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Objective: The authors measured implementation of Zero Suicide (ZS) clinical practices that support identification of suicide risk and risk mitigation, including screening, risk assessment, and lethal means counseling, across mental health specialty and primary care settings., Methods: Six health care systems in California, Colorado, Michigan, Oregon, and Washington participated. The sample included members ages ≥13 years from 2010 to 2019 (N=7,820,524 patients). The proportions of patients with suicidal ideation screening, suicide risk assessment, and lethal means counseling were estimated., Results: In 2019, patients were screened for suicidal ideation in 27.1% (range 5.0%-85.0%) of mental health visits and 2.5% (range 0.1%-35.0%) of primary care visits among a racially and ethnically diverse sample (44.9% White, 27.2% Hispanic, 13.4% Asian, and 7.7% Black). More patients screened positive for suicidal ideation in the mental health setting (10.2%) than in the primary care setting (3.8%). Of the patients screening positive for suicidal ideation in the mental health setting, 76.8% received a risk assessment, and 82.4% of those identified as being at high risk received lethal means counseling, compared with 43.2% and 82.4%, respectively, in primary care., Conclusions: Six health systems that implemented ZS showed a high level of variation in the proportions of patients receiving suicide screening and risk assessment and lethal means counseling. Two opportunities emerged for further study to increase frequency of these practices: expanding screening beyond patients with regular health care visits and implementing risk assessment with lethal means counseling in the primary care setting directly after a positive suicidal ideation screening., Competing Interests: The authors report no financial relationships with commercial interests.

Background: Routine population-based screening for depression is an essential part of evolving health care models integrating care for mental health in primary care. Depression instruments often include questions about suicidal thoughts, but how patients experience these questions in primary care is not known and may have implications for accurate identification of patients at risk., Objectives: To explore the patient experience of routine population-based depression screening/assessment followed, for some, by suicide risk assessment and discussions with providers., Design: Qualitative, interview-based study., Participants: Thirty-seven patients from Kaiser Permanente Washington who had recently screened positive for depression on the 2-item Patient Health Questionnaire [PHQ] and completed the full PHQ-9., Approach: Criterion sampling identified patients who had recently completed the PHQ-9 ninth question which asks about the frequency of thoughts about self-harm. Patients completed semi-structured interviews by phone, which were recorded and transcribed. Directive and conventional content analyses were used to apply knowledge from prior research and elucidate new information from interviews; thematic analysis was used to organize key content overall and across groups based on endorsement of suicide ideation., Key Results: Four main organizing themes emerged from analyses: (1) Participants believed being asked about suicidality was contextually appropriate and valuable, (2) some participants described a mismatch between their lived experience and the PHQ-9 ninth question, (3) suicidality disclosures involved weighing hope for help against fears of negative consequences, and (4) provider relationships and acts of listening and caring facilitated discussions about suicidality., Conclusions: All participants believed being asked questions about suicidal thoughts was appropriate, though some who disclosed suicidal thoughts described experiencing stigma and sometimes distanced themselves from suicidality. Direct communication with trusted providers, who listened and expressed empathy, bolstered comfort with disclosure. Future research should consider strategies for reducing stigma and encouraging fearless disclosure among primary care patients experiencing suicidality.

Purpose: We conducted a randomized controlled trial to compare the effectiveness of adding various forms of enhanced external support to practice facilitation on primary care practices' clinical quality measure (CQM) performance., Methods: Primary care practices across Washington, Oregon, and Idaho were eligible if they had fewer than 10 full-time clinicians. Practices were randomized to practice facilitation only, practice facilitation and shared learning, practice facilitation and educational outreach visits, or practice facilitation and both shared learning and educational outreach visits. All practices received up to 15 months of support. The primary outcome was the CQM for blood pressure control. Secondary outcomes were CQMs for appropriate aspirin therapy and smoking screening and cessation. Analyses followed an intention-to-treat approach., Results: Of 259 practices recruited, 209 agreed to be randomized. Only 42% of those offered educational outreach visits and 27% offered shared learning participated in these enhanced supports. CQM performance improved within each study arm for all 3 cardiovascular disease CQMs. After adjusting for differences between study arms, CQM improvements in the 3 enhanced practice support arms of the study did not differ significantly from those seen in practices that received practice facilitation alone (omnibus P = .40 for blood pressure CQM). Practices randomized to receive both educational outreach visits and shared learning, however, were more likely to achieve a blood pressure performance goal in 70% of patients compared with those randomized to practice facilitation alone (relative risk = 2.09; 95% CI, 1.16-3.76)., Conclusions: Although we found no significant differences in CQM performance across study arms, the ability of a practice to reach a target level of performance may be enhanced by adding both educational outreach visits and shared learning to practice facilitation., (© 2019 Annals of Family Medicine, Inc.)

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., (© 2019 Annals of Family Medicine, Inc.)

Background: Little attention has been paid to quality improvement (QI) capacity within smaller primary care practices which comprise nearly half of all primary care settings. Strategies for external support to build such capacity include practice facilitation (PF), shared learning opportunities, and educational outreach. Although PF has proven effectiveness, little is known about the comparative effectiveness of combining these strategies. Here, we describe the protocol of the "Healthy Hearts Northwest" (H2N) study, a randomized trial designed to address these questions while improving risk factors for cardiovascular disease., Methods/design: The targeted enrollment is 250 smaller primary care practices across Washington, Oregon, and Idaho. The study is utilizing a two-by-two factorial design to assess four different combinations of practice support: PF alone, PF with educational outreach, PF with shared learning opportunities, or PF with both. A mixed methods approach is being used for evaluation and will include data from (1) baseline and follow-up practice and staff surveys; (2) baseline and quarterly clinical performance measurement from each practice on four cardiovascular risk factors: appropriate aspirin use, blood pressure control, lipid management and smoking cessation support; and (3) a quality improvement capacity assessment (QICA) survey used by external practice facilitators to guide improvement efforts., Discussion: Results from this study will inform future large-scale practice improvement initiatives by providing comparisons of promising external practice support strategies and advance our understanding of how to build QI capacity in primary care., Trial Registration: ClinicalTrials.gov, NCT02839382.

Objective: The study sought to determine the impact of a pediatric behavioral health screening and colocation model on utilization of behavioral health care., Methods: In 2003, Cambridge Health Alliance, a Massachusetts public health system, introduced behavioral health screening and colocation of social workers sequentially within its pediatric practices. An interrupted time-series study was conducted to determine the impact on behavioral health care utilization in the 30 months after model implementation compared with the 18 months prior. Specifically, the change in trends of ambulatory, emergency, and inpatient behavioral health utilization was examined. Utilization data for 11,223 children ages ≥4 years 9 months to <18 years 3 months seen from 2003 to 2008 contributed to the study., Results: In the 30 months after implementation of pediatric behavioral health screening and colocation, there was a 20.4% cumulative increase in specialty behavioral health visit rates (trend of .013% per month, p=.049) and a 67.7% cumulative increase in behavioral health primary care visit rates (trend of .019% per month, p<.001) compared with the expected rates predicted by the 18-month preintervention trend. In addition, behavioral health emergency department visit rates increased 245% compared with the expected rate (trend .01% per month, p=.002)., Conclusions: After the implementation of a behavioral health screening and colocation model, more children received behavioral health treatment. Contrary to expectations, behavioral health emergency department visits also increased. Further study is needed to determine whether this is an effect of how care was organized for children newly engaged in behavioral health care or a reflection of secular trends in behavioral health utilization or both.