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Recent value-based payment reforms in the U.S. called for empirical data on how primary care practices of varying characteristics fund their integrated behavioral health services. To describe payment strategies used by U.S. primary care practices to fund behavioral health integration and compare strategies between practices with and without hospital affiliation.Baseline data were used and collected from 44 practices participating in a cluster-randomized, pragmatic trial of behavioral health integration. Data included practice characteristics and payment strategies—fee-for-service payment, pay-for-performance incentives, grants, and graduate medical education funds. Descriptive and comparative analyses using Fisher’s exact tests and independent T-tests were conducted. The sample had 26 (59.1%) hospital-affiliated (hospital/health system-owned, academic medical centers and hospital-affiliated practices) and 18 (40.9%) non-hospital-affiliated practices (community health centers/federally qualified health centers and privately-owned practices). Most practices (88.6%) received payments through fee-for-service; 63.6% received pay-for-performance incentives; 31.8% received grant funds. Collaborative Care Management billing (CPT) codes were used in six (13.6%) practices. Over half (53.8%) of hospital-affiliated practices funded their behavioral health services through fee-for-service and pay-for-performance incentives only, as opposed to two-thirds (66.7%) of non-hospital-affiliated practices required additional support from grants and/or general medical education funds. Primary care practices support behavioral health integration through diverse payment strategies. More hospital-affiliated practices compared to non-hospital-affiliated practices funded integrated behavioral health services through fee-for-service and pay-for-performance incentives. Practices without hospital affiliation relied on multiple funding streams including grants and/or general medical education funds, suggesting their approach to financial sustainment may be more precarious or challenging, compared to hospital-affiliated practices.

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.

Background: Occupational burnout is a major concern for personal well-being and patient care. We examined burnout among primary care providers (PCPs), medical residents, behavioral health providers (BHPs), nurses, and other clinical and nonclinical primary care team members. Methods: This was a cross-sectional study, nested within a larger randomized trial. Participants completed a validated 9-item burnout measure with 3 domains: depersonalization, emotional exhaustion, and personal accomplishment. Multivariable multilevel linear regression with a random intercept for each practice was used to determine mean differences in burnout across professional roles. Results: Overall burnout rates varied by professional role: PCPs 70%, medical residents 89%, BHPs 59%, nurses 66%, other clinicians 68%, and nonclinical professionals 70%. Compared with nonclinical professionals, residents experienced more burnout in more domains, followed by PCPs. PCPs, residents, and nurses reported significantly worse depersonalization and exhaustion scores. Nonclinical professionals had worse accomplishment scores than all clinical professionals except for residents. This study revealed moderate-to-high levels of burnout among primary care professionals. Discussion: Clinicians may be experiencing aspects of burnout more intensely than their nonclinical colleagues, and this may be most true for residents and PCPs. Based on these variations, interventions to mitigate burnout may need to be tailored by professional role.

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.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.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.PIP 2.0 will need further examination to confirm its continuing use as a foundational tool for evaluating integrated care. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The rates of non-communicable diseases (NCD’s) such as diabetes and hypertension are reaching epidemic proportions in Asia. Behavioral conditions are frequently comorbid with NCD’s, contribute to poor clinical outcomes, and are under detected and untreated in many Asian nations. This article reports the findings of a study examining the level of behavioral and non-behavioral care integration in clinics and hospitals in China, Cambodia, Vietnam, and Thailand. It assessed providers’ ratings of patients’ prevalence of behavioral conditions, the need for behavioral health consultants, and patients’ self-reported health risk assessments (HRA) of their lifestyle and behavioral problems. The results show low levels of available behavioral care in the participating Asian countries in comparison with the United States. The HRA results showed high rates of patients’ reported tobacco use, high-risk levels for alcohol use in men, and low levels of healthy foods intake and physical activity for men and women. The provider survey results showed moderate perceived prevalence of lifestyle and behavioral conditions and moderate perceived need for integrated behavioral care. These results suggest a need to develop and evaluate integrated healthcare services in Asia in order to address the epidemic of NCD’s.

Introduction: Understanding, categorizing, and using implementation science theories, models, and frameworks is a complex undertaking. The issues involved are even more challenging given the large number of frameworks and that some of them evolve significantly over time. As a consequence, researchers and practitioners may be unintentionally mischaracterizing frameworks or basing actions and conclusions on outdated versions of a framework. Methods: This paper addresses how the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework has been described, summarizes how the model has evolved over time, and identifies and corrects several misconceptions. Results: We address 13 specific areas where misconceptions have been noted concerning the use of RE-AIM and summarize current guidance on these issues. We also discuss key changes to RE-AIM over the past 20 years, including the evolution to Pragmatic Robust Implementation and Sustainability Model, and provide resources for potential users to guide application of the framework. Conclusions: RE-AIM and many other theories and frameworks have evolved, been misunderstood, and sometimes been misapplied. To some degree, this is inevitable, but we conclude by suggesting some actions that reviewers, framework developers, and those selecting or applying frameworks can do to prevent or alleviate these problems.

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.

Behavioral and mental health risk factors are prevalent among primary care patients and contribute substantially to premature morbidity and mortality and increased health care utilization and costs. Although prior studies have found most adults screen positive for multiple risk factors, limited research has attempted to identify factors that most commonly co-occur, which may guide future interventions. The purpose of this study was to identify subgroups of primary care patients with co-occurring risk factors and to examine sociodemographic characteristics associated with these subgroups. We assessed 12 behavioral health risk factors in a sample of adults (n = 1628) receiving care from nine primary care practices across six U.S. states in 2013. Using latent class analysis, we identified four distinct patient subgroups: a ‘Mental Health Risk’ class (prevalence = 14%; low physical activity, high stress, depressive symptoms, anxiety, and sleepiness), a ‘Substance Use Risk’ class (29%; highest tobacco, drug, alcohol use), a ‘Dietary Risk’ class (29%; high BMI, poor diet), and a ‘Lower Risk’ class (27%). Compared to the Lower Risk class, patients in the Mental Health Risk class were younger and less likely to be Latino/Hispanic, married, college educated, or employed. Patients in the Substance Use class tended to be younger, male, African American, unmarried, and less educated. African Americans were over 7 times more likely to be in the Dietary Risk versus Lower Risk class (OR 7.7, 95% CI 4.0–14.8). Given the heavy burden of behavioral health issues in primary care, efficiently addressing co-occurring risk factors in this setting is critical.

Patients with chronic conditions frequently experience behavioral comorbidities to which primary care cannot easily respond. This study observed a Vermont family medicine practice with integrated medical and behavioral health services that use a structured approach to implement a chronic care management system with Lean. The practice chose to pilot a population-based approach to improve outcomes for patients with poorly controlled Type 2 diabetes using a stepped-care model with an interprofessional team including a community health nurse. This case study observed the team’s use of Lean, with which it designed and piloted a clinical algorithm composed of patient self-assessment, endorsement of behavioral goals, shared documentation of goals and plans, and follow-up. The team redesigned workflows and measured reach (patients who engaged to the end of the pilot), outcomes (HbA1c results), and process (days between HbA1c tests). The researchers evaluated practice member self-reports about the use of Lean and facilitators and barriers to move from pilot to larger scale applications. Of 20 eligible patients recruited over 3 months, 10 agreed to participate and 9 engaged fully (45%); 106 patients were controls. Relative to controls, outcomes and process measures improved but lacked significance. Practice members identified barriers that prevented implementation of all changes needed but were in agreement that the pilot produced useful outcomes. A systematized, population-based, chronic care management service is feasible in a busy primary care practice. To test at scale, practice leadership will need to allocate staffing, invest in shared documentation, and standardize workflows to streamline office practice responsibilities.

Objective To perform a factor analysis of the Practice Integration Profile (PIP), a 30-item practice-level measure of primary care and behavioral health integration derived from the Agency for Healthcare Research and Quality's Lexicon for Behavioral Health and Primary Care Integration. Data sources The PIP was completed by 735 individuals, representing 357 practices across the United States. Study design The study design was a cross-sectional survey. An exploratory factor analysis and assessment of internal consistency reliability via Cronbach's alpha were performed. Data collection methods Participant responses were collected using REDCap, a secure, web-based data capture tool. Principal findings Five of the PIP's six domains had factor loadings for most items related to each factor representing the PIP of 0.50 or greater. However, one factor had items from two PIP domains that had loadings >0.50. A five-factor model with redistributed items resulted in improved factor loadings for all domains along with greater internal consistency reliability (>0.80). Conclusions Five of the PIP's six domains demonstrated excellent internal consistency for measures of health care resources. Although minor improvements to strengthen the PIP are possible, it is a valid and reliable measure of the integration of primary care and behavioral health.

Primary care offices are integrating behavioral health (BH) clinicians into their practices. Implementing such a change is complex, difficult, and time consuming. Lean workflow analysis may be an efficient, effective, and acceptable method for use during integration. The objectives of this study were to observe BH integration into primary care and to measure its impact.This was a prospective, mixed-methods case study in a primary care practice that served 8,426 patients over a 17-month period, with 652 patients referred to BH services. Secondary measures included primary care visits resulting in BH referrals, referrals resulting in scheduled appointments, time from referral to the scheduled appointment, and time from the referral to the first visit. Providers and staff were surveyed on the Lean method.Referrals increased from 23 to 37 per 1000 visits (P.001). Referrals resulted in more scheduled (60% to 74%; P.001) and arrived visits (44% to 53%; P = .025). Time from referral to the first scheduled visit decreased (hazard ratio, 1.60; 95% confidence interval, 1.37-1.88) as did time to first arrived visit (hazard ratio, 1.36; 95% confidence interval, 1.14-1.62). Survey responses and comments were positive.This pilot integration of BH showed significant improvements in treatment initiation and other measures. Strengths of Lean analysis included workflow improvement, system perspective, and project success. Further evaluation is indicated.

Providers working with a team in primary care settings require training to develop the unique skills needed in an integrated, team-based environment. Training focuses on developing a core set of skills that prepares team members to address patient behavioral issues. The training enhances and complements the foundational skills related to the member’s distinct function on the team. Training and workforce development programs begin by assessing the learner’s level of need then supporting core competency development. Integrated, team-based training programs and courses are aligned to address the interdependence of the three worlds (i.e., clinical, operational, financial) of healthcare delivery.

The transition to value-based healthcare is shifting reimbursement for integrated behavioral healthcare from fee-for-service to value-based contracts that emphasize improved quality, efficiency, and outcomes. The Lean Six Sigma approaches to quality improvement are well-suited to meet these new criteria. Techniques such as the value stream map, the plan-do-study-act cycle, control charts, and the A3 Report are Lean Six Sigma approaches to quantifying value-based care, evaluating improvements over time, and initiating quality improvement efforts as needed. The competencies covered in this chapter reflect the importance of improving efficiency, decreasing waste, and improving outcomes in integrated behavioral healthcare delivery. Examples of measurement and evaluation of these competencies are included.

PURPOSE Health information technology (IT) offers promising tools for improv- ing care coordination. We assessed the feasibility and acceptability of 6 proposed care coordination objectives for stage 3 of the Centers for Medicare and Medic- aid Services electronic health record incentive program (Meaningful Use) related to referrals, notification of care from other facilities, patient clinical summaries, and patient dashboards. METHODS We surveyed physician-owned and hospital/health system-affiliated primary care practices that achieved patient-centered medical home recognition and participated in the Meaningful Use program, and community health clinics with patient-centered medical home recognition (most with certified electronic health record systems). The response rate was 35.1%. We ascertained whether practices had implemented proposed objectives and perceptions of their impor- tance. We analyzed the association of organizational and contextual factors with self-reported use of health IT to support care coordination activities. RESULTS Although 78% of the 350 respondents viewed timely notification of hospital discharges as very important, only 48.7% used health IT systems to accomplish this task. The activity most frequently supported by health IT was providing clinical summaries to patients, in 76.6% of practices; however, merely 47.7% considered this activity very important. Greater use of health IT to sup- port care coordination activities was positively associated with the presence of a nonclinician responsible for care coordination and the practice's capacity for systematic change. CONCLUSIONS Even among practices having a strong commitment to the medi- cal home model, the use of health IT to support care coordination objectives is not consistent. Health IT capabilities are not currently aligned with clinicians' priorities. Many practices will need financial and technical assistance for health IT to enhance care coordination.

Behavioral health integration (BHI) entails integrated behavioral health clinicians (IBHCs) providing care-generally for mental health and substance abuse disorders and behavioral comorbidity- within the operational functioning of primary care. Because limited data exist regarding BHI in residency, we studied its impact on resident education by examining whether increased behavioral health (BH) co-management improved residents' perceived ability to treat BH conditions.We included residents from internal and family medicine training programs using BHI in residents' continuity clinics and assessed the level of co-management between primary care and IBHCs and the following domains: (1) confidence in managing BH conditions, (2) barriers to BH provision, (3) perception of autonomy when working with IBHCs, (4) satisfaction with the clinic, and (5) perceived educational value of BH learning modes.Altogether, 117 residents participated in our survey (73.1% response rate). Residents who had co-managed ≥ five patients alongside IBHCs reported significantly higher confidence than those who had co-managedlt; five patients with BH conditions. The association remained significant after adjustment for residents' level of training and specialty. In rating BH learning modes, residents rated most highly active collaboration with IBHCs and observation with feedback from clinic preceptors.BHI training within residency enhances perceived learning and confidence in providing BH care.

The lengthy and uncertain translation of research into clinical practice is well documented. Much of the current "gold standard" clinical research is slow, expensive, and lacks perceived relevance for practitioners and decision makers. In contrast, we summarize experiences conducting the My Own Health Report (MOHR) project to collect and address patient reported measures using principles of rapid, relevant pragmatic research. The methods used for rapid design and fielding of the MOHR project to improve attention to health behaviors and mental health are detailed. Within the multisite, pragmatic, implementation-focused MOHR study, we describe the four phases of the research and the key decisions made and actions taken within each. We provide concrete examples of how relevant research can be conducted transparently to rapidly provide information to practitioners. Data were collected and analyzed in 2013. The multisite (seven research centers partnered with 18 clinics) cluster randomized pragmatic delayed intervention trial was conducted in less than 18 months from receipt of funding applications to completion of data collection. Phases that were especially accelerated included funding and review, and recruitment and implementation. Conducting complex studies rapidly and efficiently is a realistic goal. Key lessons learned for prevention research include use of existing research networks; use of web-based assessment/feedback tools that are tailored to fit local needs; engaging relevant stakeholders early on and throughout the process to minimize need for redesign; and making pragmatic decisions that balance internal and external validity concerns rather than waiting for perfect solutions.

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 by providers, managers, and staff, provide an overall score and 6 domain scores derived from the Lexicon of Collaborative Care. We describe its history and psychometric properties.The PIP was tested in a convenience sample of practices. Linear regression compared scores across integration exemplars, PC with behavioral services, PC without behavioral services, and community mental health centers without PC. An additional sample rated 4 scenarios describing practices with varying degrees of integration.One hundred sixty-nine surveys were returned. Mean domain scores ran from 49 to 65. The mean total score was 55 (median 58; range 0-100) with high internal consistency (Cronbach's alpha = .95). The lowest total scores were for PC without behavioral health (27), followed by community mental health centers (44), PC with behavioral health (60), and the exemplars (86; p.001). Eleven respondents rerated their practices 37 to 194 days later. The mean change was + 1.5 (standard deviation = 11.1). Scenario scores were highly correlated with the degree of integration each scenario was designed to represent (Spearman's ρ = -0.71; P = 0.0005).These data suggest that the PIP is useful, has face, content, and internal validity, and distinguishes among types of practices with known variations in integration. We discuss how the PIP may support practices and policymakers in their integration efforts and researchers assessing the degree to which integration affects patient health outcomes. (PsycINFO Database Record

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 guidance to inform improvement activities, compare integration efforts, discriminate among practices by degree of integration, measure the effect of integration on quadruple aim outcomes, or address the needs of clinicians, regulators, and policymakers seeking new models of health care delivery and funding. We describe the development of the Practice Integration Profile (PIP), a novel instrument designed to measure levels of integrated behavioral health care within a primary care clinic. The PIP draws upon the Agency for Health care Research & Quality's (AHRQ) Lexicon of Collaborative Care which provides theoretic justification for a paradigm case of collaborative care. We used the key clauses of the Lexicon to derive domains of integration and generate measures corresponding to those key clauses. After reviewing currently used methods for identifying collaborative care, or integration, and identifying the need to improve on them, we describe a national collaboration to describe and evaluate the PIP. We also describe its potential use in practice improvement, research, responsiveness to multiple stakeholder needs, and other future directions. (PsycINFO Database Record

BackgroundRecent 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. No research has examined the benefits and methods of an SBIRT interprofessional education approach for behavioral health graduate students and medical residents. This pilot study examined the implementation of an interprofessional curriculum on SBIRT to improve attitudes, abilities, skills, and knowledge of learners planned by faculty from multiple professions at a state university.MethodsFaculty 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.ResultsPre-training surveys yielded an 89% response rate; post-training, 85%. Self-perceived attitudes did not change significantly, except a 20% increase in how rewarded learners felt while working with patients/clients with alcohol/drug use disorders (P < .01). Compared to baseline, there was a statistically significant increase in all items of self-perceived ability (P

Objective We developed and tested a measure to identify level of primary care behavioral health integration. We produced a thirty item, six domain electronically delivered measure, and a total score. Methods We generated a convenience sample of 137 survey responses, including 104 primary care practices. We provided each practice a summary of their own data, and generated a data base of all submissions. We calculated descriptive statistics. Results The mean total score was 56/100. The Vermont Integration Profile (VIP) discriminated between types of practices in the direction hypothesized. Initial test retest reliability was good. Conclusion The VIP demonstrated good feasibility and construct validity, initial reliability, low provider demand and good discrimination between types of practices.

Background There is an urgent need for efficient, equitable interventions across the disease spectrum from prevention to palliative care. To identify and prioritize such interventions, evidence of effectiveness important to potential constituents is needed on outcomes relevant to them. Methods To inform practice and policy, evidence is needed on actionable, harmonized outcomes which are feasible to collect in most settings and relevant to citizens, practitioners, and decision makers. We propose that increased priority should be given to certain outcomes that are infrequently collected across multiple domains. Results A modification of a logic model of health outcomes by Proctor et al. is used to propose key domains and measures of implementation, service delivery, biomarkers, and health and functioning outcomes. Recommendations are made to give increased priority to implementation (especially reach, resource requirements/costs; and fidelity/adaptation); Institute of Medicine service delivery categories of equity and safety; and patient reported health and functioning outcomes. Conclusions Implications of this outcomes framework include that biomarkers are not always the most important or relevant outcomes; that harmonized, pragmatic, and actionable measures are needed for each of these types of outcomes, and that significant changes in training and review of grants and publications are needed.

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.

Patient-centered health risk assessments (HRAs) that screen for unhealthy behaviors, prioritize concerns, and provide feedback may improve counseling, goal setting, and health. To evaluate the effectiveness of routinely administering a patient-centered HRA, My Own Health Report, for diet, exercise, smoking, alcohol, drug use, stress, depression, anxiety, and sleep, 18 primary care practices were randomized to ask patients to complete My Own Health Report (MOHR) before an office visit (intervention) or continue usual care (control). Intervention practice patients were more likely than control practice patients to be asked about each of eight risks (range of differences 5.3-15.8 %, p

Collaborative care has increased dramatically in the past decade, yet the variability in collaborative strategies and the diversity of settings in which collaboration is being implemented make it difficult to assess quality and outcomes. Therefore, three aims were addressed in the current study: (a) describe and characterize the sites in the Collaborative Care Research Network (CCRN), (b) identify factors associated with practices' self-identified collaborative care model (e.g., coordinated, integrated, care management), and (c) identify limitations of available survey data elements so as to propose additional elements for future surveys. Initial (CCRN) sites completed surveys regarding several organizational factors (e.g., setting type, size of patient population, number of behavioral health providers). Results from 39 sites showed significant heterogeneity in self-identified type of collaborative care model practiced (e.g., integrated care, coordinated care), type of practice setting (e.g., academic, federally qualified health center, military), size of clinic, and ratio of behavioral health providers to medical providers. This diversity in network site characteristics can provide a rich platform to address a number of questions regarding the current practice of collaborative care. Recommendations are made to improve future surveys to better understand elements of the patient-centered medical home and the role it may play in outcomes. (PsycINFO Database Record (c) 2012 APA, all rights reserved).

Currently integrating mental health, substance abuse, and health behavior into Patient-Centered Medical Homes (PCMH) is being advocated with increasing frequency. There are no current reports describing efforts to accomplish this. A theory-based project was developed to integrate mental health, substance abuse, and health behavior services into the fabric and culture of an NCQA-certified level-three PCMH using funding from the Vermont legislature. A mixed methods case report of data from the first 34 months reviews planning, development, implementation, care model, information technology (IT), and data collection, and reports results using the elements of a RE-AIM framework. Early accomplishment of most RE-AIM dimensions is observed. Implementation remains a struggle, specifically the questions of role responsibilities, form, and financing. This effort is a successful pilot implementation of the Primary Care Behavioral Health (PCBH) model in the PCMH with the potential for dissemination toward additional implementation and a model for a comparative effectiveness trial.

Although the benefits of integrating behavioral health (BH) services into primary care are well established (World Health Organization and World Organization of Family Doctors, 2012; Chiles et al. in Clin Psychol–Sci Pr 6:204–220, 1999; Cummings 1997; O’Donohue et al. 2003; Olfson et al. in Health Aff 18:79–93, 1999; Katon et al. in Ann Intern Med 124:917–925, 2001; Simon et al. in Arch Gen Psychiatry 52:850–856, 1995; Anderson et al. in Diabetes Care 24:1069–1078, 2001; Ciechanowski et al. in Arch Intern Med 160:3278–3285, 2000; Egede et al. in Diabetes Care 25:464–470, 2002), research has focused primarily on describing the types of interventions behavioral health providers (BHPs) employ rather than on reasons for referral, treatment initiation rates, or the patient characteristics that may impact them. This study presents the results of a multisite card study organized by The Collaborative Care Research Network, a subnetwork of the American Academy of Family Physicians’ National Research Network devoted to conducting practice-based research focused on the provision of BH and health behavior services within primary care practices. The goals of the study included: (1) identifying the characteristics of patients referred for BH services; (2) codifying reasons for referral and whether patients were treated for the referral; (3) exploring any differences between patients who initiated BH contact and those who did not; and (4) assessing the types and frequency of BH services provided to patients who attended at least one appointment. Of the 200 patients referred to a BHP, 81 % had an initial contact, 71 % of which occurred on the same day. Men and women were equally likely to engage with a BHP although the time between appointments varied by gender. Depression and anxiety were the primary reasons for referral. Practice-based research is a viable strategy for advancing the knowledge about integrated primary care.

Many grant proposals identify the use of a given evaluation model or framework but offer little about how such models are implemented. The authors discuss what it means to employ a specific model, RE-AIM, and key dimensions from this model for program planning, implementation, evaluation, and reporting. The authors report both conceptual and content specifications for the use of the RE-AIM model and a content review of 42 recent dissemination and implementation grant applications to National Institutes of Health that proposed the use of this model. Outcomes include the extent to which proposals addressed the overall RE-AIM model and specific items within the five dimensions in their methods or evaluation plans. The majority of grants used only some elements of the model (less than 10% contained thorough measures across all RE-AIM dimensions). Few met criteria for “fully developed use” of RE-AIM and the percentage of key issues addressed varied from, on average, 45% to 78% across the RE-AIM dimensions. The results and discussion of key criteria should help investigators in their use of RE-AIM and illuminate the broader issue of comprehensive use of evaluation models.

Efficacy trials have generated interventions to improve health behaviors and biomarkers. However, these efforts have had limited impact on practice and policy. It is suggested that key methodologic and contextual issues have contributed to this state of affairs. Current research paradigms generally have not provided the answers needed for more probable and more rapid translation. A major shift is proposed to produce research with more rapid clinical, public health, and policy impact.

The Patient-centered Medical Home (PCMH) is an innovative, improved, and evolving approach to providing primary care that has gained broad acceptance in the United States. The Joint Principles of the PCMH, formulated and endorsed in February 2007, are sound and describe the ideal toward which we aspire. However, there is an element running implicitly through these joint principles that is difficult to achieve yet indispensable to the success of the entire PCMH concept. The incorporation of behavioral health care has not always been included as practices transform to accommodate to the PCMH ideals. This is an alarming development because the PCMH will be incomplete and ineffective without the full incorporation of this element, and retrofitting will be much more difficult than prospectively integrating into the original design of the PCMH. Therefore we offer a complementary set of joint principles that recognizes the centrality of behavioral health care as part of the PCMH. This document follows the order and language of the original joint principles while emphasizing what needs to be addressed to insure incorporation of the essential behavioral elements. It is intended to supplement and not replace the original Joint Principles document, which still stands.

Health psychology has made limited progress becoming an accepted part of mainstream medical research and practice. Although abundant efficacy research has generated considerable evidence-based interventions that are effective primary medical interventions or adjuncts to other medical treatments, evidence of acceptance within medicine and especially primary care is meager. This special edition of the Journal of Clinical Psychology is an effort to assist movement in this area. It is a combination of commentaries concerning aspects of clinical collaboration within primary care, a discussion of issues that are barriers to implementation, and a wide range of research efforts supporting models of collaborative interventions between health psychology and primary care. It also identifies mechanisms that may account for the effectiveness of certain types of interventions. Taken as a whole the volume supports the importance and viability of clinical health psychology research and practice in an area of fundamental importance—the general health of patients in medical settings—the location where most people present psychological problems and receive treatment in response. © 2009 Wiley Periodicals, Inc. J Clin Psychol 65:1–4, 2009.

There is increased attention to the medical and economic consequences of psychological problems comorbid with medical issues. There is also a clear awareness that most psychological problems are assessed and responded to in nonpsychiatric medical settings. This has furthered interest and attention in implementing screening procedures to better identify psychological, behavioral, and substance abuse problems in medical settings. Such interest is taking the form of recommendations from federal government task forces, and the funding of large projects to include screening in medical settings. At the same time there has been further attention to brief, valid, and reliable measures with which to capture psychological comorbidities. However, there have been multiple concerns raised about a variety of issues concerning the utility and effectiveness of such screening procedures and the identification of multiple issues to be considered in screening design. The author outlines and reviews the rationale and concerns about screening, identifies the issues that need to be considered in screening program development, and describes the efforts to develop a screening capacity in a rural family practice.

Psychology and other behavioral health professions have amassed a broad empirical and clinical literature suggesting many medical presentations are best responded to with the addition of evidence based behavioral interventions. Despite this, psychology has not achieved a regular presence as part of medical practice. We suggest specific reasons for the current state of affairs including clinical, operational, societal labels, financial and training dimensions. Medical, psychological, administrative, and financial perspectives are reviewed. If the goals of health care system reform are to be reached then we must identify and challenge the current limitations of health care. This paper will identify the elements that need to be changed in order for psychology to be integrated into medicine rather than excluded from its policy, planning and operations.

Psychology and medicine research and practice have demonstrated substantial and unique bodies of knowledge designed to both improve patient care and respond to contemporary health care needs for use of evidence and cost consciousness. At their full potential they represent a significant paradigm shift in healthcare. Despite impressive successes, it is clear that we are just on the cusp of such a change. These findings have had limited impact and penetration into medical practice, particularly outside of academic medicine and large, organized systems of health care, and there are multiple examples of such limitations in various arenas of health care. There also appear to be common themes to such examples which provide us opportunities to consider how psychologists might move things ahead. They also suggest how our unique position in academic medicine can both limit our impact and provide ways of creating continued shifts in the healthcare paradigm.

Research often fails to find its way into practice or policy in a timely way, if at all. Given the current pressure and pace of health care change, many authors have recommended different approaches to make health care research more relevant and rapid. An emerging standard for research, the “5 R’s” is a synthesis of recommendations for care delivery research that (1) is relevant to stakeholders; (2) is rapid and recursive in application; (3) redefines rigor; (4) reports on resources required; and (5) is replicable. Relevance flows from substantive ongoing participation by stakeholders. Rapidity and recursiveness occur through accelerated design and peer reviews followed by short learning/implementation cycles through which questions and answers evolve over time. Rigor is the disciplined conduct of shared learning within the specific changing situations in diverse settings. Resource reporting includes costs of interventions. Replicability involves designing for the factors that may affect subsequent implementation of an intervention or program in different contexts. These R’s of the research process are mutually reinforcing and can be supported by training that fosters collaborative and reciprocal relationships among researchers, implementers, and other stakeholders. In sum, a standard is emerging for research that is both rigorous and relevant. Consistent and bold application will increase the value, timeliness, and applicability of the research enterprise.

Psychological comorbidity with medical illness is associated with poor health status, complicated medical management, and increased utilization and greater costs of medical services. Hypnosis practitioners in specialty psychological or psychiatric treatment settings infrequently treat such patients, since there is a greater likelihood of patients' psychological problems being treated solely in primary medical care. Referring patients from primary care to the mental health system will most likely not result in patients initiating psychological or hypnotic treatment. At the same time, integrated provision of medical and psychological treatment in the medical office has demonstrated much higher rates of initiation of treatment and improved medical outcomes. Although hypnosis has been found to be an empirically effective treatment for many medical problems, when hypnosis practitioners do not practice in these medical sites then patients do not have access to effective hypnotic interventions for cotreatment of medical problems.

Hypnosis and relaxation are prominent ancillary clinical techniques in the treatment of acute and chronic pain. This article evaluates the evidence and support for the use of these techniques as part of medical treatment. Questions are raised about the utility of grouping hypnosis and relaxation together and we review a continuum of self-regulation techniques upon which hypnosis and self regulation appear to be points. We conclude that we are not yet able to identify a continuum of effectiveness despite there being significant support for hypnotic interventions and some, but more modest, support for relaxation. In addition to clarifying methodological dilemmas we urge that future research must specifically assess hypnotic suggestibility independent of whether the intervention is or is not hypnosis, evaluate non-specific effects, and review dose effect as part of further investigation.