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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. Annals Early Access article., (© 2024 Annals of Family Medicine, Inc.)

Background: The COVID-19 pandemic disrupted how primary care patients with chronic pain received care. Our study sought to understand how long-term opioid therapy (LtOT) for chronic pain changed over the course of the pandemic overall and for different demographic subgroups., Methods: We used data from electronic health records of 64 primary care clinics across Washington state and Idaho to identify patients who had a chronic pain diagnosis and were receiving long-term opioid therapy. We defined 10-month periods in 2019 to 2021 as prepandemic, early pandemic and late pandemic and used generalized estimating equations analysis to compare across these time periods and demographic characteristics., Results: We found a proportional decrease in LtOT for chronic pain in the early months of the pandemic (OR = 0.94, P = .007 ) followed by an increase late pandemic (OR = 1.08, P = .002 ). Comparing late pandemic to prepandemic, identifying as Asian or Black, having fewer comorbidities, or living in an urban area were associated with higher likelihood of being prescribed LtOT., Discussion: The use of LtOT for chronic pain in primary care has increased from before to after the COVID-19 pandemic with racial/ethnic and geographic disparities. Future research is needed to understand these disparities in LtOT and their effect on patient outcomes., Competing Interests: Conflict of interest: None., (© Copyright 2024 by the American Board of Family Medicine.)

Background: Chronic 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., Methods: Forty-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., Discussion: As 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 Registration: ClinicalTrials.gov NCT02868983 . Registered on August 16, 2016.

A movement towards integrated behavioral health (IBH) in primary care continues to grow, among an accumulating evidence base for its effectiveness for improving care. However, healthcare organizations struggle to navigate where to target their limited resources for improving integration. We evaluated a cross-model framework of IBH core processes and structures. We used a mixed-methods approach for evaluation of the framework, which included (a) an evaluation survey of national experts and stakeholders, (b) crosswalks with common IBH measures, and (c) a real-world usability test. Five core IBH principles, mapping to 25 processes, and nine clinic structures were defined. Survey responses from 29 IBH domain and policy experts and stakeholders resulted in uniformly high ratings of importance and variable levels of feasibility for measurement, particularly with respect to electronic health record (EHR) systems. A real-world usability test resulted in good uptake and use of the framework across a state-wide effort. An IBH Cross-Model Framework of core principles, processes, and structures generated good acceptability and showed good real-world utility in a state-wide effort to improve IBH across disparate levels of integration in diverse primary care settings. Findings identify feasible areas of measurement, particularly with EHR systems. Next steps include testing the relationship between the individual framework components and patient outcomes to help guide clinics towards prioritizing efforts focused on improving integration., (© Society of Behavioral Medicine 2020. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

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.

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.)

Practice-based research networks bring together academic researchers and primary care clinicians to conduct research that improves health outcomes in real-world settings. The Washington, Wyoming, Alaska, Montana, and Idaho region Practice and Research Network implemented a health data-sharing infrastructure across 9 clinics in 3 primary care organizations. Following implementation, we identified challenges and solutions. Challenges included working with diverse primary care organizations, adoption of health information data-sharing technology in a rapidly changing local and national landscape, and limited resources for implementation. Overarching solutions included working with a multidisciplinary academic implementation team, maintaining flexibility, and starting with an established network for primary care organizations. Approaches outlined may generalize to similar initiatives and facilitate adoption of health data sharing in other practice-based research networks.

Integrating behavioral health into primary care can improve access to behavioral health and patient health outcomes. We used 2017-2021 American Board of Family Medicine continuing certificate examination registration questionnaire responses to determine the characteristics of family physicians who work collaboratively with behavioral health professionals. With a 100% response rate, 38.8% of 25,222 family physicians reported working collaboratively with behavioral health professionals, with those working in independently owned practices and in the South having substantially lower rates. Future research exploring these differences could help develop strategies to support family physicians implement integrated behavioral health to improve care for patients in these communities. [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]

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]