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Integrating primary care and behavioral health is an important focus of health system transformation. Cross-case comparative analysis of 19 practices in the United States describing integrated care clinical workflows. Surveys, observation visits, and key informant interviews analyzed using immersion-crystallization. Staff performed tasks and behaviors--guided by protocols or scripts--to support 4 workflow phases: (1) identifying; (2) engaging/transitioning; (3) providing treatment; and (4) monitoring/adjusting care. Shared electronic health records and accessible staffing/scheduling facilitated workflows. Stakeholders should consider these workflow phases, address structural features, and utilize a developmental approach as they operationalize integrated care delivery. [ABSTRACT FROM AUTHOR]

Purpose: This article describes the electronic health record (EHR)-related experiences of practices striving to integrate behavioral health and primary care using tailored, evidenced-based strategies from 2012 to 2014; and the challenges, workarounds and initial health information technology (HIT) solutions that emerged during implementation., Methods: This was an observational, cross-case comparative study of 11 diverse practices, including 8 primary care clinics and 3 community mental health centers focused on the implementation of integrated care. Practice characteristics (eg, practice ownership, federal designation, geographic area, provider composition, EHR system, and patient panel characteristics) were collected using a practice information survey and analyzed to report descriptive information. A multidisciplinary team used a grounded theory approach to analyze program documents, field notes from practice observation visits, online diaries, and semistructured interviews., Results: Eight primary care practices used a single EHR and 3 practices used 2 different EHRs, 1 to document behavioral health and 1 to document primary care information. Practices experienced common challenges with their EHRs' capabilities to 1) document and track relevant behavioral health and physical health information, 2) support communication and coordination of care among integrated teams, and 3) exchange information with tablet devices and other EHRs. Practices developed workarounds in response to these challenges: double documentation and duplicate data entry, scanning and transporting documents, reliance on patient or clinician recall for inaccessible EHR information, and use of freestanding tracking systems. As practices gained experience with integration, they began to move beyond workarounds to more permanent HIT solutions ranging in complexity from customized EHR templates, EHR upgrades, and unified EHRs., Conclusion: Integrating behavioral health and primary care further burdens EHRs. Vendors, in cooperation with clinicians, should intentionally design EHR products that support integrated care delivery functions, such as data documentation and reporting to support tracking patients with emotional and behavioral problems over time and settings, integrated teams working from shared care plans, template-driven documentation for common behavioral health conditions such as depression, and improved registry functionality and interoperability. This work will require financial support and cooperative efforts among clinicians, EHR vendors, practice assistance organizations, regulators, standards setters, and workforce educators., (© Copyright 2015 by the American Board of Family Medicine.)

Purpose: To examine the interrelationship among behavioral health clinician (BHC) staffing, scheduling, and a primary care practice's approach to delivering integrated care., Methods: Observational cross-case comparative analysis of 17 primary care practices in the United States focused on implementation of integrated care. Practices varied in size, ownership, geographic location, and integrated care experience. A multidisciplinary team analyzed documents, practice surveys, field notes from observation visits, implementation diaries, and semistructured interviews using a grounded theory approach., Results: Across the 17 practices, staffing ratios ranged from 1 BHC covering 0.3 to 36.5 primary care clinicians (PCCs). BHC scheduling varied from 50-minute prescheduled appointments to open, flexible schedules slotted in 15-minute increments. However, staffing and scheduling patterns generally clustered in 2 ways and enabled BHCs to be engaged by referral or warm handoff. Five practices predominantly used warm handoffs to engage BHCs and had higher BHC-to-PCC staffing ratios; multiple BHCs on staff; and shorter, more flexible BHC appointment schedules. Staffing and scheduling structures that enabled warm handoffs supported BHC engagement with patients concurrent with the identification of behavioral health needs. Twelve practices primarily used referrals to engage BHCs and had lower BHC-to-PCC staffing ratios and BHC schedules prefilled with visits. This enabled some BHCs to bill for services, but also made them less accessible to PCCs in when patients presented with behavioral health needs during a clinical encounter. Three of these practices were experimenting with open scheduling and briefer BHC visits to enable real-time access while managing resources., Conclusion: Practices' approaches to PCC-BHC staffing, scheduling, and delivery of integrated care mutually influenced each other and were shaped by the local context. Practice leaders, educators, clinicians, funders, researchers, and policy makers must consider these factors as they seek to optimize integrated systems of care., (© Copyright 2015 by the American Board of Family Medicine.)

Background: Significant investments and effort are being devoted to health care reform, yet little is known about the costs of improvements. Practical tools are needed to allow for systematic assessment of practice expenses. We report here a field trial of a standardized expenditure data collection instrument., Methods: Combining economic and primary care practice consultation, an expenditure data collection instrument was created. The instrument underwent observed feasibility testing and was fielded by 10 practice-based research networks in 30 practices conducting 10 different health behavior change interventions., Results: Start-up and operating expenses were successfully collected for 87% and 97% of the practices, respectively. Data collection time and effort were considerable but acceptable. Three elements were necessary to collect expenditure data: (1) an intervention-specific data collection instrument, (2) a field guide, and (3) economic oversight and assistance. Fully 90% of networks reported that they planned to collect expenditure data in the future and study participation increased the likelihood of their participation in a future expenditure study., Conclusions: It is feasible to systematically collect intervention-specific expenses in primary care using formal expenditure methods. However, most practices and researchers lack the knowledge, expertise, and resources to collect such data independently. Further assistance and education is necessary to obtain reliable information about the expenses to transform and improve primary care.

Background: If behavior-change services are to be offered routinely in primary care practices, providers must be appropriately compensated. Estimating what is spent by practices in providing such services is a critical component of establishing appropriate payment and was the objective of this study., Methods: In-practice expenditure data were collected for ten different interventions, using a standardized instrument in 29 practices nested in ten practice-based research networks across the U.S. during 2006-2007. The data were analyzed using standard templates to create credible estimates of the expenses incurred for both the start-up period and the implementation phase of the interventions., Results: Average monthly start-up expenses were $1860 per practice (SE=$455). Most start-up expenditures were for staff training. Average monthly incremental costs were $58 ($15 for provision of direct care [SE=$5]; $43 in overhead [SE=$17]) per patient participant. The bulk of the intervention expenditures was spent on the recruitment and screening of patient participants., Conclusions: Primary care practices must spend money to address their patients' unhealthy behaviors--at least $1860 to initiate systematic approaches and $58 monthly per participating patient to implement the approaches routinely. Until primary care payment systems incorporate these expenses, it is unlikely that these services will be readily available.

Purpose: The leading causes of premature death in the United States are linked to 4 behaviors: smoking, unhealthy diet, physical inactivity, and risky alcohol use. We report lessons from 17 exploratory projects funded under Prescription for Health that tested the feasibility of innovative behavior change strategies for at least 2 of these behaviors in primary care practices., Methods: Seventeen practice-based research networks (PBRNs) implemented and evaluated tools, cues, and techniques in 120 family medicine, internal medicine, pediatric, and nursing practices across an ethnically diverse sample of adults, children, and adolescents in rural and urban settings. We reviewed progress reports and notes from site visits and 3 meetings to generate overarching lessons., Results: PBRNs successfully implemented their projects in diverse practices despite reported logistical challenges and practice constraints. The networks showed that distributing the effort across the care team and throughout the practice and community is possible. Although each behavior required specific attention, each did not require its own separate staff and system. Three models emerged as helpful guides for the comprehensive redesign of health behavior counseling, but they require adaptation for use in real-world primary care settings. Traditional methods of collaboration yielded mixed results, making obvious a need for dedicated collaboration funds and a better framework to identify and align high-yield opportunities., Conclusions: These projects confirm the feasibility of health behavior counseling in primary care practice. They also highlight the need for substantive practice redesign, and the value of models and frameworks to guide redesign and collaborative efforts.

Purpose: With increasing evidence for the value of behavior change counseling, there is a need for health behavior measurements that can be implemented in primary care research. This article discusses criteria for and reviews self-report measures to briefly assess cigarette smoking, eating patterns, physical activity, and risky drinking across the life course. It then proposes pragmatic measures for use in practice-based research., Methods: Drawing from literature reviews, previous multisite studies, personal communications with experts in the field, and guidance from an expert panel, we identified self-report behavior change measures and gave priority to items that addressed Healthy People 2010 goals, as well as those that were practical (ie, shorter, and easier to score and use for intervention), were sensitive to change, and produced results that could directly inform primary care intervention., Results: Separate recommendations are described for measures for adults and for children/adolescents. We recommend a set of 22 items for adults and 16 items for adolescents to track succinctly their status on the 4 health behaviors above. Perfected measures remain elusive: newly developed measures of physical activity and eating patterns are recommended, and in general, the brief measures for adults are currently better validated than are the child measures., Conclusions: A set of totally satisfactory practical instruments for measuring behavior change in primary care settings does not yet exist. There is sufficient progress to encourage use of and further research on the proposed items. Use of a common set of items across different interventions and projects will help to advance clinical and behavioral research in primary care settings.