A Cluster Randomized Trial of Primary Care Practice Redesign to Integrate Behavioral Health for Those Who Need It Most: Patients With Multiple Chronic Conditions.

PURPOSE: Patient outcomes can improve when primary care and behavioral health providers use a collaborative system of care, but integrating these services is difficult. We tested the effectiveness of a practice intervention for improving patient outcomes by enhancing integrated behavioral health (IBH) activities. METHODS: We conducted a pragmatic, cluster randomized controlled trial. The intervention combined practice redesign, quality improvement coaching, provider and staff education, and collaborative learning. At baseline and 2 years, staff at 42 primary care practices completed the Practice Integration Profile (PIP) as a measure of IBH. Adult patients with multiple chronic medical and behavioral conditions completed the Patient-Reported Outcomes Measurement Information System (PROMIS-29) survey. Primary outcomes were the change in 8 PROMIS-29 domain scores. Secondary outcomes included change in level of integration. RESULTS: Intervention assignment had no effect on change in outcomes reported by 2,426 patients who completed both baseline and 2-year surveys. Practices assigned to the intervention improved PIP workflow scores but not PIP total scores. Baseline PIP total score was significantly associated with patient-reported function, independent of intervention. Active practices that completed intervention workbooks (n = 13) improved patient-reported outcomes and practice integration (P ≤ .05) compared with other active practices (n = 7). CONCLUSION: Intervention assignment had no effect on change in patient outcomes; however, we did observe improved patient outcomes among practices that entered the study with greater IBH. We also observed more improvement of integration and patient outcomes among active practices that completed the intervention compared to active practices that did not. Additional research is needed to understand how implementation efforts to enhance IBH can best reach patients.

An Evaluation of STFM's National Addiction Curriculum.

BACKGROUND AND OBJECTIVES: Family physicians are well positioned to treat patients with substance use disorders (SUDs), expand access to care, destigmatize addiction, and provide a biopsychosocial treatment approach. There is a great need to train residents and faculty to competency in SUD treatment. Through the Society of Teachers of Family Medicine (STFM) Addiction Collaborative, we created and evaluated the first national family medicine (FM) addiction curriculum using evidence-based content and teaching principles. METHODS: After launching the curriculum with 25 FM residency programs, we collected formative feedback through monthly faculty development sessions and summative feedback through 8 focus groups with 33 faculty members and 21 residents. We used qualitative thematic analysis to assess the value of the curriculum. RESULTS: The curriculum enriched resident and faculty knowledge across all SUD topics. It changed their attitudes in viewing addiction as a chronic disease within the scope of FM practice, increased confidence, and decreased stigma. It nurtured behavior change, enhancing communication and assessment skills and encouraging collaboration across disciplines. Participants valued the flipped-classroom approach, videos, cases, role plays, ready-made teacher's guides, and one-page summaries. Having protected time to complete the modules and temporally coupling the modules with the live, faculty-led sessions enhanced learning. CONCLUSION: The curriculum provides a comprehensive, ready-made, evidenced-based platform for training residents and faculty in SUDs. It can be implemented by faculty with all levels of prior expertise, cotaught by physicians and behavioral health providers, tailored to each program's didactic schedule, and modified based on the local culture and resource availability.

Preparing residents to practice integrated behavioral health care: Multi-site feasibility study of a competency-based curriculum.

OBJECTIVE: Workforce development is essential for the dissemination of team-based integrated behavioral healthcare. There is limited literature on training family medicine residents to function within an integrated behavioral health (IBH) system. The purpose of this pilot study was to assess the feasibility and value of an IBH competency-based curriculum for family medicine residents across multiple programs. METHODS: Residency programs were recruited using professional listservs and networks to test a competency-based, multi-modal curriculum for preparing residents to practice IBH in primary care. Faculty instructors who led the workshop were invited to complete semi-structured interviews to examine the feasibility and appropriateness of the curriculum. Interview data were analyzed using thematic analysis to identify, analyze, and report patterns. Residents completed a survey of perceived IBH skill and knowledge before and after training. A paired-sample t-test was used to determine significant differences pre- and post-training. RESULTS: All five instructors completed interviews. Results suggest IBH training is valuable. Instructors gave specific feedback on online modules, implementation flexibility, and adjusting faculty development to differing levels of experience. Nineteen of forty residents (48%) completed anonymous pre-, post-, and retrospective-training surveys. Residents reported an increase in competence after training. CONCLUSION: The results of this pilot suggest that IBH training implementation is feasible, desirable, timely, and may improve resident ability to work on an IBH team. Training should accommodate variations in program structure and faculty expertise.

Practice integration profile revised: Improving item readability and completion.

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. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Essential integrated behavioral health care skills for primary care providers: A Delphi study.

INTRODUCTION: Workforce development is a vital process for advancing the field of integrated behavioral health in primary care (IBHPC) and depends on the development of job-specific skills that meet the needs of patients and other team members. Job-specific skills guide both university- and worksite-based training programs in preparing future cohorts of health care professionals in IBHPC; however, there are no extant training criteria for nontrainee primary care providers. METHOD: A multiround survey using a modified Delphi technique was conducted. Participants were recruited from a large national research network, university alumni and community health center partners. Participants included allopathic and osteopathic physicians, physician assistants and nurse practitioners serving as primary care providers in a variety of IBHPC settings. In the survey, participants were instructed to categorize 22 skills as "Essential," "Compatible," or "Irrelevant" for IBHPC practice. Categorized responses were analyzed using descriptive statistics and comments were analyzed using a modified thematic analysis method. RESULTS: Fifty-four participants were recruited for the study, with 43 participating in round 1, 38 participating in round 2, and 36 participating in round 3. After 3 rounds, 19 skills received at least 80% consensus as "Essential" and 22 received at least 50% consensus as "Essential." Comment themes revealed participants were overall agreeable with skills, but had concerns about role, training, and time constraints. DISCUSSION: Primary care providers can prepare for and enhance IBHPC practice by developing skills identified as essential. Employers can adapt this skill list for efforts related to recruiting, hiring, and onboarding. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Expanding interprofessional teams: Training future health care professionals in screening, brief intervention, and referral to treatment (SBIRT).

INTRODUCTION: Substance misuse persists and is undertreated across the United States (Substance Abuse and Mental Health Services Administration, 2021). Further enhancing the skill sets and capacity of interprofessional members of primary care teams to include proficiency in the Screening, Brief Intervention, and Referral to Treatment (SBIRT) model could help to alleviate the "treatment gap" (those requiring treatment, but not receiving it) by enhancing interprofessional teams at the pregraduate level (e.g., health educators, health coaches) to expand capacity and meet the volume of patients with substance use-related needs. METHOD: In this study, SBIRT knowledge, training satisfaction, and efficacy were evaluated among undergraduate and graduate health and behavioral health students before and after exposure to a series of online training modules. RESULTS: On completion of the training, there were positive percent increases in overall mean knowledge and self-efficacy when compared with pretraining. At posttraining, graduate level students, regardless of discipline, reported greater knowledge than undergraduate students; there were no differences in efficacy or satisfaction among the groups. Additional analysis at the graduate level evaluated differences between behavioral health and medical trainees. No differences were found in knowledge or efficacy between groups at posttest, despite medical trainees reporting significantly lower efficacy at pretest. DISCUSSION: The findings of this study reinforce the need and potential to incorporate SBIRT training into higher education curricula for interprofessional health care professions to begin expanding the integrated care team's knowledge and efficacy in the provision of SBIRT to address the treatment gap. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Patient screening for integrated behavioral health in adult primary care: A rapid review of effective procedures.

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. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Couple and family interventions for high mortality health conditions: A strategic review (2010-2019).

The earliest publications in the field of marriage and family therapy introduced interventions conducted with families experiencing complex health conditions. This strategic review captures an evaluation of efficacy for 87 couple and family interventions published between 2010 and 2019 with a focus on the leading causes of mortality in the United States. These health conditions include chromosomal anomalies and accidents with infants aged 0-4 years; accidents and cancer among children aged 5-14; accidents among adolescents aged 15-24; and heart disease, cancer, accidents, chronic lower respiratory diseases, stroke, Alzheimer's disease, diabetes, influenza/pneumonia, and nephritis/nephrosis among adults 25 and older. Results support the need for greater inclusion of couples and families in assessments and interventions. The greatest chasm in efficacy research was with minoritized couples and families. Implications include ways to initiate couple and family interventions in the context of health conditions with attention given to accessibility, recruitment, retention, and evaluation.

Measuring Productivity in Primary Care Behavioral Health: A Delphi Study.

High productivity by behavioral health consultants (BHC) is a defining aspect of the primary care behavioral health (PCBH) model to maximize access to care and is often measured by patient volume. Studies of productivity in health care settings suggest a single productivity target may not be optimal. We used a Delphi method to obtain expert consensus on an operational definition of high productivity by BHCs in the PCBH model. Clinicians, managers, and researchers in PCBH were recruited to participate in a multi-round survey using a modified Delphi technique and develop consensus on PCBH productivity metrics. Ten participants completed all three survey rounds and rated 28 metrics. After three rounds, two direct metrics (average number of billable BHC visits each day; number of patients seen per day) received at least 80% consensus as "Essential", two received at least 50%, and five received less than 50%. One influencer (level of integration at the practice) received at least 80% consensus as "Very Much" influential, 19 received at least 50%, and eight items received less than 50%. Several themes arose from participant comments. PCBH productivity can be interpreted as being high volume. Numerous practice factors influence how productive a BHC may be. Future studies should determine the feasibility of our metrics in clinical practice, establish productivity expectations based on patient needs and clinic resources, and identify patient-, clinician-, or practice-level moderators of productivity.

Further Experience with the Practice Integration Profile: A Measure of Behavioral Health and Primary Care Integration.

Valid measures of behavioral health integration have the potential to enable comparisons of various models of integration, contribute to the overall development of high-quality care, and evaluate outcomes that are strategically aligned with standard improvement efforts. The Practice Integration Profile has proven to discriminate among clinic types and integration efforts. We continued the validation of the measure's internal consistency, intra-rater consistency, and inter-rater consistency with a separate and larger sample from a broader array of practices. We found that the Practice Integration Profile demonstrated a high level of internal consistency, suggesting empirically sound measurement of independent attributes of integration, and high reliability over time. The Practice Integration Profile provides internally consistent and interpretable results and can serve as both a quality improvement and health services research tool.

Integrated behavioral health training for primary care clinicians: Five lessons learned from a negative study.

INTRODUCTION: There are very few studies examining the effectiveness of integrated behavioral health training for primary care clinicians. The purpose of this article is to review the findings of a negative study examining the effectiveness of medical resident training in integrated behavioral health and offer specific ideas for future research in workforce development. METHODS: Twenty-three family medicine residents from a community-based residency program in the mid-Atlantic region completed a required rotation in which they consulted with behavioral health in primary care, observed psychotherapy, read behavioral medicine books, and received individual instruction. Fourteen residents completed a survey pre- and postrotation, and all 23 residents completed a semistructured interview postrotation. RESULTS: Survey findings demonstrate that resident attitudes about collaboration and behavioral health consultants did not significantly change as a result of the rotation. Findings also show that internal referral orders for behavioral health services dropped sharply after the rotation. Qualitative data suggest that residents value integrated behavioral health. DISCUSSION: There are five lessons to learn from this negative study: learning outcomes should match learning activities, residents benefit from direct observation, longitudinal data help measure change over time, collaborative care curriculum evaluation deserves collaborative partnership with other training sites, and evaluating the resident and the behavioral health provider offers a systems viewpoint and new insights. Future research should identify core knowledge and skills for primary care clinicians working in settings with integrated behavioral health and evaluate the long-term effectiveness of a curriculum based on those competencies. (PsycINFO Database Record

Integrated primary care: a systematic review of program characteristics.

The integration of behavioral health services into primary care medical settings may be part of the solution to the fragmented health care system currently found in the United States. Although integrated primary care (IPC) is implemented in various locations across the United States, little information is available about how IPC is specifically practiced. Using a systematic review design, we extracted data from 76 articles to examine 6 categories of IPC program characteristics, including collaboration practices (e.g., shared decision-making, written communication, hallway conversations), program models, behavioral health interventions, behavioral health training and supervision, behavioral health provider type, and setting. Findings show that most IPC programs include psychoeducation, medication, follow-up contact, psychotherapy, and at least 1 care management strategy as part of treatment. Fewer than half of researchers report communication between providers, and even fewer report collaboration as a "shared decision making process." A third of researchers report training and/or supervising behavioral health providers to work in an IPC program, and a fourth report recruiting nurses as behavioral health providers. Of all the studies, family-based interventions were used in 1. We recommend that future researchers report more information about collaboration processes as well as training and supervision of behavioral health providers. We also recommend that researchers develop IPC programs that involve family members in treatment and better implement theory into future IPC programs to support conceptualization and replication of IPC program models.

Loss of calcium/calmodulin-dependent protein kinase II activity in cortical astrocytes decreases glutamate uptake and induces neurotoxic release of ATP.

The extent of calcium/calmodulin-dependent protein kinase II (CaMKII) inactivation in the brain after ischemia correlates with the extent of damage. We have previously shown that a loss of CaMKII activity in neurons is detrimental to neuronal viability by inducing excitotoxic glutamate release. In the current study we extend these findings to show that the ability of astrocytes to buffer extracellular glutamate is reduced when CaMKII is inhibited. Furthermore, CaMKII inhibition in astrocytes is associated with the rapid onset of intracellular calcium oscillations. Surprisingly, this rapid calcium influx is blocked by the N-type calcium channel antagonist, ω-conotoxin. Although the function of N-type calcium channels within astrocytes is controversial, these voltage-gated calcium channels have been linked to calcium-dependent vesicular gliotransmitter release. When extracellular glutamate and ATP levels are measured after CaMKII inhibition within our enriched astrocyte cultures, no alterations in glutamate levels are observed, whereas ATP levels in the extracellular environment significantly increase. Extracellular ATP accumulation associated with CaMKII inhibition contributes both to calcium oscillations within astrocytes and ultimately cortical neuron toxicity. Thus, a loss of CaMKII signaling within astrocytes dysregulates glutamate uptake and supports ATP release, two processes that would compromise neuronal survival after ischemic/excitotoxic insults.

Development of o-chlorophenyl substituted pyrimidines as exceptionally potent aurora kinase inhibitors.

The o-carboxylic acid substituted bisanilinopyrimidine 1 was identified as a potent hit (Aurora A IC(50) = 6.1 ± 1.0 nM) from in-house screening. Detailed structure-activity relationship (SAR) studies indicated that polar substituents at the para position of the B-ring are critical for potent activity. X-ray crystallography studies revealed that compound 1 is a type I inhibitor that binds the Aurora kinase active site in a DFG-in conformation. Structure-activity guided replacement of the A-ring carboxylic acid with halogens and incorporation of fluorine at the pyrimidine 5-position led to highly potent inhibitors of Aurora A that bind in a DFG-out conformation. B-Ring modifications were undertaken to improve the solubility and cell permeability. Compounds such as 9m with water-solubilizing moieties at the para position of the B-ring inhibited the autophosphorylation of Aurora A in MDA-MB-468 breast cancer cells.