Welcome to the JUNE 2019 research review, where I review some of the latest research findings and developments in the field of integrated behavioral health. There are two trends I am seeing in the literature that comes to my email inbox. First, researchers are evaluating the impact of integration on patient populations with complex health needs (e.g., complicated diabetes, multiple chronic conditions, social determinants of health). This month you will see five studies examining such populations. Second, there is a growing consensus that workforce development is paramount to the success of integrated care teams. Check out the article below on team characteristics for interprofessional primary care.

Here are some highlights to consider as you read the titles and abstracts below. First, there is very little research on comprehensive assessment of older patients in primary care, despite a large body of evidence supporting its use in hospitals. This patient population will continue to grow over time as we learn new ways to live longer. Primary care clinics can focus their integrated care teams on identifying the risks and needs of older adults. Second, read the opinion piece on Universal Primary Mental Health Providers. The author makes an argument that behavioral health integration actually contributes to mental health stigma. Finally, there is a call for making health informatics a standard part of post-graduate medical education. Perhaps it should be part of all training for all health care disciplines.

Each article has a link in the title and then the abstract right below it.

Outcome Research

Effects of a Behavioral Health and Chronic Illness Care Intervention on Patient Outcomes in Primary Care Practices in the Dakotas

From 2012 to 2015, Sanford Health, a large health care system, integrated behavioral health services and chronic condition care management in some of its primary care practices in the Dakotas and rural Minnesota. Using difference-in-differences analyses for fee-for-service Medicare beneficiaries attributed to 22 participating practices and 91 matched comparison practices, we found that the program increased the receipt of four recommended diabetes care processes by 8.6% (p=.048) and, by slowing the increase in emergency department (ED) visits, reduced them by 4.9% (p=.07) relative to the comparison group. However, the findings are mixed: the program did not affect hospital admissions, readmissions, or Medicare spending. In addition, the program increased admissions for ambulatory care–sensitive conditions by 13.6% (p=.07) relative to the comparison group. Sanford’s program provides a concrete example of how to incorporate behavioral health services in primary care in underserved areas with some positive results on quality-of-care processes and ED utilization.

Measuring the effectiveness of embedding social workers in integrated primary health care teams working with older adults with complex needs

Background Despite the policy agenda for health and social care collaboration currently focused on integrated care systems, there is limited evidence that examines whether embedding social workers in integrated primary health and social care teams working with older adults is effective.

Aim The study aimed to establish whether embedding social workers in integrated primary care teams (IPCTs) for older adults in Nottinghamshire was cost-effective.

Method A mixed methods approach collected quantitative and qualitative data that was triangulated using a TRI-Q model. Cost and care quality data were collected from patients in receipt of social worker involvement in three different IPCTs. Patients with similarly complex needs, who were receiving involvement from social work only district teams in the same localities acted as a comparator group. Interviews were conducted with patients and carers and with social workers and GPs working in the IPCTs. Seven focus groups were conducted with IPCT members representing social work and health disciplines.

Results The cost data were analyzed using ANCOVA to identify any significant differences in costs across the teams. The result showed costs in two of the IPCTs were significantly lower than controls. Care quality indicators were also greater in these IPCTs. Thematic analysis highlighted the important of knowledge exchange that arose from social work embeddedness as indicative of the optimal conditions for effective integrated working and care delivery to be achieved.

Conclusion The findings suggested that embedding social workers in IPCTs offers both higher quality and more cost-effective care for older people if the optimum conditions for integration are met.

Measurement

Validation of an Expanded Measure of Integrated Care Provider Fidelity: PPAQ-2  

This study aimed to validate the factor structure of the expanded Primary Care Behavioral Health Provider Adherence Questionnaire (PPAQ-2), which is designed to assess provider fidelity to both the Primary Care Behavioral Health (PCBH) and collaborative care management (CCM) models of integrated primary care. Two-hundred fifty-three integrated care providers completed self-reports of professional background, perceptions of clinic integration and related practice barriers, and the PPAQ-2. Confirmatory factor analyses were conducted to assess the theorized factor structure and criterion validity was assessed through correlational analysis. Factor analyses demonstrated adequate fit with the data and acceptable to excellent composite reliabilities across five PCBH domains and five CCM domains. Validity was demonstrated by correlations between adherence scores and measures of clinic integration and barriers to fidelity. The PPAQ-2 is a psychometrically sound measure that can be used in future integrated care dismantling studies to identify provider behaviors that best predict patient outcomes.

Comprehensive geriatric assessment in primary care: a systematic review

Background: Comprehensive geriatric assessment (CGA) involves the multidimensional assessment and management of an older person. It is well described in hospital and home-based settings. A novel approach could be to perform CGA within primary healthcare, the initial community located healthcare setting for patients, improving accessibility to a co-located multidisciplinary team.

Aim: To appraise the evidence on CGA implemented within the primary care practice.

Methods: The review followed PRISMA recommendations. Eligible studies reported CGA on persons aged ≥ 65 in a primary care practice. Studies focusing on a single condition were excluded. Searches were run in five databases; reference lists and publications were screened. Two researchers independently screened for eligibility and assessed study quality. All study outcomes were reviewed.

Results: The authors screened 9003 titles, 145 abstracts and 97 full texts. Four studies were included. Limited study bias was observed. Studies were heterogeneous in design and reported outcomes. CGAs were led by a geriatrician (n = 3) or nurse practitioner (n = 1), with varied length and extent of follow-up (12–48 months). Post-intervention hospital admission rates showed mixed results, with improved adherence to medication modifications. No improvement in survival or functional outcomes was observed. Interventions were widely accepted and potentially cost-effective.

Discussion: The four studies demonstrated that CGA was acceptable and provided variable outcome benefit. Further research is needed to identify the most effective strategy for implementing CGA in primary care. Particular questions include identification of patients suitable for CGA within primary care CGA, a consensus list of outcome measures, and the role of different healthcare professionals in delivering CGA.

Implementation Science

Reach of a low-intensity, multicomponent childhood overweight and obesity intervention delivered in an integrated primary care setting

Reach (i.e., proportion and representativeness of participants) of low-intensity, multicomponent childhood overweight/obesity interventions delivered in primary care settings with low-income and/or minority families is unknown. The purpose of this research is to describe the reach of a low-intensity, multicomponent childhood overweight/obesity intervention delivered in an integrated primary care setting in a federally qualified health center (FQHC). Eligibility criteria included children aged 4–10 years with a body mass index (BMI) ≥85th percentile, with a female caregiver. Using the electronic health record (EHR) and release forms, families were broadly categorized into groupings from recruitment flow, with differing proportions calculated from these groupings. Representativeness was determined using EHR data from families who were informed about the program (n = 963). Three calculated reach rates ranged from 54.9% to 3.9%. Lower reach rates were calculated using the number of families randomized (n = 73) as the numerator and the children from families who were informed about the program (n = 963) or all eligible children in the FQHC attending appointments (n = 1,864) as denominators. The first two steps in recruitment, informing families about the program and families initiating participation, were where the largest decreases in reach occurred. Children who were randomized were older, had a higher BMI, had a greater number of medical diagnoses indicating overweight or obesity, and were Hispanic. Reach of the intervention was low. Strategies that assist with reducing time for informing families of treatment and increasing families’ awareness of their child’s weight status should assist with enhancing reach.

Workforce Development

Implications of interprofessional primary care team characteristics for health services and patient health outcomes: A systematic review with narrative synthesis

Interprofessional primary care (IPPC) teams are promoted as an alternative to single profession physician practices in primary care with focus on preventive care and chronic disease management. Characteristics of teams can have an impact on their performance.

We synthesized quantitative, qualitative or mixed-methods evidence addressing the design of IPPC teams. We searched Ovid MEDLINE, Embase, CINAHL, and PAIS using search terms focused on IPPC teams. Studies were included if they discussed the influence of team structure, organization, financial arrangements, or policies and procedures, or either health care processes or outputs, health outcomes, or costs, and were conducted in Australia, Canada, the United Kingdom or New Zealand between 2003 and 2016. We screened 11,707 titles, 5366 abstracts, and selected 77 full text articles (38 qualitative, 31 quantitative and 8 mixed-methods).

Literature focused on the implications of team characteristics on team processes, such as teamwork, collaboration, or satisfaction of patients or providers. Despite heterogeneity of contexts, some trends are observable: shared space, common vision and goals, clear definitions of roles, and leadership as important to good teamwork. The impacts of these on health care outputs or patient health are not clear. To move the state of knowledge beyond perception of what works well for IPPC teams, researchers should focus on quantitative causal inference about the linkages between team characteristics and patient health.

The Next Step in Integrated Care: Universal Primary Mental Health Providers

Current models of mental health care often do not address three barriers to mental health: the binary view of mental illness (healthy vs. mentally ill), stigma, and prevention. Care models where some patients are selected for referral or consultation with a mental health professional can reinforce this binary view and the stigma associated with seeing mental health services. By only selecting patients who currently are experiencing mental health problems, current integrated care models do not offer sufficient avenues for prevention. To address these barriers, this article proposes building on current models through the development of primary mental health providers (PMHPs). PMHPs—like primary care providers—would provide regular check-ups, assessments, prevention interventions, first-line treatment, or referral to more specialized professionals. This universal approach will help decrease the binary view of mental health, decrease the stigma of seeing a mental health professional through universal access, and improve prevention efforts.

Training pediatric residents in behavioral health collaboration: Roles, evaluation, and advocacy for pediatric psychologists.

Objective: This commentary describes the current state of pediatric resident training in behavioral health and highlights specific pediatric residency training modalities that may be facilitated or enhanced by involvement of pediatric psychologists. Method: Several calls to action have been made recently by pediatrics organizations around the need to improve behavioral health training in residency programs. A growing body of literature suggests that behavioral health clinicians’ involvement in pediatric residency training, particularly in the context of the integrated behavioral health (IBH) model, is highly valued and sought after by residency program training directors as a mechanism to improve behavioral health competencies and collaboration. This literature base is reviewed through the lens of potential applications by pediatric psychologists. Results: Incorporating pediatric psychologists into the day-to-day training and functioning of pediatric residents through didactic as well as clinical service exposure has been recommended as a means to facilitate learning enhancement in behavioral health service delivery and team-based care. Conclusion: Systematic evaluation and advocacy on behalf of pediatric psychologists’ involvement in pediatric residency training in behavioral health is a timely next step in addressing a recognized need in the field of pediatrics. (PsycINFO Database Record (c) 2019 APA, all rights reserved)

Health informatics competencies in postgraduate medical education and training in the UK: a mixed methods study

Abstract

Objective To assess health informatics (HI) training in UK postgraduate medical education, across all specialties, against international standards in the context of UK digital health initiatives (e.g., Health Data Research UK, National Health Service Digital Academy and Global Digital Exemplars).

Design A mixed methods study of UK postgraduate clinician training curricula (71 specialties) against international HI standards: scoping review, curricular content analysis and expert consultation.

Setting and participants A scoping literature review (PubMed until March 2017) informed development of a contemporary framework of HI competency domains for doctors. National training curricula for 71 postgraduate medical specialties were obtained from the UK General Medical Council and were analyzed. Seven UK HI experts were consulted regarding findings.

Outcomes The International Medical Informatics Association (IMIA) Recommendations for Biomedical and Health Informatics Education were used to develop a framework of competency domains. The number (maximum 50) of HI competency domains included in each of the 71 UK postgraduate medical specialties was investigated. After expert review, a universal HI competency framework was proposed.

Results A framework of 50 HI competency domains was developed using 21 curricula from a scoping review, curricular content analysis and expert consultation. All 71 UK postgraduate medical curricula documents were mapped across 29 of 50 framework domains; that is, 21 domains were unrepresented. Curricula mapped between 0 (child and adolescent psychiatry and core surgical training) and 16 (chemical pathology and pediatric and perinatal pathology) of the 50 domains (median=7). Expert consultation found that HI competencies should be universal and integrated with existing competencies for UK clinicians and were under-represented in current curricula. Additional universal HI competencies were identified, including information governance and security and secondary use of data.

Conclusions Postgraduate medical education in the UK neglects HI competencies set out by international standards. Key HI competencies need to be urgently integrated into training curricula to prepare doctors for work in increasingly digitized healthcare environments.

Dissemination Research

Innovations for integrated care: The Association of Medicine and Psychiatry recognizes new models

This editorial looks at the current state of the integration of medicine and psychiatry in clinical practice. We note selected recent triumphs and barriers to implementing integrated care, highlighting some gaps and priorities for future innovations. In contrast to the relatively more orderly culture of health services research, where some notable innovations in integrated care were funded, tested, and published, the health care marketplace can be a difficult place to identify and track the innovations that could shape health care reform. Recognizing the need to find, describe, and disseminate the most innovative models in integrated care, the Association of Medicine and Psychiatry (AMP) launched in 2016 the Innovative Models for Integrated Care Awards. Although many service innovations solve local problems, some can also act as models to be adopted in multiple settings. The projects that win AMP Innovative Models for Integrated Care Awards are selected for their innovativeness, their clinical importance, their generalizability, and their effectiveness. We briefly describe here the four models that earned these awards at the 2017 AMP Annual Meeting. They demonstrate innovations across a range of settings and populations: inpatient general hospital patients under constant observation in New York, severely mentally ill patients in a federally qualified health center in San Francisco, outpatients in a VA women’s health center in Chicago, and HIV patients in an academic infectious disease clinic in Charleston, South Carolina. These model descriptions aim to encourage the implementation of innovative models that advance the integration of medicine and psychiatry.

Family-Oriented Care

What factors influence healthcare professionals to refer children and families to pediatric psychology?

Objectives: This study aimed to investigate factors influencing referral of children with physical illness to pediatric psychology. Due to high rates of mental health problems within this population, studies have shown that referral to pediatric psychology should be increased. However, few studies have examined factors shaping healthcare professionals’ referral behavior.

Methods: This study used the theory of planned behavior to develop a questionnaire which explores factors influencing the referral of children and families to pediatric psychology. Psychometric properties of the questionnaire were examined.

Results: The questionnaire was found to have good reliability and validity. The main constructs of the theory of planned behavior were useful in predicting intention to refer to pediatric psychology. Specific beliefs about referral were shown to influence intention to refer.

Conclusion: Findings suggest that individual attitudes and beliefs can impact healthcare professionals’ referral behavior, indicating that multidisciplinary interventions and inter-professional education relating to the psychological aspects of illness are required.

Technology

Use of a Mobile Phone App to Treat Depression Comorbid With Hypertension or Diabetes: A Pilot Study in Brazil and Peru

Background: Depression is underdiagnosed and undertreated in primary health care. When associated with chronic physical disorders, it worsens outcomes. There is a clear gap in the treatment of depression in low- and middle-income countries (LMICs), where specialists and funds are scarce. Interventions supported by mobile health (mHealth) technologies may help to reduce this gap. Mobile phones are widely used in LMICs, offering potentially feasible and affordable alternatives for the management of depression among individuals with chronic disorders.

Objective: This study aimed to explore the potential effectiveness of an mHealth intervention to help people with depressive symptoms and comorbid hypertension or diabetes and explore the feasibility of conducting large randomized controlled trials (RCTs).

Methods: Emotional Control (CONEMO) is a low-intensity psychoeducational 6-week intervention delivered via mobile phones and assisted by a nurse for reducing depressive symptoms among individuals with diabetes or hypertension. CONEMO was tested in 3 pilot studies, 1 in São Paulo, Brazil, and 2 in Lima, Peru. Depressive symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9) at enrollment and at 6-week follow-up.

Results: The 3 pilot studies included a total of 66 people. Most participants were females aged between 41 and 60 years. There was a reduction in depressive symptoms as measured by PHQ-9 in all pilot studies. In total, 58% (38/66) of the participants reached treatment success rate (PHQ-9 <10), with 62% (13/21) from São Paulo, 62% (13/21) from the first Lima pilot, and 50% (12/24) from the second Lima pilot study. The intervention, the app, and the support offered by the nurse and nurse assistants were well received by participants in both settings.

Conclusions: The intervention was feasible in both settings. Clinical data suggested that CONEMO may help in decreasing participants’ depressive symptoms. The findings also indicated that it was possible to conduct RCTs in these settings.