Primary Care-Mental Health Integration in the VA: Shifting Mental Health Services for Common Mental Illnesses to Primary Care

Mental health care provision in community health centers and hospital emergency department utilization

OBJECTIVES

To examine whether community health centers (CHCs) are effective in offsetting mental health emergency department (ED) visits.

DATA SOURCES AND STUDY SETTING

The HRSA Uniform Data System and the HCUP State ED Databases for Florida patients during 2012-2019.

STUDY DESIGN

We identified CHC-year-specific service areas using patient origin zip codes. We then estimated panel data models for number of ED mental health visits per capita in a CHC's service area. Models measured CHC mental health utilization as number of visits, unique patients, and intensity (visits per patient).

PRINCIPAL FINDINGS

CHC mental health utilization increased approximately 100% during 2012-2019. Increased CHC mental health provision was associated with small reductions in ED mental health utilization. An annual increase of 1000 CHC mental health care visits (5%) was associated with 0.44% fewer ED mental health care visits (p = 0.153), and an increase of 1000 CHC mental health care patients (15%) with 1.9% fewer ED mental health care visits (p = 0.123). An increase of 1 annual mental health visit per patient was associated with 16% fewer ED mental health care visits (p = 0.011).

CONCLUSIONS

Results suggest that mental health provision in CHCs may reduce reliance on hospital EDs, albeit minimally. Policies that promote alignment of services between CHCs and local hospitals may accelerate this effect.

Co-occurring Medical Multimorbidity, Mental Illness, and Substance Use Disorders Among Older Criminal Legal System-Involved Veterans

BACKGROUND

Older veterans involved in the criminal legal system (CLS) may have patterns of multimorbidity that place them at risk for poor health outcomes.

OBJECTIVES

To estimate the prevalence of medical multimorbidity (≥2 chronic medical diseases), substance use disorders (SUDs), and mental illness among CLS-involved veterans aged 50 and older.

RESEARCH DESIGN

Using Veterans Health Administration health records, we estimated the prevalence of mental illness, SUD, medical multimorbidity, and the co-occurrence of these conditions among veterans by CLS involvement as indicated by Veterans Justice Programs encounters. Multivariable logistic regression models assessed the association between CLS involvement, the odds for each condition, and the co-occurrence of conditions.

SUBJECTS

Veterans aged 50 and older who received services at Veterans Health Administration facilities in 2019 (n=4,669,447).

METHODS

Mental illness, SUD, medical multimorbidity.

RESULTS

An estimated 0.5% (n=24,973) of veterans aged 50 and older had CLS involvement. For individual conditions, veterans with CLS involvement had a lower prevalence of medical multimorbidity compared with veterans without but had a higher prevalence of all mental illnesses and SUDs. After adjusting for demographic factors, CLS involvement remained associated with concurrent mental illness and SUD (adjusted odds ratio [aOR] 5.52, 95% CI=5.35-5.69), SUD and medical multimorbidity (aOR=2.09, 95% CI=2.04-2.15), mental illness and medical multimorbidity (aOR=1.04, 95% CI=1.01-1.06), and having all 3 simultaneously (aOR=2.42, 95% CI=2.35-2.49).

CONCLUSIONS

Older veterans involved in the CLS are at high risk for co-occurring mental illness, SUDs, and medical multimorbidity, all of which require appropriate care and treatment. Integrated care rather than disease-specific care is imperative for this population.

Effects of Virtual Care and Same-Day Access to Integrated Care on Specialty Mental Health Engagement in the Veterans Health Administration

BACKGROUND

In the Veterans Health Administration (VA), Primary Care-Mental Health Integration (PC-MHI) clinics offer mental health services embedded in primary care, a strategy shown to reduce overall specialty mental health clinic burden while facilitating prompt referrals when indicated. Among newly initiated patients, same-day access to PC-MHI from primary care increases subsequent specialty mental health engagement. However, the impact of virtual care on the association between same-day access to PC-MHI and subsequent mental health engagement remains unclear.

OBJECTIVE

To examine the effects of same-day access to PC-MHI and virtual care use on specialty mental health engagement.

METHODS

We used administrative data from 3066 veterans who initiated mental health care at a large, California VA PC-MHI clinic during 3/1/2018 to 2/28/2022 and had no previous mental health visits for at least 2 years prior to the index appointment. We conducted Poisson regression analyses to examine the effects of same-day access to PC-MHI, virtual access to PC-MHI and their combined effect on subsequent specialty mental health engagement.

RESULTS

Same-day access to PC-MHI from primary care was positively associated with specialty mental health engagement (IRR = 1.19; 95% CI 1.14-1.24). Virtual access to PC-MHI was negatively associated with specialty mental health engagement (IRR = 0.83; 95% CI 0.79-0.87). The positive effect of same-day access on specialty mental health engagement was smaller among patients who initiated PC-MHI in a virtual visit (IRR = 1.07) compared to in-person visits (IRR = 1.29; 95% CI 1.22-1.36).

CONCLUSIONS

Although same-day access to PC-MHI increased overall specialty mental health engagement, the magnitude of this effect varied between in-person and virtual modalities. More research is needed to understand mechanisms of the association between virtual care use, same-day access to PC-MHI, and specialty mental health engagement.

Prevalence and determinants of women's satisfaction on the quality of safe abortion service in Northwest Ethiopia

Background

The standard of treatment in developing countries is harmed by a complex political landscape, an uncertain economic climate, rapid population growth, and clients are constantly complaining about the poor health system. Patients’ assessments of the benefits and shortcomings of the service provided to them are expressed as satisfied or dissatisfied. The objective of this study was to determine the magnitude of women’s satisfaction on quality of safe abortion and factors associated with it in Northwest Ethiopia.

Methods

Institution-based cross-sectional study design was done to collect data from 618 women in the selected health facilities in Northwest Ethiopia. Women having the gestational trophoblastic disease (partial mole) and those who cannot hear or are seriously ill during the data collection period were excluded. The study subjects were chosen using a randomization process, and each participant was questioned after receiving all necessary abortion treatment and giving verbal consent. Both bivariable and multivariable logistic regression analysis was carried out to determine covariates significantly associated with women’s satisfaction on quality of abortion.

Results

The highest proportion of women who were reasoned out to terminate the fetus in the current pregnancy was due to financial problems (29.36%) and partner coercion (23.85%). Client satisfaction with safe abortion services in the study region was 25.10% (95% CI; 21.81–28.70). Women were 53.2% satisfied with the art of treatment/interpersonal abilities, 59.2% satisfied with the professional quality of care professionals, 54.5% satisfied with the physical environment, and 49.8% satisfied with the structure of the health care system, respectively. In the multivariable logistic regression analysis, women’s living solely 0.47(0.26–0.87) & living with 2 to 4 people 0.11(0.04–0.29), college and above level of education 1.78(1.01–3.15), wanted the status of pregnancy 0.44(0.23–0.85) and post-abortion contraceptive users 1.70(1.01–2.89) were factors significantly associated with women’s satisfaction level.

Conclusion

In this study, one-fourth of the women were satisfied with the quality of safe abortion services. Family size, women’s educational status, maternity status, and post-abortion contraception use were predictors of women’s satisfaction with the quality of abortion. Ethiopia’s government should concentrate on addressing contraception needs in order to prevent women from having multiple abortions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13690-022-00897-0.

Patient- and provider-level factors that underlie alcohol use disorder treatment offer and acceptance in veterans with cirrhosis

BACKGROUND

Untreated alcohol use disorder (AUD) is associated with poor cirrhosis outcomes. We evaluated factors associated with AUD treatment discussions and initiation in the Veterans Health Administration.

METHODS

Chart reviews were conducted for veterans with International Classification of Diseases codes for both cirrhosis and AUD who were receiving care at one of three large medical centers in 2020. Factors associated with a 1-year offer of AUD treatment and its acceptance were assessed using regression models, which included as covariates demographic characteristics, comorbidities, and depression, as measured by the patient health questionnaire (PHQ-2) from the electronic health record.

RESULTS

The cohort included 654 veterans, 68 of whom were engaged in AUD treatment at baseline and 174 who were documented as being in AUD remission. Treatment was offered to 264 (64%) of the 412 veterans with opportunities to initiate it. AUD treatment discussions were most often documented by practitioners in primary care (n = 162), hepatology (n = 45), or both (n = 41). Multivariable logistic regression modeling revealed that treatment was significantly more likely to be offered to patients with co-occurring bipolar disorder (OR 2.94, p = 0.03) or depression (1.50, p = 0.05) or who were younger (0.97, p = 0.01). Of the 264 patients offered AUD treatment, 107 (40%) agreed to initiate it. Acceptance of an offer of treatment was significantly associated with hospitalization in the prior year (OR 1.74, p = 0.05), prior AUD treatment (9.92, p < 0.0001), and a higher PHQ-2 depression score (2.85, p = 0.004).

CONCLUSIONS

We identified factors associated with an offer of AUD treatment and its initiation among veterans with cirrhosis. Application of these findings could increase the likelihood that veterans with alcoholic cirrhosis initiate AUD treatment.

Association of Team-Based Care and Continuity of Care with Hospitalizations for Veterans with Comorbid Mental and Physical Health Conditions

BACKGROUND

Integrating mental health in primary care settings is associated with improved screening and detection of mental illness. In 2010, the Veterans Health Administration launched a patient-centered medical home (PCMH) model nationally across all clinical sites that integrated mental health into primary care-the Patient Aligned Care Team (PACT) initiative. Team-based delivery of continuous primary and mental health care, as found in effective collaborative care models, is thought to be crucial to managing veterans with mental health disorders. The association between clinic implementation of specific aspects of PACT and clinical outcomes of veterans with mental health disorders remains unknown.

OBJECTIVE

To examine the association between clinic implementation of team-based care and continuity of care and subsequent hospitalizations among veterans with mental health disorders.

DESIGN

Retrospective cohort study.

PATIENTS

A total of 1,444,942 veterans with comorbid mental health disorders and physical health conditions receiving primary care in 831 VA PACT clinics in fiscal year (FY) 2015.

MAIN MEASURES

We examined the clinic-level implementation of team-based care and continuity of care in the clinic where veterans received their primary care. Our primary outcome was any hospitalization in the VA or fee-based service in FY2016. We examined the impact of clinic-level implementation of team-based care and continuity of care on having a hospitalization, adjusting for patient demographic, clinical characteristics, and facility characteristics.

KEY RESULTS

Veterans receiving care in clinics with the greatest versus lowest quartile of implementation of team-based care had lower rates of hospitalization (8.8% vs. 12.3%; adjusted OR = 0.92, 95% CI 0.85-0.99, p < 0.035). There was not a statistically significant association between clinic-level implementation of continuity of care and hospitalization.

CONCLUSIONS

Veterans receiving care in clinics with greater implementation of team-based care had statistically significant lower rates of hospitalization.

Integrating network theory into the study of integrated healthcare

Healthcare policy in the United States (U.S.) has focused on promoting integrated healthcare to combat fragmentation (e.g., 1993 Health Security Act, 2010 Affordable Care Act). Researchers have responded by studying coordination and developing typologies of integration. Yet, after three decades, research evidence for the benefits of coordination and integration are lacking. We argue that research efforts need to refocus in three ways: (1) use social networks to study relational coordination and integrated healthcare, (2) analyze integrated healthcare at three levels of analysis (micro, meso, macro), and (3) focus on clinical integration as the most proximate impact on patient outcomes. We use examples to illustrate the utility of such refocusing and present avenues for future research.

Mental health care integration and primary care patient experience in the Veterans Health Administration

BACKGROUND

Mental health specialists and care managers facilitate comprehensive care provision within medical homes. Despite implementation challenges, mental health integration is thought to improve patient-centered primary care.

OBJECTIVES

To examine the relationship between primary care patient experience and mental health integration.

RESEARCH DESIGN

Cross-sectional surveys from 168 primary care clinicians (PCPs) (n = 226) matched with assigned patients' surveys (n = 1734) in one Veterans Health Administration (VA) region, fiscal years 2012-2013. Multilevel regression models examined patient experience and mental health integration, adjusting for patient and PCP characteristics.

MEASURES

Patient experience outcomes were (1) experience with PCP and (2) receipt of comprehensive care, such as talked about "stress". Independent variables represented mental health integration- (1) PCP-rated communication with mental health and (2) proportion of clinic patients who saw integrated specialists.

RESULTS

50% and 43% of patients rated their PCPs 10/10 and reported receiving comprehensive care, respectively. Neither patient experience or receipt of comprehensive care was significantly associated with PCP's ratings of communication with mental health, nor with proportion of clinic patients who saw integrated specialists. Among a subsample of patients who rated their mental health as poor/fair, however, we detected an association between proportion of clinic patients who saw integrated specialists and patient experience (odds ratio = 1.05, 95% confidence interval = 1.01-1.09, p = .01).

CONCLUSIONS

No association was observed between mental health integration and primary care patients' reported care experiences, but a significant association existed among patients who reported poor/fair mental health. More research is needed to understand patient experiences with regard to care model implementation.

Treatment Differences in Primary and Specialty Settings in Veterans with Major Depression

INTRODUCTION

The Veterans Health Administration (VHA) supports the nation's largest primary care-mental health integration (PC-MHI) collaborative care model to increase treatment of mild to moderate common mental disorders in primary care (PC) and refer more severe-complex cases to specialty mental health (SMH) settings. It is unclear how this treatment assignment works in practice.

METHODS

Patients (n = 2610) who sought incident episode VHA treatment for depression completed a baseline self-report questionnaire about depression severity-complexity. Administrative data were used to determine settings and types of treatment during the next 30 days.

RESULTS

Thirty-four percent (34.2%) of depressed patients received treatment in PC settings, 65.8% in SMH settings. PC patients had less severe and fewer comorbid depressive episodes. Patients with lowest severity and/or complexity were most likely to receive PC antidepressant medication treatment; those with highest severity and/or complexity were most likely to receive combined treatment in SMH settings. Assignment of patients across settings and types of treatment was stronger than found in previous civilian studies but less pronounced than expected (cross-validated AUC = 0.50-0.68).

DISCUSSION

By expanding access to evidence-based treatments, VHA's PC-MHI increases consistency of treatment assignment. Reasons for assignment being less pronounced than expected and implications for treatment response will require continued study.

Improving Geropsychology Competencies of Veterans Affairs Psychologists

Older adults are more likely to seek mental health care through integrated care settings such as primary care. Currently, there exists a significant shortage of mental health providers trained in geropsychology and integrated care competencies. To address this need within the Veterans Health Administration, a national workforce development program was extended to include psychologists, which is called the Geriatric Scholars Program-Psychology Track (GSP-P). The GSP-P has two overarching educational program aims: (1) to improve geropsychology competencies of practicing VA psychologists, particularly those working within integrated settings (e.g., primary care) and (2) enrich psychologists' abilities to enact change in their clinical settings. Ninety-eight VA clinicians participated in the GSP-P, which includes a multi-day in-person course, from 2014 to 2018. Participants completed measures assessing confidence and self-reported knowledge in geropsychology and integrated care competencies pre-course and 3-months post-completion. Two-weeks post-course participants responded to open-ended survey questions regarding their perceptions of the course and potential applications of learning. Significant improvements in confidence in and knowledge of geropsychology and integrated care competencies emerged from pre-course to 3-months post-completion. Qualitative findings demonstrated that participants valued the face-to-face, integrated multimodal educational program. Findings provided insights regarding clinicians' planned application of the knowledge acquired, such as modifying treatments for older patients. Specialized workforce programs such as the GSP-P have a significant, positive impact on the care of older Veterans.

Does Mental Health Care Integration Affect Primary Care Clinician Burnout? Results from a Longitudinal Veterans Affairs Survey

BACKGROUND

Burnout among primary care clinicians (PCPs) is associated with negative health and productivity consequences. The Veterans Health Administration (VA) embedded mental health specialists and care managers in primary care to manage common psychiatric diseases. While challenging to implement, mental health integration is a team-based care model thought to improve clinician well-being.

OBJECTIVE

To examine the relationships between PCP-reported burnout (and secondarily, job satisfaction) and mental health integration at provider and clinic levels DESIGN: Analysis of 286 cross-sectional surveys in 2012 (n = 171) and 2013 (n = 115) PARTICIPANTS: 210 PCPs in one VA region MAIN MEASURES: Outcomes were PCP-reported burnout (Maslach Burnout Inventory emotional exhaustion subscale), and secondarily, job satisfaction. Two independent variables represented mental health integration: (1) PCP-specialty communication rating and (2) proportion of clinic patients who saw integrated specialists. Using multilevel regression models, we examined PCP-reported burnout (and job satisfaction) and mental health integration, adjusting for PCP characteristics (e.g., gender), PCP ratings of team functioning (communication, knowledge/skills, satisfaction), and organizational factors.

KEY RESULTS

On average, PCPs reported high burnout (29, range = 9-54) across all VA healthcare systems. In total, 46% of PCPs reported "very easy" communication with mental health; 9% of primary clinic patients had seen integrated specialists. Burnout was not significantly associated with mental health communication ratings (β coefficient = - 0.96, standard error [SE] = 1.29, p = 0.46), nor with proportion of clinic patients who saw integrated specialists (β = 0.02, SE = 0.11, p = 0.88). No associations were observed with job satisfaction either. Among study participants, PCPs with poor team functioning, as exhibited by low team communication ratings, reported high burnout (β = - 1.28, SE = 0.22, p < 0.001) and low job satisfaction (β = 0.12, SE = 0.02, p < 0.001).

CONCLUSIONS

As currently implemented, primary care and mental health integration did not appear to impact PCP-reported burnout, nor job satisfaction. More research is needed to explore care model variation among clinics in order to optimize implementation to enhance PCP well-being.

Regional Adoption of Primary Care-Mental Health Integration in Veterans Health Administration Patient-Centered Medical Homes

INTRODUCTION

Behavioral health integration is important, yet difficult to implement, in patient-centered medical homes. The Veterans Health Administration (VA) mandated evidence-based collaborative care models through Primary Care-Mental Health Integration (PC-MHI) in large PC clinics. This study characterized PC-MHI programs among all PC clinics, including small sites exempt from program implementation, in one VA region.

METHODS

Researchers administered a cross-sectional key informant organizational survey on PC-MHI among VA PC clinics in Southern California, Arizona, and New Mexico (n = 69 distinct sites) from February to May 2018. Researchers analyzed PC clinic leaders' responses to five items about organizational structure and practice management.

RESULTS

Researchers received surveys from 65 clinics (94% response rate). Although only 38% were required to implement on-site PC-MHI programs, 95% of participating clinics reported providing access to such services. The majority reported having integrated, colocated, or tele-MH providers (94%) and care management (77%). Most stated same-day services (59%) and "warm" handoffs (56%) were always available, the former varying significantly based on clinic size and distance from affiliated VA hospitals.

CONCLUSIONS

Regional adoption of PC-MHI was high, including telemedicine, among VA patient-centered medical homes, regardless of whether implementation was required. Small, remote PC clinics that voluntarily provide PC-MHI services may need more support.

The Role of the Patient-Centered Medical Home in Treating Depression

PURPOSE OF REVIEW

This review discusses the role of the patient-centered medical home (PCMH) in treating depression, focusing on findings from primary care-based studies and their implications for the PCMH.

RECENT FINDINGS

Pharmacotherapy, psychotherapy, and collaborative care are evidence-based treatments for depression that can be delivered in primary care and extended to diverse populations. Recent research aligns with the core components of the PCMH model. The core components of the PCMH are critical elements of depression treatment. Comprehensive care within the PCMH addresses medical and behavioral health concerns, including depression. Psychiatric and psychological care must be flexibly delivered so services remain accessible yet patient-centered. To ensure the quality and safety of treatment, depression symptoms must be consistently monitored. Coordination within and occasionally outside of the PCMH is needed to ensure patients receive the appropriate level of care. More research is needed to empirically evaluate depression treatment within the PCMH.

Finding mental health providers in the United States: a national survey and implications for policy and practice

BACKGROUND

Research suggests that a major barrier to mental health treatment is not knowing where to go for services, yet little is known about the specific steps people take to find treatment.

AIMS

To (1) understand the process people would undertake if they decided they needed mental health treatment and (2) examine how well the process that current non-treatment-seeking individuals describe matches that used by individuals currently in treatment.

METHODS

Adults recruited online via Amazon's Mechanical Turk (N = 669) answered questions about finding a mental health provider. Participants who had (N = 167) and had not (N = 502) seen a mental health provider in the past month were compared.

RESULTS

Both groups indicated they would rely on Internet searches and recommendations of family, friends and physicians to find mental health providers. The order in which participants indicated they would use each step was similar across groups as was participants' confidence these steps would help them find a provider. Differences emerged in the factors each group indicated were important to their selection of a provider.

CONCLUSIONS

Results can inform mental health providers and policy makers regarding the importance of clear and informative online mental health information, including thorough information about appropriate mental health providers.

High Quality of Care Persists With Shifting Depression Services From VA Specialty to Integrated Primary Care

BACKGROUND/OBJECTIVE

Offering depression collaborative care services in primary care (PC) settings can reduce use of nonintegrated mental health care resources and improve mental health care access, particularly for vulnerable PC patients. Tests of effects on depression care quality, however, are needed. We examined overall quality of depression care and tested whether increasing clinic engagement in Veterans Affairs (VA)'s Primary Care-Mental Health Integration (PC-MHI) services was associated with differences in depression care quality over time.

METHODS

We conducted a retrospective longitudinal cohort study of 80,136 Veterans seen in 26 Southern California VA PC clinics (October 1, 2008-September 30, 2013). Using multilevel regression models adjusting for year, clinic, and patient characteristics, we predicted effects of clinic PC-MHI engagement (ie, percent of PC patients receiving PC-MHI services) on 3 VA-developed longitudinal electronic population-based depression quality measures among Veterans newly diagnosed with depression (n=12,533).

RESULTS

Clinic PC-MHI engagement rates were not associated with significant depression care quality differences. Across all clinics, average rates of follow-up within 84 or 180 days were, 66.4% and 74.5%, respectively. Receipt of minimally appropriate treatment was 80.5%. Treatment probabilities were significantly higher for vulnerable PC patients (homeless: 4.5%, P=0.03; serious mental illness: 15.2%, P<0.001), than for otherwise similar patients without these characteristics.

CONCLUSIONS/POLICY IMPLICATIONS

Study patients treated in PC clinics with greater PC-MHI engagement received similarly high quality depression care, and even higher quality for vulnerable patients. Findings support increasing use of PC-MHI models to the extent that they confer some advantage over existing services (eg, access, patient satisfaction) other than quality of care.

The Association between Mental Health Disorders and History of Unintended Pregnancy among Women Veterans

BACKGROUND

Women Veterans have high rates of mental health disorders and other psychosocial factors which may render this population particularly vulnerable to negative health outcomes associated with unintended pregnancy.

OBJECTIVE

The objective of our study was to assess the relationship between self-reported mental illness and history of unintended pregnancy among women Veterans.

DESIGN AND PARTICIPANTS

Data are from a nationally representative, cross-sectional telephone survey of women Veterans, ages 18-45, who used VA for primary care within 12 months prior to interview (survey completion rate 83%).

MAIN MEASURES

Predictors were self-report of any and number of mental health disorders (depression, anxiety, post-traumatic stress disorder, bipolar disorder, or schizophrenia). Outcomes were any and number of unintended pregnancies. Multivariable logistic and negative binomial regression were used to assess relationships between mental illness and unintended pregnancy. To assess women's current risk of unintended pregnancy, we examined associations between any mental health disorder and contraceptive use at last sex among heterosexually active women not desiring pregnancy.

KEY RESULTS

Among 2297 women Veterans, 1580 (68.8%) reported a history of at least one mental health disorder, with 20.1, 21.6, and 27.0% reporting one, two, or three or more conditions, respectively. Any history of unintended pregnancy was reported by 1315 women (57.3%); 28.3% reported one, 15.6% reported two, and 13.4% reported three or more. Compared to women with no mental illness, women with any mental health disorder were more likely to report any unintended pregnancy (60.3 vs. 50.5%; adjusted OR 1.40; 95% CI 1.15, 1.71) and to have experienced greater numbers of unintended pregnancies (adjusted incidence rate ratio 1.29; 95% CI 1.15, 1.44). Increasing numbers of mental health disorders were associated with greater numbers of unintended pregnancies. Contraceptive use and method efficacy at last sex did not differ by mental health status.

CONCLUSIONS

Women Veterans with mental health disorders are more likely to have experienced any and greater numbers of unintended pregnancies than Veterans without mental health disorders.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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