development (HSR&D), Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System
| | - Lisa V. Rubenstein
- VA Health Services Research & Development (HSR&D), Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System
- University of California, Los Angeles School of Medicine, Division of General Internal Medicine and Health Services Research, Los Angeles, California
- RAND Health Program, RAND Corporation, Santa Monica, California
| | - Edmund F. Chaney
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington
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Kolko DJ, McGuier EA, Turchi R, Thompson E, Iyengar S, Smith SN, Hoagwood K, Liebrecht C, Bennett IM, Powell BJ, Kelleher K, Silva M, Kilbourne AM. Care team and practice-level implementation strategies to optimize pediatric collaborative care: study protocol for a cluster-randomized hybrid type III trial. Implement Sci 2022; 17:20. [PMID: 35193619 PMCID: PMC8862323 DOI: 10.1186/s13012-022-01195-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 01/31/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Implementation facilitation is an effective strategy to support the implementation of evidence-based practices (EBPs), but our understanding of multilevel strategies and the mechanisms of change within the "black box" of implementation facilitation is limited. This implementation trial seeks to disentangle and evaluate the effects of facilitation strategies that separately target the care team and leadership levels on implementation of a collaborative care model in pediatric primary care. Strategies targeting the provider care team (TEAM) should engage team-level mechanisms, and strategies targeting leaders (LEAD) should engage organizational mechanisms. METHODS We will conduct a hybrid type 3 effectiveness-implementation trial in a 2 × 2 factorial design to evaluate the main and interactive effects of TEAM and LEAD and test for mediation and moderation of effects. Twenty-four pediatric primary care practices will receive standard REP training to implement Doctor-Office Collaborative Care (DOCC) and then be randomized to (1) Standard REP only, (2) TEAM, (3) LEAD, or (4) TEAM + LEAD. Implementation outcomes are DOCC service delivery and change in practice-level care management competencies. Clinical outcomes are child symptom severity and quality of life. DISCUSSION This statewide trial is one of the first to test the unique and synergistic effects of implementation strategies targeting care teams and practice leadership. It will advance our knowledge of effective care team and practice-level implementation strategies and mechanisms of change. Findings will support efforts to improve common child behavioral health conditions by optimizing scale-up and sustainment of CCMs in a pediatric patient-centered medical home. TRIAL REGISTRATION ClinicalTrials.gov, NCT04946253 . Registered June 30, 2021.
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Affiliation(s)
- David J Kolko
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Elizabeth A McGuier
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Renee Turchi
- Department of Pediatrics, Drexel University College of Medicine and St. Christopher's Hospital for Children, Philadelphia, PA, USA
| | - Eileen Thompson
- PA Medical Home Program, PA Chapter, American Academy of Pediatrics, Media, PA, USA
| | - Satish Iyengar
- Department of Statistics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Shawna N Smith
- Department of Health Management & Policy, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Kimberly Hoagwood
- Department of Child and Adolescent Psychiatry, New York University Langone Health, New York, NY, USA
| | - Celeste Liebrecht
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Ian M Bennett
- Departments of Family Medicine and Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - Byron J Powell
- Center for Mental Health Services Research, Brown School, Washington University in St. Louis, One Brookings Drive, St. Louis, MO, 63130, USA
- Division of Infectious Diseases, John T. Milliken Department of Medicine, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Kelly Kelleher
- Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, OH, USA
- Nationwide Children's Hospital Research Institute, Columbus, OH, USA
| | - Maria Silva
- Allegheny Family Network, Pittsburgh, PA, USA
| | - Amy M Kilbourne
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
- VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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Stolzmann K, Lew RA, Miller CJ, Kim B, Wu H, Bauer MS. Does balancing site characteristics result in balanced population characteristics in a cluster-randomized controlled trial? HEALTH SERVICES AND OUTCOMES RESEARCH METHODOLOGY 2022. [DOI: 10.1007/s10742-022-00271-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Kim B, Miller CJ, Ritchie MJ, Smith JL, Kirchner JE, Stolzmann K, Connolly SL, Drummond KL, Bauer MS. Time-motion analysis of external facilitation for implementing the Collaborative Chronic Care Model in general mental health clinics: Use of an interval-based data collection approach. IMPLEMENTATION RESEARCH AND PRACTICE 2022; 3:26334895221086275. [PMID: 37091094 PMCID: PMC9924237 DOI: 10.1177/26334895221086275] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Facilitation is an effective strategy to implement evidence-based practices, often involving external facilitators (EFs) bringing content expertise to implementation sites. Estimating time spent on multifaceted EF activities is complex. Furthermore, collecting continuous time-motion data for facilitation tasks is challenging. However, organizations need this information to allocate implementation resources to sites. Thus, our objectives were to conduct a time-motion analysis of external facilitation, and compare continuous versus noncontinuous approaches to collecting time-motion data. Methods: We analyzed EF time-motion data from six VA mental health clinics implementing the evidence-based Collaborative Chronic Care Model (CCM). We documented EF activities during pre-implementation (4-6 weeks) and implementation (12 months) phases. We collected continuous data during the pre-implementation phase, followed by data collection over a 2-week period (henceforth, "a two-week interval") at each of three time points (beginning/middle/end) during the implementation phase. As a validity check, we assessed how closely interval data represented continuous data collected throughout implementation for two of the sites. Results: EFs spent 21.8 ± 4.5 h/site during pre-implementation off-site, then 27.5 ± 4.6 h/site site-visiting to initiate implementation. Based on the 2-week interval data, EFs spent 2.5 ± 0.8, 1.4 ± 0.6, and 1.2 ± 0.6 h/week toward the implementation's beginning, middle, and end, respectively. Prevalent activities were preparation/planning, process monitoring, program adaptation, problem identification, and problem-solving. Across all activities, 73.6% of EF time involved email, phone, or video communication. For the two continuous data sites, computed weekly time averages toward the implementation's beginning, middle, and end differed from the interval data's averages by 1.0, 0.1, and 0.2 h, respectively. Activities inconsistently captured in the interval data included irregular assessment, stakeholder engagement, and network development. Conclusions: Time-motion analysis of CCM implementation showed initial higher-intensity EF involvement that tapered. The 2-week interval data collection approach, if accounting for its potential underestimation of irregular activities, may be promising/efficient for implementation studies collecting time-motion data.
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Affiliation(s)
- Bo Kim
- Center for Healthcare Organization and
Implementation Research, VA Boston Healthcare System, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA,
USA
| | - Christopher J. Miller
- Center for Healthcare Organization and
Implementation Research, VA Boston Healthcare System, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA,
USA
| | - Mona J. Ritchie
- VA Behavioral Health Quality Enhancement
Research Initiative (QUERI), Central Arkansas Veterans Healthcare
System, North Little Rock, AR, USA
- Department of Psychiatry, University of Arkansas for Medical
Sciences, Little Rock, AR, USA
| | - Jeffrey L. Smith
- VA Behavioral Health Quality Enhancement
Research Initiative (QUERI), Central Arkansas Veterans Healthcare
System, North Little Rock, AR, USA
- Department of Psychiatry, University of Arkansas for Medical
Sciences, Little Rock, AR, USA
| | - JoAnn E. Kirchner
- VA Behavioral Health Quality Enhancement
Research Initiative (QUERI), Central Arkansas Veterans Healthcare
System, North Little Rock, AR, USA
- Department of Psychiatry, University of Arkansas for Medical
Sciences, Little Rock, AR, USA
| | - Kelly Stolzmann
- Center for Healthcare Organization and
Implementation Research, VA Boston Healthcare System, Boston, MA, USA
| | - Samantha L. Connolly
- Center for Healthcare Organization and
Implementation Research, VA Boston Healthcare System, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA,
USA
| | - Karen L. Drummond
- VA Behavioral Health Quality Enhancement
Research Initiative (QUERI), Central Arkansas Veterans Healthcare
System, North Little Rock, AR, USA
- Department of Psychiatry, University of Arkansas for Medical
Sciences, Little Rock, AR, USA
| | - Mark S. Bauer
- Department of Psychiatry, Harvard Medical School, Boston, MA,
USA
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Prom MC, Denduluri A, Philpotts LL, Rondon MB, Borba CPC, Gelaye B, Byatt N. A Systematic Review of Interventions That Integrate Perinatal Mental Health Care Into Routine Maternal Care in Low- and Middle-Income Countries. Front Psychiatry 2022; 13:859341. [PMID: 35360136 PMCID: PMC8964099 DOI: 10.3389/fpsyt.2022.859341] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 02/17/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Women in low- and middle-income countries (LMICs) are disproportionally affected by perinatal depression and anxiety and lack access to mental health care. Integrating perinatal mental health care into routine maternal care is recommended to address gaps in access to mental health care in such under-resourced settings. Understanding the effectiveness of interventions that integrate perinatal mental health care into routine maternal care in LMICs is critical to inform ongoing intervention development, implementation, and scale-up. This systematic review aims to assess the effectiveness of interventions that integrate perinatal mental health care into routine maternal care to improve maternal mental health and infant health outcomes in LMICs. METHOD In accordance with the PRISMA guidelines, an electronic database search was conducted seeking publications of controlled trials examining interventions that aimed to integrate perinatal mental health care into routine maternal care in LMICs. Abstracts and full text articles were independently reviewed by two authors for inclusion utilizing Covidence Review Software. Data was extracted and narrative synthesis was conducted. FINDINGS Twenty studies met eligibility criteria from the initial search results of 2,382 unique citations. There was substantial heterogeneity between the study samples, intervention designs, and outcome assessments. Less than half of the studies focused on women with active depression or anxiety. Most studies (85%) implemented single intervention designs involving psychological, psychosocial, psychoeducational, or adjuvant emotion/stress management. There were few interventions utilizing multicomponent approaches, pharmacotherapy, or referral to mental health specialists. Outcome measures and assessment timing were highly variable. Eighteen studies demonstrated significantly greater improvement on depression and/or anxiety measures in the intervention group(s) as compared to control. CONCLUSION Integrated interventions can be effective in LMICs. The findings provide a critical understanding of current interventions design gaps. This includes the lack of comprehensive intervention designs that incorporate increasing intensity of treatment for more severe illness, pharmacotherapy, mental health specialist referrals, and non-mental health professional training and supervision. The findings also provide strategies to overcome design and implementation barriers in LMICs. Study findings provide a foundation for future evidence-based adaptation, implementation, and scale-up of interventions that integrate perinatal mental health care into routine maternal care in LMICs. SYSTEMATIC REVIEW REGISTRATION [https://www.crd.york.ac.uk/prospero/display_ record.php?ID=CRD42021259092], identifier [CRD42021259092].
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Affiliation(s)
- Maria C Prom
- Chester M. Pierce Division of Global Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Amrutha Denduluri
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Lisa L Philpotts
- Treadwell Library, Massachusetts General Hospital, Boston, MA, United States
| | - Marta B Rondon
- Department of Psychiatry, Instituto Nacional Materno Perinatal, Lima, Peru
| | - Christina P C Borba
- Department of Psychiatry, Global and Local Center for Mental Health Disparities, Boston Medical Center, Boston University School of Medicine, Boston, MA, United States
| | - Bizu Gelaye
- Chester M. Pierce Division of Global Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Nancy Byatt
- Department of Psychiatry, University of Massachusetts Chan Medical School, UMass Memorial Health Care, Worcester, MA, United States
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30
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Goldman ML, Smali E, Richkin T, Pincus HA, Chung H. Implementation of Behavioral Health Integration in Small Primary Care Settings: Lessons Learned and Future Directions. Community Ment Health J 2022; 58:136-144. [PMID: 33638059 DOI: 10.1007/s10597-021-00802-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 02/12/2021] [Indexed: 11/29/2022]
Abstract
Primary care practices are in great need of practical guidance on the steps they can take to build behavioral health integration (BHI) capacities, particularly for smaller practice settings with fewer resources. 11 small primary care sites (≤ 5 providers) throughout New York State utilized a continuum framework of core components of BHI in combination with technical assistance. Surveys were collected at baseline, 6-months, and 12-months. Semi-structured interviews and focus groups were conducted during site visits, and a stakeholder roundtable was facilitated to address broader themes. Data were analyzed using qualitative thematic analysis. Practices reported successful engagement with the framework and actively participated in planning and advancing BHI operations. Greater success was observed in practices with existing on-site BHI services, identified champions for BHI, early and sustained training and involvement of providers and administrators, use of collaborative agreements with external behavioral health providers, and capacity to successfully receive reimbursements for BHI services. Advancing health information technologies was a challenge across sites. Financing and policy factors were viewed as critically important to advance integration efforts. The pilot of a continuum framework offers lessons for primary care practices and policymakers to advance integrated BH care.
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Affiliation(s)
- Matthew L Goldman
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, USA. .,Comprehensive Crisis Services, San Francisco Department of Public Health, 1380 Howard St, San Francisco, CA, 94103, USA.
| | | | - Talia Richkin
- Research Foundation for Mental Health, Inc., New York, USA
| | - Harold Alan Pincus
- Department of Psychiatry, Columbia University and the New York State Psychiatric Institute, New York, USA
| | - Henry Chung
- Montefiore Health System and Albert Einstein College of Medicine, New York, USA
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31
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Song AA, Oslin DW, Wolk CB. Characteristics of Patients Who Attended Behavioral Health Services After Primary Care Referral With Referral Management Support. Psychiatr Serv 2021; 72:1455-1459. [PMID: 34074145 DOI: 10.1176/appi.ps.202000535] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE This study examined whether documented disparities in access to behavioral health specialty care persisted in a novel integrated primary care model situated in a large health system when triage and referral management supports were provided by a centralized resource center for patients with behavioral health needs. METHODS Patients triaged and referred to specialty behavioral health care who did or did not attend a specialty care visit (N=1,450) were compared in terms of various demographic and clinical characteristics by using binary logistic regression. RESULTS Among patients with attendance data, financially unstable individuals were more likely than financially stable counterparts to miss their first appointment with a specialty behavioral health provider after referral from primary care. Previously documented attendance disparities based on race, ethnicity, and illness severity were not observed. CONCLUSIONS These findings can inform targeted strategies to increase attendance among patients with financial insecurity and reduce disparities in outpatient behavioral health services.
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Affiliation(s)
- Angela A Song
- Department of Psychiatry, Perelman School of Medicine (Song, Oslin, Wolk) and Leonard Davis Institute for Health Economics (Wolk), University of Pennsylvania, Philadelphia; Mental Illness Research, Education, and Clinical Center, Corporal Michael J. Crescenz VA Medical Center, Philadelphia (Oslin)
| | - David W Oslin
- Department of Psychiatry, Perelman School of Medicine (Song, Oslin, Wolk) and Leonard Davis Institute for Health Economics (Wolk), University of Pennsylvania, Philadelphia; Mental Illness Research, Education, and Clinical Center, Corporal Michael J. Crescenz VA Medical Center, Philadelphia (Oslin)
| | - Courtney Benjamin Wolk
- Department of Psychiatry, Perelman School of Medicine (Song, Oslin, Wolk) and Leonard Davis Institute for Health Economics (Wolk), University of Pennsylvania, Philadelphia; Mental Illness Research, Education, and Clinical Center, Corporal Michael J. Crescenz VA Medical Center, Philadelphia (Oslin)
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32
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McGinty EE, Presskreischer R, Breslau J, Brown JD, Domino ME, Druss BG, Horvitz-Lennon M, Murphy KA, Pincus HA, Daumit GL. Improving Physical Health Among People With Serious Mental Illness: The Role of the Specialty Mental Health Sector. Psychiatr Serv 2021; 72:1301-1310. [PMID: 34074150 PMCID: PMC8570967 DOI: 10.1176/appi.ps.202000768] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
People with serious mental illness die 10-20 years earlier, compared with the overall population, and the excess mortality is driven by undertreated physical health conditions. In the United States, there is growing interest in models integrating physical health care delivery, management, or coordination into specialty mental health programs, sometimes called "reverse integration." In November 2019, the Johns Hopkins ALACRITY Center for Health and Longevity in Mental Illness convened a forum of 25 experts to discuss the current state of the evidence on integrated care models based in the specialty mental health system and to identify priorities for future research, policy, and practice. This article summarizes the group's conclusions. Key research priorities include identifying the active ingredients in multicomponent integrated care models and developing and validating integration performance metrics. Key policy and practice recommendations include developing new financing mechanisms and implementing strategies to build workforce and data capacity. Forum participants also highlighted an overarching need to address socioeconomic risks contributing to excess mortality among adults with serious mental illness.
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Affiliation(s)
- Emma E McGinty
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore (McGinty, Presskreischer); RAND Corporation, Pittsburgh (Breslau) and Boston (Horvitz-Lennon); Mathematica, Washington, D.C. (Brown); Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill (Domino); Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta (Druss); Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore (Murphy, Daumit); Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York City (Pincus)
| | - Rachel Presskreischer
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore (McGinty, Presskreischer); RAND Corporation, Pittsburgh (Breslau) and Boston (Horvitz-Lennon); Mathematica, Washington, D.C. (Brown); Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill (Domino); Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta (Druss); Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore (Murphy, Daumit); Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York City (Pincus)
| | - Joshua Breslau
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore (McGinty, Presskreischer); RAND Corporation, Pittsburgh (Breslau) and Boston (Horvitz-Lennon); Mathematica, Washington, D.C. (Brown); Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill (Domino); Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta (Druss); Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore (Murphy, Daumit); Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York City (Pincus)
| | - Jonathan D Brown
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore (McGinty, Presskreischer); RAND Corporation, Pittsburgh (Breslau) and Boston (Horvitz-Lennon); Mathematica, Washington, D.C. (Brown); Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill (Domino); Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta (Druss); Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore (Murphy, Daumit); Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York City (Pincus)
| | - Marisa Elena Domino
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore (McGinty, Presskreischer); RAND Corporation, Pittsburgh (Breslau) and Boston (Horvitz-Lennon); Mathematica, Washington, D.C. (Brown); Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill (Domino); Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta (Druss); Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore (Murphy, Daumit); Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York City (Pincus)
| | - Benjamin G Druss
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore (McGinty, Presskreischer); RAND Corporation, Pittsburgh (Breslau) and Boston (Horvitz-Lennon); Mathematica, Washington, D.C. (Brown); Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill (Domino); Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta (Druss); Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore (Murphy, Daumit); Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York City (Pincus)
| | - Marcela Horvitz-Lennon
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore (McGinty, Presskreischer); RAND Corporation, Pittsburgh (Breslau) and Boston (Horvitz-Lennon); Mathematica, Washington, D.C. (Brown); Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill (Domino); Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta (Druss); Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore (Murphy, Daumit); Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York City (Pincus)
| | - Karly A Murphy
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore (McGinty, Presskreischer); RAND Corporation, Pittsburgh (Breslau) and Boston (Horvitz-Lennon); Mathematica, Washington, D.C. (Brown); Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill (Domino); Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta (Druss); Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore (Murphy, Daumit); Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York City (Pincus)
| | - Harold Alan Pincus
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore (McGinty, Presskreischer); RAND Corporation, Pittsburgh (Breslau) and Boston (Horvitz-Lennon); Mathematica, Washington, D.C. (Brown); Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill (Domino); Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta (Druss); Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore (Murphy, Daumit); Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York City (Pincus)
| | - Gail L Daumit
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore (McGinty, Presskreischer); RAND Corporation, Pittsburgh (Breslau) and Boston (Horvitz-Lennon); Mathematica, Washington, D.C. (Brown); Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill (Domino); Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta (Druss); Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore (Murphy, Daumit); Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York City (Pincus)
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Sandheimer C, Björkelund C, Hensing G, Hedenrud T. Implementation of a Care Manager Organization and Its Association with Health Care Contacts and Psychotherapy: A Register-Based Study of Real-Life Outcomes at Primary Health Care Centers in Sweden. Int J Gen Med 2021; 14:5621-5630. [PMID: 34548814 PMCID: PMC8449647 DOI: 10.2147/ijgm.s323363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 08/26/2021] [Indexed: 11/24/2022] Open
Abstract
Background A care manager organization, based on a collaborative care model, was implemented in the primary health care service in Region Västra Götaland, Sweden, to improve the care of persons with common mental disorders (CMDs). We aimed to investigate the association between the care manager organization and number of health care contacts, and the extent of psychotherapy among female and male patients with CMD compared to primary health care centers (PHCCs) offering usual care, in the introductory year of implementation with one year follow-up. Methods This register-based study included all PHCCs in the region, which were analyzed in two groups depending on their care manager status. The study periods were 2015.09.01–2016.08.31 (first year) and 2016.09.01–2017.08.31 (second year). Data on health care contacts and psychotherapy per PHCC were obtained from a health care register. The mean number and proportion of visits to different health care professionals, and the proportion of patients with short-term versus long-term psychotherapy were measured. A linear mixed-effects model for cross-sectional and longitudinal analysis was implemented as well as a generalized linear regression model for possible interaction effects of PHCC characteristic on care manager status and outcomes. Results PHCCs with a care manager organization had more nurse contacts (p = 0.001 for both year 1 and year 2) compared to PHCCs with usual care. PHCCs with usual care had a significantly lower proportion of visits to psychotherapists and a higher proportion of both female and male patients receiving short-term psychotherapy (1–5 sessions vs ≥6) over time and compared to PHCCs with a care manager organization. Conclusion With a care manager organization, nurse contacts increased at the PHCCs. However, this did not negatively influence the visits to a general practitioner and to psychotherapists. This evaluation showed that the care manager organization at PHCC level implies higher accessibility and sustainability of care for up to two years after implementation.
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Affiliation(s)
- Christine Sandheimer
- Social Medicine, School of Public Health and Community Medicine, Institute of Medicine, The Sahlgenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Cecilia Björkelund
- Primary Health Care, School of Public Health and Community Medicine, Institute of Medicine, The Sahlgenska Academy, University of Gothenburg, Gothenburg, Sweden.,Research and Development, Primary Health Care, Region Västra Götaland, Sweden
| | - Gunnel Hensing
- Social Medicine, School of Public Health and Community Medicine, Institute of Medicine, The Sahlgenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Tove Hedenrud
- Medicine Use & Pharmaceutical Policy, School of Public Health and Community Medicine, Institute of Medicine, The Sahlgenska Academy, University of Gothenburg, Gothenburg, Sweden
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34
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Charlesworth CJ, Zhu JM, Horvitz-Lennon M, McConnell KJ. Use of behavioral health care in Medicaid managed care carve-out versus carve-in arrangements. Health Serv Res 2021; 56:805-816. [PMID: 34312839 DOI: 10.1111/1475-6773.13703] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 04/01/2021] [Accepted: 04/14/2021] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To evaluate differences in access to behavioral health services for Medicaid enrollees covered by a Medicaid entity that integrated the financing of behavioral and physical health care ("carve-in group") versus a Medicaid entity that separated this financing ("carve-out group"). DATA SOURCES/STUDY SETTING Medicaid claims data from two Medicaid entities in the Portland, Oregon tri-county area in 2016. STUDY DESIGN In this cross-sectional study, we compared differences across enrollees in the carve-in versus carve-out group, using a machine learning approach to incorporate a large set of covariates and minimize potential selection bias. Our primary outcomes included behavioral health visits for a variety of different provider types. Secondary outcomes included inpatient, emergency department, and primary care visits. DATA COLLECTION We used Medicaid claims, including adults with at least 9 months of enrollment. PRINCIPAL FINDINGS The study population included 45,786 adults with mental health conditions. Relative to the carve-out group, individuals in the carve-in group were more likely to access outpatient behavioral health (2.39 percentage points, p < 0.0001, with a baseline rate of approximately 73%). The carve-in group was also more likely to access primary care physicians, psychologists, and social workers and less likely to access psychiatrists and behavioral health specialists. Access to outpatient behavioral health visits was more likely in the carve-in arrangement among individuals with mild or moderate mental health conditions (compared to individuals with severe mental illness) and among black enrollees (compared to white enrollees). CONCLUSIONS Financial integration of physical and behavioral health in Medicaid managed care was associated with greater access to behavioral health services, particularly for individuals with mild or moderate mental health conditions and for black enrollees. Recent changes to incentivize financial integration should be monitored to assess differential impacts by illness severity, race and ethnicity, provider types, and other factors.
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Affiliation(s)
- Christina J Charlesworth
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, Oregon, USA
| | - Jane M Zhu
- Division of General Internal Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Marcela Horvitz-Lennon
- RAND Corporation, Cambridge Heath Alliance and Harvard Medical School, Boston, Massachusetts, USA
| | - K John McConnell
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, Oregon, USA
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35
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Prom MC, Canelos V, Fernandez PJ, Gergen Barnett K, Gordon CM, Pace CA, Ng LC. Implementation of Integrated Behavioral Health Care in a Large Medical Center: Benefits, Challenges, and Recommendations. J Behav Health Serv Res 2021; 48:346-362. [PMID: 33241465 PMCID: PMC8144234 DOI: 10.1007/s11414-020-09742-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2020] [Indexed: 11/27/2022]
Abstract
Integrated behavioral health care (IBHC) models in primary care are positioned to address the unmet needs of traditional behavioral health models. However, research support is limited to specific populations, settings, and behavioral health conditions. Empirical evidence is lacking for expansion to larger health systems and diverse behavioral health conditions. This study examines perspectives on IBHC implementation in a large medical center. Semi-structured interviews were conducted with 24 health providers and administrators in two primary care clinics with IBHC. Thematic analysis demonstrated that participants had an overall favorable perception of IBHC, but also perceived implementation challenges, including difficulties with access, underutilization, team dynamics, and financial and interdepartmental issues. The findings suggest that IBHC implementation barriers in existing large health systems risk diminishing potential benefits and successful adoption. These barriers can be combated by incorporating systems change strategies into implementation frameworks, with a focus on barrier prevention and detection and long-term sustainability.
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Affiliation(s)
- Maria C Prom
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
| | - Victoria Canelos
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Boston University School of Medicine, Boston, MA, USA
| | - Pedro J Fernandez
- Department of Psychiatry, Boston Medical Center, Boston, MA, USA
- Department of Psychiatry, UT Southwestern, Dallas, TX, USA
| | - Katherine Gergen Barnett
- Department of Family Medicine, Boston Medical Center and Boston University School of Medicine, Boston, MA, USA
| | - Cindy M Gordon
- Department of Psychiatry, Boston Medical Center, Boston, MA, USA
| | - Christine A Pace
- Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, MA, USA
| | - Lauren C Ng
- Department of Psychiatry, Boston Medical Center and Boston University, Boston, MA, USA
- Department of Psychology, UCLA, Los Angeles, CA, USA
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36
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Bauer MS, Stolzmann K, Miller CJ, Kim B, Connolly SL, Lew R. Implementing the Collaborative Chronic Care Model in Mental Health Clinics: Achieving and Sustaining Clinical Effects. Psychiatr Serv 2021; 72:586-589. [PMID: 33730885 DOI: 10.1176/appi.ps.202000117] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Collaborative chronic care models (CCMs) were established with implementation support in nine mental health clinics. This study sought to determine whether their clinical impact was maintained after implementation support ceased. METHODS Posttrial data were analyzed from a randomized stepped-wedge CCM implementation trial in general mental health clinics in nine Department of Veterans Affairs medical centers. Sites received 1 year of implementation support, which was associated with reduced mental health hospitalization rates compared with non-CCM clinics in the same medical centers. Hospitalization rates for the year after implementation support were analyzed by using repeated measures logistic regression comparing the same clinics. RESULTS Hospitalization rates for the postsupport year did not differ from comparison clinics either in the population that initially showed the difference or the population active in the clinics at the end of the year of implementation support. CONCLUSIONS Clinical effects of the CCM may wane after cessation of active implementation support.
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Affiliation(s)
- Mark S Bauer
- Center for Healthcare Organization and Implementation Research, and the Behavior Health Quality Enhancement Research Initiative, U.S. Department of Veterans Affairs (VA), Boston (all authors); Department of Psychiatry, Harvard Medical School, Boston (Bauer, Miller, Kim, Connolly); Department of Biostatistics, Boston University School of Medicine, Boston (Lew)
| | - Kelly Stolzmann
- Center for Healthcare Organization and Implementation Research, and the Behavior Health Quality Enhancement Research Initiative, U.S. Department of Veterans Affairs (VA), Boston (all authors); Department of Psychiatry, Harvard Medical School, Boston (Bauer, Miller, Kim, Connolly); Department of Biostatistics, Boston University School of Medicine, Boston (Lew)
| | - Christopher J Miller
- Center for Healthcare Organization and Implementation Research, and the Behavior Health Quality Enhancement Research Initiative, U.S. Department of Veterans Affairs (VA), Boston (all authors); Department of Psychiatry, Harvard Medical School, Boston (Bauer, Miller, Kim, Connolly); Department of Biostatistics, Boston University School of Medicine, Boston (Lew)
| | - Bo Kim
- Center for Healthcare Organization and Implementation Research, and the Behavior Health Quality Enhancement Research Initiative, U.S. Department of Veterans Affairs (VA), Boston (all authors); Department of Psychiatry, Harvard Medical School, Boston (Bauer, Miller, Kim, Connolly); Department of Biostatistics, Boston University School of Medicine, Boston (Lew)
| | - Samantha L Connolly
- Center for Healthcare Organization and Implementation Research, and the Behavior Health Quality Enhancement Research Initiative, U.S. Department of Veterans Affairs (VA), Boston (all authors); Department of Psychiatry, Harvard Medical School, Boston (Bauer, Miller, Kim, Connolly); Department of Biostatistics, Boston University School of Medicine, Boston (Lew)
| | - Robert Lew
- Center for Healthcare Organization and Implementation Research, and the Behavior Health Quality Enhancement Research Initiative, U.S. Department of Veterans Affairs (VA), Boston (all authors); Department of Psychiatry, Harvard Medical School, Boston (Bauer, Miller, Kim, Connolly); Department of Biostatistics, Boston University School of Medicine, Boston (Lew)
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McKenzie KJ, Fletcher SL, Pierce D, Gunn JM. Moving from "let's fix them" to "actually listen": the development of a primary care intervention for mental-physical multimorbidity. BMC Health Serv Res 2021; 21:301. [PMID: 33794883 PMCID: PMC8017734 DOI: 10.1186/s12913-021-06307-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 03/22/2021] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Effective person-centred interventions are needed to support people living with mental-physical multimorbidity to achieve better health and wellbeing outcomes. Depression is identified as the most common mental health condition co-occurring with a physical health condition and is the focus of this intervention development study. The aim of this study is to identify the key components needed for an effective intervention based on a clear theoretical foundation, consideration of how motivational interviewing can inform the intervention, clinical guidelines to date, and the insights of primary care nurses. METHODS A multimethod approach to intervention development involving review and integration of the theoretical principles of Theory of Planned Behavior and the patient-centred clinical skills of motivational interviewing, review of the expert consensus clinical guidelines for multimorbidity, and incorporation of a thematic analysis of group interviews with Australian nurses about their perspectives of what is needed in intervention to support people living with mental-physical multimorbidity. RESULTS Three mechanisms emerged from the review of theory, guidelines and practitioner perspective; the intervention needs to actively 'engage' patients through the development of a collaborative and empathic relationship, 'focus' on the patient's priorities, and 'empower' people to make behaviour change. CONCLUSION The outcome of the present study is a fully described primary care intervention for people living with mental-physical multimorbidity, with a particular focus on people living with depression and a physical health condition. It builds on theory, expert consensus guidelines and clinician perspective, and is to be tested in a clinical trial.
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Affiliation(s)
- Kylie J McKenzie
- Department of General Practice, University of Melbourne, Melbourne, Australia.
| | - Susan L Fletcher
- Department of General Practice, University of Melbourne, Melbourne, Australia
| | - David Pierce
- Department of Rural Health, University of Melbourne, Ballarat, Australia
| | - Jane M Gunn
- Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
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Wolk CB, Alter CL, Kishton R, Rado J, Atlas JA, Press MJ, Jordan N, Grant M, Livesey C, Rosenthal LJ, Smith JD. Improving Payment for Collaborative Mental Health Care in Primary Care. Med Care 2021; 59:324-326. [PMID: 33427798 DOI: 10.1097/mlr.0000000000001485] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND There is strong evidence supporting implementation of the Collaborative Care Model within primary care. Fee-for-service payment codes, published by Current Procedural Terminology in 2018, have made collaborative care separately reimbursable for the first time. These codes (ie, 99492-99494) reimburse for time spent per month by any member of the care team engaged in Collaborative Care, including behavioral care managers, primary care providers, and consulting psychiatrists. Time-based billing for these codes presents challenges for providers delivering Collaborative Care services. OBJECTIVES Based on experience from multiple health care organizations, we reflect on these challenges and provide suggestions for implementation and future refinement of the codes. CONCLUSIONS Further refinements to the codes are encouraged, including moving from a calendar month to a 30-day reimbursement cycle. In addition, we recommend payers adopt the new code proposed by the Centers for Medicare and Medicaid Services to account for smaller increments of time.
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Affiliation(s)
- Courtney Benjamin Wolk
- Department of Psychiatry, Perelman School of Medicine
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Carol L Alter
- Department of Psychiatry, Baylor Scott & White, Temple, TX
| | - Rachel Kishton
- National Clinician Scholars Program, University of Pennsylvania, Philadelphia, PA
| | - Jeffrey Rado
- Northwestern Medicine
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - Matthew J Press
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Primary Care Service Line, University of Pennsylvania Health System, Philadelphia, PA
| | - Neil Jordan
- Departments of Psychiatry and Behavioral Sciences
- Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago
- Center of Innovation for Complex Chronic Healthcare, Hines, IL
| | - Michael Grant
- Department of Information Sciences (Population Health), Northwestern Medicine
| | | | - Lisa J Rosenthal
- Northwestern Medicine
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Justin D Smith
- Departments of Psychiatry and Behavioral Sciences
- Preventive Medicine
- Medical Social Sciences
- Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
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Ruderman MA, Kim B, Stolzmann K, Connolly S, Miller CJ, Bauer MS. Time course and heterogeneity of treatment effect of the collaborative chronic care model on psychiatric hospitalization rates: A survival analysis using routinely collected electronic medical records. PLoS One 2021; 16:e0249007. [PMID: 33765038 PMCID: PMC7993804 DOI: 10.1371/journal.pone.0249007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 03/09/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Health systems are undergoing widespread adoption of the collaborative chronic care model (CCM). Care structured around the CCM may reduce costly psychiatric hospitalizations. Little is known, however, about the time course or heterogeneity of treatment effects (HTE) for CCM on psychiatric hospitalization. RATIONALE Assessment of CCM implementation support on psychiatric hospitalization might be more efficient if the timing were informed by an expected time course. Further, understanding HTE could help determine who should be referred for intervention. OBJECTIVES (i) Estimate the trajectory of CCM effect on psychiatric hospitalization rates. (ii) Explore HTE for CCM across demographic and clinical characteristics. METHODS Data from a stepped wedge CCM implementation trial were reanalyzed using 5 570 patients in CCM treatment and 46 443 patients receiving usual care. Time-to-event data was constructed from routine medical records. Effect trajectory of CCM on psychiatric hospitalization was simulated from an extended Cox model over one year of implementation support. Covariate risk contributions were estimated from subset stratified Cox models without using simulation. Ratios of hazard ratios (RHR) allowed comparison by trial arm for HTE analysis, also without simulation. No standard Cox proportional hazards models were used for either estimating the time-course or heterogeneity of treatment effect. RESULTS The effect of CCM implementation support increased most rapidly immediately after implementation start and grew more gradually throughout the rest of the study. On the final study day, psychiatric hospitalization rates in the treatment arm were 17% to 49% times lower than controls, with adjustment for all model covariates (HR 0.66; 95% CI 0.51-0.83). Our analysis of HTE favored usual care for those with a history of prior psychiatric hospitalization (RHR 4.92; 95% CI 3.15-7.7) but favored CCM for those with depression (RHR 0.61; 95% CI: 0.41-0.91). Having a single medical diagnosis, compared to having none, favored CCM (RHR 0.52; 95% CI 0.31-0.86). CONCLUSION Reduction of psychiatric hospitalization is evident immediately after start of CCM implementation support, but assessments may be better timed once the effect size begins to stabilize, which may be as early as six months. HTE findings for CCM can guide future research on utility of CCM in specific populations.
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Affiliation(s)
- Michael A. Ruderman
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Jamaica Plain, Boston, Massachusetts, United States of America
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Bo Kim
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Jamaica Plain, Boston, Massachusetts, United States of America
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Kelly Stolzmann
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Jamaica Plain, Boston, Massachusetts, United States of America
| | - Samantha Connolly
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Jamaica Plain, Boston, Massachusetts, United States of America
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Christopher J. Miller
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Jamaica Plain, Boston, Massachusetts, United States of America
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Mark S. Bauer
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Jamaica Plain, Boston, Massachusetts, United States of America
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, United States of America
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Sullivan JL, Kim B, Miller CJ, Elwy AR, Drummond KL, Connolly SL, Riendeau RP, Bauer MS. Collaborative chronic care model implementation within outpatient behavioral health care teams: qualitative results from a multisite trial using implementation facilitation. Implement Sci Commun 2021; 2:33. [PMID: 33762023 PMCID: PMC7992349 DOI: 10.1186/s43058-021-00133-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 03/08/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This paper reports on a qualitative evaluation of a hybrid type II stepped-wedge, cluster randomized trial using implementation facilitation to implement team-based care in the form of the collaborative chronic care model (CCM) in interdisciplinary outpatient mental health teams. The objective of this analysis is to compare the alignment of sites' clinical processes with the CCM elements at baseline (time 1) and after 12 months of implementation facilitation (time 2) from the perspective of providers. METHODS We conducted semi-structured interviews to assess the extent to which six CCM elements were in place: work role redesign, patient self-management support, provider decision support, clinical information systems, linkages to community resources, and organizational/leadership support. Interviews were transcribed and a priori CCM elements were coded using a directed content analysis approach at times 1 and 2. We sought consensus on, and compared, the extent to which each CCM element was in place at times 1 and 2. RESULTS We conducted 27 and 31 telephone interviews at times 1 and 2, respectively, with outpatient mental health providers at nine participating sites. At time 1 and time 2, three CCM elements were most frequently present across the sites: work role redesign, patient self-management support, and provider decision support. The CCM elements with increased implementation from time 1 to time 2 were work role redesign, patient self-management support, and clinical information systems. For two CCM elements, linkages to community resources and organizational/leadership support, some sites had increased implementation at time 2 compared to time 1, while others had reductions. For the provider decision support element, we saw little change in the extent of its implementation. CONCLUSIONS Sites increased the extent of implementation on several CCM elements. The most progress was made in the CCM elements where sites had CCM-aligned processes in place at time 1. Teams made progress on elements they could more easily control, such as work role redesign. Our results suggest that maximizing the benefits of CCM-based outpatient mental health care may require targeting resources and training toward specific CCM elements-especially in the use of clinical information systems and linking with community resources. TRIAL REGISTRATION Clinical Trials NCT02543840 .
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Affiliation(s)
- Jennifer L Sullivan
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 S. Huntington Ave (152M), Boston, MA, USA.
- Department of Health Law, Policy and Management, Boston University School of Public Health, 715 Albany St, Talbot Building, Boston, MA, USA.
| | - Bo Kim
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 S. Huntington Ave (152M), Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Christopher J Miller
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 S. Huntington Ave (152M), Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - A Rani Elwy
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, 200 Springs Road (152), Bedford, MA, USA
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Karen L Drummond
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA
- Department of Psychiatry, University of Arkansas for Medical Sciences College of Medicine, Little Rock, AR, USA
| | - Samantha L Connolly
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 S. Huntington Ave (152M), Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Rachel P Riendeau
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 S. Huntington Ave (152M), Boston, MA, USA
| | - Mark S Bauer
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 S. Huntington Ave (152M), Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
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Wolk CB, Last BS, Livesey C, Oquendo MA, Press MJ, Mandell DS, Ingram E, Futterer AC, Kinkler GP, Oslin DW. Addressing Common Challenges in the Implementation of Collaborative Care for Mental Health: The Penn Integrated Care Program. Ann Fam Med 2021; 19:148-156. [PMID: 33685876 PMCID: PMC7939709 DOI: 10.1370/afm.2651] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 09/28/2020] [Accepted: 10/05/2020] [Indexed: 11/09/2022] Open
Abstract
PURPOSE We developed and implemented a new model of collaborative care that includes a triage and referral management system. We present initial implementation metrics using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework. METHODS Primary care clinicians in 8 practices referred patients with any unmet mental health needs to the Penn Integrated Care program. Assessments were conducted using validated measures. Patients were primarily triaged to collaborative care (26%) or specialty mental health care with active referral management (70%). We conducted 50 qualitative interviews to understand the implementation process and inform program refinement. Our primary outcomes were reach and implementation metrics, including referral and encounter rates derived from the electronic health record. RESULTS In 12 months, 6,124 unique patients were referred. Assessed patients reported symptoms consistent with a range of conditions from mild to moderate depression and anxiety to serious mental illnesses including psychosis and acute suicidal ideation. Among patients enrolled in collaborative care, treatment entailed a mean of 7.2 (SD 5.1) encounters over 78.1 (SD 51.3) days. Remission of symptoms was achieved by 32.6% of patients with depression and 39.5% of patients with anxiety. Stakeholders viewed the program favorably and had concrete suggestions to ensure sustainability. CONCLUSIONS The Penn Integrated Care program demonstrated broad reach. Implementation was consistent with collaborative care as delivered in seminal studies of the model. Our results provide insight into a model for launching and implementing collaborative care to meet the needs of a diverse group of patients with the full range of mental health conditions seen in primary care.
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Affiliation(s)
- Courtney Benjamin Wolk
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Briana S Last
- Department of Psychology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Cecilia Livesey
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Maria A Oquendo
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew J Press
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
- Primary Care Service Line, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - David S Mandell
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Erin Ingram
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Mental Illness Research, Education, and Clinical Center at the Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Anne C Futterer
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Grace P Kinkler
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David W Oslin
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Mental Illness Research, Education, and Clinical Center at the Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
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Fletcher S, Chondros P, Densley K, Murray E, Dowrick C, Coe A, Hegarty K, Davidson S, Wachtler C, Mihalopoulos C, Lee YY, Chatterton ML, Palmer VJ, Gunn J. Matching depression management to severity prognosis in primary care: results of the Target-D randomised controlled trial. Br J Gen Pract 2021; 71:e85-e94. [PMID: 33431380 PMCID: PMC7846356 DOI: 10.3399/bjgp.2020.0783] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 12/11/2020] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Mental health treatment rates are increasing, but the burden of disease has not reduced. Tools to support efficient resource distribution are required. AIM To investigate whether a person-centred e-health (Target-D) platform matching depression care to symptom severity prognosis can improve depressive symptoms relative to usual care. DESIGN AND SETTING Stratified individually randomised controlled trial in 14 general practices in Melbourne, Australia, from April 2016 to February 2019. In total, 1868 participants aged 18-65 years who had current depressive symptoms; internet access; no recent change to antidepressant; no current antipsychotic medication; and no current psychological therapy were randomised (1:1) via computer-generated allocation to intervention or usual care. METHOD The intervention was an e-health platform accessed in the GP waiting room, comprising symptom feedback, priority-setting, and prognosis-matched management options (online self-help, online guided psychological therapy, or nurse-led collaborative care). Management options were flexible, neither participants nor staff were blinded, and there were no substantive protocol deviations. The primary outcome was depressive symptom severity (9-item Patient Health Questionnaire [PHQ-9]) at 3 months. RESULTS In intention to treat analysis, estimated between- arm difference in mean PHQ-9 scores at 3 months was -0.88 (95% confidence interval [CI] = -1.45 to -0.31) favouring the intervention, and -0.59 at 12 months (95% CI = -1.18 to 0.01); standardised effect sizes of -0.16 (95% CI = -0.26 to -0.05) and -0.10 (95% CI = -0.21 to 0.002), respectively. No serious adverse events were reported. CONCLUSION Matching management to prognosis using a person-centred e-health platform improves depressive symptoms at 3 months compared to usual care and could feasibly be implemented at scale. Scope exists to enhance the uptake of management options.
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Affiliation(s)
- Susan Fletcher
- Department of General Practice, Melbourne Medical School, University of Melbourne, Melbourne, Australia
| | - Patty Chondros
- Department of General Practice, Melbourne Medical School, University of Melbourne, Melbourne, Australia
| | - Konstancja Densley
- Department of General Practice, Melbourne Medical School, University of Melbourne, Melbourne, Australia
| | - Elizabeth Murray
- Department of General Practice, Melbourne Medical School, University of Melbourne, Melbourne, Australia; professor of eHealth and primary care, Research Department of Primary Care and Population Health, University College London, London, UK
| | - Christopher Dowrick
- Department of General Practice, Melbourne Medical School, University of Melbourne, Melbourne, Australia; professor of primary medical care, Department of Health Services Research, University of Liverpool, Liverpool, UK
| | - Amy Coe
- Department of General Practice, Melbourne Medical School, University of Melbourne, Melbourne, Australia
| | - Kelsey Hegarty
- Department of General Practice, Melbourne Medical School, University of Melbourne; director, Centre for Family Violence Prevention, The Royal Women's Hospital, Melbourne, Australia
| | - Sandra Davidson
- Department of General Practice, Melbourne Medical School, University of Melbourne, Melbourne, Australia
| | - Caroline Wachtler
- Department of General Practice, Melbourne Medical School, University of Melbourne, Melbourne, Australia; family medicine resident, Department of General Practice and Primary Care, Karolinska Institutet, Solna, Sweden
| | - Cathrine Mihalopoulos
- Deakin Health Economics, Institute for Health Transformation, Deakin University, Geelong, Australia
| | - Yong Yi Lee
- Deakin Health Economics, Institute for Health Transformation, Deakin University, Geelong; honorary fellow, School of Public Health, University of Queensland, Brisbane; health economist, Policy and Epidemiology Group, Queensland Centre for Mental Health Research, Brisbane, Australia
| | - Mary Lou Chatterton
- Deakin Health Economics, Institute for Health Transformation, Deakin University, Geelong, Australia
| | - Victoria J Palmer
- Department of General Practice, Melbourne Medical School, University of Melbourne, Melbourne, Australia
| | - Jane Gunn
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne; chair of primary care research, Department of General Practice, Melbourne Medical School, University of Melbourne, Melbourne, Australia
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Rodie DJ, Fitzgibbon K, Perivolaris A, Crawford A, Geist R, Levinson A, Mitchell B, Oslin D, Sunderji N, Mulsant BH. The primary care assessment and research of a telephone intervention for neuropsychiatric conditions with education and resources study: Design, rationale, and sample of the PARTNERs randomized controlled trial. Contemp Clin Trials 2021; 103:106284. [PMID: 33476774 DOI: 10.1016/j.cct.2021.106284] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 01/06/2021] [Accepted: 01/11/2021] [Indexed: 11/25/2022]
Abstract
While most patients with depression, anxiety, or at-risk drinking receive care exclusively in primary care settings, primary care providers experience challenges in diagnosing and treating these common problems. Over the past two decades, the collaborative care model has addressed these challenges. However, this model has been adopted very slowly due to the high costs of care managers; inability to sustain their role in small practices; and the perceived lack of relevance of interventions focused on a specific psychiatric diagnosis. Thus, we designed an innovative randomized clinical trial (RCT), the Primary Care Assessment and Research of a Telephone Intervention for Neuropsychiatric Conditions with Education and Resources study (PARTNERs). This RCT compared the outcomes of enhanced usual care and a novel model of collaborative care in primary care patients with depressive disorders, generalized anxiety, social phobia, panic disorder, at-risk drinking, or alcohol use disorders. These conditions were selected because they are present in almost a third of patients seen in primary care settings. Innovations included assigning the care manager role to trained lay providers supported by computer-based tools; providing all care management centrally by phone - i.e., the intervention was delivered without any face-to-face contact between the patient and the care team; and basing patient eligibility and treatment selection on a transdiagnostic approach using the same eligibility criteria and the same treatment algorithms regardless of the participants' specific psychiatric diagnosis. This paper describes the design of this RCT and discusses the rationale for its main design features.
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Affiliation(s)
- David J Rodie
- Centre for Addiction and Mental Health, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | | | | | - Allison Crawford
- Centre for Addiction and Mental Health, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Rose Geist
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Hospital for Sick Children, Toronto, ON, Canada
| | - Andrea Levinson
- Centre for Addiction and Mental Health, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | | | - David Oslin
- University of Pennsylvania and the Department of Veteran Affairs, Philadelphia, PA, United States of America
| | - Nadiya Sunderji
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Waypoint Centre for Mental Health Care, Penetanguishene, ON, Canada
| | - Benoit H Mulsant
- Centre for Addiction and Mental Health, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada.
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Eisman AB, Hutton DW, Prosser LA, Smith SN, Kilbourne AM. Cost-effectiveness of the Adaptive Implementation of Effective Programs Trial (ADEPT): approaches to adopting implementation strategies. Implement Sci 2020; 15:109. [PMID: 33317593 PMCID: PMC7734829 DOI: 10.1186/s13012-020-01069-w] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 12/01/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Theory-based methods to support the uptake of evidence-based practices (EBPs) are critical to improving mental health outcomes. Implementation strategy costs can be substantial, and few have been rigorously evaluated. The purpose of this study is to conduct a cost-effectiveness analysis to identify the most cost-effective approach to deploying implementation strategies to enhance the uptake of Life Goals, a mental health EBP. METHODS We used data from a previously conducted randomized trial to compare the cost-effectiveness of Replicating Effective Programs (REP) combined with external and/or internal facilitation among sites non-responsive to REP. REP is a low-level strategy that includes EBP packaging, training, and technical assistance. External facilitation (EF) involves external expert support, and internal facilitation (IF) augments EF with protected time for internal staff to support EBP implementation. We developed a decision tree to assess 1-year costs and outcomes for four implementation strategies: (1) REP only, (2) REP+EF, (3) REP+EF add IF if needed, (4) REP+EF/IF. The analysis used a 1-year time horizon and assumed a health payer perspective. Our outcome was quality-adjusted life years (QALYs). The economic outcome was the incremental cost-effectiveness ratio (ICER). We conducted deterministic and probabilistic sensitivity analysis (PSA). RESULTS Our results indicate that REP+EF add IF is the most cost-effective option with an ICER of $593/QALY. The REP+EF/IF and REP+EF only conditions are dominated (i.e., more expensive and less effective than comparators). One-way sensitivity analyses indicate that results are sensitive to utilities for REP+EF and REP+EF add IF. The PSA results indicate that REP+EF, add IF is the optimal strategy in 30% of iterations at the threshold of $100,000/QALY. CONCLUSIONS Our results suggest that the most cost-effective implementation support begins with a less intensive, less costly strategy initially and increases as needed to enhance EBP uptake. Using this approach, implementation support resources can be judiciously allocated to those clinics that would most benefit. Our results were not robust to changes in the utility measure. Research is needed that incorporates robust and relevant utilities in implementation studies to determine the most cost-effective strategies. This study advances economic evaluation of implementation by assessing costs and utilities across multiple implementation strategy combinations. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02151331 , 05/30/2014.
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Affiliation(s)
- Andria B Eisman
- Community Health, Division of Kinesiology, Health and Sport Studies, College of Education, Wayne State University, 2153 Faculty/Administration Building, 656 West Kirby, Detroit, MI, 48202, USA.
| | - David W Hutton
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Lisa A Prosser
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, 48109, USA
- Susan B. Meister Child Health Evaluation & Research Center, Dept of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - Shawna N Smith
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, 48109, USA
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - Amy M Kilbourne
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
- Quality Enhancement Research Initiative, U.S. Department of Veterans Affairs, Washington, USA
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Gomes FA, Magalhães PV, Magee T, Brietzke E, Kunz M, Kapczinski F. Clinical correlates of high burden of general medical comorbidities in patients with bipolar disorder. JOURNAL OF AFFECTIVE DISORDERS REPORTS 2020. [DOI: 10.1016/j.jadr.2020.100001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Smith SN, Liebrecht CM, Bauer MS, Kilbourne AM. Comparative effectiveness of external vs blended facilitation on collaborative care model implementation in slow-implementer community practices. Health Serv Res 2020; 55:954-965. [PMID: 33125166 DOI: 10.1111/1475-6773.13583] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE To evaluate the comparative effectiveness of external facilitation (EF) vs external + internal facilitation (EF/IF), on uptake of a collaborative chronic care model (CCM) in community practices that were slower to implement under low-level implementation support. STUDY SETTING Primary data were collected from 43 community practices in Michigan and Colorado at baseline and for 12 months following randomization. STUDY DESIGN Sites that failed to meet a pre-established implementation benchmark after six months of low-level implementation support were randomized to add either EF or EF/IF support for up to 12 months. Key outcomes were change in number of patients receiving the CCM and number of patients receiving a clinically significant dose of the CCM. Moderators' analyses further examined whether comparative effectiveness was dependent on prerandomization adoption, number of providers trained or practice size. Facilitation log data were used for exploratory follow-up analyses. DATA COLLECTION Sites reported monthly on number of patients that had received the CCM. Facilitation logs were completed by study EF and site IFs and shared with the study team. PRINCIPAL FINDINGS N = 21 sites were randomized to EF and 22 to EF/IF. Overall, EF/IF practices saw more uptake than EF sites after 12 months (ΔEF/IF-EF = 4.4 patients, 95% CI = 1.87-6.87). Moderators' analyses, however, revealed that it was only sites with no prerandomization uptake of the CCM (nonadopter sites) that saw significantly more benefit from EF/IF (ΔEF/IF-EF = 9.2 patients, 95% CI: 5.72, 12.63). For sites with prerandomization uptake (adopter sites), EF/IF offered no additional benefit (ΔEF/IF-EF = -0.9; 95% CI: -4.40, 2.60). Number of providers trained and practice size were not significant moderators. CONCLUSIONS Although stepping up to the more intensive EF/IF did outperform EF overall, its benefit was limited to sites that failed to deliver any CCM under the low-level strategy. Once one or more providers were delivering the CCM, additional on-site personnel did not appear to add value to the implementation effort.
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Affiliation(s)
- Shawna N Smith
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA.,Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Celeste M Liebrecht
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Mark S Bauer
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Amy M Kilbourne
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, Michigan, USA.,Quality Enhancement Research Initiative, U.S. Department of Veterans Affairs, Washington, District of Columbia, USA
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Miller CJ, Griffith KN, Stolzmann K, Kim B, Connolly SL, Bauer MS. An Economic Analysis of the Implementation of Team-based Collaborative Care in Outpatient General Mental Health Clinics. Med Care 2020; 58:874-880. [PMID: 32732780 PMCID: PMC8177737 DOI: 10.1097/mlr.0000000000001372] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Collaborative Chronic Care Models represent an evidence-based way to structure care for chronic conditions, including mental health conditions. Few studies, however, have examined the cost implications of collaborative care for mental health. OBJECTIVE We aimed to conduct an economic analysis of implementing collaborative care in 9 outpatient general mental health clinics. RESEARCH DESIGN Analyses were derived from a stepped wedge hybrid implementation-effectiveness trial. We conducted cost-minimization analyses from the health system perspective, incorporating implementation costs, outpatient costs, and inpatient costs for the year before collaborative care implementation and the implementation year. We used a difference-in-differences approach and conducted 1-way sensitivity analyses to determine the robustness of results to variations ±15% in model parameters, along with probabilistic sensitivity analysis using Monte Carlo simulation. SUBJECTS Our treatment group included 5507 patients who were initially engaged in care within 9 outpatient general mental health teams that underwent collaborative care implementation. We compared costs for this group to 45,981 control patients who received mental health treatment as usual at the same medical centers. RESULTS Collaborative care implementation cost about $40 per patient and was associated with a significant decrease in inpatient costs and a nonsignificant increase in outpatient mental health costs. This implementation was associated with $78 in cost savings per patient. Monte Carlo simulation suggested that implementation was cost saving in 78% of iterations. CONCLUSIONS Collaborative care implementation for mental health teams was associated with significant reductions in mental health hospitalizations, leading to substantial cost savings of about $1.70 for every dollar spent for implementation.
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Affiliation(s)
- Christopher J. Miller
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System
- Department of Psychiatry, Harvard Medical School
| | - Kevin N. Griffith
- Partnered Evidence-Based Policy Resource Center (PEPReC), VA Boston Healthcare System
- Department of Health Law, Policy, & Management, Boston University School of Public Health, Boston, MA
| | - Kelly Stolzmann
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System
| | - Bo Kim
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System
- Department of Psychiatry, Harvard Medical School
| | - Samantha L. Connolly
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System
- Department of Psychiatry, Harvard Medical School
| | - Mark S. Bauer
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System
- Department of Psychiatry, Harvard Medical School
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Hunter SC, Kim B, Mudge A, Hall L, Young A, McRae P, Kitson AL. Experiences of using the i-PARIHS framework: a co-designed case study of four multi-site implementation projects. BMC Health Serv Res 2020; 20:573. [PMID: 32576197 PMCID: PMC7310499 DOI: 10.1186/s12913-020-05354-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 05/24/2020] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework is an implementation framework that has been developed and refined over the last 20 years. Its underlying philosophy is that implementing research into healthcare practice is complex, unpredictable and non-linear which therefore requires a flexible and responsive approach to implementation. Facilitation is recognized as the central ingredient of this approach, and i-PARIHS now provides a Facilitation Guide with associated tools. This multiple case study of four implementation projects explored how the i-PARIHS framework has been practically operationalized by diverse implementation project teams. METHODS A co-design approach was used to elicit the experiences of four implementation project teams who used the i-PARIHS framework to guide their implementation approach. We conducted the established co-design steps of (i) setting up for success, (ii) gathering the experience, and (iii) understanding the experience. In particular we explored teams' approaches to setting up their projects; why and how they used the i-PARIHS framework and what they learnt from the experience. RESULTS We found both commonalities and differences in the use of i-PARIHS across the four implementation projects: (i) all the projects used the Facilitation Checklist that accompanies i-PARIHS as a starting point, (ii) the projects differed in how facilitation was carried out, (iii) existing tools were adapted for distinct phases: pre-implementation, during implementation, and post-implementation stages; and (iv) project-specific tools were often developed for monitoring implementation activities and fidelity. CONCLUSIONS We have provided a detailed overview of how current users of i-PARIHS are operationalising the framework, which existing tools they are using or adapting to use, and where they have needed to develop new tools to best utilise the framework. Importantly, this study highlights the value of existing tools from the published i-PARIHS Facilitation Guide and provides a starting point to further refine and add to these tools within a future Mobilising Implementation of i-PARIHS (or "Mi-PARIHS") suite of resources. Specifically, Mi-PARIHS might include more explicit guidance and/or tools for developing a structured implementation plan and monitoring fidelity to the implementation plan, including recording how strategies are tailored to an evolving context.
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Affiliation(s)
- S C Hunter
- College of Nursing and Health Sciences, Flinders University, Sturt Road, Bedford Park, Adelaide, SA, 5042, Australia.
- Caring Futures Institute, Flinders University, Adelaide, SA, Australia.
| | - B Kim
- Centre for Healthcare Organization and Implementation Research, U.S. Department of Veterans Affairs, Boston, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - A Mudge
- Internal Medicine Research Unit, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
- School of Clinical Medicine, University of Queensland, Brisbane, QLD, Australia
| | - L Hall
- School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
| | - A Young
- Nutrition and Dietetics, Royal Brisbane and Women's Hospital, QLD, Brisbane, Australia
- School of Exercise and Nutrition Sciences, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
| | - P McRae
- Internal Medicine Research Unit, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - A L Kitson
- College of Nursing and Health Sciences, Flinders University, Sturt Road, Bedford Park, Adelaide, SA, 5042, Australia
- Caring Futures Institute, Flinders University, Adelaide, SA, Australia
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The Collaborative Chronic Care Model for Mental Health Conditions: From Evidence Synthesis to Policy Impact to Scale-up and Spread. Med Care 2020; 57 Suppl 10 Suppl 3:S221-S227. [PMID: 31517791 PMCID: PMC6749976 DOI: 10.1097/mlr.0000000000001145] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Extensive evidence indicates that Collaborative Chronic Care Models (CCMs) improve outcome in chronic medical conditions and depression treated in primary care. Beginning with an evidence synthesis which indicated that CCMs are also effective for multiple mental health conditions, we describe a multistage process that translated this knowledge into evidence-based health system change in the US Department of Veterans Affairs (VA). EVIDENCE SYNTHESIS In 2010, recognizing that there had been numerous CCM trials for a wide variety of mental health conditions, we conducted an evidence synthesis compiling randomized controlled trials of CCMs for any mental health condition. The systematic review demonstrated CCM effectiveness across mental health conditions and treatment venues. Cumulative meta-analysis and meta-regression further informed our approach to subsequent CCM implementation. POLICY IMPACT In 2015, based on the evidence synthesis, VA Office of Mental Health and Suicide Prevention (OMHSP) adopted the CCM as the model for their outpatient mental health teams. RANDOMIZED IMPLEMENTATION TRIAL In 2015-2018 we partnered with OMHSP to conduct a 9-site stepped wedge implementation trial, guided by insights from the evidence synthesis. SCALE-UP AND SPREAD In 2017 OMHSP launched an effort to scale-up and spread the CCM to additional VA medical centers. Seventeen facilitators were trained and 28 facilities engaged in facilitation. DISCUSSION Evidence synthesis provided leverage for evidence-based policy change. This formed the foundation for a health care leadership/researcher partnership, which conducted an implementation trial and subsequent scale-up and spread effort to enhance adoption of the CCM, as informed by the evidence synthesis.
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Miller CJ, Wiltsey-Stirman S, Baumann AA. Iterative Decision-making for Evaluation of Adaptations (IDEA): A decision tree for balancing adaptation, fidelity, and intervention impact. JOURNAL OF COMMUNITY PSYCHOLOGY 2020; 48:1163-1177. [PMID: 31970812 PMCID: PMC7261620 DOI: 10.1002/jcop.22279] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 10/23/2019] [Accepted: 10/26/2019] [Indexed: 05/17/2023]
Abstract
BACKGROUND Evidence-based practices (EBPs) are frequently adapted to maximize outcomes while maintaining fidelity to core EBP elements. Many step-by-step frameworks for adapting EBPs have been developed, but these models may not account for common complexities in the adaptation process. In this paper, we introduce the Iterative Decision-making for Evaluation of Adaptations (IDEA), a tool to guide adaptations that addresses these issues. FRAMEWORK DESIGN AND USE Adapting EBPs requires attending to key contingencies incorporated into the IDEA, including: the need for adaptations; fidelity to core EBP elements; the timeframe in which to make adaptations; the potential to collect pilot data; key clinical and implementation outcomes; and stakeholder viewpoints. We use two examples to illustrate application of the IDEA. CONCLUSIONS The IDEA is a practical tool to guide EBP adaptation that incorporates important decision points and the dynamism of ongoing adaptation. Its use may help implementation scientists, clinicians, and administrators maximize EBP impact.
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Affiliation(s)
- Christopher J Miller
- Department of Psychiatry, VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research (CHOIR), Harvard Medical School, Boston, Massachusetts
| | - Shannon Wiltsey-Stirman
- Department of Psychiatry and Behavioral Sciences, VA Palo Alto Healthcare System, National Center for PTSD Dissemination and Training Division, Stanford University, Stanford, California
| | - Ana A Baumann
- Brown School, Washington University in St. Louis, St. Louis, Missouri
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