Patterns & Predictors of Telehealth Utilization Among Individuals Who Use Substances: Implications for the Future of Virtual Behavioral Health Services.

Telehealth dramatically expanded during the COVID-19 pandemic, but there remains a dearth of literature examining how this service modality is utilized by individuals who use substances. This study examined patterns of telehealth use and individual level sources of variation among clients receiving counseling in an outpatient substance use clinic in early 2021 (n = 370). Univariate statistics described the percentage of counseling visits delivered via telehealth. OLS regression explored individual level demographic and clinical characteristics that predicted greater telehealth utilization. Overall, more than two thirds (86%) of counseling visits were conducted via telehealth. Individuals with unstable housing or with a co-occurring serious mental illness used less telehealth. Findings suggest that while telehealth appears to be an acceptable way to deliver substance use counseling, patterns varied among vulnerable subgroups. As telehealth becomes further integrated into behavioral health services delivery, it is critical to uncover sources of this variation and identify potential solutions.

The Impact of Structural Integration on Clinical Outcomes among Individuals with Serious Mental Illness and Chronic Illness.

Though considered a best practice, there is substantial variation in how integrated behavioral health (IBH) services are structured. This study examined the impact of IBH structure on health outcomes among individuals with serious mental illness (SMI) and chronic disease receiving care in community health centers (CHCs). Data from the ADVANCE network identified 8,548 individuals with co-occurring SMI diabetes and 16,600 with an SMI and hypertension. Logistic regression tested whether IBH type impacted disease specific health outcomes among these populations. Among those with diabetes or hypertension, colocated care was associated with better health outcomes related to HbA1c, blood pressure control, and BMI compared to less coordinated and unintegrated care, though there was significant variation in this relationship across SMI diagnoses. Results reflect that colocation of primary care and behavioral health may improve outcomes for individuals with bipolar disorder or major depression and chronic disease, but that CHC-based integrated care may not be optimized for individuals with schizophrenia.

The Impact of Delivery Reform on Health Information Exchange with Behavioral Health Providers: Results from a National Representative Survey of Ambulatory Physicians.

Health information exchange (HIE) is an effective way to coordinate care, but HIE between health and behavioral health providers is limited. Recent delivery reform models, including the Accountable Care Organization (ACO) and Patient Centered Medical Home (PCMH) prioritize interprofessional collaboration, but little is known about their impact on behavioral health HIE. This study explores whether delivery reform participation affects behavioral health HIE among ambulatory health providers using pooled 2015-2019 data from the National Electronic Health Record Survey, a nationally representative survey of ambulatory physicians' technology use (n = 8,703). The independent variable in this analysis was provider participation in ACO, PCMH, Hybrid ACO-PCMH, or standard care. The dependent variable was HIE with behavioral health providers. Chi square analysis estimated unweighted rates of behavioral health HIE across reform models. Logistic regression estimated the impact of delivery reform participation on rates of behavioral health HIE. Unweighted estimates indicated that Hybrid ACO-PCMH providers had the highest rates of HIE (n = 330, 33%). In the fully adjust model, rates of HIE were higher among ACO (AOR = 2.66, p < .01), PCMH (AOR = 4.73, p < .001) and Hybrid ACO-PCMH participants (AOR = 5.55, p < .001) compared to standard care, but they did not significantly vary between delivery models. Physicians infrequently engage in HIE with behavioral health providers. Compared to standard care, higher rates of HIE were found across all models of delivery reform. More work is needed to identify common elements of delivery reform models that are most effective in supporting this behavior.

Acceptability of Health Information Exchange and Patient Portal Use in Depression Care Among Underrepresented Patients.

BACKGROUND: Depression is often untreated or undertreated, particularly among underrepresented groups, such as racial and ethnic minorities, and individuals of lower socioeconomic status. Electronic health information exchange (HIE) is a recommended practice to improve care coordination and encourage patient engagement in services, but it remains underutilized in depression care. Understanding factors affecting acceptance and adoption of this technology among underrepresented patient populations is needed to increase dissemination of HIE within mental health treatment. OBJECTIVE: The present study aims to identify patient barriers and facilitators towards the acceptance of HIE within the context of depression treatment and to examine how HIE impacts depression-related care coordination and patient activation. DESIGN: Semi-structured qualitative interviews were conducted with 27 patients. PARTICIPANTS: Respondents were English-speaking adults (> 18) receiving depression treatment within a large, safety-net primary care clinic. APPROACH: A grounded theory approach was used to code and analyze data for emergent themes. Thematic analysis was guided by the Unified Theory of Acceptance and Use of Technology, a leading informatics theory used to predict end-user adoption of technology. KEY RESULTS: Respondents reported that HIE made depression care more convenient, transparent, and trustworthy. Though respondents desired greater access to their health records, stigma surrounding depression inhibited acceptance of electronic communication and information sharing. Confusing electronic interface also diminished perceived benefits of HIE. CONCLUSION(S): Respondents desire greater transparency in their depression care. While HIE was perceived to improve the overall quality of depression care, stigma associated with mental illness undermined more robust adoption of this technology among underserved populations.

Understanding Health Talk in Behavioral Health Encounters: A Qualitative Analysis.

Although physical and behavioral health conditions commonly cooccur, best practices making behavioral health treatment responsive to clients' health needs are limited. Particularly little is known about how physical health is addressed by clinicians within routine therapeutic treatment. This study describes the frequency and type of health talk occurring within integrated behavioral health sessions, and explores how this talk functions within ongoing therapeutic work. Participants in this study included 51 dyads of clinical social workers (n = 13) and clients (n = 51) receiving therapy within an integrated community health and behavioral health center. Therapy sessions were recorded and transcribed verbatim. Content analysis determined the frequency and content of health talk in sessions. Thematic analysis was used to understand the function of health talk within these visits. Health talk occurred in 92% (n = 47) of sessions. Clients initiated the majority of discussions. Talk about sleep (40%, n = 19), diet/exercise (35%, n = 16), and chronic health conditions (28%, n = 13) were most common. Health talk either complimented or conflicted with therapeutic work, depending on the topic discussed and when it occurred during session. Health talk changed the scope of therapeutic work by integrating care coordination into routine practice. Health talk was pervasive and was frequently initiated by clients, signaling its relevance to clients' recovery. Providers leveraged heath talk to complement their therapeutic work, but these strategies were not universally applied. Care coordination activities were a part of routine therapy. Practice and policy changes that support a more interdisciplinary approach to clinical work are needed.

Whose System is it Anyway? How Clients and Providers Evaluate the Impact of Session EHR Use on Communication in Mental Health Treatment.

Electronic health records are common in mental health settings. While providers often express concern that in-session computing will damage client-provider communication, some work suggests that clients do not share this worry. As the majority of this research has been conducted in medical settings, less is known about how clients evaluate in session computing in mental health treatment, and whether this pattern of discordance persists in this setting. This study describes and compares the perceived impact of in-session computing on communication in mental health treatment from the clients and provider perspective, and examined sources of variation in client ratings. Thirteen providers and 53 clients participated in this study, representing 53 unique client-provider dyads. Results suggest that providers perceived in-session computing as more harmful to communication than clients. Client ratings varied by race, age and visit type but were not influenced by how often the computer was used during session.

Delivering person-centered care with an electronic health record.

BACKGROUND: Electronic health records are now widely adopted in medical and behavioral health settings. While they have the potential to improve the quality of care, the research findings on their impact on clinical practice and outcomes have been mixed. This study explores how the electronic health record and its stage of development influenced the implementation of person-centered care planning in community mental health clinics. METHODS: The study was set in five community mental health clinics which utilized an EHR and had been trained in person-centered care planning. Using an objective quantitative measure of fidelity, the study examined fidelity to PCCP across time and by stage of EHR development. Data from focus groups, interviews with clinic leaders and consultant reports was analyzed to explore the process of implementation and the role of the electronic health record. RESULTS: All clinics demonstrated an overall increase in PCCP fidelity at the conclusion of the study period but there were significant differences in PCCP fidelity among clinics with EHRs in different stages of development. Electronic health records emerged as a significant implementation factor in the qualitative data with clinics being unable to individualize service plans and encountering technical difficulties. Barriers to person-centered care included drop-down boxes and pre-determined outcomes. Clinic responses included customizing their record or developing workarounds. CONCLUSIONS: The study demonstrated the need to align the electronic health record with a person-centered approach which includes individualizing information and orienting service plans to personal life goals. The ability of clinics to be able to customize their records and balance the need for unique and aggregate information in the record is critical to improve both the provider experience and the quality of care. TRIAL REGISTRATION: Clinicaltrials.gov , NCT02299492 , registered on November 24, 2014.

Do Providers Know What They Do Not Know? A Correlational Study of Knowledge Acquisition and Person-Centered Care.

Person-centered care (PCC) is a central feature of health care reform, yet the tools needed to deliver this practice have not been implemented consistently. Person-centered care planning (PCCP) is a treatment planning approach operationalizing the values of recovery. To better understand PCCP implementation, this study examined the relationship between recovery knowledge and self-reported PCCP behaviors among 224 community mental health center staff. Results indicated that increased knowledge decreased the likelihood of endorsing non-recovery implementation barriers and self-reporting a high level of PCCP implementation. Findings suggest that individuals have difficulty assessing their performance, and point to the importance of objective fidelity measures.

Integrating the Electronic Health Record into Behavioral Health Encounters: Strategies, Barriers, and Implications for Practice.

Despite increasing rates of electronic health record (EHR) adoption, the impact of these systems on the delivery of behavioral health treatment remains poorly understood. This qualitative study examined the experiences of 37 behavioral health providers using EHRs during face-to-face visits. Providers described environmental, relational and system related strategies that were used to meaningfully integrate EHRs into treatment and enhance the patient-centeredness of clinical encounters. Barriers to deploying these techniques were also identified. Results contribute to limited research exploring EHR use in behavioral health care, and provide important insight into how systems can be optimized within this context.

Using Collaborative Documentation to Support Person-Centered Care in Substance Use Settings.

The delivery of person-centered care (PCC) is critical to promoting service engagement among individuals who use substances. Collaborative documentation (CD) is an emerging person-centered practice used in community mental health, but has not been evaluated in substance use settings. This qualitative study conducted focus groups with substance use treatment providers (n=22) in an outpatient clinic to examine the impact of CD on PCC and clinical quality. Rapid qualitative analysis methods were used to identify key themes. Participants reported that using CD reduced documentation time and helped build trust and better understand their clients. Using CD presented unique challenges and opportunities when used with mandated populations or those with complex symptoms. The importance of honoring clients' preference not to collaborate in care was a salient theme. Findings indicate that CD can promote PCC in substance use treatment. Targeted strategies to optimize CD for mandated and clinically complex populations are needed.

Barriers to Health Information Exchange Among Ambulatory Physicians: Results From a Nationally Representative Sample.

PURPOSE: Health information exchange (HIE) improves healthcare quality, but is underutilized by providers. This study used a nationally representative survey of ambulatory physicians to examine barriers to HIE, and identify which barriers have the greatest impact on providers' use of HIE. METHODS: A pooled sample of 1,292 physicians from the 2018-2019 National Electronic Health Record Survey was used. Univariate statistics described rates and patterns of eight common barriers to HIE. Multivariate logistic regression examined the relationship between each barrier and the use of HIE. RESULTS: Barriers to HIE were common and diverse. Negative attitudes toward HIE's ability to improve clinical quality significantly decreased HIE use (OR = .44, p < .01). CONCLUSIONS: To increase adoption of HIE, efforts should focus on addressing providers' negative attitudes toward HIE. These findings can guide targeted implementation strategies to improve HIE adoption.

Identifying key roles and responsibilities of peer workers in behavioral health services: A scoping review.

OBJECTIVE: The roles and responsibilities of peer workers (PWs) are not well articulated. This scoping review aims to systematically identify and describe the roles of PWs in outpatient, community based mental health and substance use services, and compare their roles and responsibilities across these service settings METHODS: The scoping review was a priori developed and implemented according to the Joanna Briggs Institute methodology, which includes stating the review objectives, conducting a three-step search method, and charting the results. RESULTS: Forty-four peer reviewed manuscripts were included in the review. PWs were used more often in mental health (n = 27) than substance use (n = 10) programs. Peers adopted a wide range of skills. Across program contexts, peers were frequently used as a source of informal support or mentorship and care coordination. Mental health programs often used peers to deliver manualized interventions, while substance use programs more frequently leveraged PWs to facilitate service linkage and engagement. CONCLUSION: Roles of peers differed between substance use and mental health programs, reflecting significant diversity in how peers are being integrated into the behavioral health workforce. PRACTICE IMPLICATIONS: Peer certification programs must balance consistency with the wide range of skills required of this workforce.

The impact of electronic health record functions on patterns of depression treatment in primary care.

BACKGROUND: Many individuals with depression are not being linked to treatment by their primary care providers. Electronic health records (EHRs) are common in medicine, but their impact on depression treatment is mixed. Because EHRs are diverse, differences may be attributable to differences in functionality. This study examines the relationship between EHR functions, and patterns of depression treatment in primary care. METHODS: secondary analyses from the 2013-2016 National Ambulatory Medical Care Survey examined adult primary care patients with new or acute depression (n = 5,368). Bivariate comparisons examined patterns of depression treatment by general EHR use, and logistic regression examined the impact of individual EHR functions on treatment receipt. RESULTS: Half the sample (57%; N = 3,034) was linked to depression treatment. Of this, 98.5% (n = 2,985) were prescribed antidepressants, while 4.3% (n = 130) were linked to mental health. EHR use did not impact mental health linkages, but EHR functions did affect antidepressant prescribing. Medication reconciliation decreased the odds of receiving an antidepressant (OR = .60, p < .05), while contraindication warnings increased the likelihood of an antidepressant prescription (OR = 1.91, p < .001). CONCLUSIONS: EHR systems did not impact mental health linkages but improved rates of antidepressant prescribing. Optimizing the use of contraindication warnings may be a key mechanism to encourage antidepressant treatment.

Shared Decision Making in Primary Care Based Depression Treatment: Communication and Decision-Making Preferences Among an Underserved Patient Population.

Objectives: Although depression is a significant public health issue, many individuals experiencing depressive symptoms are not effectively linked to treatment by their primary care provider, with underserved populations have disproportionately lower rates of engagement in depression care. Shared decision making (SDM) is an evidence-based health communication framework that can improve collaboration and optimize treatment for patients, but there is much unknown about how to translate SDM into primary care depression treatment among underserved communities. This study seeks to explore patients' experiences of SDM, and articulate communication and decision-making preferences among an underserved patient population receiving depression treatment in an urban, safety net primary care clinic. Methods: Twenty-seven patients with a depressive disorder completed a brief, quantitative survey and an in-depth semi-structured interview. Surveys measured patient demographics and their subjective experience of SDM. Qualitative interview probed for patients' communication preferences, including ideal decision-making processes around depression care. Interviews were transcribed verbatim and analyzed using thematic analysis. Univariate statistics report quantitative findings. Results: Overall qualitative and quantitative findings indicate high levels of SDM. Stigma related to depression negatively affected patients' initial attitude toward seeking treatment, and underscored the importance of patient-provider rapport. In terms of communication and decision-making preferences, patients preferred collaboration with doctors during the information sharing process, but desired control over the final, decisional outcome. Trust between patients and providers emerged as a critical precondition to effective SDM. Respondents highlighted several provider behaviors that helped facilitated such an optimal environment for SDM to occur. Conclusion: Underserved patients with depression preferred taking an active role in their depression care, but looked for providers as partner in this process. Due to the stigma of depression, effective SDM first requires primary care providers to ensure that they have created a safe and trusting environment where patients are able to discuss their depression openly.

Computer use in mental health treatment: Understanding collaborative documentation and its effect on the therapeutic alliance.

Amid increases in electronic health record adoption, many psychotherapists are concerned that in-session computing may harm the client-provider relationship, also known as the therapeutic alliance. The emerging practice of collaborative documentation (CD) is one strategy designed to prevent this outcome. Little empirical work has examined the effects of in-session computing generally or CD specifically within the psychotherapeutic context. This study explores how CD is being implemented in psychotherapy and examines how both the frequency of computing and the use of CD affects the therapeutic alliance. Psychotherapists in this study engaged in an average of 42 (SD = 38.5) computing episodes. CD was present in 39% of sessions (N = 21). Regression models found that among providers, increases in computing frequency predicted decreases in alliance (ß = -.18, p < .05). Conversely, among clients, the use of CD improved alliance (ß = .43, p < .01). Findings suggest that psychotherapists use computers often, but parties view the effect of electronic health records differently. Reconciling this disparity and continuing to develop effective technology-based best practices is imperative. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

A Help or a Hindrance: The Role of Electronic Health Records in Implementing New Practices in Community Mental Health Clinics.

OBJECTIVE: Practice innovation requires adequate organizational resources. Electronic health records (EHRs) are a key organizational resource affecting routine practice delivery, although their capacity to support practice innovation in mental health is largely unknown. This study examined the influence of EHR availability on community mental health clinic (CMHC) providers' fidelity to person-centered care planning (PCCP), an emergent practice that integrates person-centered principles into the mental health service planning process. METHODS: Participants included direct providers and supervisors implementing PCCP in seven CMHCs. Fidelity to PCCP was measured by using chart reviews of 378 service plans across three time points. Mixed-effects regression models were used to examine the influence of EHR availability on fidelity to PCCP at each time point. RESULTS: Findings suggest that EHRs did not influence PCCP delivery at baseline but were positively associated with fidelity postimplementation. CONCLUSIONS: EHRs are an organizational resource that can support practice innovation in mental health when paired with clinic-wide implementation efforts.

Perceptions of patient-centred care among providers and patients in the orthopaedic department of a tertiary care hospital in Karachi, Pakistan.

OBJECTIVE: This study examined the perspectives of 18 health care providers (nurses, consultant doctors, residents, radiologists, and physiotherapists) and 18 patients regarding best practices for patient-centred care (PCC) in a free private hospital in Pakistan, studying the congruence between provider and patient perspectives. METHODS: Six focus group interviews (FGIs) were conducted from January to March 2017: three with providers and three with patients. Focus group interviews were audio-recorded and transcribed verbatim. A deductive approach was used to analyse the data using the key dimensions of Scholl's framework, which was then complemented with constant comparison analysis to explore variability and similarity among participants across the six focus groups. RESULTS: Findings indicated that providers and patients acknowledged maintaining a collaborative relationship with patients by using empathy. Patients and providers agreed that providers allocated time to counsel the patient and alleviated their fears. Family involvement was seen as a key indicator in decision making for patients. Some discrepancies were found between patient and provider perceptions of inhibitors to PCC, notably a lack of teamwork exhibited by providers and continuity of care offered postdischarge. CONCLUSIONS: We recommend practices of PCC that are congruent with non-Western settings where religion and family play a primary role in matters dealing with patients' illnesses. Our findings suggest the need for recurrent training to improve teamwork among providers; questioning the implicit agreement of patients who may be vulnerable to decision making of authoritarian figures in their family; and the inclusion of peer-support workers or community health workers to offer aftercare support to patients in their home.

Open Notes Use in Psychiatry-The Need for Multilevel Efforts in Research and Practice.

This Viewpoint highlights barriers to incorporating the use of open notes as a component of patient-centered psychiatric care.

National Rates and Patterns of Depression Screening in Primary Care: Results From 2012 and 2013.

OBJECTIVES: Despite high prevalence rates of depression in primary care, depressive symptoms are often undetected by physicians. Screening for depression is now recommended as a part of routine primary care; however, recent estimates of rates and patterns of depression screening are lacking in the literature. This study examined national rates and patterns of depression screening among visits to office-based primary care physicians. METHODS: A secondary analysis of data from the 2012 and 2013 National Ambulatory Medical Care Survey was conducted. The sample consisted of 33,653 physician-patient encounters. RESULTS: The overall rate of depression screening was 4.2%. African Americans were half as likely to be screened compared with whites, and elderly patients were half as likely to be screened compared with middle-aged patients. Patients with a chronic condition were more likely than patients without a chronic condition to receive depression screening, and the likelihood of being screened increased with each additional chronic condition. Providers who had fully adopted electronic health records (EHRs) were more likely to screen for depression compared with providers who used paper charts. Screening rates were not associated with providers' intentions to participate in the federal program that provides financial incentives for the meaningful use of certified EHRs. CONCLUSIONS: Overall rates of depression screening were low. Current screening practices may exacerbate existing disparities in depression care. EHR systems may be an effective tool to improve screening rates.