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Sullivan AW, Lozowski-Sullivan S. The Continuum of Intervention Models in Integrated Behavioral Health. Pediatr Clin North Am 2021; 68:551-561. [PMID: 34044984 DOI: 10.1016/j.pcl.2021.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The current models of clinical collaboration between physicians and psychologists/social workers in the pediatric outpatient primary care setting fall along a continuum of integration of services and philosophies of care. Domains of integration include physical office location, the targeted patient population, the level of professional adaptation to other professions' model of training, and the influence of current models of reimbursement. Included here is an analysis of those models based on each continuum of integration. Each model is discussed with respect to where it falls on each continuum.
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Affiliation(s)
- Alexander W Sullivan
- Department of Social Work, Wayne State University, 5447 Woodward Avenue, Detroit, MI 48202, USA
| | - Sheryl Lozowski-Sullivan
- Department of Pediatric and Adolescent Medicine, Western Michigan University, Homer Stryker MD School of Medicine, 1000 Oakland Drive, Kalamazoo, MI 49008-8071, USA.
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Rodie DJ, Fitzgibbon K, Perivolaris A, Crawford A, Geist R, Levinson A, Mitchell B, Oslin D, Sunderji N, Mulsant BH. The primary care assessment and research of a telephone intervention for neuropsychiatric conditions with education and resources study: Design, rationale, and sample of the PARTNERs randomized controlled trial. Contemp Clin Trials 2021; 103:106284. [PMID: 33476774 DOI: 10.1016/j.cct.2021.106284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 01/06/2021] [Accepted: 01/11/2021] [Indexed: 11/25/2022]
Abstract
While most patients with depression, anxiety, or at-risk drinking receive care exclusively in primary care settings, primary care providers experience challenges in diagnosing and treating these common problems. Over the past two decades, the collaborative care model has addressed these challenges. However, this model has been adopted very slowly due to the high costs of care managers; inability to sustain their role in small practices; and the perceived lack of relevance of interventions focused on a specific psychiatric diagnosis. Thus, we designed an innovative randomized clinical trial (RCT), the Primary Care Assessment and Research of a Telephone Intervention for Neuropsychiatric Conditions with Education and Resources study (PARTNERs). This RCT compared the outcomes of enhanced usual care and a novel model of collaborative care in primary care patients with depressive disorders, generalized anxiety, social phobia, panic disorder, at-risk drinking, or alcohol use disorders. These conditions were selected because they are present in almost a third of patients seen in primary care settings. Innovations included assigning the care manager role to trained lay providers supported by computer-based tools; providing all care management centrally by phone - i.e., the intervention was delivered without any face-to-face contact between the patient and the care team; and basing patient eligibility and treatment selection on a transdiagnostic approach using the same eligibility criteria and the same treatment algorithms regardless of the participants' specific psychiatric diagnosis. This paper describes the design of this RCT and discusses the rationale for its main design features.
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Affiliation(s)
- David J Rodie
- Centre for Addiction and Mental Health, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | | | | | - Allison Crawford
- Centre for Addiction and Mental Health, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Rose Geist
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Hospital for Sick Children, Toronto, ON, Canada
| | - Andrea Levinson
- Centre for Addiction and Mental Health, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | | | - David Oslin
- University of Pennsylvania and the Department of Veteran Affairs, Philadelphia, PA, United States of America
| | - Nadiya Sunderji
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Waypoint Centre for Mental Health Care, Penetanguishene, ON, Canada
| | - Benoit H Mulsant
- Centre for Addiction and Mental Health, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada.
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Collins C, O’Shea MT, Cunniffe J, Finegan P. Health system changes needed to support people consulting general practice out of hours services in Ireland. Int J Ment Health Syst 2018; 12:56. [PMID: 30344620 PMCID: PMC6186104 DOI: 10.1186/s13033-018-0235-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 10/06/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Mental illness acts as a barrier to accessing and obtaining effective medical care. It has been shown that out of hours services are an important first stop for emergency care for people experiencing mental health difficulties. However, little is in fact known about the use of out of hours general practice services by people experiencing mental health difficulties. AIM To establish the number and range of consultations that have a primary or related mental health issue attending general practitioner (GP) out of hours and to document adherence to their follow-up care referral. DESIGN AND SETTING Descriptive study in one large out of hours primary care service in the South East of Ireland (Caredoc). METHODS An anonymous extraction of retrospective data from 1 year of the out of hours' electronic database was undertaken. Patients who attended the out of hours with a possible mental health issue and were referred to the psychiatric services or back to their own GP, were tracked via phone follow-up with hospitals and GPs over 6 months to establish if they attended for the recommend follow-up care. RESULTS Over a 1 year period, there were 3844 out of hours presentations with a mental health component. Overall, 9.3% were referred by the out of hours GP for follow-up to a hospital emergency department (ED) or were advised to attend their own GP. A total of 104 patients who were advised to attend their GP or ED following their consultation with the out of hours GP were tracked. Twenty-seven patients were referred back to their GP of which the follow-up call to the GP revealed that 44.5% did not attend. Seventy-seven patients were referred to the hospital services, of whom 37.7% did not attend. CONCLUSIONS There are significant challenges at the interface of primary care and secondary mental health services in Ireland. As expounded by the WHO and WONCA, in order to be effective and efficient, care for mental health must be coordinated with services at different levels of care complemented by the broader health system.
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Affiliation(s)
- C. Collins
- Irish College of General Practitioners, 4-5 Lincoln Place, Dublin 2, Ireland
| | - M. T. O’Shea
- Irish College of General Practitioners, 4-5 Lincoln Place, Dublin 2, Ireland
| | | | - P. Finegan
- Irish College of General Practitioners, 4-5 Lincoln Place, Dublin 2, Ireland
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Wray LO, Ritchie MJ, Oslin DW, Beehler GP. Enhancing implementation of measurement-based mental health care in primary care: a mixed-methods randomized effectiveness evaluation of implementation facilitation. BMC Health Serv Res 2018; 18:753. [PMID: 30285718 PMCID: PMC6171308 DOI: 10.1186/s12913-018-3493-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 08/23/2018] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Mental health care lags behind other forms of medical care in its reliance on subjective clinician assessment. Although routine use of standardized patient-reported outcome measures, measurement-based care (MBC), can improve patient outcomes and engagement, clinician efficiency, and, collaboration across care team members, full implementation of this complex practice change can be challenging. This study seeks to understand whether and how an intensive facilitation strategy can be effective in supporting the implementation of MBC. Implementation researchers partnering with US Department of Veterans Affairs (VA) leaders are conducting the study within the context of a national initiative to support MBC implementation throughout VA mental health services. This study will focus specifically on VA Primary Care-Mental Health Integration (PCMHI) programs. METHODS A mixed-methods, multiple case study design will include 12 PCMHI sites recruited from the 23 PCMHI programs that volunteered to participate in the VA national initiative. Guided by a study partnership panel, sites are clustered into similar groups using administrative metrics. Site pairs are recruited from within these groups. Within pairs, sites are randomized to the implementation facilitation strategy (external facilitation plus QI team) or standard VA national support. The implementation strategy provides an external facilitator and MBC experts who work with intervention sites to form a QI team, develop an implementation plan, and, identify and overcome barriers to implementation. The RE-AIM framework guides the evaluation of the implementation facilitation strategy which will utilize data from administrative, medical record, and primary qualitative and quantitative sources. Guided by the iPARIHS framework and using a mixed methods approach, we will also examine factors associated with implementation success. Finally, we will explore whether implementation of MBC increases primary care team communication and function related to the care of mental health conditions. DISCUSSION MBC has significant potential to improve mental health care but it represents a major change in practice. Understanding factors that can support MBC implementation is essential to attaining its potential benefits and spreading these benefits across the health care system.
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Affiliation(s)
- Laura O. Wray
- Department of Veterans Affairs, VA Center for Integrated Healthcare, 3495 Bailey Avenue, Buffalo, NY 14215 USA
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 955 Main Street, Suite 6186, Buffalo, NY 14203 USA
| | - Mona J. Ritchie
- Department of Veterans Affairs, VA Quality Enhancement Research Initiative (QUERI) for Team-Based Behavioral Health, 2200 Ft Roots Dr, Bdg 58, North Little Rock, AR 72114 USA
- Department of Psychiatry, University of Arkansas for Medical Sciences, 4301 W Markham St, #755, Little Rock, AR 72205 USA
| | - David W. Oslin
- VISN 4 Mental Illness Research, Education, and Clinical Center, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Avenue, Philadelphia, PA 19104 USA
- Department of Psychiatry, Perlman School of Medicine, University of Pennsylvania, 3900 Chestnut St, Philadelphia, PA 19104 USA
| | - Gregory P. Beehler
- Department of Veterans Affairs, VA Center for Integrated Healthcare, 3495 Bailey Avenue, Buffalo, NY 14215 USA
- Schools of Public Health and Health Professions, University at Buffalo, 401 Kimball Tower, 955 Main Street, Buffalo, NY 14214 USA
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Thorpe K, Jain S, Joski P. Prevalence And Spending Associated With Patients Who Have A Behavioral Health Disorder And Other Conditions. Health Aff (Millwood) 2018; 36:124-132. [PMID: 28069855 DOI: 10.1377/hlthaff.2016.0875] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
People with multiple medical conditions are a growing and increasingly costly segment of the U.S. POPULATION Despite the co-occurrence of physical and behavioral health comorbidities, the US health care system tends to treat these conditions separately rather than holistically. To identify opportunities for population health improvement, we examined the treated prevalence of and health care spending on behavioral health disorders, by the number of coexisting physical disorders, among noninstitutionalized adults. The vast majority (85 percent) of spending was attributed to treatment of the physical comorbidities. Only 15 percent was attributed to treatments of the behavioral disorders; of these, a primary diagnosis of depression was most common, seen in 57 percent of the sample. These findings suggest the potential to improve outcomes and reduce spending by applying collaborative care models more broadly. Policies should promote payment and delivery reforms that advance the integration of behavioral health and primary care.
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Affiliation(s)
- Ken Thorpe
- Ken Thorpe is the Robert W. Woodruff Professor and Chair of the Department of Health Policy and Management, Rollins School of Public Health, at Emory University, in Atlanta, Georgia
| | - Sanjula Jain
- Sanjula Jain is a doctoral student in health services research and health policy, Rollins School of Public Health, Emory University
| | - Peter Joski
- Peter Joski is a senior associate in the Department of Health Policy and Management, Rollins School of Public Health, Emory University
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Williams EC, Achtmeyer CE, Young JP, Berger D, Curran G, Bradley KA, Richards J, Siegel MB, Ludman EJ, Lapham GT, Forehand M, Harris AHS. Barriers to and Facilitators of Alcohol Use Disorder Pharmacotherapy in Primary Care: A Qualitative Study in Five VA Clinics. J Gen Intern Med 2018; 33:258-267. [PMID: 29086341 PMCID: PMC5834954 DOI: 10.1007/s11606-017-4202-z] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 06/30/2017] [Accepted: 09/28/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Three medications are FDA-approved and recommended for treating alcohol use disorders (AUD) but they are not offered to most patients with AUD. Primary care (PC) may be an optimal setting in which to offer and prescribe AUD medications, but multiple barriers are likely. OBJECTIVE This qualitative study used social marketing theory, a behavior change approach that employs business marketing techniques including "segmenting the market," to describe (1) barriers and facilitators to prescribing AUD medications in PC, and (2) beliefs of PC providers after they were segmented into groups more and less willing to prescribe AUD medications. DESIGN Qualitative, interview-based study. PARTICIPANTS Twenty-four providers from five VA PC clinics. APPROACH Providers completed in-person semi-structured interviews, which were recorded, transcribed, and analyzed using social marketing theory and thematic analysis. Providers were divided into two groups based on consensus review. KEY RESULTS Barriers included lack of knowledge and experience, beliefs that medications cannot replace specialty addiction treatment, and alcohol-related stigma. Facilitators included training, support for prescribing, and behavioral staff to support follow-up. Providers more willing to prescribe viewed prescribing for AUD as part of their role as a PC provider, framed medications as a potentially effective "tool" or "foot in the door" for treating AUD, and believed that providing AUD medications in PC might catalyze change while reducing stigma and addressing other barriers to specialty treatment. Those less willing believed that medications could not effectively treat AUD, and that treating AUD was the role of specialty addiction treatment providers, not PC providers, and would require time and expertise they do not have. CONCLUSIONS We identified barriers to and facilitators of prescribing AUD medications in PC, which, if addressed and/or capitalized on, may increase provision of AUD medications. Providers more willing to prescribe may be the optimal target of a customized implementation intervention to promote changes in prescribing.
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Affiliation(s)
- Emily C Williams
- Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, S-152, Seattle, WA, 98108, USA. .,Department of Health Services, University of Washington, Seattle, WA, USA.
| | - Carol E Achtmeyer
- Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, S-152, Seattle, WA, 98108, USA.,General Medicine Service, Veterans Affairs (VA) Puget Sound Health Care System - Seattle Division, Seattle, WA, USA.,Center of Excellence in Substance Abuse Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System - Seattle Division, Seattle, WA, USA
| | - Jessica P Young
- Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, S-152, Seattle, WA, 98108, USA
| | - Douglas Berger
- General Medicine Service, Veterans Affairs (VA) Puget Sound Health Care System - Seattle Division, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA
| | - Geoffrey Curran
- Central Arkansas Veterans Health Care System, Little Rock, AR, USA
| | - Katharine A Bradley
- Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, S-152, Seattle, WA, 98108, USA.,Department of Health Services, University of Washington, Seattle, WA, USA.,Center of Excellence in Substance Abuse Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System - Seattle Division, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA
| | - Julie Richards
- Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, S-152, Seattle, WA, 98108, USA.,Department of Health Services, University of Washington, Seattle, WA, USA
| | - Michael B Siegel
- Department of Community Health Sciences, Boston University School of Public Heath, Boston, MA, USA
| | - Evette J Ludman
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - Gwen T Lapham
- Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, S-152, Seattle, WA, 98108, USA.,Center of Excellence in Substance Abuse Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System - Seattle Division, Seattle, WA, USA
| | - Mark Forehand
- Foster School of Business, University of Washington, Seattle, WA, USA
| | - Alex H S Harris
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, USA
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Chauhan M, Niazi SK. Caring for Patients With Chronic Physical and Mental Health Conditions: Lessons From TEAMcare and COMPASS. FOCUS: JOURNAL OF LIFE LONG LEARNING IN PSYCHIATRY 2017; 15:279-283. [PMID: 31975858 DOI: 10.1176/appi.focus.20170008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Depression is one of the leading causes of disability worldwide. It often coexists with other chronic conditions, contributing to poor self-management and subsequent poor health outcomes, increased service utilization and cost of care, and poor quality of life. Most patients with depression seek care in primary care settings. Patients given collaborative care for depression alone or for depression with commonly co-occurring general medical conditions have demonstrated improved outcomes. This article reviews findings from the TEAMcare (an integrated multicondition collaborative care program for chronic illnesses) and COMPASS (Care of Mental, Physical and Substance-Use Syndromes) programs to highlight the evidence supporting the effectiveness of the collaborative care model and its implementation in diverse settings.
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Affiliation(s)
- Mohit Chauhan
- Dr. Chauhan and Dr. Niazi are with the Department of Psychiatry and Psychology, Mayo Clinic Jacksonville, Jacksonville, Florida
| | - Shehzad K Niazi
- Dr. Chauhan and Dr. Niazi are with the Department of Psychiatry and Psychology, Mayo Clinic Jacksonville, Jacksonville, Florida
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Bergamo C, Juarez-Colunga E, Capp R. Association of mental health disorders and Medicaid with ED admissions for ambulatory care-sensitive condition conditions. Am J Emerg Med 2016; 34:820-4. [PMID: 26887865 DOI: 10.1016/j.ajem.2016.01.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 01/14/2016] [Accepted: 01/18/2016] [Indexed: 10/22/2022] Open
Abstract
INTRODUCTION Adult Medicaid enrollees are more likely to have mental health disorders (MHDs) than privately insured patients and also have high rates of emergency department (ED) visits for ambulatory care-sensitive conditions (ACSCs). We aimed to evaluate the association of MHD and insurance type with ED admissions for ACSC in the United States. METHODS We conducted a cross-sectional study of ED visits made by adults aged 18 to 64 years using the corrected 2011 National Emergency Department Survey. Using multivariable logistic regression analysis, we controlled for sociodemographics and clinical variables to determine the association between insurance type, MHD, Medicaid, and MHD (as an interaction variable) and ED admissions for ACSC. RESULTS There were 131 million ED visits in 2011; after exclusions, 1.4 million admissions were included in our study. Of all ED visits, 44.7% had an MHD, of which 49.9% were covered by Medicaid and 38.1% were covered by private insurance. A total of 32.6% (95% confidence interval, 32.5%-32.7%) of ED admissions were for an ACSC. Medicaid-covered ED visits were more likely to result in ACSC hospital admission (odds ratio, 1.32; 95% confidence interval, 1.30-1.35) compared with visits covered by private insurance. Among patients with MHD, those with Medicaid insurance had 1.6 times the odds of ACSC admission compared with those privately insured. CONCLUSION Among all ED admissions, patients covered by Medicaid are more likely to be admitted for an ACSC when compared with those covered by private insurance, with a larger association being present among patients with MHD comorbidities.
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Affiliation(s)
- Cara Bergamo
- Denver Health Emergency Medicine Program, Denver Health Medical Center, Denver, CO.
| | | | - Roberta Capp
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
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Wong EC, Jaycox LH, Ayer L, Batka C, Harris R, Naftel S, Paddock SM. Evaluating the Implementation of the Re-Engineering Systems of Primary Care Treatment in the Military (RESPECT-Mil). RAND HEALTH QUARTERLY 2015; 5:13. [PMID: 28083389 PMCID: PMC5158293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
A RAND team conducted an independent implementation evaluation of the Re-Engineering Systems of Primary Care Treatment in the Military (RESPECT-Mil) Program, a system of care designed to screen, assess, and treat posttraumatic stress disorder and depression among active duty service members in the Army's primary care settings. Evaluating the Implementation of the Re-Engineering Systems of Primary Care Treatment in the Military (RESPECT-Mil) presents the results from RAND's assessment of the implementation of RESPECT-Mil in military treatment facilities and makes recommendations to improve the delivery of mental health care in these settings. Analyses were based on existing program data used to monitor fidelity to RESPECT-Mil across the Army's primary care clinics, as well as discussions with key stakeholders. During the time of the evaluation, efforts were under way to implement the Patient Centered Medical Home, and uncertainties remained about the implications for the RESPECT-Mil program. Consideration of this transition was made in designing the evaluation and applying its findings more broadly to the implementation of collaborative care within military primary care settings.
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Kwan BM, Valeras AB, Levey SB, Nease DE, Talen ME. An Evidence Roadmap for Implementation of Integrated Behavioral Health under the Affordable Care Act. AIMS Public Health 2015; 2:691-717. [PMID: 29546130 PMCID: PMC5690436 DOI: 10.3934/publichealth.2015.4.691] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Accepted: 10/14/2015] [Indexed: 01/18/2023] Open
Abstract
The Affordable Care Act (ACA) created incentives and opportunities to redesign health care to better address mental and behavioral health needs. The integration of behavioral health and primary care is increasingly viewed as an answer to address such needs, and it is advisable that evidence-based models and interventions be implemented whenever possible with fidelity. At the same time, there are few evidence-based models, especially beyond depression and anxiety, and thus further research and evaluation is needed. Resources being allocated to adoption of models of integrated behavioral health care (IBHC) should include quality improvement, evaluation, and translational research efforts using mixed methodology to enhance the evidence base for IBHC in the context of health care reform. This paper covers six key aspects of the evidence for IBHC, consistent with mental and behavioral health elements of the ACA related to infrastructure, payments, and workforce. The evidence for major IBHC models is summarized, as well as evidence for targeted populations and conditions, education and training, information technology, implementation, and cost and sustainability.
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Affiliation(s)
- Bethany M Kwan
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO, United States
| | - Aimee B Valeras
- NH Dartmouth Family Medicine Residency, Concord Hospital Family Health Center, Concord, NH, United States
| | - Shandra Brown Levey
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO, United States
| | - Donald E Nease
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO, United States
| | - Mary E Talen
- Northwestern Family Medicine Residency, Northwestern McGaw Medical Center and University, Chicago, IL, United States
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Tai B, Hu L, Ghitza UE, Sparenborg S, VanVeldhuisen P, Lindblad R. Patient registries for substance use disorders. Subst Abuse Rehabil 2014; 5:81-6. [PMID: 25114612 PMCID: PMC4114906 DOI: 10.2147/sar.s64977] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
This commentary discusses the need for developing patient registries of substance use disorders (SUD) in general medical settings. A patient registry is a tool that documents the natural history of target diseases. Clinicians and researchers use registries to monitor patient comorbidities, care procedures and processes, and treatment effectiveness for the purpose of improving care quality. Enactments of the Affordable Care Act 2010 and the Mental Health Parity and Addiction Equity Act 2008 open opportunities for many substance users to receive treatment services in general medical settings. An increased number of patients with a wide spectrum of SUD will initially receive services with a chronic disease management approach in primary care. The establishment of computer-based SUD patient registries can be assisted by wide adoption of electronic health record systems. The linkage of SUD patient registries with electronic health record systems can facilitate the advancement of SUD treatment research efforts and improve patient care.
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Affiliation(s)
- Betty Tai
- Center for the Clinical Trials Network, National Institute on Drug Abuse, National Institutes of Health, Bethesda, MD, USA
| | - Lian Hu
- The EMMES Corporation, Rockville, MD, USA
| | - Udi E Ghitza
- Center for the Clinical Trials Network, National Institute on Drug Abuse, National Institutes of Health, Bethesda, MD, USA
| | - Steven Sparenborg
- Center for the Clinical Trials Network, National Institute on Drug Abuse, National Institutes of Health, Bethesda, MD, USA
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12
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Bhattacharya R, Shen C, Sambamoorthi U. Depression and ambulatory care sensitive hospitalizations among Medicare beneficiaries with chronic physical conditions. Gen Hosp Psychiatry 2014; 36:460-5. [PMID: 24999083 PMCID: PMC4138245 DOI: 10.1016/j.genhosppsych.2014.05.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 05/21/2014] [Accepted: 05/27/2014] [Indexed: 11/19/2022]
Abstract
OBJECTIVE We examined the association between depression and hospitalizations for Ambulatory Care Sensitive Conditions (H-ACSC) among Medicare beneficiaries with chronic physical conditions. METHODS We used a retrospective longitudinal design using multiple years (2002-2009) of linked fee-for-service Medicare claims and survey data from Medicare Current Beneficiary Survey to create six longitudinal panels. We followed individuals in each panel for a period of 3-years; first year served as the baseline and subsequent 2-years served as the follow-up. We measured depression, chronic physical conditions and other characteristics at baseline and examined H-ACSC at follow-up. We identified chronic physical conditions from survey data and H-ACSC and depression from fee-for-service Medicare claims. We analyzed unadjusted and adjusted relationships between depression and the risk of H-ACSC with chi-square tests and logistic regressions. RESULTS Among all Medicare beneficiaries, 9.3% had diagnosed depression. Medicare beneficiaries with depression had higher rates of any H-ACSC as compared to those without depression (13.6% vs. 7.7%). Multivariable regression indicated that, compared to those without depression, Medicare beneficiaries with depression were more likely to experience any H-ACSC. CONCLUSIONS Depression was associated with greater risk of H-ACSC, suggesting that health care quality measures may need to include depression as a risk-adjustment variable.
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Affiliation(s)
- Rituparna Bhattacharya
- Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia University, Morgantown, WV 26506, USA.
| | - Chan Shen
- Department of Biostatistics, University of Texas, MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Usha Sambamoorthi
- Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia University, Morgantown, WV 26506, USA
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Intimate Partner Violence: Perspectives on Universal Screening for Women in VHA Primary Care. Womens Health Issues 2013; 23:e73-6. [DOI: 10.1016/j.whi.2012.12.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Accepted: 12/11/2012] [Indexed: 11/22/2022]
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Johnson-Lawrence V, Zivin K, Szymanski BR, Pfeiffer PN, McCarthy JF. VA primary care-mental health integration: patient characteristics and receipt of mental health services, 2008-2010. Psychiatr Serv 2012; 63:1137-41. [PMID: 23117512 PMCID: PMC4049174 DOI: 10.1176/appi.ps.201100365] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE In 2007, the U.S. Department of Veterans Affairs (VA) health system began nationwide implementation of primary care-mental health integration (PC-MHI) programs to enhance mental health access and promote treatment of common mental health conditions for patients in primary care settings. This report describes patients initiating PC-MHI services in fiscal years (FYs) 2008-2010, including those who received prior mental health services. METHODS Using VA administrative records, the investigators examined characteristics and services utilization of individuals who initiated PC-MHI services in FY 2008 (N=76,985), FY 2009 (N=107,417), or FY 2010 (N=149,938). RESULTS PC-MHI service initiation increased by 95%, from 76,985 to 149,938 veterans. Over time, new user cohorts were increasingly younger, newer to VA services, and less likely to have received VA mental health treatment in the prior year. CONCLUSIONS This study documents substantial expansion in VA PC-MHI program activity. PC-MHI program expansion may increase access to mental health services in primary care settings.
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Affiliation(s)
- Vicki Johnson-Lawrence
- Department of Health Behavior and Health Education, University of Michigan, Ann Arbor, 1415 Washington Heights, Ann Arbor, MI 48109, USA.
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Nash JM, McKay KM, Vogel ME, Masters KS. Functional roles and foundational characteristics of psychologists in integrated primary care. J Clin Psychol Med Settings 2012; 19:93-104. [PMID: 22415522 DOI: 10.1007/s10880-011-9290-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Psychologists are presented with unprecedented opportunities to integrate their work in primary care settings. Although some roles of psychologists in primary care overlap with those in traditional psychology practice settings, a number are distinct reflecting the uniqueness of the primary care culture. In this paper, we first describe the integrated primary care setting, with a focus on those settings that have components of patient centered medical home. We then describe functional roles and foundational characteristics of psychologists in integrated primary care. The description of functional roles emphasizes the diversity of roles performed. The foundational characteristics identified are those that we consider the 'primary care ethic,' or core characteristics of psychologists that serve as the basis for the various functional roles in integrated primary care. The 'primary care ethic' includes attitudes, values, knowledge, and abilities that are essential to the psychologist being a valued, effective, and productive primary care team member.
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Affiliation(s)
- Justin M Nash
- Department of Family Medicine, Warren Alpert Medical School of Brown University and Memorial Hospital of Rhode Island, 111 Brewster Street, Pawtucket, RI 02860, USA.
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Engel AG, Malta LS, Davies CA, Baker MM. Clinical effectiveness of using an integrated model to treat depressive symptoms in veterans affairs primary care clinics and its impact on health care utilization. Prim Care Companion CNS Disord 2011; 13:10m01096. [PMID: 22132351 DOI: 10.4088/pcc.10m01096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2010] [Accepted: 01/31/2011] [Indexed: 10/17/2022] Open
Abstract
OBJECTIVE To determine if veterans treated in an integrated mental health program within a Veterans Affairs (VA) primary care clinic sustained long-term improvement in depressive symptoms and changed their use of health care. METHOD In this pilot program, 72 veterans were offered short-term treatment for depressive symptoms by a colocated psychiatrist who was integrated into a VA primary care team (October 1, 1997, through September 30, 1999). Patients were assessed initially and at their final session using the Hamilton Depression Rating Scale. Veterans who completed treatment were referred back to their primary care provider or to specialty mental health services. Patients were contacted and invited to be reevaluated 3 to 5 years later using the same measure (December 1, 2001, through November 30, 2002). Health care utilization data were collected for 1 year preintervention and 2 years postintervention. Outcomes for treatment completers were compared to outcomes for those who declined or dropped out of treatment. RESULTS Of 48 patients who agreed to participate in the study, 27 completed treatment and showed a significant decline in symptoms from pretreatment to follow-up (P = .008) compared to 16 noncompleters, as well as a moderate-to-large between-group effect size (d = 0.78) and trends for higher remission and response rates. Completers ranked significantly higher in the number of antidepressant prescriptions filled before (P = .002) and after treatment (P = .001) and in the number of medical visits postintervention (year 1: P = .021; year 2: P = .023), without an associated cost increase. CONCLUSIONS Colocated mental health care integrated into VA primary care is associated with sustained improvement of depressive symptoms in a heterogeneous patient population with a high incidence of psychiatric comorbidities. This finding compares favorably with the results of earlier controlled clinical trials and suggests a potential effect on health care utilization.
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Affiliation(s)
- Anna G Engel
- Department of Psychiatry, Boston VA Healthcare System, West Roxbury, and Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA.
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Implementing collaborative care for depression treatment in primary care: a cluster randomized evaluation of a quality improvement practice redesign. Implement Sci 2011; 6:121. [PMID: 22032247 PMCID: PMC3219630 DOI: 10.1186/1748-5908-6-121] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2009] [Accepted: 10/27/2011] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Meta-analyses show collaborative care models (CCMs) with nurse care management are effective for improving primary care for depression. This study aimed to develop CCM approaches that could be sustained and spread within Veterans Affairs (VA). Evidence-based quality improvement (EBQI) uses QI approaches within a research/clinical partnership to redesign care. The study used EBQI methods for CCM redesign, tested the effectiveness of the locally adapted model as implemented, and assessed the contextual factors shaping intervention effectiveness. METHODS The study intervention is EBQI as applied to CCM implementation. The study uses a cluster randomized design as a formative evaluation tool to test and improve the effectiveness of the redesign process, with seven intervention and three non-intervention VA primary care practices in five different states. The primary study outcome is patient antidepressant use. The context evaluation is descriptive and uses subgroup analysis. The primary context evaluation measure is naturalistic primary care clinician (PCC) predilection to adopt CCM.For the randomized evaluation, trained telephone research interviewers enrolled consecutive primary care patients with major depression in the evaluation, referred enrolled patients in intervention practices to the implemented CCM, and re-surveyed at seven months. RESULTS Interviewers enrolled 288 CCM site and 258 non-CCM site patients. Enrolled intervention site patients were more likely to receive appropriate antidepressant care (66% versus 43%, p = 0.01), but showed no significant difference in symptom improvement compared to usual care. In terms of context, only 40% of enrolled patients received complete care management per protocol. PCC predilection to adopt CCM had substantial effects on patient participation, with patients belonging to early adopter clinicians completing adequate care manager follow-up significantly more often than patients of clinicians with low predilection to adopt CCM (74% versus 48%%, p = 0.003). CONCLUSIONS Depression CCM designed and implemented by primary care practices using EBQI improved antidepressant initiation. Combining QI methods with a randomized evaluation proved challenging, but enabled new insights into the process of translating research-based CCM into practice. Future research on the effects of PCC attitudes and skills on CCM results, as well as on enhancing the link between improved antidepressant use and symptom outcomes, is needed. TRIAL REGISTRATION ClinicalTrials.gov: NCT00105820.
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Machado RJ, Tomlinson V. Bridging the gap between primary care and mental health. J Psychosoc Nurs Ment Health Serv 2011; 49:24-9; quiz 44. [PMID: 22007852 DOI: 10.3928/02793695-20111004-02] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2011] [Accepted: 08/19/2011] [Indexed: 11/20/2022]
Abstract
Major depression is a leading cause of disability in the United States and is frequently diagnosed and managed within a primary care setting, with less-than-optimal results. Studies have shown that adequate follow up significantly affects patient outcomes, including mortality; however, primary care providers face many challenges in providing this care within the constraints of a primary care setting. Collaborative care models have been shown to be effective in managing depression, and accordingly, the Translating Initiatives for Depression into Effective Solutions (TIDES) model was selected by the Bay Pines Veterans Affairs Healthcare System to help primary care providers manage depressed patients within the primary care setting. This article describes the implementation of TIDES and identifies a new role for mental health nurses outside of the traditional mental health setting.
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Affiliation(s)
- Robert J Machado
- Primary Care-Behavioral Health Care Management, Bay Pines Veterans Affairs Healthcare System, Bay Pines, Florida 33744, USA.
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Seal KH, Cohen G, Bertenthal D, Cohen BE, Maguen S, Daley A. Reducing barriers to mental health and social services for Iraq and Afghanistan veterans: outcomes of an integrated primary care clinic. J Gen Intern Med 2011; 26:1160-7. [PMID: 21647750 PMCID: PMC3181313 DOI: 10.1007/s11606-011-1746-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2011] [Revised: 04/05/2011] [Accepted: 05/02/2011] [Indexed: 11/30/2022]
Abstract
BACKGROUND Despite high rates of post-deployment psychosocial problems in Iraq and Afghanistan veterans, mental health and social services are under-utilized. OBJECTIVE To evaluate whether a Department of Veterans Affairs (VA) integrated care (IC) clinic (established in April 2007), offering an initial three-part primary care, mental health and social services visit, improved psychosocial services utilization in Iraq and Afghanistan veterans compared to usual care (UC), a standard primary care visit with referral for psychosocial services as needed. DESIGN Retrospective cohort study using VA administrative data. POPULATION Five hundred and twenty-six Iraq and Afghanistan veterans initiating primary care at a VA medical center between April 1, 2005 and April 31, 2009. MAIN MEASURES Multivariable models compared the independent effects of primary care clinic type (IC versus UC) on mental health and social services utilization outcomes. KEY RESULTS After 2007, compared to UC, veterans presenting to the IC primary care clinic were significantly more likely to have had a within-30-day mental health evaluation (92% versus 59%, p < 0.001) and social services evaluation [77% (IC) versus 56% (UC), p < 0.001]. This exceeded background system-wide increases in mental health services utilization that occurred in the UC Clinic after 2007 compared to before 2007. In particular, female veterans, younger veterans, and those with positive mental health screens were independently more likely to have had mental health and social service evaluations if seen in the IC versus UC clinic. Among veterans who screened positive for ≥ 1 mental health disorder(s), there was a median of 1 follow-up specialty mental health visit within the first year in both clinics. CONCLUSIONS Among Iraq and Afghanistan veterans new to primary care, an integrated primary care visit further improved the likelihood of an initial mental health and social services evaluation over background increases, but did not improve retention in specialty mental health services.
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Affiliation(s)
- Karen H Seal
- San Francisco VA Medical Center, San Francisco, CA 94121, USA.
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Williams LS, Ofner S, Yu Z, Beyth RJ, Plue L, Damush T. Pre-post evaluation of automated reminders may improve detection and management of post-stroke depression. J Gen Intern Med 2011; 26:852-7. [PMID: 21499827 PMCID: PMC3138982 DOI: 10.1007/s11606-011-1709-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Post-stroke depression (PSD) occurs in at least one-third of stroke survivors, is associated with worse functional outcomes and increased mortality, and is frequently underdiagnosed and undertreated. OBJECTIVE To evaluate the effectiveness of an electronic medical record-based system intervention to improve the proportion of veterans screened and treated for PSD. DESIGN Quasi-experimental study comparing PSD screening and treatment among veterans receiving post-stroke outpatient care one year prior to the intervention (the control group) to those receiving outpatient care during the intervention period (the intervention group); contemporaneous data from non-study sites included to assess temporal trends in depression diagnosis and treatment. PARTICIPANTS Veterans hospitalized for ischemic stroke and/or receiving primary care (PC) or neurology outpatient follow-up within six months post-stroke at two (Veterans Affairs) VA Medical Centers. INTERVENTIONS We formed clinical improvement teams at both sites. Teams developed PSD screening and treatment reminders and designed tailored implementation strategies for reminder use in PC and neurology clinics. MAIN MEASURES Proportion screened for PSD within 6 months post-stroke; proportion screening positive for PSD who received an appropriate treatment action within 6 months post-stroke. KEY RESULTS In unadjusted analyses, PSD screening was performed within 6 months for 85% of intervention (N = 278) vs. 50% of control (N = 374) patients (OR 6.2 , p < 0.001), and treatment action was received by 83% of intervention vs. 73% of control patients who screened positive (OR 1.8 p = 0.13). After adjusting for intervention, site and number of follow-up visits, intervention patients were more likely to be screened (OR 4.8, p < 0.001) and to receive a treatment action if screened positive (OR 2.45, p = 0.05). Analyses of temporal trends in non-study sites revealed no trend toward general increase in PSD detection or treatment. CONCLUSIONS Automated depression screening in primary and specialty care can improve detection and treatment of PSD.
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Initiation of Primary Care-Mental Health Integration programs in the VA Health System: associations with psychiatric diagnoses in primary care. Med Care 2010; 48:843-51. [PMID: 20706160 DOI: 10.1097/mlr.0b013e3181e5792b] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Providing collaborative mental health treatment within primary care settings improves depression outcomes and may improve detection of mental disorders. Few studies have assessed the effect of collaborative mental health treatment programs on diagnosis of mental disorders in primary care populations. In 2008, many Department of Veterans Affairs (VA) facilities implemented collaborative care programs, as part of the VA's Primary Care-Mental Health Integration (PC-MHI) program. OBJECTIVES To assess the prevalence of diagnosed mental health conditions among primary care patient populations in association with PC-MHI programs, overall and for patient subpopulations that may be less likely to receive mental health treatment. RESEARCH DESIGN Using a difference-in-differences analysis, we evaluated whether the rates of psychiatric diagnoses among primary care patient populations at 294 VA facilities changed from fiscal year (FY)07 to FY08, and whether trends differed at facilities with PC-MHI encounters in FY08. Subgroup analyses examined whether trends differed by patient age and race/ethnicity. SUBJECTS, MEASURES, AND RESULTS: From FY07 to FY08, the prevalence of diagnosed depression, anxiety, post-traumatic stress disorder, and alcohol abuse increased more in the 137 facilities with PC-MHI program encounters than in the 157 facilities without these encounters. Increases were more likely among patients who were younger (18-64) and white. CONCLUSIONS Initiation of PC-MHI programs was associated with elevated diagnosis patterns, which may enhance recognition of mental health needs among primary care patients. Increases in diagnosis prevalence were not uniform across patient subgroups. Further research is needed on treatment processes and outcomes for individuals receiving services in PC-MHI programs.
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Alexander CL, Arnkoff DB, Glass CR. Bringing psychotherapy to primary care: Innovations and challenges. ACTA ACUST UNITED AC 2010. [DOI: 10.1111/j.1468-2850.2010.01211.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Liu CF, Rubenstein LV, Kirchner JE, Fortney JC, Perkins MW, Ober SK, Pyne JM, Chaney EF. Organizational cost of quality improvement for depression care. Health Serv Res 2009; 44:225-44. [PMID: 19146566 DOI: 10.1111/j.1475-6773.2008.00911.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE We documented organizational costs for depression care quality improvement (QI) to develop an evidence-based, Veterans Health Administration (VA) adapted depression care model for primary care practices that performed well for patients, was sustained over time, and could be spread nationally in VA. DATA SOURCES AND STUDY SETTING Project records and surveys from three multistate VA administrative regions and seven of their primary care practices. STUDY DESIGN Descriptive analysis. DATA COLLECTION We documented project time commitments and expenses for 86 clinical QI and 42 technical expert support team participants for 4 years from initial contact through care model design, Plan-Do-Study-Act cycles, and achievement of stable workloads in which models functioned as routine care. We assessed time, salary costs, and costs for conference calls, meetings, e-mails, and other activities. PRINCIPLE FINDINGS Over an average of 27 months, all clinics began referring patients to care managers. Clinical participants spent 1,086 hours at a cost of $84,438. Technical experts spent 2,147 hours costing $197,787. Eighty-five percent of costs derived from initial regional engagement activities and care model design. CONCLUSIONS Organizational costs of the QI process for depression care in a large health care system were significant, and should be accounted for when planning for implementation of evidence-based depression care.
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Affiliation(s)
- Chuan-Fen Liu
- Northwest Center for Outcomes Research in Older Adults, VA Puget Sound Healthcare System, 1100 Olive Way, Suite 1400, Seattle, WA 98101, USA.
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Ross JT, TenHave T, Eakin AC, Difilippo S, Oslin DW. A randomized controlled trial of a close monitoring program for minor depression and distress. J Gen Intern Med 2008; 23:1379-85. [PMID: 18498013 PMCID: PMC2518035 DOI: 10.1007/s11606-008-0663-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2007] [Revised: 04/03/2008] [Accepted: 05/01/2008] [Indexed: 12/01/2022]
Abstract
BACKGROUND Minor depression is almost twice as common in primary care (PC) as major depression. Despite the high prevalence, few evidence-based algorithms exist for managing patients with minor depression or patients presenting solely with distress. OBJECTIVES The aim of this study was to test the effectiveness of a telephone-based close monitoring program to manage PC patients with minor depression or distress. DESIGN Subjects were randomly assigned to either the control arm (usual care; UC) or the intervention arm (close monitoring; CM). We hypothesized that those randomized to CM would exhibit less depression and be less likely to have symptoms progress to the point of meeting diagnostic criteria. SUBJECTS Overall, 223 PC subjects with minor depression or distress consented to participation in this trial. MEASUREMENTS At baseline, subjects completed a telephone-based evaluation comprised of validated diagnostic assessments of depression and other MH disorders. Outcomes were assessed at six months utilizing this same battery. Chart reviews were conducted to track care received, such as prescribed antidepressants and MH and primary care visits. RESULTS Subjects in the CM arm exhibited fewer psychiatric diagnoses than those in the UC arm (chi(2) = 4.04, 1 df, p = 0.04). In addition, the intervention group showed improved overall physical health (SF-12 PCS scores) (M = 45.1, SD = 11.8 versus M = 41.5, SD = 12.4) (chi(2) = 5.90, 1 df, p = .02). CONCLUSIONS Those randomized to CM exhibited less MH problems at the conclusion of the trial, indicating that the close monitoring program is effective, feasible and valuable. The findings of this study will allow us to enhance clinical care and support the integration of mental health services and primary care.
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Affiliation(s)
- Jennifer T Ross
- Philadelphia Veterans Affairs Medical Center, Philadelphia, PA 19104, USA
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Yano EM. The role of organizational research in implementing evidence-based practice: QUERI Series. Implement Sci 2008; 3:29. [PMID: 18510749 PMCID: PMC2481253 DOI: 10.1186/1748-5908-3-29] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2006] [Accepted: 05/29/2008] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Health care organizations exert significant influence on the manner in which clinicians practice and the processes and outcomes of care that patients experience. A greater understanding of the organizational milieu into which innovations will be introduced, as well as the organizational factors that are likely to foster or hinder the adoption and use of new technologies, care arrangements and quality improvement (QI) strategies are central to the effective implementation of research into practice. Unfortunately, much implementation research seems to not recognize or adequately address the influence and importance of organizations. Using examples from the U.S. Department of Veterans Affairs (VA) Quality Enhancement Research Initiative (QUERI), we describe the role of organizational research in advancing the implementation of evidence-based practice into routine care settings. METHODS Using the six-step QUERI process as a foundation, we present an organizational research framework designed to improve and accelerate the implementation of evidence-based practice into routine care. Specific QUERI-related organizational research applications are reviewed, with discussion of the measures and methods used to apply them. We describe these applications in the context of a continuum of organizational research activities to be conducted before, during and after implementation. RESULTS Since QUERI's inception, various approaches to organizational research have been employed to foster progress through QUERI's six-step process. We report on how explicit integration of the evaluation of organizational factors into QUERI planning has informed the design of more effective care delivery system interventions and enabled their improved "fit" to individual VA facilities or practices. We examine the value and challenges in conducting organizational research, and briefly describe the contributions of organizational theory and environmental context to the research framework. CONCLUSION Understanding the organizational context of delivering evidence-based practice is a critical adjunct to efforts to systematically improve quality. Given the size and diversity of VA practices, coupled with unique organizational data sources, QUERI is well-positioned to make valuable contributions to the field of implementation science. More explicit accommodation of organizational inquiry into implementation research agendas has helped QUERI researchers to better frame and extend their work as they move toward regional and national spread activities.
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Affiliation(s)
- Elizabeth M Yano
- Veterans Affairs (VA) Health Services Research and Development (HSR&D) Center of Excellence for the Study of Healthcare Provider Behaviour, VA Greater Los Angeles Healthcare System, Sepulveda, CA, USA.
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Smith MW, Barnett PG. The role of economics in the QUERI program: QUERI Series. Implement Sci 2008; 3:20. [PMID: 18430199 PMCID: PMC2390584 DOI: 10.1186/1748-5908-3-20] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2006] [Accepted: 04/22/2008] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND The United States (U.S.) Department of Veterans Affairs (VA) Quality Enhancement Research Initiative (QUERI) has implemented economic analyses in single-site and multi-site clinical trials. To date, no one has reviewed whether the QUERI Centers are taking an optimal approach to doing so. Consistent with the continuous learning culture of the QUERI Program, this paper provides such a reflection. METHODS We present a case study of QUERI as an example of how economic considerations can and should be integrated into implementation research within both single and multi-site studies. We review theoretical and applied cost research in implementation studies outside and within VA. We also present a critique of the use of economic research within the QUERI program. RESULTS Economic evaluation is a key element of implementation research. QUERI has contributed many developments in the field of implementation but has only recently begun multi-site implementation trials across multiple regions within the national VA healthcare system. These trials are unusual in their emphasis on developing detailed costs of implementation, as well as in the use of business case analyses (budget impact analyses). CONCLUSION Economics appears to play an important role in QUERI implementation studies, only after implementation has reached the stage of multi-site trials. Economic analysis could better inform the choice of which clinical best practices to implement and the choice of implementation interventions to employ. QUERI economics also would benefit from research on costing methods and development of widely accepted international standards for implementation economics.
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Affiliation(s)
- Mark W Smith
- Health Economics Resource Center, US Department of Veterans Affairs, Menlo Park, California, USA
- Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Palo Alto, California, USA
| | - Paul G Barnett
- Health Economics Resource Center, US Department of Veterans Affairs, Menlo Park, California, USA
- Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Palo Alto, California, USA
- Department of Health Research and Policy, Stanford University School of Medicine, Palo Alto, California, USA
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Abrams TE, Vaughan-Sarrazin M, Rosenthal GE. Variations in the associations between psychiatric comorbidity and hospital mortality according to the method of identifying psychiatric diagnoses. J Gen Intern Med 2008; 23:317-22. [PMID: 18214622 PMCID: PMC2359482 DOI: 10.1007/s11606-008-0518-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2007] [Revised: 11/13/2007] [Accepted: 12/28/2007] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Little is known about associations between psychiatric comorbidity and hospital mortality for acute medical conditions. This study examined if associations varied according to the method of identifying psychiatric comorbidity and agreement between the different methods. PATIENTS/PARTICIPANTS The sample included 31,218 consecutive admissions to 168 Veterans Affairs facilities in 2004 with a principle diagnosis of congestive heart failure (CHF) or pneumonia. Psychiatric comorbidity was identified by: (1) secondary diagnosis codes from index admission, (2) prior outpatient diagnosis codes, (3) and prior mental health clinic visits. Generalized estimating equations (GEE) adjusted in-hospital mortality for demographics, comorbidity, and severity of illness, as measured by laboratory data. MEASUREMENTS AND MAIN RESULTS Rates of psychiatric comorbidities were 9.0% using inpatient diagnosis codes, 27.4% using outpatient diagnosis codes, and 31.0% using mental health visits for CHF and 14.5%, 33.1%, and 34.1%, respectively, for pneumonia. Agreement was highest for outpatient codes and mental health visits (kappa = 0.51 for pneumonia and 0.50 for CHF). In GEE analyses, the adjusted odds of death for patients with psychiatric comorbidity were lower when such comorbidity was identified by mental health visits for both pneumonia (odds ratio [OR] = 0.85; P = .009) and CHF (OR = 0.70; P < .001) and by inpatient diagnosis for pneumonia (OR = 0.63; P < or = .001) but not for CHF (OR = 0.75; P = .128). The odds of death were similar (P > .2) for psychiatric comorbidity as identified by outpatient codes for pneumonia (OR = 1.04) and CHF (OR = 0.93). CONCLUSIONS The method used to identify psychiatric comorbidities in acute medical populations has a strong influence on the rates of identification and the associations between psychiatric illnesses with hospital mortality.
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Affiliation(s)
- Thad E Abrams
- The Center for Research in the Implementation of Innovative Strategies in Practice (CRIISP), Iowa City VA Healthcare System, Iowa City, IA, USA.
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Zeiss AM, Karlin BE. Integrating Mental Health and Primary Care Services in the Department of Veterans Affairs Health Care System. J Clin Psychol Med Settings 2008; 15:73-8. [DOI: 10.1007/s10880-008-9100-4] [Citation(s) in RCA: 123] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2008] [Accepted: 01/25/2008] [Indexed: 11/30/2022]
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Stetler CB, Mittman BS, Francis J. Overview of the VA Quality Enhancement Research Initiative (QUERI) and QUERI theme articles: QUERI Series. Implement Sci 2008; 3:8. [PMID: 18279503 PMCID: PMC2289837 DOI: 10.1186/1748-5908-3-8] [Citation(s) in RCA: 121] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2006] [Accepted: 02/15/2008] [Indexed: 11/25/2022] Open
Abstract
Background Continuing challenges to timely adoption of evidence-based clinical practices in healthcare have generated intense interest in the development and application of new implementation methods and frameworks. These challenges led the United States (U.S.) Department of Veterans Affairs (VA) to create the Quality Enhancement Research Initiative (QUERI) in the late 1990s. QUERI's purpose was to harness VA's health services research expertise and resources in an ongoing system-wide effort to improve the performance of the VA healthcare system and, thus, quality of care for veterans. QUERI in turn created a systematic means of involving VA researchers both in enhancing VA healthcare quality, by implementing evidence-based practices, and in contributing to the continuing development of implementation science. The efforts of VA researchers to improve healthcare delivery practices through QUERI and related initiatives are documented in a growing body of literature. The scientific frameworks and methodological approaches developed and employed by QUERI are less well described. A QUERI Series of articles in Implementation Science will illustrate many of these QUERI tools. This Overview article introduces both QUERI and the Series. Methods The Overview briefly explains the purpose and context of the QUERI Program. It then describes the following: the key operational structure of QUERI Centers, guiding frameworks designed to enhance implementation and related research, QUERI's progress and promise to date, and the Series' general content. QUERI's frameworks include a core set of steps for diagnosing and closing quality gaps and, simultaneously, advancing implementation science. Throughout the paper, the envisioned involvement and activities of VA researchers within QUERI Centers also are highlighted. The Series is then described, illustrating the use of QUERI frameworks and other tools designed to respond to implementation challenges. Conclusion QUERI's simultaneous pursuit of improvement and research goals within a large healthcare system may be unique. However, descriptions of this still-evolving effort, including its conceptual frameworks, methodological approaches, and enabling processes, should have applicability to implementation researchers in a range of health care settings. Thus, the Series is offered as a resource for other implementation research programs and researchers pursuing common goals in improving care and developing the field of implementation science.
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Jordan N, Lee TA, Valenstein M, Weiss KB. Effect of care setting on evidence-based depression treatment for veterans with COPD and comorbid depression. J Gen Intern Med 2007; 22:1447-52. [PMID: 17687614 PMCID: PMC2305861 DOI: 10.1007/s11606-007-0328-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2006] [Revised: 05/21/2007] [Accepted: 07/03/2007] [Indexed: 11/24/2022]
Abstract
BACKGROUND Patients with chronic obstructive pulmonary disorder (COPD) frequently have co-occurring depressive disorders and are often seen in multiple-care settings. Existing research does not assess the impact of care setting on delivery of evidence-based depression care for these patients. OBJECTIVE To examine the prevalence of guideline-concordant depression treatment among these co-morbid patients, and to examine whether the likelihood of receiving guideline-concordant treatment differed by care setting. DESIGN Retrospective cohort study. PATIENTS A total of 5,517 veterans with COPD that experienced a new treatment episode for major depressive disorder. MEASUREMENTS AND MAIN RESULTS Concordance with VA treatment guidelines for depression; multivariate analyses of the relationship between guideline-concordant depression treatment and care setting. More than two-thirds of the sample was over age 65 and 97% were male. Only 50.6% of patients had guideline-concordant antidepressant coverage (defined by the VA). Fewer than 17% of patients received guideline recommended follow-up (> or = 3 outpatient visits during the acute phase), and only 9.9% of the cohort received both guideline-concordant antidepressant coverage and follow-up visits. Being seen in a mental health clinic during the acute phase was associated with a 7-fold increase in the odds of receiving guideline-concordant care compared to primary care only. Patients seen in pulmonary care settings were also more likely to receive guideline-concordant care compared to primary care only. CONCLUSIONS Most VA patients with COPD and an acute depressive episode receive suboptimal depression management. Improvements in depression treatment may be particularly important for those patients seen exclusively in primary care settings.
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Affiliation(s)
- Neil Jordan
- Center for Management of Complex Chronic Care, Hines VA Hospital, Hines, IL, USA.
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Abstract
Mental health and primary care delivery systems have evolved to operate differently. For example, attention to multiple medical issues, health maintenance, and structured diagnostic procedures are standard elements of primary care rarely incorporated into mental health care. A multidisciplinary treatment approach, group care, and case management are common features of mental health treatment settings only rarely used in primary care practices. Advances in treatments for mental health disorders and increased knowledge of the integral link between mental health and physical health encourage mental health disorder treatment in primary care settings, which reach the most patients. Effective integration of mental health care into primary care requires systematic and pragmatic change that builds on the strengths of both mental health and primary care.
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Affiliation(s)
- Stephen Thielke
- Geriatric Mental Health Services, Department of Psychiatry and Behavioral Sciences, Box 356560, University of Washington, Seattle, WA 98195, USA.
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Dorr D, Bonner LM, Cohen AN, Shoai RS, Perrin R, Chaney E, Young AS. Informatics systems to promote improved care for chronic illness: a literature review. J Am Med Inform Assoc 2007; 14:156-63. [PMID: 17213491 PMCID: PMC2213468 DOI: 10.1197/jamia.m2255] [Citation(s) in RCA: 169] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE To understand information systems components important in supporting team-based care of chronic illness through a literature search. DESIGN Systematic search of literature from 1996-2005 for evaluations of information systems used in the care of chronic illness. MEASUREMENTS The relationship of design, quality, information systems components, setting, and other factors with process, quality outcomes, and health care costs was evaluated. RESULTS In all, 109 articles were reviewed involving 112 information system descriptions. Chronic diseases targeted included diabetes (42.9% of reviewed articles), heart disease (36.6%), and mental illness (23.2%), among others. System users were primarily physicians, nurses, and patients. Sixty-seven percent of reviewed experiments had positive outcomes; 94% of uncontrolled, observational studies claimed positive results. Components closely correlated with positive experimental results were connection to an electronic medical record, computerized prompts, population management (including reports and feedback), specialized decision support, electronic scheduling, and personal health records. Barriers identified included costs, data privacy and security concerns, and failure to consider workflow. CONCLUSION The majority of published studies revealed a positive impact of specific health information technology components on chronic illness care. Implications for future research and system designs are discussed.
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Affiliation(s)
- David Dorr
- Oregon Health & Science University, Department of Medical Informatics & Clinical Epidemiology, Portland, OR, USA.
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Grace GD, Christensen RC. Recognizing psychologically masked illnesses: the need for collaborative relationships in mental health care. PRIMARY CARE COMPANION TO THE JOURNAL OF CLINICAL PSYCHIATRY 2007; 9:433-6. [PMID: 18185822 PMCID: PMC2139921 DOI: 10.4088/pcc.v09n0605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2007] [Accepted: 07/31/2007] [Indexed: 10/20/2022]
Abstract
BACKGROUND Both research and clinical experience support the view that unrecognized medical illnesses in mental health, as well as in primary care, treatment settings can directly cause or exacerbate a patient's presenting psychological symptoms. No study has compared medical and nonmedical health care professionals on their respective abilities to identify common medical illnesses that frequently masquerade as psychological disorders. METHOD In this study, 24 psychiatrists, 20 primary care physicians, 31 psychologists, and 17 social workers, recruited between November 2005 and April 2007, were asked to complete a questionnaire designed to measure the respondents' knowledge of masked medical illness. The questionnaire consisted of 10 different clinical vignettes in which a patient is seeking treatment for psychological problems that are due to a hidden medical illness. Statistical (analysis of covariance) comparisons of questionnaire scores were conducted between the medically trained and nonmedically trained participants. RESULTS After adjusting for clinical experience, medical mental health care professionals demonstrated significantly greater knowledge of medical illnesses that commonly masquerade as psychological disorders (F = 177.02, df = 1,82, p = .000, partial eta(2) = .68) than did nonmedical providers. In addition, correlational results showed a strong relationship (r = .82, N = 92, p < .001) between the presence of medical training and knowledge of masked medical illness in mental health care. CONCLUSIONS Study findings suggest that non-medical mental health care providers may be at increased risk of not recognizing masked medical illnesses in their patients. On the basis of these findings, proposed collaborative and educational approaches to minimize this risk and improve patient care are described.
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Affiliation(s)
- Glenn D Grace
- North Florida/South Georgia Veterans Health System and the Department of Clinical and Health Psychology, University of Florida, Gainesville ; and the Community Psychiatry Program, University of Florida College of Medicine, Jacksonville
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