Addressing Common Challenges in the Implementation of Collaborative Care for Mental Health: The Penn Integrated Care Program

Engaging primary care patients at risk for suicide in mental health treatment: user insights to inform implementation strategy design

BACKGROUND

Given that the majority of suicide decedents visit primary care in the year preceding death, primary care has been identified as a key setting in which to engage patients at risk for suicide in mental health services. The objective of this research was to identify barriers and facilitators to engagement in mental health services among primary care patients at risk for suicide to inform the development of strategies to increase engagement.

METHODS

Seventy-four semi-structured qualitative interviews were conducted with primary care patients (n = 20), primary care (n = 18) and behavioral health (n = 12) clinicians, mental health intake coordinators (n = 4), and health system and clinic leaders (n = 20). Patients who had been referred for mental health services from primary care and reported an elevated score (≥ 1) on item 9 on the Patient Health Questionnaire at the time of referral were eligible to participate. Eligible clinicians and leaders were employed in a primary care or behavioral health setting in a single large health system with an integrated mental health program. Interviews typically lasted 30-60 min, were completed over video conference or phone, and were coded by members of the research team using a rapid qualitative analysis procedure.

RESULTS

Participants were primarily female (64.9%), white (70.3%) and non-Hispanic/Latine (91.9%). The most identified barriers to mental health care engagement were waitlists, capacity limits, insurance, patient characteristics, communication, collaboration, and/or difficulties surrounding travel. The most commonly cited facilitators of engagement included telehealth, integrated care models, reminders, case management support, psychoeducation, motivational enhancement, and scheduling flexibility. Concrete suggestions for improving engagement in mental health services included increasing communication between providers, streamlining referral and intake processes, providing reminders and follow ups, and advocacy for increased reimbursement for suicide risk assessment.

CONCLUSIONS

Results underscore the myriad barriers patients at risk for suicide encounter when attempting to engage in mental health care in a primary care setting. Facilitators of engagement and suggestions for improving connections to care were also identified, which can inform the design of implementation strategies to improve engagement in mental health services among primary care patients at risk for suicide.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05021224 (Registered August 19, 2021).

Social prescribing for suicide prevention: a rapid review

This rapid review delves into the realm of social prescribing as a novel approach to suicide prevention by addressing the social determinants of health. Through an exploration of various databases including MEDLINE, PsychInfo, WILEY, and Sage, a total of 3,063 articles were initially identified as potentially relevant to the research. Following a meticulous screening process, 13 articles were included in the final review, shedding light on the potential effectiveness and impact of social prescribing interventions on suicide prevention. Key findings indicate the need for additional monitoring and support for individuals at risk of suicide, emphasising warm referrals and sustained connections after referral to enhance the efficacy of social prescribing models. The review also highlights the importance of social capital and trust among vulnerable populations, underscoring the significance of community-based referrals in suicide prevention initiatives. Overall, this review identifies the potential of social prescribing as a valuable tool in mitigating suicide risk factors and promoting mental health and wellbeing in diverse populations.

Change in suicidal ideation, depression, and anxiety following collaborative care in the community

BACKGROUND

The Collaborative Care Model (CoCM) increases access to mental health treatment and improves outcomes among patients with mild to moderate psychopathology; however, it is unclear how effective CoCM is for patients with elevated suicide risk.

METHODS

We examined data from the Penn Integrated Care program, a CoCM program including an intake and referral management center plus traditional CoCM services implemented in primary care clinics within a large, diverse academic medical system. In this community setting, we examined: (1) characteristics of patients with and without suicidal ideation who initiated CoCM, (2) changes in suicidal ideation (Patient Health Questionnaire-9 [PHQ-9] item 9), depression (PHQ-9 total scores), and anxiety (Generalized Anxiety Disorder Scale-7 scores) from the first to last CoCM visit overall and across demographic subgroups, and (3) the relationship between amount of CoCM services provided and degree of symptom reduction.

RESULTS

From 2018 to 2022, 3,487 patients were referred to CoCM, initiated treatment for at least 15 days, and had completed symptom measures at the first and last visit. Patients were 74% female, 45% Black/African American, and 45% White. The percentage of patients reporting suicidal ideation declined 11%-7% from the first to last visit. Suicidal ideation severity typically improved, and very rarely worsened, during CoCM. Depression and anxiety declined significantly among patients with and without suicidal ideation and across demographic subgroups; however, the magnitude of these declines differed across race, ethnicity, and age. Patients with suicidal ideation at the start of CoCM had higher depression scores than patients without suicidal ideation at the start and end of treatment. Longer CoCM episodes were associated with greater reductions in depression severity.

CONCLUSIONS

Suicidal ideation, depression, and anxiety declined following CoCM among individuals with suicidal ideation in a community setting. Findings are consistent with emerging evidence from clinical trials suggesting CoCM's potential for increasing access to mental healthcare and improving outcomes among patients at risk for suicide.

Safety planning intervention and follow-up: A telehealth service model for suicidal individuals in emergency department settings: Study design and protocol

BACKGROUND

The Safety Planning Intervention with follow-up services (SPI+) is a promising suicide prevention intervention, yet many Emergency Departments (EDs) lack the resources for adequate implementation. Comprehensive strategies addressing structural and organizational barriers are needed to optimize SPI+ implementation and scale-up. This protocol describes a test of one strategy in which ED staff connect at-risk patients to expert clinicians from a Suicide Prevention Consultation Center (SPCC) via telehealth.

METHOD

This stepped wedge, cluster-randomized trial compares the effectiveness, implementation, cost, and cost offsets of SPI+ delivered by SPCC clinicians versus ED-based clinicians (enhanced usual care; EUC). Eight EDs will start with EUC and cross over to the SPCC phase. Blocks of two EDs will be randomly assigned to start dates 3 months apart. Approximately 13,320 adults discharged following a suicide-related ED visit will be included; EUC and SPCC samples will comprise patients from before and after SPCC crossover, respectively. Effectiveness data sources are electronic health records, administrative claims, and the National Death Index. Primary effectiveness outcomes are presence of suicidal behavior and number/type of mental healthcare visits and secondary outcomes include number/type of suicide-related acute services 6-months post-discharge. We will use the same data sources to assess cost offsets to gauge SPCC scalability and sustainability. We will examine preliminary implementation outcomes (reach, adoption, fidelity, acceptability, and feasibility) through patient, clinician, and health-system leader interviews and surveys.

CONCLUSION

If the SPCC demonstrates clinical effectiveness and health system cost reduction, it may be a scalable model for evidence-based suicide prevention in the ED.

Core Components and Implementation Determinants of Multilevel Service Delivery Frameworks Across Child Mental Health Service Settings

Multilevel service delivery frameworks are approaches to structuring and organizing a spectrum of evidence-based services and supports, focused on assessment, prevention, and intervention designed for the local context. Exemplar frameworks in child mental health include positive behavioral interventions and supports in education, collaborative care in primary care, and systems of care in community mental health settings. Yet, their high-quality implementation has lagged. This work proposes a conceptual foundation for multilevel service delivery frameworks spanning diverse mental health service settings that can inform development of strategic implementation supports. We draw upon the existing literature for three exemplar multilevel service delivery frameworks in different child mental health service settings to (1) identify core components common to each framework, and (2) to highlight prominent implementation determinants that interface with each core component. Six interrelated components of multilevel service delivery frameworks were identified, including, (1) a systems-level approach, (2) data-driven problem solving and decision-making, (3) multiple levels of service intensity using evidence-based practices, (4) cross-linking service sectors, (5) multiple providers working together, including in teams, and (6) built-in implementation strategies that facilitate delivery of the overall model. Implementation determinants that interface with core components were identified at each contextual level. The conceptual foundation provided in this paper has the potential to facilitate cross-sector knowledge sharing, promote generalization across service settings, and provide direction for researchers, system leaders, and implementation intermediaries/practitioners working to strategically support the high-quality implementation of these frameworks.

Treating individuals with suicidal ideation in primary care: Patient-level characteristics associated with follow-up in the Collaborative Care Model

INTRODUCTION

The Collaborative Care Model (CoCM) is an evidence-based approach which embeds behavioral health providers (BHPs) into primary care. Whether patients with suicidal ideation (SI) are willing to engage in CoCM is unclear.

METHODS

Using Patient Health Questionnaire-9 (PHQ-9) administrative data from primary care practices within an urban academic health system, we identified patients with and without SI who were referred to a CoCM BHP. We compared engagement, defined as attendance at ≥1 CoCM visit, across groups.

RESULTS

Between 2018 and 2022, 7391 primary care patients were referred to a CoCM BHP. Eight hundred and ninety-two of these patients reported SI on the PHQ-9 (754 on "several days" during the previous 2 weeks and 138 on "more than half or most days"). Across groups, most patients engaged in CoCM. Patients reporting SI on several days engaged at a lower rate (61.4%) than those reporting SI on more than half or most days (65.9%). Both SI groups engaged at a lower rate than the 6499 patients who did not report SI (67.5%).

CONCLUSION

Most patients referred to a CoCM BHP engaged in ≥1 visit. Rates were lower for patients with SI, with the lowest rate among those reporting SI on several days.

Challenges and strategies for conducting research in primary health care practice: an integrative review

BACKGROUND

Providing accessible and high-quality patient-centered healthcare remains a challenge in many countries, despite global efforts to strengthen primary health care (PHC). Research and knowledge management are integral to enhancing PHC, facilitating the implementation of successful strategies, and promoting the use of evidence-based practices. Practice-based research in primary care (PC-PBR) has emerged as a valuable approach, with its external validity to diverse PHC settings, making it an effective means of translating research findings into professional practice.

OBJECTIVE

To identify challenges and strategies for conducting practice-based research in primary health care services.

METHOD

An integrative literature review was conducted by searching the PubMed, Embase, Scopus, Web of Science, and Lilacs databases. The research question, guided by the PICo framework, directed the execution of study selection and data extraction. Data analysis followed the RAdAR method's three phases: pre-analysis, data analysis, and interpretation of results.

RESULTS

Out of 440 initially identified articles, 26 met the inclusion criteria. Most studies were conducted in high-income countries, primarily the United States. The challenges and strategies for PC-PBR were categorized into six themes: research planning, infrastructure, engagement of healthcare professionals, knowledge translation, the relationship between universities and health services, and international collaboration. Notable challenges included research planning complexities, lack of infrastructure, difficulties in engaging healthcare professionals, and barriers to knowledge translation. Strategies underscore the importance of adapting research agendas to local contexts, providing research training, fostering stakeholder engagement, and establishing practice-based research networks.

CONCLUSION

The challenges encountered in PC-PBR are consistent across various contexts, highlighting the need for systematic, long-term actions involving health managers, decision-makers, academics, diverse healthcare professionals, and patients. This approach is essential to transform primary care, especially in low- and middle-income countries, into an innovative, comprehensive, patient-centered, and accessible healthcare system. By addressing these challenges and implementing the strategies, PC-PBR can play a pivotal role in bridging the gap between research and practice, ultimately improving patient care and population health.

Adapting psychotherapy in collaborative care for treating opioid use disorder and co-occurring psychiatric conditions in primary care

INTRODUCTION

Opioid use disorder (OUD) and psychiatric conditions commonly co-occur yet are infrequently treated with evidence-based therapeutic approaches, resulting in poor outcomes. These conditions, separately, present challenges to treatment initiation, retention, and success. These challenges are compounded when individuals have OUD and psychiatric conditions.

METHOD

Recognizing the complex needs of these individuals, gaps in care, and the potential for primary care to bridge these gaps, we developed a psychotherapy program that integrates brief, evidence-based psychotherapies for substance use, depression, and anxiety, building on traditional elements of the Collaborative Care Model (CoCM). In this article, we describe this psychotherapy program in a primary care setting as part of a compendium of collaborative services.

RESULTS

Patients receive up to 12 sessions of evidence-based psychotherapy and case management based on a structured treatment manual that guides treatment via Motivational Enhancement; Cognitive Behavioral Therapies for depression, anxiety, and/or substance use disorder; and/or Behavioral Activation components.

DISCUSSION

Novel, integrated treatments are needed to advance service delivery for individuals with OUD and psychiatric conditions and these programs must be rigorously evaluated. We describe our team's efforts to test our psychotherapy program in a large primary care network as part of an ongoing three-arm randomized controlled trial. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Implementation Barriers and Experiences of Eligible Patients Who Failed to Enroll in Collaborative Care for Depression and Anxiety

BACKGROUND

Effective and efficient implementation of the Collaborative Care Model (CoCM) for depression and anxiety is imperative for program success. Studies examining barriers to implementation often omit patient perspectives.

OBJECTIVES

To explore experiences and attitudes of eligible patients referred to CoCM who declined participation or were unable to be reached, and identify implementation barriers to inform strategies.

DESIGN

Convergent mixed-methods study with a survey and interview.

PARTICIPANTS

Primary care patients at an academic medical center who were referred to a CoCM program for anxiety and depression by their primary care clinician (PCC) but declined participation or were unable to be reached by the behavioral health care manager to initiate care (n = 80). Interviews were conducted with 45 survey respondents.

MAIN MEASURES

Survey of patients' referral experiences and behavioral health preferences as they related to failing to enroll in the program. Interview questions were developed using the Consolidated Framework for Implementation Research version 2.0 (CFIR 2.0) to identify implementation barriers to enrollment.

KEY RESULTS

Survey results found that patients were uncertain about insurance coverage, did not understand the program, and felt services were not necessary. Referred patients who declined participation were concerned about how their mental health information would be used and preferred treatment without medication. Men agreed more that they did not need services. Qualitative results exhibited a variety of implementation determinants (n = 23) across the five CFIR 2.0 domains. Barriers included mental health stigma, perceiving behavioral health as outside of primary care practice guidelines, short or infrequent primary care appointments, prioritizing physical health over mental health, receiving inaccurate program information, low motivation to engage, and a less established relationship with their PCC.

CONCLUSIONS

Multiple barriers to enrollment led to failing to link patients to care, which can inform implementation strategies to address the patient-reported experiences and concerns.

Leveraging behavioral economics and implementation science to engage patients at risk for suicide in mental health treatment: a pilot study protocol

BACKGROUND

Primary care is an ideal setting to connect individuals at risk for suicide to follow-up care; however, only half of the patients referred from the primary care attend an initial mental health visit. We aim to develop acceptable, feasible, low-cost, and effective new strategies to increase treatment initiation among at-risk individuals identified in primary care.

METHODS

We will conduct a multi-phase, mixed-methods study. First, we will conduct a chart review study by using administrative data, including medical records, to identify characteristics of primary care patients at risk for suicide who do or do not attend an initial mental health visit following a referral. Second, we will conduct a mixed methods study by using direct observations and qualitative interviews with key stakeholders (N = 65) to understand barriers and facilitators to mental health service initiation among at-risk individuals. Stakeholders will include patients with suicidal ideation referred from primary care who do and do not attend a first mental health visit, primary care and behavioral health providers, and individuals involved in the referral process. We also will collect preliminary self-report and behavioral data regarding potential mechanisms of behavior change (i.e., self-regulation and social support) from patients. Third, we will leverage these findings, relevant frameworks, and the extant literature to conduct a multi-arm, non-randomized feasibility trial. During this trial, we will rapidly prototype and test strategies to support attendance at initial mental health visits. Strategies will be developed with subject matter experts (N = 10) and iteratively pilot tested (~5 patients per strategy) and refined. Research will be completed in the Penn Integrated Care Program (PIC), which includes fourteen primary care clinics in Philadelphia that provide infrastructure for electronic referrals, patient communication, and data access.

DISCUSSION

We will leverage frameworks and methods from behavioral economics and implementation science to develop strategies to increase mental health treatment initiation among individuals at risk for suicide identified in primary care. This project will lead to an evaluation of these strategies in a fully powered randomized trial and contribute to improvements in access to and engagement in mental health services for individuals at risk for suicide.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05021224.

Engagement in and Benefits of a Short-Term, Brief Psychotherapy Intervention for PTSD During Pregnancy

Trauma-related symptoms and post-traumatic stress disorder (PTSD) are common during pregnancy and have adverse effects on pregnancy and birth outcomes, post-partum maternal mental health, and child development. The arousal symptoms associated with PTSD, including heightened or dysregulated physiology, may contribute to these adverse outcomes. Low-income minoritized women may be at highest risk given more lifetime exposure to trauma and limited access to mental health care. While evidence-based psychotherapies for PTSD exist, none are targeted to non-treatment seeking individuals nor specifically integrated with prenatal care. Thus, we developed and tested the efficacy of a short-term (four sessions) brief (30-45 min) psychotherapeutic intervention designed to address PTSD symptoms in pregnant women receiving prenatal care at two urban medical centers. Participants were 32 pregnant women with an average gestational age of 18.5 weeks at the time of enrollment. The sample was overwhelmingly non-Caucasian, single, and reported very low income. Participants completed measures of trauma-related symptoms (Post-traumatic Stress Disorder Checklist, PCL), and depression (Edinburgh post-natal Depression Scale, EPDS) at baseline, twice during treatment, post-treatment, and at 10-14 weeks post-partum. The intervention was successful at significantly decreasing symptoms of PTSD (PCL score = -20.27, 95% CI: -25.62, -14.92, P < 0.001, W = -7.43) and depression (EPDS score = -4.81, 95% CI: -7.55, -2.06, P = 0.001, W = -3.23) by the final session. These benefits were sustained at post-treatment and post-partum follow ups. Future research should further explore the effectiveness of this treatment in a randomized controlled trial.

Characteristics of Patients Who Attended Behavioral Health Services After Primary Care Referral With Referral Management Support

OBJECTIVE

This study examined whether documented disparities in access to behavioral health specialty care persisted in a novel integrated primary care model situated in a large health system when triage and referral management supports were provided by a centralized resource center for patients with behavioral health needs.

METHODS

Patients triaged and referred to specialty behavioral health care who did or did not attend a specialty care visit (N=1,450) were compared in terms of various demographic and clinical characteristics by using binary logistic regression.

RESULTS

Among patients with attendance data, financially unstable individuals were more likely than financially stable counterparts to miss their first appointment with a specialty behavioral health provider after referral from primary care. Previously documented attendance disparities based on race, ethnicity, and illness severity were not observed.

CONCLUSIONS

These findings can inform targeted strategies to increase attendance among patients with financial insecurity and reduce disparities in outpatient behavioral health services.

A pilot study of participatory and rapid implementation approaches to increase depression screening in primary care

BACKGROUND

Most individuals with depression go unidentified and untreated. In 2016 the US Preventive Services Task Force released guidelines recommending universal screening in primary care to identify patients with depression and to link them to treatment. Feasible, acceptable, and effective strategies to implement these guidelines are needed.

METHODS

This three-phased study employed rapid participatory methods to design and test strategies to increase depression screening at Penn Medicine, a large health system with 90 primary care practices. First, researchers solicited ideas and barriers from stakeholders to increase screening using an innovation tournament-a crowdsourcing method that invites stakeholders to submit ideas to address a workplace challenge. Second, a panel of stakeholders and scientists deliberated over and ranked the tournament ideas. An instant runoff election was held to select the winning idea. Third, the research team piloted the winning idea in a primary care practice using rapid prototyping, an approach that quickly refines and iterates strategy designs.

RESULTS

The innovation tournament yielded 31 ideas and 32 barriers from diverse stakeholders (12 primary care physicians, 10 medical assistants, 4 nurse practitioners, 2 practice managers, and 4 patient support assistants). A panel of 6 stakeholders and scientists deliberated on the ideas and voted for patient self-report (i.e., through tablet computers, text message, or an online patient portal) as the winning idea. The research team rapid prototyped tablets in one primary care practice with one physician over 5 five-hour shifts to examine the feasibility, acceptability, and effectiveness of the strategy. Most patients, the physician, and medical assistants found the tablets acceptable and feasible. However, patient support assistants struggled to incorporate them in their workflow and expressed concerns about scaling up the process. Depression screening rates were higher using tablets compared to usual care; follow-up was comparable between tablets and usual care.

CONCLUSIONS

Rapid participatory methods engaged and amplified the voices of diverse stakeholders in primary care. These methods helped design an acceptable and feasible implementation strategy that showed promise for increasing depression screening in a primary care setting. The next step is to evaluate the strategy in a randomized controlled trial across primary care practices.