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BackgroundChronic diseases that drive morbidity, mortality, and health care costs are largely influenced by human behavior. Behavioral health conditions such as anxiety, depression, and substance use disorders can often be effectively managed. The majority of patients in need of behavioral health care are seen in primary care, which often has difficulty responding. Some primary care practices are providing integrated behavioral health care (IBH), where primary care and behavioral health providers work together, in one location, using a team-based approach. Research suggests there may be an association between IBH and improved patient outcomes. However, it is often difficult for practices to achieve high levels of integration. The Integrating Behavioral Health and Primary Care study responds to this need by testing the effectiveness of a comprehensive practice-level intervention designed to improve outcomes in patients with multiple chronic medical and behavioral health conditions by increasing the practice's degree of behavioral health integration.MethodsForty-five primary care practices, with existing onsite behavioral health care, will be recruited for this study. Forty-three practices will be randomized to the intervention or usual care arm, while 2 practices will be considered "Vanguard" (pilot) practices for developing the intervention. The intervention is a 24-month supported practice change process including an online curriculum, a practice redesign and implementation workbook, remote quality improvement coaching services, and an online learning community. Each practice's degree of behavioral health integration will be measured using the Practice Integration Profile. Approximately 75 patients with both chronic medical and behavioral health conditions from each practice will be asked to complete a series of surveys to measure patient-centered outcomes. Change in practice degree of behavioral health integration and patient-centered outcomes will be compared between the two groups. Practice-level case studies will be conducted to better understand the contextual factors influencing integration.DiscussionAs primary care practices are encouraged to provide IBH services, evidence-based interventions to increase practice integration will be needed. This study will demonstrate the effectiveness of one such intervention in a pragmatic, real-world setting.Trial registrationClinicalTrials.gov NCT02868983 . Registered on August 16, 2016.

The United States is facing a social isolation and loneliness crisis. In response, the US Surgeon General issued an advisory in May 2023 recommending actions that health care, community programs, and social services can take to collaboratively improve social connection. Primary care has a critical role to play in implementing the Surgeon General's recommendations. We present social isolation and loneliness as medical issues and highlight next steps for the primary care sector to combat this epidemic. [ABSTRACT FROM AUTHOR]

Background: Opioids are more commonly prescribed for chronic pain in rural settings in the USA, yet little is known about how the rural context influences efforts to improve opioid medication management. Methods: The Six Building Blocks is an evidence-based program that guides primary care practices in making system-based improvements in managing patients using long-term opioid therapy. It was implemented at 6 rural and rural-serving organizations with 20 clinic locations over a 15-month period. To gain further insight about their experience with implementing the program, interviews and focus groups were conducted with staff and clinicians at the six organizations at the end of the 15 months and transcribed. Team members used a template analysis approach, a form of qualitative thematic analysis, to code these data for barriers, facilitators, and corresponding subcodes. Results: Facilitators to making systems-based changes in opioid management within a rural practice context included a desire to help patients and their community, external pressures to make changes in opioid management, a desire to reduce workplace stress, external support for the clinic, supportive clinic leadership, and receptivity of patients. Barriers to making changes included competing demands on clinicians and staff, a culture of clinician autonomy, inadequate data systems, and a lack of patient resources in rural areas. Discussion: The barriers and facilitators identified here point to potentially unique determinants of practice that should be considered when addressing opioid prescribing for chronic pain in the rural setting. [ABSTRACT FROM AUTHOR]

Background: Patients with a substance use disorder (SUD) often present with co-occurring chronic conditions in primary care. Despite the high co-occurrence of chronic medical conditions and SUD, little is known about whether chronic condition outcomes or related service utilization in primary care varies between patients with versus without documented SUDs. This study examined whether having a SUD influenced the use of primary care services and common chronic condition outcomes for patients with diabetes, hypertension, and obesity.Methods: A longitudinal cohort observational study examined electronic health record data from 21 primary care clinics in Washington and Idaho to examine differences in service utilization and clinical outcomes for diabetes, hypertension, and obesity in patients with and without a documented SUD diagnosis. Differences between patients with and without documented SUD diagnoses were compared over a three-year window for clinical outcome measures, including hemoglobin A1c, systolic and diastolic blood pressure, and body mass index, as well as service outcome measures, including number of encounters with primary care and co-located behavioral health providers, and orders for prescription opioids. Adult patients (N = 10,175) diagnosed with diabetes, hypertension, or obesity before the end of 2014, and who had ≥2 visits across a three-year window including at least one visit in 2014 (baseline) and at least one visit occurring 12 months or longer after the 2014 visit (follow-up) were examined.Results: Patients with SUD diagnoses and co-occurring chronic conditions were seen by providers more frequently than patients without SUD diagnoses (p's < 0.05), and patients with SUD diagnoses were more likely to be prescribed opioid medications. Chronic condition outcomes were no different for patients with versus without SUD diagnoses.Discussion: Despite the higher visit rates to providers in primary care, a majority of patients with SUD diagnoses and chronic medical conditions in primary care did not get seen by co-located behavioral health providers, who can potentially provide and support evidence informed care for both SUD and chronic conditions. Patients with chronic medical conditions also were more likely to get prescribed opioids if they had an SUD diagnosis. Care pathway innovations for SUDs that include greater utilization of evidence-informed co-treatment of SUDs and chronic conditions within primary care settings may be necessary for improving care overall for patients with comorbid SUDs and chronic conditions. [ABSTRACT FROM AUTHOR]

We use prescription of statin medications and prescription of warfarin to explore the capacity of electronic health record data to (1) describe cohorts of patients prescribed these medications and (2) identify cohorts of patients with evidence of adverse events related to prescription of these medications. This study was conducted in the WWAMI region Practice and Research Network (WPRN)., a network of primary care practices across Washington, Wyoming, Alaska, Montana and Idaho DataQUEST, an electronic data-sharing infrastructure. We used electronic health record data to describe cohorts of patients prescribed statin or warfarin medications and reported the proportions of patients with adverse events. Among the 35,445 active patients, 1745 received at least one statin prescription and 301 received at least one warfarin prescription. Only 3 percent of statin patients had evidence of myopathy; 51 patients (17% of those prescribed warfarin) had a bleeding complication. Primary-care electronic health record data can effectively be used to identify patients prescribed specific medications and patients potentially experiencing medication adverse events. [ABSTRACT FROM AUTHOR]

Purpose: Six key elements of opioid medication management redesign in primary care have been previously identified. Here, we examine the effect of implementing these Six Building Blocks on opioid-prescribing practices.Methods: Six rural-serving organizations with 20 clinic locations received support for 15 months during the period October 2015 to May 2017 to implement the Six Building Blocks. Patients undergoing long-term opioid therapy (LtOT) at these study sites were compared with patients undergoing LtOT enrolled in a regional health plan who did not receive care at the study sites but who resided in the same primary care service areas (control group). Outcomes were monthly trend in the proportion of patients undergoing LtOT prescribed a ≥100 morphine equivalent dose (MED) of opioids daily and the total number of patients receiving an opioid prescription. An interrupted time series using difference-indifference analysis was used for tests of significance.Results: The proportion of patients prescribed a ≥100 MED of opioids daily decreased 2.2% (11.8% to 9.6%) among patients at the intervention clinics and 1.3% (14.0% to 12.7%) among patients in the control group. The rate of decrease was significantly greater among study patients than among patients in the control group (P = .018). The rate of decrease in the number of patients on LtOT at intervention clinics increased during the intervention period compared with the preintervention period (P <.001).Conclusions: Efforts to redesign opioid medication management in primary care resulted in a significant decrease in opioid prescribing. Future research is needed to determine if these results are generalizable to other settings and to assess implications for patient-reported outcomes. [ABSTRACT FROM AUTHOR]

Context: Digital therapeutics may be uniquely positioned to address challenges reported by providers in chronic pain (CP) management. Previous studies have shown patient-provider discordance in priorities for CP management, which can be addressed in digital therapeutics development to encourage implementation and use. Objective: To assess primary care providers' and patients' perceptions of CP treatment goals and motivators for use of a digital therapeutic delivering CP related behavioral interventions. Study Design: Quantitative surveys. Setting: Participants were recruited from four primary care clinics in Washington and Colorado, two patient support groups, and one research community stakeholder group. Population studied: The sample included 31 patients and 39 providers. Most patients identified as male (61.3%), non-Hispanic White (96.8%) and had experienced pain for one year or longer (90.3%). A mix of provider roles were included: primary care providers (46.2%), behavioral health providers (41.0%), clinical pharmacists (5.1%), and nurses (5.1%). All providers had experience treating patients with CP. Outcomes: Participants rated 10 CP treatment goals (e.g., quality of life, selfmanagement skills) and 11 motivators for use (e.g., coaching, insurance payment coverage) of digital therapeutics on a 5-point Likert-scale. Descriptive statistics and Chi-Square tests were computed. Results: Patients and providers differed in their perceptions of importance across all treatment goals. Patients' ratings of treatment goals ranged from least to very important, whereas providers uniformly rated all treatment goals as very or extremely important (p < .05), and provider ratings of importance were consistently higher than patients (p < .05). Patients and providers on average did not rate motivators for use very high and they differed in their perceptions across six specific motivators. Providers rated friend recommendations and coaching features as more likely to motivate use than patients did (p < .05). Providers tended to rate more uniformly than patients on motivators related to insurance covering most of the cost, it being recommended by a provider or friend, and if the program was personalized with coaching (p < .05). Conclusions: Incorporating digital therapeutics in routine primary care may help improve CP management by providing customizable features that address diverse treatment goals, and bridge differing perspectives between providers and patients. [ABSTRACT FROM AUTHOR]

Context: Digital therapeutics are growing as a solution to improve access and quality of care. Increasing evidence has shown the efficacy of digital therapeutics in managing pain for patients, but they are underutilized by primary care providers who see over half of the patients with chronic pain. Engaging providers to develop and use digital therapeutics with patients in chronic pain management has become necessary. Objective: This study explored primary care providers' challenges and strategies in chronic pain management to identify needs and practice gaps that inform development of digital therapeutics for chronic pain. Study Design: Qualitative study, using a human-centered design approach. Setting: Eleven providers from four primary care clinics in Washington and Colorado participated in semistructured interviews between July and October 2021. Population studied: The sample (N=11) included seven primary care physicians, two behavioral health providers, one physician assistant and one nurse. Most providers worked in clinics affiliated with urban, academic health systems or in federally qualified health centers. Outcomes: Interviews focused on provider goals in chronic pain management, challenges and strategies used, and perceptions of digital therapeutics. Results: Four themes related to provider needs emerged: patient-provider alliance, team-based care, tracking and monitoring, and social determinants of health. Providers desired resources to streamline pain education, counseling, and goal setting with patients. Greater accessibility to multidisciplinary care team consultations and nonpharmacological pain treatments would be beneficial to providers and patients. Infrastructure and systems are needed for providers to systematically track and monitor patients' pain. Providers requested assistance with connecting underserved patients to wraparound social services and addressing healthcare access barriers. Conclusion: Digital therapeutics for chronic pain would benefit from incorporating multimodal features that strengthen patient-provider alliance, increase access to non-pharmacological treatment options, support population health tracking and management, and provide equitable solutions that require lower sophistication of device and Internet access. Leveraging digital therapeutics in healthcare settings requires meeting provider needs at individual care and system levels. [ABSTRACT FROM AUTHOR]

Context: The widespread adoption of electronic health records (EHRs) offers significant opportunities to conduct research with clinical data from patients outside traditional academic research settings. Because EHRs are designed primarily for clinical care and billing, significant challenges are inherent in the use of EHR data for clinical and translational research. Efficient processes are needed for translational researchers to overcome these challenges. The Data QUEST Coordinating Center (DQCC), which oversees Data QUEST - a primary care EHR data sharing infrastructure - created processes that that guide EHR data extraction for clinical and translational research across these diverse practices. We describe these processes and their application in a case example. Case Description: The DQCC process for developing EHR data extractions not only supports researchers access to EHR data, but supports this access for the purpose of answering scientific questions. This process requires complex coordination across multiple domains, including: 1) understanding the context of EHR data; 2) creating and maintaining a governance structure to support exchange of EHR data; and 3) defining data parameters that are used in order to extract data from the EHR.1,2,3,4We use the Northwest-Alaska Pharmacogenomics Research Network (NWA-PGRN) as a case example that focuses on pharmacogenomic discovery and clinical applications to describe the DQCC process. The NWA-PGRN collaborates with Data QUEST to explore ways to leverage primary care EHR data to support pharmacogenomics research. Findings: Preliminary analysis on the case example shows that initial decisions about how researchers define the study population can influence study outcomes. Major Themes and Conclusions: The experience of the DQCC demonstrates that Coordinating Centers provide expertise in helping researchers understand the context of EHR data, create and maintain governance structures, and guide the definition of parameters for data extractions. This expertise is critical to support research with EHR data. Replication of these strategies through Coordinating Centers may lead to more efficient translational research. Investigators must also consider the impact of initial decisions in defining study groups that may potentially affect outcomes. Acknowledgements We acknowledge the Northwest Alaska Pharmacogenomics Research Network group for supporting the infrastructure and data collection, and Imara West for her assistance in data cleaning and analysis. This project was funded by the National Institute of General Medical Science (U01 GM092676) and the National Center for Advancing Translational Sciences of the National Institutes of Health (UL1TR000423). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health [ABSTRACT FROM AUTHOR]

Introduction: Integrating behavioral health in primary care improves quality of care and outcomes for patients with comorbid conditions. Shortage of a trained behavioral health workforce limits adoption. Professional psychology training programs contribute to recruitment, retention, and development of skilled providers, who value and deliver behavioral health services in primary care. This study interviewed a cohort of established psychology training programs in real-world, state-wide clinical primary care settings and identified their strategies and challenges with teaching practices and program resources that impact the robust quality of training. Method: Between December 2020 and March 2021, we conducted semistructured interviews with 12 licensed psychologists who oversaw nine integrated primary care psychology training programs at the internship and postdoctoral levels across Washington State. Data were analyzed using a thematic approach. Results: Programs taught psychology trainees about integrated primary care via extensive onboarding, modeling and shadowing, structured learning environment, interprofessional education opportunities, flexible and cross-disciplinary supervision, and a psychologically safe space. Teaching challenges included balancing scheduled and curbside supervision, pivoting to telehealth, and aligning trainee expectations and program requirements. Training programs were funded through different and multiple sources, but most lacked a stable funding mechanism, compounded by barriers for psychology trainees to bill for services, a lack of control over organization's budgeting decisions, and instability in funding renewal. Conclusion: Synergistic support from program, organization, and system/policy levels are needed to align teaching activities with clinical practice environments and invest in the growth and sustainability of psychology training programs on integrated primary care. [ABSTRACT FROM AUTHOR]

Background: Most people with alcohol or opioid use disorders (AUD or OUD) are not diagnosed or treated for these conditions in primary care. This study takes a critical step toward quantifying service gaps and directing improvement efforts for AUD and OUD by using electronic health record (EHR) data from diverse primary care organizations to quantify the extent to which AUD and OUD are underdiagnosed and undertreated in primary care practices.Methods: We extracted and integrated diagnosis, medication, and behavioral health visit data from the EHRs of 21 primary care clinics within four independent healthcare organizations representing community health centers and rural hospital-associated clinics in the Pacific Northwest United States. Rates of documented AUD and OUD diagnoses, pharmacological treatments, and behavioral health visits were evaluated over a two-year period (2015-2016).Results: Out of 47,502 adult primary care patients, 1476 (3.1%) had documented AUD; of these, 115 (7.8%) had orders for AUD medications and 271 (18.4%) had at least one documented visit with a non-physician behavioral health specialist. Only 402 (0.8%) patients had documented OUD, and of these, 107 (26.6%) received OUD medications and 119 (29.6%) had at least one documented visit with a non-physician behavioral health specialist. Rates of AUD diagnosis and AUD and OUD medications were higher in clinics that had co-located non-physician behavioral health specialists.Conclusions: AUD and OUD are underdiagnosed and undertreated within a sample of independent primary care organizations serving mostly rural patients. Primary care organizations likely need service models, technologies, and workforces, including non-physician behavioral health specialists, to improve capacities to diagnose and treat AUD and OUD. [ABSTRACT FROM AUTHOR]