Nomination of Natalie Levkovich for the 2019 CFHA Don Bloch Award.

Don Bloch's legacy is expansive and deep, epitomized by his vision, systemic orientation, innovative work, and a paragon of connecting people. Natalie Levkovich has continued this tradition as past president of the Collaborative Family Healthcare Association (CFHA), Chief Executive Officer of the Health Federation of Philadelphia, and contributor to numerous boards and projects. She is a fervent champion for improving population health by increasing access to high quality care for all, especially the most marginalized. The nomination highlights four central themes to her innovative and remarkable leadership. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Does the Primary Care Behavioral Health Model Reduce Emergency Department Visits?

OBJECTIVE: To examine the impact of integrating behavioral health services using the primary care behavioral health (PCBH) model on emergency department (ED) utilization. DATA SOURCES: Utilization data from three Dane County, Wisconsin hospitals and four primary care clinics from 2003 to 2011. STUDY DESIGN: We used a retrospective, quasi-experimental, controlled, pre-post study design. Starting in 2007, two clinics began integrating behavioral health into their primary care practices with a third starting in 2010. A fourth, nonimplementing, community clinic served as control. Change in emergency department and primary care utilization (number of visits) for patients diagnosed with mood and anxiety disorders was the outcomes of interest. DATA COLLECTION: Retrospective data were obtained from electronic patient records from the three main area hospitals along with primary care data from participating clinics. PRINCIPAL FINDINGS: Following the introduction of the PCBH model, one clinic experienced a statistically significant (p < .01, 95 percent CI 6.3-16.3 percent), 11.3 percent decrease in the ratio of ED visits to primary care encounters, relative to a control site, but two other intervention clinics did not. CONCLUSIONS: The PCBH model may be associated with a reduction in ED utilization, but better-controlled studies are needed to confirm this result.

The State and Future of the Primary Care Behavioral Health Model of Service Delivery Workforce.

The growth of the Primary Care Behavioral Health model (PCBH) nationally has highlighted and created a workforce development challenge given that most mental health professionals are not trained for primary care specialization. This work provides a review of the current efforts to retrain mental health professionals to fulfill roles as Behavioral Health Consultants (BHCs) including certificate programs, technical assistance programs, literature and on-the-job training, as well as detail the future needs of the workforce if the model is to sustainably proliferate. Eight recommendations are offered including: (1) the development of an interprofessional certification body for PCBH training criteria, (2) integration of PCBH model specific curricula in graduate studies, (3) integration of program development skill building in curricula, (4) efforts to develop faculty for PCBH model awareness, (5) intentional efforts to draw students to graduate programs for PCBH model training, (6) a national employment clearinghouse, (7) efforts to coalesce current knowledge around the provision of technical assistance to sites, and (8) workforce specific research efforts.

An interview with Neftali Serrano, PsyD: Collaborative family healthcare association's new executive director.

The Collaborative Family Healthcare Association (CFHA) is continually evolving along with policies, funding, and models of healthcare in the U.S. With a vision of integrated healthcare for all as the standard of care, the new executive director of CFHA describes his perspective on how we can move closer towards this vision, the remaining barriers, models of integration, and why CFHA is a unique and necessary professional organization for those with a passion for delivering whole-person comprehensive healthcare. (PsycINFO Database Record

Initial examination of characteristics of patients who are high utilizers of an established primary care behavioral health consultation service.

Obective: Although much has been studied regarding high-utilizing patients of medical services, no studies have been published regarding high-utilizing patients of integrated primary care behavioral health (PCBH) services. The primary purpose of the current study was to examine characteristics of high-utilizing patients of PCBH services and model adherence. The secondary purpose was to describe the process of conducting this research by clinicians in integrated care. METHOD: Data were obtained from electronic health records retrospectively for the study's time period, 2007-2013, for the sample of all patients who met with the behavioral health consultation team during that time. Variables include demographics, diagnoses, involvement in additional services, and scores on a patient-complexity scale for a subset of patients. Chi-square analyses, t tests and logistic regression analyses were performed. RESULTS: The results demonstrate significant associations between key demographic characteristics, use of population-based augmentation services (i.e., consulting psychiatry, care management, substance-abuse consulting), and high-utilizing status. Model adherence was maintained over time. Logistic regression analysis, controlling for high-utilizing status and number of visits, demonstrated a significant relationship between more complex diagnostic categories and behavioral health issues. DISCUSSION: There are differences between high-utilizing patients and nonhigh-utilizing patients suggestive of increased clinical severity and appropriate use of services while maintaining PCBH model integrity. The use of the population-based augmentation services is associated with high-utilizer status, and reflects the ability of these services to target those patients who most need the clinical care. (PsycINFO Database Record

Using standardized patients as a means of training and evaluating behavioral health consultants in primary care.

INTRODUCTION: The Health Federation of Philadelphia, which hosts a network of Behavioral Health Consultants (BHC) operating within the Primary Care Behavioral Health model (PCBH), identified a need to systematically evaluate PCBH model fidelity and to rigorously evaluate the competency assessment process to further their workforce development. A simulated patient exercise was developed for evaluating BHC PCBH specific competencies. METHOD: A simulated BHC encounter was held at a clinical learning center using standardized patients, repeated twice over 2 years. A competency based rating scale was developed by the network for the simulation (BHC-ORS), patient feedback was captured using the Working Alliance Inventory (WAI), and BHC feedback was collected using a questionnaire. Dedicated consultants were hired to develop the internal process, as well as conduct the evaluation in a way that might make a contribution to research. RESULTS: Targeted PCBH competencies generally improved after being identified as training needs in Year 1 of the simulation. Patient feedback showed average ratings for the majority of the BHCs. BHCs identified the experience as valid and useful. Important changes in methodology between Years 1 and 2 of the pilot limited a more complete analysis. DISCUSSION: The use of simulated patients to evaluate BHC adherence to the PCBH model was helpful for training and adds to the workforce development literature. The authors suggest that doing practice based research will always entail unanticipated needs that interfere with quantitative research but that there are ways in which researchers can attempt to anticipate these changes. Review of possible applications to community PCBH practice is included. (PsycINFO Database Record

Visit Patterns for Severe Mental Illness with Implementation of Integrated Care: A Pilot Retrospective Cohort Study.

There is increasing interest in models that integrate behavioral health services into primary care. For patients with severe mental illness, a population with disproportionate morbidity and mortality, little is known about the impact of such models on primary care clinic utilization and provider panels. We performed a retrospective cohort pilot study examining visit patterns for 1,105 patients with severe mental illness (SMI), overall and by provider, before and after the implementation of a primary care behavioral health model which had a ramp up period from 5/06-8/07. We used 2003-2012 electronic health record data from two clinics of a Federally Qualified Health Center and conducted interrupted time series and chi-square analyses. During the intervention period there was a significant increase in the proportion of visits per month to the clinic for patient with SMI relative to overall visits (0.27; 95% CI 0.22-0.32). After the intervention period, this rate declined (-0.23; -0.19-0.28) but remained above the pre-intervention period. After integration of behavioral health into our primary care clinics, there was a sharp increase in the number of patients with severe mental illness, suggesting patient willingness to explore receiving care under this model. Clinics looking to adopt the model should be mindful of potential changes in patient subpopulations and proactively manage this transition.

Consulting psychiatry within an integrated primary care model.

After implementation of an integrated consulting psychiatry model and psychology services within primary care at a federally qualified health center, patients have increased access to needed mental health services, and primary care clinicians receive the support and collaboration needed to meet the psychiatric needs of the population.

Exemplars in the use of technology for management of depression in primary care.

PURPOSE: Depression care management as part of larger efforts to integrate behavioral health care into primary care has been shown to be effective in helping patients and primary care clinicians achieve improved outcomes within the primary care environment. Central to care management systems is the use of registries which enable effective clinic population management. The aim of this article is to detail the methods and utility of technology in depression care management processes while also highlighting the real-world variations and barriers that exist in different clinical environments, namely a federally qualified health center and a Veterans Administration clinic. METHODS: We analyzed descriptive data from the registries of Access Community Health Centers and the William S. Middleton Veterans Administration clinics along with historical reviews of their respective care management processes. RESULTS: Both registry reviews showed trend data indicating improvement in scores of depression and provided baseline data on important system variables, such as the number of patients who are not making progress, the percentage of patients who are unreachable by phone, and the kind of actions needed to ensure evidence-based and efficient care. Both sites also highlighted systemic technical barriers to more complete implementation of care management processes. CONCLUSIONS: Care management processes are an effective and efficient part of population-based care for depression in primary care. Implementation depends on available resources including hardware, software, and clinical personnel. Additionally, care management processes and technology have evolved over time based on local needs and are part of an integrated method to support the work of primary care clinicians in providing care for patients with depression.

The effect of behavioral health consultation on the care of depression by primary care clinicians.

PURPOSE: The aim of this study is to assess the impact of an integrated care model, called the Behavioral Health Consultation model, in the delivery of care for depression in an urban Federally Qualified Health Center, and to gauge the receptiveness of primary care clinicians to increasing their responsibility for the mental health care of their patients. METHODS: We reviewed electronic medical records to measure referral rates to mental health specialty care, patient engagement in care, management of psychotropic medications, and initiation of antidepressant medication, comparing data from the year prior to program implementation to that from the third year post-implementation. Clinician attitudes were assessed using an online anonymous questionnaire. RESULTS: Statistically significant findings included post-implementation increases in the use of standardized measures of depression, documentation of behavioral goals and patient visits to the primary care clinician (increased engagement), decreases in initiation rates of antidepressant medications, and decreases in referrals to mental health specialty care. No significant difference was found in rates of dosage changes or change to new medications among patients who were already on psychiatric medications. Clinicians reported near universal acceptance of the behavioral health consultation program and willingness to increase their role in managing patient mental health issues. CONCLUSIONS: This study demonstrates that a behavioral health consultation program in an urban community health center can improve adherence to evidence-based indicators in the care of depression, making it possible to manage the majority of patients presenting with depression in the primary care setting.