Barriers to physical and mental condition integrated service delivery

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Assessing the need for pre-mental health competencies in undergraduate education: insights from graduate faculty surveys

Introduction

Despite the value of clinical competencies for masters- and doctoral-level practitioners as well as the tremendous variability in preparedness for graduate school and at graduation from graduate school, there are no competency standards for students pursuing mental healthcare careers prior to graduate study. This study aimed to identify potential pre-mental health competency standards for undergraduates pursuing mental healthcare careers.

Methods

Faculty at masters and doctoral programs in a range of mental healthcare fields were asked to rate their expectations of entry-level competence and the perceived entry-level competence of their first-year, bachelor-level graduate students on 42 sub-competencies derived from the APA's Competency Benchmarks in Professional Psychology.

Results

Faculty of both masters (N = 320) and doctoral (N = 220) programs reported high expectations of first-year graduate students for 11 competency categories (professional values/attitudes; relationships; management-administration; interdisciplinary systems; individual/cultural diversity; advocacy; scientific knowledge and methods; reflective practice, self-assessment, and self-care; ethical standards and policy; supervision, and research/evaluation) and 25 sub-competencies. Faculty in masters programs rated students as not meeting their expectations in 28 sub-competencies, while faculty in doctoral programs rated students as not meeting their expectations in 17 sub-competencies. Faculty recommended internships as well as improvement in writing, counseling skills, professional behavior, diversity, equity, and inclusion, cultural competence and humility, research methods, reading research, connecting research to practice, and education about the different mental healthcare professions.

Discussion

Our findings suggest that students would benefit from intentional training in multiple pre-mental health competency areas at the undergraduate level to facilitate graduate-level training in mental healthcare and to better prepare our future clinicians.

Care transitions from the specialty to the primary care setting: A scoping literature review of potential barriers and facilitators with implications for mental health care

BACKGROUND, AIMS AND OBJECTIVES

This scoping review aimed to understand potential barriers and facilitators in transitioning patients from specialty to primary care settings, to inform the implementation of an intervention to promote active consideration of psychiatrically stable patients for transition from the specialty mental health setting back to primary care.

METHODS

Guided by Levac and colleagues' six-stage methodological framework for conducting scoping studies, we systematically searched electronic article databases for peer-reviewed literature from January 2000 to May 2016. We included identified articles that discuss findings related to potential barriers and facilitators in transitioning patients from specialty to primary care settings. We performed descriptive and thematic analyses of results to generate emergent codes and their categorizations.

RESULTS

Our database search yielded 906 unique articles, 23 of which we included in our scoping review. All but one of the included studies were conducted in North America. Identified potential barriers and facilitators spanned eight emergent themes-(i) primary care accessibility, especially in terms of timely availability of appointments, (ii) clarity in respective roles of specialty care and primary care in managing a patient, (iii) timely exchange of information, (iv) transition process management, (v) perceived ability of primary care providers to manage specialty conditions, (vi) perceived ability of patients to self-manage, (vii) leadership support and (viii) support for implementing initiatives to promote transitions.

CONCLUSIONS

Findings from this scoping review enable an increased understanding of current practices and considerations regarding care transitions from specialty to primary care settings. The importance of role clarification, shared clinical information systems, confidence in care competency, and adequate organizational support to promote appropriate transitions were themes most widely reported across the reviewed studies. Few studies specifically examined the transition from specialty mental health to primary care. Future studies should account for mental health-specific symptomatic patterns and recovery trajectories, such as prevalent chronicity and frequency of relapse, in planning and conducting transitions from specialty mental health back to primary care.

Augmenting the efficacy of benzodiazepine taper with telehealth-delivered cognitive behavioral therapy for anxiety disorders in patients using prescription opioids: A pilot randomized controlled trial

The risks of concomitant benzodiazepine (BZ) and opioid use are significant. Despite the urgent need to reduce BZ use among patients taking opioids, no treatment intervention research to our knowledge has addressed treatment for this concurrent, high-risk use. The current study will evaluate the efficacy of augmenting BZ taper procedures with CBT for anxiety disorders that has been adapted specifically for patients with concomitant BZ and opioid use (either use as prescribed or misuse), a high-risk patient population. Research combining rapidly scalable behavioral interventions ancillary to pharmacological approaches delivered via telehealth in primary care settings is innovative and important given concerning trends in rising prevalence of BZ/opioid co-prescription, BZ-associated overdose deaths, and known barriers to implementation of behavioral health interventions in primary care. CBT delivery using telehealth has the potential to aid adherence and promote access and dissemination of procedures in primary care. Lastly, the current study will utilize an experimental therapeutics approach to preliminarily explore the mechanism of action for the proposed interventions. The overall aim of the present pilot randomized controlled trial is to examine the feasibility and preliminary efficacy of a BZ taper with CBT for anxiety disorders adapted for patients with concomitant BZ (BZT + CBT) and opioid use to a BZ taper with a control health education program (BZT + HE) in a sample of individuals (N = 54) who have been prescribed and are taking benzodiazepines and opioids for at least 3 months prior to baseline and experience anxious distress. Screening and outcome measures, methods, and implications are described. Trial Registration: ClinicalTrials.gov (NCT05573906).

"Our Job is to be so Temporary": Designing Digital Tools that Meet the Needs of Care Managers and their Patients with Mental Health Concerns

Digital tools have potential to support collaborative management of mental health conditions, but we need to better understand how to integrate them in routine healthcare, particularly for patients with both physical and mental health needs. We therefore conducted interviews and design workshops with 1) a group of care managers who support patients with complex health needs, and 2) their patients whose health needs include mental health concerns. We investigate both groups' views of potential applications of digital tools within care management. Findings suggest that care managers felt underprepared to play an ongoing role in addressing mental health issues and had concerns about the burden and ambiguity of providing support through new digital channels. In contrast, patients envisioned benefiting from ongoing mental health support from care managers, including support in using digital tools. Patients' and care managers' needs may diverge such that meeting both through the same tools presents a significant challenge. We discuss how successful design and integration of digital tools into care management would require reconceptualizing these professionals' roles in mental health support.

The effectiveness of nurse practitioner care for patients with mental health conditions in primary care settings: A systematic review

BACKGROUND

The nurse practitioner (NP) workforce is key to meeting the demand for mental health services in primary care settings.

PURPOSE

The purpose of this study is to synthesize the evidence focused on the effectiveness of NP care for patients with mental health conditions in primary care settings, particularly focused on primary care NPs and psychiatric mental health NPs and patients with anxiety, depression, and substance use disorders.

METHODS

Studies published since 2014 in the United States studying NP care of patients with anxiety, depression, or substance use disorders in primary care settings were included.

FINDINGS

Seventeen studies were included. Four high-quality studies showed that NP evidence-based care and prescribing were comparable to that of physicians. Seven low-quality studies suggest that NP-led collaborative care is associated with reduced symptoms.

DISCUSSION

More high-quality evidence is needed to determine the effectiveness of NP care for patients with mental health conditions in primary care settings.

Integrated Care for Complicated Patients: A Role for Combined Training and Practice

Patients with chronic medical disease frequently have comorbid psychiatric illness, yet mental and physical healthcare is frequently siloed in the United States. Integrated behavioral healthcare models, such as medicine-psychiatry services, are feasible, improve patient outcomes, and reduce costs. The Duke University Hospital medicine-psychiatry service provides holistic patient care and serves as a model for those interested in developing combined services or training programs elsewhere. Combined residency training in psychiatry is a way to provide a workforce of physician-scientist educators adept at providing coordinated, integrated care for complex patients with comorbid illness.

Payment strategies for behavioral health integration in hospital-affiliated and non-hospital-affiliated primary care practices

Recent value-based payment reforms in the U.S. called for empirical data on how primary care practices of varying characteristics fund their integrated behavioral health services. To describe payment strategies used by U.S. primary care practices to fund behavioral health integration and compare strategies between practices with and without hospital affiliation.Baseline data were used and collected from 44 practices participating in a cluster-randomized, pragmatic trial of behavioral health integration. Data included practice characteristics and payment strategies-fee-for-service payment, pay-for-performance incentives, grants, and graduate medical education funds. Descriptive and comparative analyses using Fisher's exact tests and independent T-tests were conducted. The sample had 26 (59.1%) hospital-affiliated (hospital/health system-owned, academic medical centers and hospital-affiliated practices) and 18 (40.9%) non-hospital-affiliated practices (community health centers/federally qualified health centers and privately-owned practices). Most practices (88.6%) received payments through fee-for-service; 63.6% received pay-for-performance incentives; 31.8% received grant funds. Collaborative Care Management billing (CPT) codes were used in six (13.6%) practices. Over half (53.8%) of hospital-affiliated practices funded their behavioral health services through fee-for-service and pay-for-performance incentives only, as opposed to two-thirds (66.7%) of non-hospital-affiliated practices required additional support from grants and/or general medical education funds. Primary care practices support behavioral health integration through diverse payment strategies. More hospital-affiliated practices compared to non-hospital-affiliated practices funded integrated behavioral health services through fee-for-service and pay-for-performance incentives. Practices without hospital affiliation relied on multiple funding streams including grants and/or general medical education funds, suggesting their approach to financial sustainment may be more precarious or challenging, compared to hospital-affiliated practices.

Novel Approach to Integrating Mental Health Care into a Primary Care Setting: Development, Implementation, and Outcomes

It is now widely accepted that there is a growing discrepancy between demand and access to adequate treatment for behavioral or mental health conditions in the United States. This results in immense personal, societal, and economic costs. One rapidly growing method of addressing this discrepancy is to integrate mental health services into the primary care setting, which has become the de facto service provider for these conditions. In this paper, we describe the development and implementation of a novel integrated care program in a large mid-western university-based healthcare system, drawn from the collaborative care model, and describe the benefits in terms of both health care utilization and depression outcomes. Limitations and proposed future directions are discussed.

Implementing collaborative care for major depression in a cancer center: An observational study using mixed-methods

OBJECTIVES

To describe the implementation of a collaborative care (CC) screening and treatment program for major depression in people with cancer, found to be effective in clinical trials, into routine outpatient care of a cancer center.

METHOD

A mixed-methods observational study guided by the RE-AIM implementation framework using quantitative and qualitative data collected over five years.

RESULTS

Program set-up took three years and required more involvement of CC experts than anticipated. Barriers to implementation were uncertainty about whether oncology or psychiatry owned the program and the hospital's organizational complexity. Selecting and training CC team members was a major task. 90% (14,412/16,074) of patients participated in depression screening and 61% (136/224) of those offered treatment attended at least one session. Depression outcomes were similar to trial benchmarks (61%; 78/127 patients had a treatment response). After two years the program obtained long-term funding. Facilitators of implementation were strong trial evidence, effective integration into cancer care and ongoing clinical and managerial support.

CONCLUSION

A CC program for major depression, designed for the cancer setting, can be successfully implemented into routine care, but requires time, persistence and involvement of CC experts. Once operating it can be an effective and valued component of medical care.

Incorporating Behavioral Health Providers onto Inpatient Medical Teams: A Feasibility Study

Behavioral health providers (BHPs) have long been incorporated into clinical medical settings, however, they have yet to be included in inpatient hospital settings. Inclusion of BHPs in this setting is logical given the high rates of psychosocial problems experienced by hospitalized patients and because BHPs can effectively treat psychosocial challenges, including mental health disorders and behavioral health difficulties. We worked to determine the feasibility of incorporating BHPs onto the inpatient medical team and to discover if integrating BHPs onto the team could decrease the barriers present in standard consult-liaison models of care. Researchers collected information on patient and provider satisfaction with BHP services and tracked admission diagnosis, reasons for referral, and interventions delivered. Results indicated that the integration of BHPs onto the inpatient team is feasible and reduces numerous barriers. The incorporation of BHPs onto inpatient medical teams can mitigate barriers experienced within the current consult-liaison model.

Caring for Families Impacted by Opioid Use: A Qualitative Analysis of Integrated Program Designs

OBJECTIVE

We sought to 1) identify models of integrated care that offer medical care and social services for children and families impacted by opioid use disorder (OUD) in the postpartum year; and 2) describe how each program was developed, designed, and sustained, and explore facilitators and barriers to implementation of a dyadic, two-generation approach to care.

METHODS

In-depth semi-structured interviews (n = 23) were conducted with programs for women and children affected by OUD across North America. Using a phenomenologic approach, key program components and themes were identified. Following thematic saturation, these results were triangulated with experts in program implementation and with a subset of key informants to ensure data integrity.

RESULTS

Five distinct types of programs were identified that varied in the degree of medical and behavioral care for families. Three themes emerged unique to the provision of dyadic care: 1) families require supportive, frequent visits with a range of providers, but constraints around billable services limit care integration across the perinatal continuum; 2) individual program champions are critical, but degree and reach of interdisciplinary care is limited by siloed systems for medical and behavioral care; and 3) addressing dual, sometimes competing, responsibilities for both parental and infant health following recurrence of parental substance use presents unique challenges.

CONCLUSIONS

The key components of dyadic care models for families impacted by OUD included prioritizing care coordination, removing barriers to integrating medical and behavioral services, and ensuring the safety of children in homes with ongoing parental substance use while maintaining parental trust.

Provider perspectives on a clinical demonstration project to transition patients with stable mental health conditions to primary care

Research to improve access to mental healthcare often focuses on increasing timely referrals from primary care (PC) to specialty mental health (SMH). However, timely and appropriate transitions back to PC are indispensable for increasing access to SMH for new patients. We developed and implemented a formalized process to identify patients eligible for transition from SMH to PC. The FLOW intervention was piloted at a Veterans Health Administration community-based outpatient clinic. Qualitatively examine provider perspectives regarding patient transitions at initiation and termination of the FLOW project. Sixteen mental health providers and three PC staff completed qualitative interviews about the benefits and drawbacks of FLOW at initiation. Ten mental health providers and one PC staff completed interviews at 12-month follow-up. Primary benefits anticipated at initiation were that FLOW would increase access to SMH, provide acknowledgment of veterans' recovery, and differentiate between higher and lower intensity mental health services. SMH providers reported additional perceived benefits at 12-month follow-up, including decreased stress over their caseloads and increased ability to deliver efficient, effective treatment. Anticipated drawbacks at initiation were that veterans would get inconsistent care, PC could not offer the same level of care as SMH, and veterans might view transition as a rejection by their SMH provider. Perceived drawbacks were similar at 12-month follow-up, but there was less frequent endorsement. Findings highlight need for sustained and frequent provider education regarding (i) the appropriate characteristics of individuals eligible for transition and (ii) established procedures to ensure care coordination during and after transition.

Integrated Behavioral Health Care: Reflections of the Past

Humans have long sought to be provided with optimal health care, and the research continues in the twenty-first century. In the spirit of Galen from 19 centuries ago, empowering the patient's physician remains an important approach in health care. There is an emphasis on primary care and integration of behavioral consultation services in primary care. It remains a work in progress with help from the past and realistic hope for the future.

Adapting practice in mental healthcare settings during the COVID-19 pandemic and other contagions: systematic review

BACKGROUND

During the global COVID-19 pandemic, there has been guidance concerning adaptations that physical healthcare services can implement to aid containment, but there is relatively little guidance for how mental healthcare services should adapt service provision to better support staff and patients, and minimise contagion spread.

AIMS

This systematic review explores service adaptations in mental health services during the COVID-19 pandemic and other contagions.

METHOD

The Allied and Complementary Medicine database (AMED), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, Medline, PsycINFO and Web of Science were systematically searched for published studies from database inception to April 2020. Data were extracted focusing on changes to mental health services during contagion outbreaks. Data were analysed with thematic analysis.

RESULTS

Nineteen papers were included: six correspondence/point-of-view papers, five research papers, five reflection papers, two healthcare guideline documents and one government document. Analysis highlighted four main areas for mental health services to consider during contagion outbreaks: infection control measures to minimise contagion spread, including procedural and practical solutions across different mental health settings; service delivery, including service changes, operational planning and continuity of care; staff well-being (psychological and practical support); and information and communication.

CONCLUSIONS

Mental health services need to consider infection control measures and implement service changes to support continuity of care, and patient and staff well-being. Services also need to ensure they are communicating important information in a clear and accessible manner with their staff and patients, regarding service delivery, contagion symptoms, government guidelines and well-being.

Complex care pathways for children with multiple referrals demonstrated in a retrospective population-based study

AIM

To identify children with complex medical needs by examining their patterns of hospital care.

METHODS

We conducted a retrospective population-based study on 18 577 patients aged 6-12 years from the Haukeland University Hospital register over a 3-year period (from 2013 to 2015). Data were structured to examine the temporal patterns and sequences of referrals, care episodes and diagnoses, including flow across medical specialties.

RESULTS

Over a third of patients had repeated referrals, and 14.9% of all had three or more. Furthermore, 9.3% of patients were referred to both somatic and mental healthcare services. Patients with such combined referrals had a higher number of referrals as well as a higher number of different diagnoses. Overall, there was a high frequency of non-specific diagnoses, and 34.8% of patients still had a non-specific main diagnosis at the end of their hospital contact.

CONCLUSION

This study demonstrates an increased risk for complex care pathways in children with multiple referrals. Interdisciplinary patterns of referrals were relatively common, particularly for patients in mental health care. These findings highlight the importance of developing interdisciplinary-based approaches for patients with complex complaints.

Integrating Mental Health and Addiction Treatment Into General Medical Care: The Role of Policy

Interventions that integrate care for mental illness or substance use disorders into general medical care settings have been shown to improve patient outcomes in clinical trials, but efficacious models are complex and difficult to scale up in real-world practice settings. Existing payment policies have proven inadequate to facilitate adoption of effective integrated care models. This article provides an overview of evidence-based models of integrated care, discusses the key elements of such models, considers how existing policies have fallen short, and outlines future policy strategies. Priorities include payment policies that adequately support structural elements of integrated care and incentivize multidisciplinary team formation and accountability for patient outcomes, as well as policies to expand the specialty mental health and addiction treatment workforce and address the social determinants of health that disproportionately influence health and well-being among people with mental illness or substance use disorders.

Understanding Health Talk in Behavioral Health Encounters: A Qualitative Analysis

Although physical and behavioral health conditions commonly cooccur, best practices making behavioral health treatment responsive to clients' health needs are limited. Particularly little is known about how physical health is addressed by clinicians within routine therapeutic treatment. This study describes the frequency and type of health talk occurring within integrated behavioral health sessions, and explores how this talk functions within ongoing therapeutic work. Participants in this study included 51 dyads of clinical social workers (n = 13) and clients (n = 51) receiving therapy within an integrated community health and behavioral health center. Therapy sessions were recorded and transcribed verbatim. Content analysis determined the frequency and content of health talk in sessions. Thematic analysis was used to understand the function of health talk within these visits. Health talk occurred in 92% (n = 47) of sessions. Clients initiated the majority of discussions. Talk about sleep (40%, n = 19), diet/exercise (35%, n = 16), and chronic health conditions (28%, n = 13) were most common. Health talk either complimented or conflicted with therapeutic work, depending on the topic discussed and when it occurred during session. Health talk changed the scope of therapeutic work by integrating care coordination into routine practice. Health talk was pervasive and was frequently initiated by clients, signaling its relevance to clients' recovery. Providers leveraged heath talk to complement their therapeutic work, but these strategies were not universally applied. Care coordination activities were a part of routine therapy. Practice and policy changes that support a more interdisciplinary approach to clinical work are needed.

Implementation of perinatal collaborative care: a health services approach to perinatal depression care

Aim:

Our objective was to integrate lessons learned from perinatal collaborative care programs across the United States, recognizing the diversity of practice settings and patient populations, to provide guidance on successful implementation.

Background:

Collaborative care is a health services delivery system that integrates behavioral health care into primary care. While efficacious, effectiveness requires rigorous attention to implementation to ensure adherence to the core evidence base.

Methods:

Implementation strategies are divided into three pragmatic stages: preparation, program launch, and program growth and sustainment; however, these steps are non-linear and dynamic.

Findings:

The discussion that follows is not meant to be prescriptive; rather, all implementation tasks should be thoughtfully tailored to the unique needs and setting of the obstetric community and patient population. In particular, we are aware that implementation on the level described here assumes commitment of both effort and money on the part of clinicians, administrators, and the health system, and that such financial resources are not always available. We conclude with synthesis of a survey of existing collaborative care programs to identify implementation practices of existing programs.

Primary care reform and funding equity for mental health disorders in Ontario: a retrospective observational population-based study

BACKGROUND

Mental health disorders are associated with high morbidity and reduced life expectancy, and are largely managed in primary care. We sought to assess the equity of distribution of new alternative payment models and teams introduced under primary care reform in Ontario for patients with mental health disorders.

METHODS

We conducted a retrospective observational study using population-level administrative data for insured Ontario adults (age ≥ 18 yr) to identify all primary care payments to physicians that were allocated to individual patients in 2002/03 and 2011/12. We identified patients with mental health disorders using validated algorithms, and modelled the relations between per capita primary care costs and mental health disorders over time, stratified by type of mental health or substance use disorder and type of primary care payment. In an adjusted model, we adjusted for age, sex, rurality, neighbourhood income quintile, immigrant status, comorbidity and primary care model. For comparative purposes, we also examined the distribution of primary care payments for people with diabetes mellitus.

RESULTS

Total per capita primary care payments increased more slowly over the study period for patients with mental health disorders (62.0%) than for the general population (88.3%). Total payments for patients with substance use disorders increased by 142.7%, largely owing to urine drug testing in opioid substitution clinics. Adjusted total payments for those with versus without mental health disorders decreased by 10% between 2002/03 and 2011/12, driven by lower alternative payments. Similar decreases, also driven by lower alternative payments, were found for all mental health disorder subgroups except substance use and for diabetes.

INTERPRETATION

Payment and team reforms were associated with inequitable resource allocation to people with mental health disorders. The findings suggest the need for monitoring reforms for their impact on high-needs populations and making appropriate adjustments.

Interprofessional Substance Use Disorder Education in Health Professions Education Programs: A Scoping Review

PURPOSE

The authors conducted this scoping review to (1) provide a comprehensive evaluation and summation of published literature reporting on interprofessional substance use disorder (SUD) education for students in health professions education programs and (2) appraise the research quality and outcomes of interprofessional SUD education studies. Their goals were to inform health professions educators of interventions that may be useful to consider as they create their own interprofessional SUD courses and to identify areas of improvement for education and research.

METHOD

The authors searched 3 Ovid MEDLINE databases (MEDLINE, In-Process & Other Non-Indexed Citations, and Epub Ahead of Print), Embase.com, ERIC via FirstSearch, and Clarivate Analytics Web of Science from inception through December 7, 2018. The authors used the Medical Education Research Study Quality Instrument (MERSQI) to assess included studies' quality.

RESULTS

The authors screened 1,402 unique articles, and 14 met inclusion criteria. Publications dated from 2014 to 2018. Ten (71%) included students from at least 3 health professions education programs. The mean MERSQI score was 10.64 (SD = 1.73) (range, 7.5-15). Interventions varied by study, and topics included general substance use (n = 4, 29%), tobacco (n = 4, 29%), alcohol (n = 3, 21%), and opioids (n = 3, 21%). Two studies (14%) used a nonrandomized 2-group design. Four (29%) included patients in a clinical setting or panel discussion. Ten (72%) used an assessment tool with validity evidence. Studies reported interventions improved students' educational outcomes related to SUDs and/or interprofessionalism.

CONCLUSIONS

Interprofessional SUD educational interventions improved health professions students' knowledge, skills, and attitudes toward SUDs and interprofessional collaboration. Future SUD curriculum design should emphasize assessment and measure changes in students' behaviors and patient or health care outcomes. Interprofessional SUD education can be instrumental in preparing the future workforce to manage this pressing and complex public health threat.

Examining health care providers' and middle-level managers' readiness for change: a qualitative study

Background

Readiness is a critical precursor of successful change; it denotes whether those involved in the change are motivated and empowered to participate in the change. Research on readiness tends to focus on frontline providers or individuals in non-managerial positions and offers limited attention to individuals in middle management positions who are expected to lead frontline providers in change implementation. Yet middle-level managers are also recipients of changes that are planned and decreed by those in higher positions. This study sought to examine both frontline provider and middle manager readiness for change in the context of primary care program integration.

Methods

Using a qualitative case study approach, we examined how frontline providers and middle managers experienced six readiness factors: discrepancy, appropriateness, valence, efficacy, fairness and trust in management. Data were collected through documents, meeting observation and semi-structured interviews with frontline providers and middle managers involved in the change.

Results

The findings highlighted similarities and differences in readiness experiences of frontline providers and middle managers. Across both types of participants, we found that the notion of valence should be expanded to consider individuals’ evaluation of benefits to patients and the health system; efficacy applies to both content and process of change; fairness and trust in management findings require further exploration to determine their appropriateness to be incorporated in models of readiness for change; and trust in management (or lack of trust) has a cascading influence across the levels in the organization.

Conclusions

Our study makes a contribution by nuancing and extending conceptualizations of individual readiness factors, and by highlighting the central role of middle manager readiness for change. Implications of the study include the need to consider readiness factors prior to the implementation of change and the importance of fostering readiness throughout all levels of the organization.

Lessons learned from the implementation of a medically enhanced residential treatment (MERT) model integrating intravenous antibiotics and residential addiction treatment

BACKGROUND

Hospitalizations for severe infections associated with substance use disorder (SUD) are increasing. People with SUD often remain hospitalized for many weeks instead of completing intravenous antibiotics at home; often, they are denied skilled nursing facility admission. Residential SUD treatment facilities are not equipped to administer intravenous antibiotics. We developed a medically enhanced residential treatment (MERT) model integrating residential SUD treatment and long-term IV antibiotics as part of a broader hospital-based addiction medicine service. MERT had low recruitment and retention, and ended after six months. The goal of this study was to describe the feasibility and acceptability of MERT, to understand implementation factors, and explore lessons learned.

METHODS

We conducted a mixed-methods evaluation. We included all potentially eligible MERT patients, defined by those needing ≥2 weeks of intravenous antibiotics discharged from February 1 to August 1, 2016. We used chart review to identify diagnoses, antibiotic treatment location, and number of recommended and actual IV antibiotic-days completed. We audio-recorded and transcribed key informant interviews with patients and staff. We conducted an ethnographic analysis of interview transcripts and implementation field notes.

RESULTS

Of the 45 patients needing long-term intravenous antibiotics, 18 were ineligible and 20 declined MERT. 7 enrolled in MERT and three completed their recommended intravenous antibiotic course. MERT recruitment barriers included patient ambivalence towards residential treatment, wanting to prioritize physical health needs, and fears of untreated pain in residential. MERT retention barriers included high demands of residential treatment, restrictive practices due to PICC lines, and perceptions by staff and other residents that MERT patients "stood out" as "different." Despite the challenges, key informants felt MERT was a positive construct.

CONCLUSIONS

Though MERT had many possible advantages; it proved more challenging to implement than anticipated. Our lessons may be applicable to future models integrating post-hospital intravenous antibiotics and SUD care.

Cooperative Extension Gets Moving, but How? Exploration of Extension Health Educators' Sources and Channels for Information-Seeking Practices

PURPOSE

The Cooperative Extension System (Extension) has implemented concerted efforts toward health promotion in communities across the nation by acting as an intermediary between communities and universities. Little is known about how these intermediaries communicate and learn about existing evidence-based programming. This study serves to explore this gap by learning about information sources and channels used within Extension.

DESIGN

Sequential explanatory mixed methods approach.

SETTING

National Cooperative Extension System.

PARTICIPANTS

Extension community-based health educators.

METHODS

A nationally distributed survey with follow-up semistructured interviews. Survey results were analyzed using a Kruskal-Wallis 1-way analysis of variance test paired with Bonferroni post hoc. Transcripts were analyzed by conventional content analysis.

RESULTS

One hundred twenty-one Extension educators from 33 states responded to the survey, and 18 of 20 invited participants completed the interviews. Educators' information seeking existed in 2 forms: (1) information sources for learning about programming and (2) channels by which this information is communicated. Extension educators reported contacting health specialists and other educators. Extension educators also reported using technological means of communication such as e-mail and Internet to reach information sources such as peers, specialists, academic journals, and so on.

CONCLUSION

Extension state specialists were preferred as primary sources for intervention information, and technology was acknowledged as an easy contact channel. This study identifies county-based health educators' information structures and justifies the need for future research on the role of specialists in communication efforts for educators.

Quality improvement and models of behavioral healthcare integration: Position paper #2 from the International Society of Psychiatric-Mental Health Nurses

This is the second article in a series written to present and address the position of the International Society of Psychiatric-Mental Health Nurses (ISPN) related to the notion of behavioral healthcare integration and the role of nurses in the 21st century. The first article addressed assumptions, definitions and roles related to the integration of behavioral healthcare. The purpose of this article is to focus on Integrated Care within the context of recent initiatives that endeavor to improve quality, safety and reduce costs in the US healthcare system also known as the "Triple Aim" (or more recently, the Quadruple Aim). This paper specifically focuses on the role of nurses and nursing practice by: (a) connecting the concept of integrated behavioral healthcare to quality improvement (QI) and the Quadruple Aim, and (b) highlighting examples of models of integration currently in use. Discussion of models of integration compares ways various models reinforce and actualize integration of behavioral health within primary care, in various special populations across the continuum of care, and in both inpatient and community settings. This paper also stresses innovative training programs offering nurses the skills for learning behavioral health integration through online modules and participation in Interprofessional Education (IPE) activities often through simulation approaches. This 2nd manuscript is consistent with the ISPN 2016 Position Paper and reinforces the necessity for all nurses to be educated on both the Quadruple Aim and behavioral health integration to improve patient care and subsequent care outcomes.

The Next Step in Integrated Care: Universal Primary Mental Health Providers

Current models of mental health care often do not address three barriers to mental health: the binary view of mental illness (healthy vs. mentally ill), stigma, and prevention. Care models where some patients are selected for referral or consultation with a mental health professional can reinforce this binary view and the stigma associated with seeing mental health services. By only selecting patients who currently are experiencing mental health problems, current integrated care models do not offer sufficient avenues for prevention. To address these barriers, this article proposes building on current models through the development of primary mental health providers (PMHPs). PMHPs-like primary care providers-would provide regular check-ups, assessments, prevention interventions, first-line treatment, or referral to more specialized professionals. This universal approach will help decrease the binary view of mental health, decrease the stigma of seeing a mental health professional through universal access, and improve prevention efforts.

Behavioral health conditions and potentially preventable diabetes-related hospitalizations in the United States: Findings from a national sample of commercial claims data

Objective

To characterize the relationship between potentially preventable hospitalizations (PPHs) for diabetes and behavioral health conditions in commercially insured working-age persons with diabetes in the United States.

Research design and methods

We retrospectively analyzed medical and pharmacy claims from services rendered between 2011 and 2013 for 229,039 adults with diabetes. Diabetes PPHs were identified using the Agency for Healthcare Research and Quality’s Prevention Quality Indicators v6.0 logic. We used negative binomial-logit hurdle regression models to explore the adjusted relationships between diabetes PPHs and schizophrenia, bipolar, depression, anxiety, adjustment disorder, alcohol use disorder, and drug use disorder.

Results

A total of 4,521 diabetes PPHs were experienced by 3,246 of the persons in the sample. The 20.83% of persons with one or more behavioral health conditions experienced 43.62% (1,972/4,521; 95% CI 42.18%-45.07%) of all diabetes PPHs, and the 7.14% of persons with more than one diagnosed behavioral health condition experienced 24.77% (1,120/4,521; 95% CI 23.54%-26.05%) of all diabetes PPHs. After adjusting for sociodemographic and physical health covariates, patients with depression, schizophrenia, drug or alcohol use disorders, or multiple behavioral health conditions were at significantly increased risk of experiencing at least one diabetes PPH, while patients with depression, drug use disorder, or multiple behavioral health conditions were at significantly increased risk of experiencing recurring diabetes PPHs over time.

Conclusions

A number of behavioral health conditions are associated with diabetes PPHs, which are often preventable with timely, high-quality outpatient care. The results of this study will enable clinicians, payers, and policy-makers to better focus outpatient care interventions and resources within the population of persons with diabetes.

Addressing Mental Health Concerns in Primary Care: Practices Among Medical Residents in a Rural Setting

Behavioral health issues like anxiety and depression negatively impact numerous aspects of primary care, including medical regimen adherence, communication, physical well-being, and engagement in beneficial health behaviors. This study aimed to examine internal and family medicine residents': (1) patterns of addressing mental health concerns (e.g., frequency of referral for psychotherapy and/or medication), (2) self-perceptions of competency in assessment and treatment of specific mental health disorders, and (3) frequency of utilization of efficacious therapeutic strategies during clinical encounters. Self-report surveys were administered to Family Medicine and Internal Medicine residents (N = 39). Descriptive analyses indicated that 81% of the time, residents discussed mental health concerns when it was the presenting concern, and routinely offered medication and psychotherapy (71% and 68% of the time, respectively). Residents felt most competent in addressing major depressive disorder and generalized anxiety disorder, and least competent in addressing somatization disorder and bipolar disorder. Residents reported that they most often used motivational interviewing (MI), followed by Cognitive Behavioral Therapy, psychoeducation, and solution-focused strategies during medical encounters. These findings highlight a need to identify barriers to addressing mental health conditions in primary care and potential gaps in training that might address low levels of perceived competency among medical residents.

Patient Transfer Decision Difficulty Scale: Development and psychometric testing of emergency department visits by long-term care residents

Background and objectives

Nurses serve as gatekeepers of the health of long-term care facility (LTCF) residents and are key members deciding whether residents should visit an emergency department (ED). Inappropriate decisions as to ED visits may result in ED overcrowding, excessive medical expenses, and nosocomial infections. Currently, there is a lack of effective tools for assessing the barriers and level of difficulty experienced by LTCF nurses. The purposes of this study were to develop a Patient Transfer Decision Difficulty Scale (PTDDS) and test its effectiveness.

Methods

This study randomly sampled LTCFs in Taiwan and surveyed two or three nurses in every institution selected. Registered return envelopes were provided for participants to return self-completed questionnaires. Three steps were used to develop the scale and items: in step I, the instrument was developed; in step II, psychometric testing was conducted, which entailed performing an exploratory factor analysis (EFA) to verify the construct validity and reliability of the developed items; and in step III, a confirmation study was conducted using a confirmatory factor analysis (CFA) and structural equation modeling to cross-validate the factors and items.

Results

The cumulative sum of variance explained by the measurement models of the three factors in the PTDDS was 63.54%.When deciding whether to transfer LTCF residents to EDs, the most pronounced barrier experienced by nurses were for judging the severity of “clinical episodes”, which had an explanatory power of 37.49%. The second and third pronounced barriers and decision difficulty experienced by nurses were “communication and information” and “timing of the residents’ emergency visits,” which explained 16.81% and 9.24% of the variance, respectively.

Conclusions

The cross-validation results obtained using the EFA and CFA showed favorable reliability and validity of the PTDDS. For future studies, this study recommends performing large-scale investigations of the level of decision difficulty and related factors experienced by nurses in LTCFs of varying levels and types.

A Behavioral Health Survey of Primary Care Integration in Rhode Island

Background

Integrating behavioral and primary care practices improves quality of care, but limited data exists regarding the extent or attributes of such integration. We conducted a baseline evaluation of the level and characteristics of integrated practices in Rhode Island.

Methods

The Rhode Island Department of Health 2015 Statewide Health Inventory Behavioral Health Survey was sent to behavioral health clinics and outpatient psychiatry and psychology practices. Survey questions assessed indicators of integration, including colocation, shared electronic medical records (EMRs), and shared communication systems.

Results

Only 19%, 9%, and 17% of behavioral health clinics, psychiatrists, and psychologists, respectively reported any integration with primary care practices. Compared to psychology (3.5%) and psychiatry (0.0%) practices, behavioral health clinics reported the highest level of practice colocation (10.4%, P<0.05). Compared to non-colocated practices, colocated behavioral health clinics reported higher levels of integration by other indicators, including shared EMRs (33.0% vs 0.0%, P=0.01).

Conclusion

This statewide survey demonstrated that limited integration exists between behavioral health and primary care practices in Rhode Island, and that such integration has a range of characteristics and levels. More practice integration is needed to ensure the delivery of high-quality, evidence-based care to the millions of individuals living with cooccurring behavioral and physical health needs.

Better care through an optimized mental health services continuum (Eastern Townships, Québec, Canada): A systematic and multisource literature review

INTRODUCTION

In 2014, the health authorities of the Eastern Townships (Québec, Canada) commissioned an evaluation of the mental health admission system for adults (GASMA) to identify the best GASMA organizational or structural elements and optimize the mental health services continuum.

METHODS

To develop better services, seven indicators (ie, accessibility to services, integration of levels of services, user satisfaction, guidance and management time, evaluation tools, professional composition, and interprofessional collaboration) were examined through four evaluation questions. A three-step systematic and multisource evaluation was realized. A systematic review of the scientific and gray literature was performed. This evaluation also included key informant opinions to contextualize results from this review.

RESULTS

Results from 91 scientific articles, 40 gray literature documents, and 10 interviews highlighted determinants and barriers associated with the examined indicators. From these results, 24 preliminary recommendations were formulated and discussed in a steering committee. These recommendations were then weighted and validated. This served to formulate three final recommendations.

CONCLUSION

To optimize the regional mental health services continuum, stakeholders should (1) implement a single-window access for adults with mental health needs, (2) develop alternative services based on users' needs, and (3) test the effectiveness of new methods, initiatives, and tools.

Access to treatment for alcohol use disorders following Oregon's health care reforms and Medicaid expansion

The study examines impacts of delivery system reforms and Medicaid expansion on treatment for alcohol use disorders within the Oregon Health Plan (Medicaid). Diagnoses, services and pharmacy claims related to alcohol use disorders were extracted from Medicaid encounter data. Logistic regression and interrupted time series analyses assessed the percent with alcohol use disorder entering care and the percent receiving pharmacotherapy before (January 2010-June 2012) and after (January 2013-June 2015) the initiation of Oregon's Coordinated Care Organization (CCO) model (July 2012-December 2012). Analyses also examined changes in access following Medicaid expansion (January 2014). Treatment entry rates increased from 35% in 2010 to 41% in 2015 following the introduction of CCOs and Medicaid expansion. The number of Medicaid enrollees with a diagnosed alcohol use disorder increased about 150% from 10,360 (2013) to 25,454 (2014) following Medicaid expansion. Individuals with an alcohol use disorder who were prescribed a medication to support recovery increased from 2.3% (2010) to 3.8% (2015). In Oregon, Medicaid expansion and health care reforms enhanced access and improved treatment initiation for alcohol use disorders.

Understanding new models of integrated care in developed countries: a systematic review

Background

The NHS has been challenged to adopt new integrated models of service delivery that are tailored to local populations. Evidence from the international literature is needed to support the development and implementation of these new models of care.

Objectives

The study aimed to carry out a systematic review of international evidence to enhance understanding of the mechanisms whereby new models of service delivery have an impact on health-care outcomes.

Design

The study combined rigorous and systematic methods for identification of literature, together with innovative methods for synthesis and presentation of findings.

Setting

Any setting.

Participants

Patients receiving a health-care service and/or staff delivering services.

Interventions

Changes to service delivery that increase integration and co-ordination of health and health-related services.

Main outcome measures

Outcomes related to the delivery of services, including the views and perceptions of patients/service users and staff.

Study design

Empirical work of a quantitative or qualitative design.

Data sources

We searched electronic databases (between October 2016 and March 2017) for research published from 2006 onwards in databases including MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Science Citation Index, Social Science Citation Index and The Cochrane Library. We also searched relevant websites, screened reference lists and citation searched on a previous review.

Review methods

The identified evidence was synthesised in three ways. First, data from included studies were used to develop an evidence-based logic model, and a narrative summary reports the elements of the pathway. Second, we examined the strength of evidence underpinning reported outcomes and impacts using a comparative four-item rating system. Third, we developed an applicability framework to further scrutinise and characterise the evidence.

Results

We included 267 studies in the review. The findings detail the complex pathway from new models to impacts, with evidence regarding elements of new models of integrated care, targets for change, process change, influencing factors, service-level outcomes and system-wide impacts. A number of positive outcomes were reported in the literature, with stronger evidence of perceived increased patient satisfaction and improved quality of care and access to care. There was stronger UK-only evidence of reduced outpatient appointments and waiting times. Evidence was inconsistent regarding other outcomes and system-wide impacts such as levels of activity and costs. There was an indication that new models have particular potential with patients who have complex needs.

Limitations

Defining new models of integrated care is challenging, and there is the potential that our study excluded potentially relevant literature. The review was extensive, with diverse study populations and interventions that precluded the statistical summary of effectiveness.

Conclusions

There is stronger evidence that new models of integrated care may enhance patient satisfaction and perceived quality and increase access; however, the evidence regarding other outcomes is unclear. The study recommends factors to be considered during the implementation of new models.

Future work

Links between elements of new models and outcomes require further study, together with research in a wider variety of populations.

Study registration

This study is registered as PROSPERO CRD37725.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Integrated mental health services in China: challenges and planning for the future

Eager to build an integrated community-based mental health system, in 2004 China started the '686 Programme', whose purpose was to integrate hospital and community services for patients with serious mental illness. In 2015, the National Mental Health Working Plan (2015-2020) proposed an ambitious strategy for implementing this project. The goal of this review is to assess potential opportunities for and barriers to successful implementation of a community-based mental health system that integrates hospital and community mental health services into the general healthcare system. We examine 7066 sources in both English and Chinese: the academic peer-reviewed literature, the grey literature on mental health policies, and documents from government and policymaking agencies. Although China has proposed a number of innovative programmes to address its mental health burden, several of these proposals have yet to be fully activated, particularly those that focus on integrated care. Integrating mental health services into China's general healthcare system holds great promise for increased access to and quality improvement in mental health services, as well as decreased stigma and more effective management of physical and mental health comorbidities. This article examines the challenges to integrating mental health services into China's general healthcare system, especially in the primary care sphere, including: accurately estimating mental health needs, integrating mental and physical healthcare, increasing workforce development and training, resolving interprofessional issues, financing and funding, developing an affordable and sustainable mental health system, and delivering care to specific subpopulations to meet the needs of China's diverse populace. As China's political commitment to expanding its mental health system is rapidly evolving, we offer suggestions for future directions in addressing China's mental health needs.

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

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

Behavioral Health and the Comprehensive Primary Care (CPC) Initiative: findings from the 2014 CPC behavioral health survey

BACKGROUND

Incorporating behavioral health care into patient centered medical homes is critical for improving patient health and care quality while reducing costs. Despite documented effectiveness of behavioral health integration (BHI) in primary care settings, implementation is limited outside of large health systems. We conducted a survey of BHI in primary care practices participating in the Comprehensive Primary Care (CPC) initiative, a four-year multi-payer initiative of the Centers for Medicare and Medicaid Services (CMS). We sought to explore associations between practice characteristics and the extent of BHI to illuminate possible factors influencing successful implementation.

METHOD

We fielded a survey that addressed six substantive domains (integrated space, training, access, communication and coordination, treatment planning, and available resources) and five behavioral health conditions (depression, anxiety, pain, alcohol use disorder, and cognitive function). Descriptive statistics compared BHI survey respondents to all CPC practices, documented the availability of behavioral health providers, and primary care and behavioral health provider communication. Bivariate relationships compared provider and practice characteristics and domain scores.

RESULTS

One hundred sixty-one of 188 eligible primary care practices completed the survey (86% response rate). Scores indicated basic to good baseline implementation of BHI in all domains, with lowest scores on communication and coordination and highest scores for depression. Higher scores were associated with: having any behavioral health provider, multispecialty practice, patient-centered medical home designation, and having any communication between behavioral health and primary care providers.

CONCLUSIONS

This study provides useful data on opportunities and challenges of scaling BHI integration linked to primary care transformation. Payment reform models such as CPC can assist in BHI promotion and development.

What are the barriers and facilitators to implementing Collaborative Care for depression? A systematic review

BACKGROUND

Collaborative Care is an evidence-based approach to the management of depression within primary care services recommended within NICE Guidance. However, uptake within the UK has been limited. This review aims to investigate the barriers and facilitators to implementing Collaborative Care.

METHODS

A systematic review of the literature was undertaken to uncover what barriers and facilitators have been reported by previous research into Collaborative Care for depression in primary care.

RESULTS

The review identified barriers and facilitators to successful implementation of Collaborative Care for depression in 18 studies across a range of settings. A framework analysis was applied using the Collaborative Care definition. The most commonly reported barriers related to the multi-professional approach, such as staff and organisational attitudes to integration, and poor inter-professional communication. Facilitators to successful implementation particularly focussed on improving inter-professional communication through standardised care pathways and case managers with clear role boundaries and key underpinning personal qualities.

LIMITATIONS

Not all papers were independent title and abstract screened by multiple reviewers thus limiting the reliability of the selected studies. There are many different frameworks for assessing the quality of qualitative research and little consensus as to which is most appropriate in what circumstances. The use of a quality threshold led to the exclusion of six papers that could have included further information on barriers and facilitators.

CONCLUSIONS

Although the evidence base for Collaborative Care is strong, and the population within primary care with depression is large, the preferred way to implement the approach has not been identified.

Closing the False Divide: Sustainable Approaches to Integrating Mental Health Services into Primary Care

Mental disorders account for 25% of all health-related disability worldwide. More patients receive treatment for mental disorders in the primary care sector than in the mental health specialty setting. However, brief visits, inadequate reimbursement, deficits in primary care provider (PCP) training, and competing demands often limit the capacity of the PCP to produce optimal outcomes in patients with common mental disorders. More than 80 randomized trials have shown the benefits of collaborative care (CC) models for improving outcomes of patients with depression and anxiety. Six key components of CC include a population-based approach, measurement-based care, treatment to target strategy, care management, supervision by a mental health professional (MHP), and brief psychological therapies. Multiple trials have also shown that CC for depression is equally or more cost-effective than many of the current treatments for medical disorders. Factors that may facilitate the implementation of CC include a more favorable alignment of medical and mental health services in accountable care organizations and patient-centered medical homes; greater use of telecare as well as automated outcome monitoring; identification of patients who might benefit most from CC; and systematic training of both PCPs and MHPs in integrated team-based care.

Implications of Healthcare Payment Reform for Clinical Psychologists in Medical Settings

Health reform, post the passing of the Patient Protection and Affordable Care Act, has highlighted the need to better address critical issues such as primary care, behavioral health, and payment reform. Much of this need is subsequent to robust data showing the seemingly uncontrollable growth of healthcare costs, and the exacerbation of these costs for patients with comorbid behavioral health and medical conditions. There is increasing recognition that incorporating behavioral health in primary care leads to improved outcomes and better care. To address these problems, primary care will play critical roles across the healthcare system, especially in the delivery of behavioral health services. Psychologists are uniquely positioned to take advantage of this propitious moment and can help facilitate the integration of behavioral and primary care by developing competencies in integrated care, training a capable workforce, and advocating for integrated care as the status quo.

Payment reform in the patient-centered medical home: Enabling and sustaining integrated behavioral health care

The patient-centered medical home (PCMH) is a promising framework for the redesign of primary care and more recently specialty care. As defined by the Agency for Healthcare Research and Quality, the PCMH framework has 5 attributes: comprehensive care, patient-centered care, coordinated care, accessible services, and quality and safety. Evidence increasingly demonstrates that for the PCMH to best achieve the Triple Aim (improved outcomes, decreased cost, and enhanced patient experience), treatment for behavioral health (including mental health, substance use, and life stressors) must be integrated as a central tenet. However, challenges to implementing the PCMH framework are compounded for real-world practitioners because payment reform rarely happens concurrently. Nowhere is this more evident than in attempts to integrate behavioral health clinicians into primary care. As behavioral health clinicians find opportunities to work in integrated settings, a comprehensive understanding of payment models is integral to the dialogue. This article describes alternatives to the traditional fee for service (FFS) model, including modified FFS, pay for performance, bundled payments, and global payments (i.e., capitation). We suggest that global payment structures provide the best fit to enable and sustain integrated behavioral health clinicians in ways that align with the Triple Aim. Finally, we present recommendations that offer specific, actionable steps to achieve payment reform, complement PCMH, and support integration efforts through policy. (PsycINFO Database Record

Psychologists' Contributions to Patient-Centered Medical Homes

Mounting evidence supports the value of integrated healthcare and the need for interprofessional practice within patient-centered medical homes (PCMH). Incorporating behavioral health services is key to fully implementing the PCMH concept. Unfortunately, psychologists have not been front and center in this integrative and interprofessional care movement nor have they typically received adequate training or experience to work effectively in these integrated care programs. This article builds the case for the value of PCMHs, particularly those that incorporate behavioral health services. Attention is paid to the diverse roles psychologists play in these settings, including as direct service providers, consultants, teachers/supervisors, scholars/program evaluators, and leaders. There is a discussion of the competencies psychologists must possess to play these roles effectively. Future directions are discussed, with a focus on ways psychologists can bolster the PCMH model by engaging in interprofessional partnerships related to education and training, practice, research, and leadership.

Impact of interprofessional education about psychological and medical comorbidities on practitioners' knowledge and collaborative practice: mixed method evaluation of a national program

Background

Many patients with chronic physical illnesses have co-morbid psychological illnesses, which may respond to interprofessional collaborative care. Continuing education programs frequently focus on skills and knowledge relevant for individual illnesses, and unidisciplinary care. This study evaluates the impact of “Mind the Gap”, an Australian interprofessional continuing education program about management of dual illnesses, on practitioners’ knowledge, use of psychological strategies and collaborative practice.

Methods

A 6-h module addressing knowledge and skills needed for patients with physical and psychological co-morbid illnesses was delivered to 837 practitioners from mixed health professional backgrounds, through locally-facilitated workshops at 45 Australian sites. We conducted a mixed-methods evaluation, incorporating observation, surveys and network analysis using data collected, before, immediately after, and three months after training.

Results

Six hundred forty-five participants enrolled in the evaluation (58 % GPs, 17 % nurses, 15 % mental health professionals, response rate 76 %). Participants’ knowledge and confidence to manage patients with psychological and physical illnesses improved immediately. Among the subset surveyed at three months (response rate 24 %), referral networks had increased across seven disciplines, improvements in confidence and knowledge were sustained, and doctors, but no other disciplines, reported an increase in use of motivational interviewing (85.9 % to 96.8 %) and mindfulness (58.6 % to 74 %).

Conclusions

Interprofessional workshops had an immediate impact on the stated knowledge and confidence of participants to manage patients with physical and psychological comorbidities, which appears to have been sustained. For some attendees, there was a sustained improvement in the size of their referral networks and their use of some psychological strategies.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1720-z) contains supplementary material, which is available to authorized users.

Barriers and Facilitators to HIV Testing Among Women

AIM

The purpose of this secondary analysis was to analyze for barriers and facilitators to HIV testing in women attending community health clinics.

INTRODUCTION

The Centers for Disease Control and Prevention (CDC), reported that all women account for 20% or 1 in 5 of new HIV cases (CDC, 2012). Of those new cases in heterosexual women, 5,300 were Black, 1,300 were White, and 1,200 were Hispanic/Latina. The CDC estimated that in 2012 there were 9,268 individuals living with a diagnosis of HIV or AIDS, of which 19% were women.

RESULTS

The existing de-identified data consisted of thirty individual interviews conducted using a semi-structured interview guide was collected as the initial phase of the parent study, "HIV Testing and Women's Attitudes on HIV Vaccine Trials". This secondary analysis addressed the identification of key obstacles to HIV testing and only those related portions of the transcripts were analyzed. The major themes identified were familiarity with testing, stigma, fear, perceived risks, and access to care.

CONCLUSION

The themes implicated the need to further assess women for barriers and facilitators to testing, tailor community based interventions that have the ability to decrease fear and stigma, increase trust in testing methods and offer counseling to positive results.