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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.

Background: Recent efforts to prepare healthcare professionals to care for patients/clients with substance use problems have incorporated SBIRT (Screening, Brief Intervention, and Referral to Treatment) into graduate education programs. This pilot study adds to the literature by examining the impact of an SBIRT interprofessional education approach for behavioral health graduate students and medical residents as planned by faculty from multiple professions at a state university. It measured changes in attitudes, abilities, skills, and knowledge in these interprofessionally trained students. Methods: Faculty in Counseling, Family Medicine, Internal Medicine, Nursing and Social Work departments collaborated to develop an interprofessional curriculum delivered through a small-group and active learning approach. Seventy-one residents and graduate students participated. Pre- and post-training surveys measured self-perceived attitudes, abilities, and skills along with objectively measured knowledge. Analysis examined pre- to post-training changes in scores. Results: Pre-training surveys yielded an 89% response rate; post-training, 85%. Self-perceived attitudes did not change significantly, except a 20% increase in how rewarded students felt while working with patients/clients with alcohol/drug use disorders (P < 0.01). Compared to baseline, there was a statistically significant increase in all items of self-perceived ability (P<0.01) and all items of self-perceived communication skills (P=0.04). Knowledge mean scores also increased significantly (P < 0.001) across both primary care and behavioral health student groups. Conclusions: Interprofessional training in SBIRT produced improvements in ability, skills, knowledge, and some attitudes. Such programs may inform providers who care for patients/clients with substance use problems, improving their personal experience and professional competence.

Purpose: Although many primary care clinics screen for behavioral health (BH) conditions using validated tools, it is not clear whether adult BH screening leads to better patient outcomes. Our objective was to determine the evidence base by reviewing effectiveness research for multiple strategies of BH screening in adult primary care identified in the Practice Integration Profile. Method: We conducted five rapid reviews of effectiveness research supporting BH screening strategies cited in the Practice Integration Profile. Each rapid review was conducted using an adapted REAL (Rapid Evidence Assessment of the Literature) methodology and a standardized search tailored for each screening strategy to identify evidence related to BH screening in primary care. Results: The database search yielded 931 references. Following eligibility review and extraction, we evaluated data from 20 references examining five screening strategies. Results demonstrated limited support for all five strategies and high risk of bias within most studies. Outcomes associated with various BH screening strategies were rarely the focus of study. Conclusions: There is an absence of robust, well-structured evidence supporting many of the BH screening strategies advocated for in primary care. Stakeholders may wish to understand how to ensure value when developing a robust screening program that will improve patient health outcomes. Future research should advance the science of BH screen selection, timing, and implementation by answering new questions about screening strategies. Public Significance Statement Primary care clinicians play an important role in screening patients for unmet health needs, including behavioral health concerns. Given the broad array of potential conditions that can be identified in primary care, the ability to focus on screening strategies with the greatest potential to improve patient-centered outcomes is a meaningful advance in care. The results of our rapid reviews suggest that although screening strategies were found to be important components in some studies, additional research is needed to identify evidence-based screening strategies. Keywords: behavioral medicine, delivery of health care - integrated, primary health care, rapid review, screening Supplemental materials: https://doi.org/10.1037/fsh0000700.supp This article was published Online First June 2, 2022., Patients frequently rely on primary care to address behavioral health (BH) conditions, including mental health and substance use problems, as well as chronic medical conditions with prominent behavioral components (Richman [...]

Context: Despite a growing commitment to integrating behavioral health (IBH) in primary care (PC), high levels of integration that improve care and outcomes are elusive. As previously reported to NAPCRG (2021), 'IBH-PC' studied the effectiveness of an intervention to support BH integration in a randomized controlled trial (RCT). A small improvement in BH integration was detected; there was no observed effect on patient outcomes. Objective: Secondary analysis to understand relationships among intervention completion, timing of study measures relative to COVID-19, level of BH integration, and patient reported outcomes. Study Design: Post-hoc analysis of pragmatic RCT. Setting: 42 primary care clinics with on-site BH services, in 13 states, Sep 2017-Dec 2020. Population: 2,426 adults with multiple chronic behavioral and medical conditions. Intervention: Clinic-level support to implement IBH using online curricula, workbooks, remote coaching, and online learning community. Outcomes and Predictors: Change in mean Patient-Reported Outcomes Measurement Information System scores (PROMIS) and median Practice Integration Profile (PIP); timing relative to COVID-19; and completion of the implementation stage of the intervention. Results: Higher PIP scores were associated with better patient outcomes in all 8 PROMIS domains at baseline and follow-up. This association was significant for Anxiety (CI -0.12, 0.00, P=0.05 and CI -0.09, -0.01, P=0.01, respectively), Social Participation (CI +0.01, +0.09, P=0.02 and CI +0.02, +0.10, P=0.01), and Mental Health Summary (CI 0.00, +0.09, P=0.05 and CI 0.00, +0.09, P=0.04). Additional analysis found that a longer lapse between the start of COVID-19 and collection of final outcomes was associated with smaller improvement in PIP (P=0.04). Among clinics in the intervention arm (n=20), those that completed implementation (n=13) had significantly larger improvement in PIP scores (P=0.013) than those that did not; their patients also reported more improvement in PROMIS scores for Mental Health Summary (P=0.02), Social Participation (P=0.01), and Fatigue (P=0.04). Conclusions: Post-hoc analyses identified associations among level of integration, improved patient reported health outcomes, and intervention completion. COVID-19 may have affected intervention completion. To help the field advance, future study must identify necessary conditions for successful implementation of IBH and the relationship between integration and health., Presenters Constance van Eeghen, DrPH, MHSA, Rodger Kessler, PhD, ABPP, Levi Bonnell, MPH, PhD Candidate, Jennifer O'Rourke-Lavoie, BS, Juvena Hitt, MPH, Gail Rose, PhD, Benjamin Littenberg, MD, Jessica Clifton, [...]

Context: Food, housing, and financial insecurities are social determinants of health that negatively affect health. Little is known about the long-term impact of these insecurities on functional capacity. Objective: To investigate the longitudinal effect of these SDHs on functional capacity. Study Design: Retrospective cohort study Setting or Dataset: Longitudinal surveys from 41 primary care clinics across 13 states (September 2017 to February 2021) Population Studied: 2,426 adult primary care patients with multiple chronic conditions. Outcome Measures: The primary outcome was metabolic equivalents (METs) calculated from the Duke Activity Status Index (DASI). Results: The median time between baseline and follow-up surveys was 636 days. Baseline data were collected pre-COVID-19 and follow-up data were collected during COVID-19. The prevalence of one or more insecurities was 27% at baseline and 23% at follow-up. The median functional capacity was 6.1 at both time points. Compared to no SDH, the presence of one or more SDH at baseline but not follow-up (n=266) was associated with a -0.58 reduction in METs (95% CI: -0.84, - 0.33). Any SDH at follow-up but not baseline (n=172) was associated with a -0.67 reduction in METs (95% CI: -0.97, -0.36 and any SDH at both baseline and follow-up (n=369) was associated with a -0.90 reduction in METs (95% CI: -1.14, 0.66). Conclusions: The presence of these insecurities at baseline, follow-up or both was associated with significantly worse functional capacity compared to never having had these insecurities. This suggests primary prevention of insecurities (food, housing, and financial) are essential. Even participants who had insecurities at baseline and resolved it by follow-up still had poorer functional capacity, suggesting the devastating long-term impacts. Future studies should investigate Primary Care as a resource to screen for and prevent these insecurities., Presenters Levi Bonnell, MPH, PhD Candidate, Benjamin Littenberg, MD, Abigail Crocker, PhD, Constance van Eeghen, DrPH, [...]

Introduction: We developed the Practice Integration Profile (PIP) to measure the degree of behavioral health integration in clinical practices with a focus on primary care (PC). Its 30 items, completed [...]

Insufficient knowledge exists regarding how to measure the presence and degree of integrated care. Prior estimates of integration levels are neither grounded in theory nor psychometrically validated. They provide scant [...]

Integrated behavioral health (IBH) is an approach to patient care that brings medical and behavioral health providers (BHPs) together to address both behavioral and medical needs within primary care settings. A large, pragmatic, national study aimed to test the effectiveness and measure the implementation costs of an intervention to improve IBH integration within primary care practices (IBH-PC). Assess the time and cost to practices of implementing a comprehensive practice-level intervention designed from the perspective of clinic owners to move behavioral service integration from co-location toward full integration as part of the IBH-PC study. IBH-PC program implementation costs were estimated in a representative sample of 8 practices using standard micro-econometric evaluation of activities outlined in the implementation workbook, including program implementation tasks, remote quality improvement coaching services, educational curricula, and learning community activities, over a 24-month period. The total median cost of implementing the IBH-PC program across all stages was $20,726 (range: $12,381 - $60,427). The median cost of the Planning Stage was $10,258 (range: $4,625 - $14,840), while the median cost of the Implementation Stage was $9,208 (range: $6,017 – 49,993). There were no statistically significant differences in practice or patient characteristics between the 8 selected practices and the larger IBH-PC practice sample (N=34). This study aimed to quantify the relative costs associated with integrating behavioral health into primary care. Although the cost assessment approach did not include all costs (fixed, variable, operational, and opportunity costs), the study aimed to develop a replicable and pragmatic measurement process with flexibility to adapt to emerging developments in each practice environment, providing a reasonable ballpark estimate of costs associated with implementation to help guide future executive decisions. [ABSTRACT FROM AUTHOR]

Introduction: The Practice Integration Profile (PIP) is a reliable, valid, and broadly used measure of the integration of behavioral health (BH) into primary care. The PIP assesses operational and procedural elements that are grounded in the AHRQ Lexicon for Behavioral Health and Primary Care Integration. Prior analyses of PIP data and feedback from users suggested the measure was in need of revisions. This article describes the process used to improve readability, clarity, and pragmatic utility of the instrument. Method: Two rounds of structured cognitive interviews were conducted with clinicians in primary care settings. After each round, interview transcripts were coded by an analytic team using an iterative and consensus-driven process. Themes were identified based on codes. Themes and recommendations for revisions were reviewed and modified by committee. Results: Based on feedback and a prior factor analysis of the PIP, revisions were undertaken to: (a) eliminate redundant or overlapping items; (b) clarify the meaning of items; (c) standardize the response categories, and (d) place items in the most appropriate domains. The resulting measure has 28 items in five domains. Discussion: PIP 2.0 will need further examination to confirm its continuing use as a foundational tool for evaluating integrated care. Public Significance Statement: This article presents a revised version of a previously validated survey that measures the extent to which primary care practices have integrated behavioral health care. The revised survey can be used to support practice improvement in primary care and research on such topics as the determinants of practice-level performance. [ABSTRACT FROM AUTHOR]

Background: Torture can result in impaired functional mobility, reduced quality of life, and persistent pain. Physical therapy (PT) is recommended for holistic care of survivors of torture (SOT), however there are limited evidenced-based guidelines. We conducted a scoping review to identify and describe the approach and gaps in knowledge around the PT treatment of SOT., Methods: We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Re-views. Nine databases were searched. Eligible sources involved PT treatment for SOT. Interventions were categorized into themes based on recommendations from the Physiotherapy and Refugees Edu-cation Project: 1) trauma-informed care, 2) body-awareness and empowerment, 3) pain management., Results: The final analysis included 15 sources. Eight sources included all three themes; three of these eight sources were research studies examining outcomes following the PT intervention. While out-comes of these studies were significant for improvement among the PT groups, results must be taken cautiously due to methodological limitations of the trials. Studies assessing treatment that included only one theme resulted in no differences between the control and intervention groups., Conclusions: We describe the scope of the literature regarding PT for SOT. A trauma-informed PT approach, co-ordinated with pain management, and body-awareness and empowerment interventions may address the complex needs of survivors. However, rigorous studies of this three-themed approach are lacking. As SOT seek medical services, healthcare providers must be prepared to care for these vulnerable people. Physical therapists are encouraged to utilize a holistic approach, and to examine outcomes of this approach for SOT.

Context: Most patients in need of behavioral health (BH) care are seen in primary care, which often has difficulty responding. Some practices integrate behavioral health care (IBH), with medical and BH providers at the same location, working as a team. However, it is difficult to achieve high levels of integration. Objective: Test the effectiveness of a practice intervention designed to increase BH integration. Study Design: Pragmatic, cluster-randomized controlled trial. Setting: 43 primary care practices with on-site BH services in 13 states. Population: 2,460 adults with multiple chronic medical and behavioral conditions. Intervention: 24-month practice change process including an online curriculum, a practice redesign and implementation workbook, remote quality improvement coaching services, and an online learning community. Outcomes: Primary outcomes were changes in the 8 Patient-Reported Outcomes Measurement Information System (PROMIS-29) domain scores. Secondary outcomes were changes in medication adherence, self-reported healthcare utilization, time lost due to disability, cardiovascular capacity, patient centeredness, provider empathy, and several condition-specific measures. A sample of practice staff completed the Practice Integration Profile at each time point to estimate the degree of BH integration in that site. Practice-level case studies estimated the typical costs of implementing the intervention. Results: The intervention had no significant effect on any of the primary or secondary outcomes. Subgroup analyses showed no convincing patterns of effect in any populations. COVID-19 was apparently not a moderating influence of the effect of the intervention on outcomes. The intervention had a modest effect on the degree of practice integration, reaching statistical significance in the Workflow domain. The median cost of the intervention was $18,204 per practice. In post-hoc analysis, level of BH integration was associated with improved patient outcomes independent of the intervention, both at baseline and longitudinally. Conclusions: The specific intervention tested in this study was inexpensive, but had only a small impact on the degree of BH integration, and none on patient outcomes. However, practices that had more integration at baseline had better patient outcomes, independent of the intervention. Although this particular intervention was ineffective, IBH remains an attractive strategy for improving patient outcomes., Competing Interests: Authors report none., (© 2021 Annals of Family Medicine, Inc.)

Objective: Use an established quality improvement method, Lean A3, to improve the process of opioid prescribing in an academic rheumatology ambulatory clinic., Methods: This retrospective pre-postintervention analysis of rheumatology records included patients prescribed opioids at least once during the study period. Lean A3 was used to develop a Controlled Substance Visit Protocol to standardize eight recommended elements of the opioid prescribing workflow. Analyses included changes in the recommended workflow elements and changes in opioid prescribing volume., Results: Improvements were observed in seven of the eight recommended elements. Patient education, including treatment agreements and consent forms (39% completion for both preimplementation) increased to 78% and 80%, respectively ( P < 0.001 for both). Risk assessment, as measured by the Current Opioid Misuse Measure, increased from 0.5% to 76% ( P < 0.001). Best practices in prescribing, including prescribing in multiples of seven to avoid weekend refill requests, increased from 1% to 79% ( P < 0.001). Monitoring parameters, including standardized functional assessment (0% vs. 86%), prescription drug monitoring program queries (49% vs. 84%), and urine testing (1% vs. 32%) all increased ( P < 0.001). Visits scheduled at least quarterly for patients on chronic opioids did not change ( P = 0.18). Overall, the number of patients prescribed opioids (185 vs. 160; P < 0.001) and annual prescription opioid morphine milligram equivalents (MMEs) (1 933 585 MME vs. 1 386 368 MME; P < 0.001) decreased., Conclusion: The Lean A3 method is a successful quality improvement tool for improving and sustaining opioid prescribing within a single academic rheumatology clinic. This method has potential applicability to similar clinics interested in improving opioid prescribing., (© 2019 The Authors. ACR Open Rheumatology published by Wiley Periodicals, Inc. on behalf of American College of Rheumatology.)