The association of self-perceived changes due to COVID-19 with mental and physical health among adult primary care patients with multiple chronic conditions: A US-based longitudinal study.

Introduction: This study explores the association between self-perceived personal and community changes due to COVID-19 and health among vulnerable primary care patients experiencing multiple chronic conditions. Methods: Between September 2017 and February 2021, we obtained data from 2,426 primary care patients managing multiple chronic conditions from across the United States. We assessed the relationship between self-perceived personal and community changes due to COVID-19 and change in health measured by the PROMIS-29 mental and physical health summary scores, GAD-7 (anxiety), andPHQ-9 (depression), and DASI (functional capacity) adjusting for relevant demographic, neighborhood characteristics, and county covariates. Results: After adjustment, self-perceived personal and community changes due to COVID-19 were associated with significantly worse mental health summary scores (ß = -0.55; 95% Confidence Interval (CI) = -0.72, -0.37), anxiety (ß = 0.28; 95% CI = 0.16, 0.39), depression (ß = 0.35; 95% CI = 0.22, 0.47), and physical health summary scores (ß = -0.44; 95% CI = 0.88, 0.00). There was no association with functional capacity (ß = - 0.05; 95% CI = -0.16, 0.05). Discussion: Among adults managing multiple chronic conditions, self-perceived personal and community changes due to COVID-19 were associated with health. This vulnerable population may be particularly susceptible to the negative effects of COVID-19. As we do not know the long-term health effects of COVID, this paper establishes a baseline of epidemiological data on COVID-19 burden and health among primary care patients with multiple chronic conditions.

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.

Community Health Teams: a qualitative study about the factors influencing the decision-making process.

BACKGROUND: The purpose of this study was to explore the factors influencing how individual Community Health Teams (CHTs) make decisions about what services to offer and how to allocate their resources. METHODS: We conducted thirteen semi-structured interviews with all 13 CHTs program managers between January and March, 2021. We analyzed interviewees descriptions of their service offerings, resources allocation, and decision-making process to identify themes. RESULTS: Four major themes emerged from the interview data as factors influencing community health team program managers' decision-making process: commitment to offering high-quality care coordination, Blueprint's stable and flexible structure, use of data in priority setting, and leveraging community partnerships and local resources. CONCLUSIONS: Community-based CHTs with flexible funding allowed programs to tailor service offerings in response to community needs. It is important for teams to have access to community-level data. Teams are cultivating and leveraging community partners to increase their care coordination capacity, which is focus of their work. CHTs are a model for leveraging community partnerships to increase service capacity and pubic engagement in health services for other states to replicate.

Integrating behavioural health and primary care: qualitative findings on contextual factors that influence integration.

BACKGROUND: Integrating behavioural health care into primary care practices may increase patients' access to behavioural health services and improve health outcomes. However, few studies have explored factors that influence integration processes. OBJECTIVE: We sought to better understand contextual factors that support or impede behavioural health integration in primary care practices. METHODS: We conducted 71 semi-structured interviews with providers, staff, and leaders from eight primary care practices in the United States with integrated behavioural health services, which were participating in a randomized control, pragmatic trial: Integrating Behavioural Health and Primary Care. Practices were selected for diversity on geographic location, size, ownership, and experience with integration. We conducted a thematic analysis of the qualitative data derived from the interviews. RESULTS: We identified four categories of contextual factors influencing behavioural health integration: leadership commitment to integration, financial considerations, workflow and communication systems, and providers' perspectives on integration and team-based healthcare. Supportive factors included leaders' commitment to integration, adequate staffing, customized communication and workflow systems, collaborative practice culture, and healthy working relationships amongst providers. Impediments included staffing issues and payment models that do not reimburse for activities required to support integrated care. CONCLUSION: Interviewees described various benefits of integration, including providers feeling better equipped to address patients' needs due to collaboration between medical and behavioural providers and resulting interdisciplinary learning. Given concerns about provider burnout, this finding warrants further study.

This study examines the integration of behavioural health services, such as mental health counselling, into primary care practices. We conducted interviews with representatives from eight primary care practices with integrated behavioural health services. The participating practices are located in diverse geographic locations across the United States, and all were engaged in a large, national project entitled Integrating Behavioural Health and Primary Care. A total of 71 healthcare providers, staff, and practice leaders were interviewed and asked to discuss the factors that influenced efforts to integrate behavioural healthcare in their primary care practice. We analysed the interview transcripts and identified factors that supported or impeded behavioural health integration. Supportive factors included practice leaders' commitment to integration, adequate staffing, customized communication and workflow systems within the practice, a collaborative practice culture, and healthy working relationships amongst the medical and behavioural health providers. Impediments included staffing issues and a lack of reimbursement from insurance companies and government payers for the time and effort that practice staff needs to devote in order to provide integrated care. Interviewees described various benefits of behavioural health integration, including providers feeling better equipped to address patients' needs due to collaboration between medical and behavioural providers.

Intraclass Correlation and Variance in the Characteristics of Primary Care Patients Managing Chronic Medical and Behavioral Conditions.

Background To avoid statistical errors, researchers who recruit patients from selected medical practices and analyze them at the individual level need to account for the clustered nature of their sample. This is most often done using the intraclass correlation coefficients (ICCs), a measure of how strongly subjects recruited from the same cluster (in this case patients from a clinic) resemble each other. Aims The aim is to support the design of cluster-randomized studies by supplying estimates of variance and ICC of various measures using a population of patients from multiple primary care clinics. Materials and methods ICCs were extracted from a large cluster-randomized pragmatic clinical trial of adult primary care patients managing multiple chronic conditions, the Integrating Behavioral Health and Primary Care study (IBH-PC). IBH-PC collected demographics and patient-reported health outcomes on over 3,000 adults from 44 primary care practices in 13 states across the US. We present estimates of the standard deviation and ICC for gender, race, ethnicity, marital status, employment, income, education, social determinants of health, PROMIS-29 functional status, Duke Activity Status Index (DASI), nine-item Patient Health Questionnaire (PHQ-9) depression score, Generalized Anxiety Disorder (GAD-7) anxiety score, Asthma Symptom Utility Index, restricted activity days, medication adherence, health care visits in the past month, emergency room visits in the past year, hospital days in the past year, perception of quality and patient-centeredness of care, alcoholic drinks per month, and the GAIN substance use disorder screener. Results ICCs varied broadly with the highest values found for race and income and the lowest for short-term estimates of the GAIN. Conclusions These values can be used to inform the design, especially power estimates and sample size requirements, of future studies.

Outcomes of Delay of Care After the Onset of COVID-19 for Patients Managing Multiple Chronic Conditions.

PURPOSE: Many patients delayed health care during COVID-19. We assessed the extent to which patients managing multiple chronic conditions (MCC) delayed care in the first months of the pandemic, reasons for delay, and impact of delay on patient-reported physical and behavioral health (BH) outcomes. METHODS: As part of a large clinical trial conducted April 2016-June, 2021, primary care patients managing MCC were surveyed about physical and behavioral symptoms and functioning. Surveys administered between September 3, 2020, and March 16, 2021, included questions about the extent of and reasons for any delayed medical and BH care since COVID-19. Multivariable linear regression was used to assess health outcomes as a function of delay of care status. RESULTS: Among patients who delayed medical care, 58% delayed more than once. Among those who delayed behavioral health care, 63% delayed more than once. Participants who delayed multiple times tended to be younger, female, unmarried, and reported food, financial, and housing insecurities and worse health. The primary reasons for delaying care were lack of availability of in-person visits and perceived lack of urgency. Participants who delayed care multiple times had significantly worse outcomes on nearly every measure of physical and mental health, compared with participants who delayed care once or did not delay. CONCLUSIONS: Delay of care was substantial. Patients who delayed care multiple times were in poorer health and thus in need of more care. Effective strategies for reengaging patients in deferred care should be identified and implemented on multiple levels. TRIAL REGISTRATION: ClinicalTrials.gov NCT02868983. Registered on August 16, 2016.

Older adults' willingness to take magnesium to treat depression.

Context: Depression affects up to 15% of community-dwelling older adults. Late-life depression is frequently underdiagnosed and undertreated. When depression in older adults is identified, up to 80% of treatment occurs in primary care. Currently available treatments have significant limitations (e.g., modest effectiveness, high costs, adverse effects, poor adherence, and social stigma), therefore additional treatment options are essential. Over the counter magnesium chloride is inexpensive, widely available, generally safe, well-absorbed, and was efficacious in prior studies, often within 2 weeks. Objective: To collect background information on magnesium supplement use and acceptability in older adults with a depression. Study Design: Online survey. Dataset: National sample. Population Studied: Adults 65 and older living in the United States currently experiencing symptoms of depression based on Patient Health Questionnaire (PHQ- 2) results. Outcome Measures: The primary outcome was willingness to take magnesium supplements instead of prescription medication for the treatment of depression. Secondary measures included current supplement use, comfort level with taking magnesium to treat depression, and whether they think magnesium would help improve symptoms of depression. Results: Of 153 respondents, 97 (63%) were female, 143 (93%) identified as white, and 130 (85%) were between the ages 65 and 75 years. 112 (73%) took a supplement daily, including 15 (10%) taking magnesium. 50 (33%) were currently being treated for depression. On a 4-point Likert scale ranging from "Strongly Agree" to "Strongly Disagree," 83% of respondents "Agreed" or "Strongly Agreed" in terms of their willingness to take magnesium instead of a prescription medication. A majority also "Agreed" or "Strongly Agreed" that they were willing (89%) and comfortable (89%) with taking magnesium to treat depression and also that it would improve symptoms of depression (73%). Women were more likely to agree with these statements (p<0.05), but there were no differences based on age or current treatment for depression. Conclusions: A majority of older community-dwelling adults are willing to take magnesium for the treatment of depression. Many adults are already taking at least 1 over the counter supplement daily. Further research is needed to determine the efficacy of magnesium supplements as an alternative treatment option in this population.

Development and validation of the patient centeredness index for primary care.

AIMS AND OBJECTIVES: To describe the development of the Patient Centeredness Index (PCI), evaluate its psychometric characteristics and evaluate the relationships between scores on the PCI and an established measure of empathy. BACKGROUND: Patient centeredness helps patients manage multiple chronic conditions with their providers, nurses and other team members. However, no instrument exists for evaluating patient centeredness within primary care practices treating this population. DESIGN: Multi-site instrument development and validation. STROBE reporting guidelines were followed. METHODS: To identify themes, we consulted literature on patient centeredness and engaged stakeholders who had or were caring for people with multiple chronic conditions (n = 7). We composed and refined items to represent those themes with input from clinicians and researchers. To evaluate reliability and convergent validity, we administered surveys to participants (n = 3622) with chronic conditions recruited from 44 primary care practices for a large-scale cluster randomised clinical trial of the effects of a practice-level intervention on patient and practice-level outcomes. Participants chose to complete the 16-item survey online, on paper or by phone. Surveys assessed demographics, number of chronic conditions and ratings of provider empathy. We conducted exploratory factor analysis to model the interrelationships among items. RESULTS: A single factor explained 93% of total variance. Factor loadings ranged from 0.55-0.85, and item-test correlations were ≥.67. Cronbach's alpha was .93. A moderate, linear correlation with ratings of provider's empathy (r = .65) supports convergent validity. CONCLUSIONS: The PCI is a new tool for obtaining patient perceptions of the patient centeredness of their primary care practice. The PCI shows acceptable reliability and evidence of convergent validity among patients managing chronic conditions. RELEVANCE TO CLINICAL PRACTICE: The PCI rapidly identifies patients' perspectives on patient centeredness of their practice, making it ideal for administration in busy primary care settings that aim to efficiently address patient-identified needs. TRIAL REGISTRATION: Clinicaltrials.org Protocol ID: WLPS-1409-24372. TITLE: Integrating Behavioural Health and Primary Care for Comorbid Behavioural and Medical Problems (IBHPC).

Integrating behavioral health & primary care for multiple chronic diseases: Clinical trial of a practice redesign toolkit.

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

Integrating Behavioral Health and Primary Care (IBH-PC) to improve patient-centered outcomes in adults with multiple chronic medical and behavioral health conditions: study protocol for a pragmatic cluster-randomized control trial.

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.