Applying Lessons From Behavioral Health Integration to Social Care Integration in Primary Care.

Interest and incentives are increasing around strategies whereby the health care sector can better identify and address patients' social and economic needs in the context of primary care delivery. This interest is likely to accelerate during the economic recession following the OVID-19 pandemic. Yet effective and sustainable strategies for integrating social care practices (eg, patient-facing social risk screening and activities to address identified needs) have not been clearly established. Lessons learned from more than 2 decades of research on behavioral health integration could be applied to efforts to integrate social care into primary care. In this article, we synthesize learnings from primary care and behavioral health care integration, and translate them into organizing principles with the goal of advancing social care integration practices to improve the health of both patients and communities.

A systematic review of stigma in sexual and gender minority health interventions.

Stigma against sexual and gender minorities is a major driver of health disparities. Psychological and behavioral interventions that do not address the stigma experienced by sexual and gender minorities may be less efficacious. We conducted a systematic review of existing psychological and behavioral health interventions for sexual and gender minorities to investigate how interventions target sexual and gender minority stigma and consider how stigma could affect intervention efficacy. Preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines were followed. Eligible studies were peer reviewed and published in English between January 2003 and July 2019 and reported empirical results of behavioral or psychological interventions implemented among sexual and gender minorities. All interventions addressed stigma. We identified 37 eligible interventions. Most interventions targeted sexual minority men. Interventions were frequently developed or adapted for implementation among sexual and gender minorities and addressed multiple levels and types of stigma. Interventions most frequently targeted proximal stressors, including internalized and anticipated stigma. HIV and mental health were the most commonly targeted health outcomes. A limited number of studies investigated the moderating or mediating effects of stigma on intervention efficacy. The application of an intersectional framework was frequently absent and rarely amounted to addressing sources of stigma beyond sexual and gender minority identities. A growing number of interventions address sexual and gender minority stigma in an effort to prevent deleterious health effects. Future research is needed to assess whether stigma modifies the effectiveness of existing psychological and behavioral interventions among sexual and gender minorities. Further, the application of intersectional frameworks is needed to more comprehensively intervene on multiple, intersecting sources of stigma faced by the diverse sexual and gender minority community.

Challenges and Opportunities for the Prevention and Treatment of Cardiovascular Disease Among Young Adults: Report From a National Heart, Lung, and Blood Institute Working Group.

Improvements in cardiovascular disease (CVD) rates among young adults in the past 2 decades have been offset by increasing racial/ethnic and gender disparities, persistence of unhealthy lifestyle habits, overweight and obesity, and other CVD risk factors. To enhance the promotion of cardiovascular health among young adults 18 to 39 years old, the medical and broader public health community must understand the biological, interpersonal, and behavioral features of this life stage. Therefore, the National Heart, Lung, and Blood Institute, with support from the Office of Behavioral and Social Science Research, convened a 2-day workshop in Bethesda, Maryland, in September 2017 to identify research challenges and opportunities related to the cardiovascular health of young adults. The current generation of young adults live in an environment undergoing substantial economic, social, and technological transformations, differentiating them from prior research cohorts of young adults. Although the accumulation of clinical and behavioral risk factors for CVD begins early in life, and research suggests early risk is an important determinant of future events, few trials have studied prevention and treatment of CVD in participants <40 years old. Building an evidence base for CVD prevention in this population will require the engagement of young adults, who are often disconnected from the healthcare system and may not prioritize long-term health. These changes demand a repositioning of existing evidence-based treatments to accommodate new sociotechnical contexts. In this article, the authors review the recent literature and current research opportunities to advance the cardiovascular health of today's young adults.

Salivary Bioscience and the Future of Behavioral Medicine.

Behavioral medicine research from across the globe has been catalyzed by the quest to understand the interactions between psychological, social, and physiological factors underlying disparities in human health. A more complete biopsychosocial model increasingly integrates advanced clinical and laboratory assessments of relevant environmental chemicals, biological mediators of inflammation, cardiometabolic and endocrine markers, infectious disease exposure, and genetic polymorphisms determined from saliva specimens. The overarching aims are to identify mechanisms, decode moderating processes that translate adversity into risk, and verify the impact of clinical intervention. This special issue of the International Journal of Behavioral Medicine highlights novel contributions of salivary bioscience with emphasis on research utilizing varied research designs (i.e., experimental, longitudinal, dyadic), incorporating a broad array of salivary analytes, and investigating the influence of psychological and social factors on human health.

Environmental, social, and economic factors related to the intersection of food security, dietary quality, and obesity: an introduction to a special issue of the Translational Behavioral Medicine journal.

This special issue of Translational Behavioral Medicine solicited papers focusing on the intersection of food security, dietary quality, and obesity. Specifically, the special issue seeks to highlight research that provides actionable takeaways related to policy, systems, and environmental (PSE) approaches for practitioners and policymakers. The purpose of this introduction was to summarize relevant background literature and then briefly introduce topics covered by the articles included in the special issue. There are economic, environmental, and social factors that create systemic barriers that drive persistent poverty in communities and underlay the intersection of food security, dietary quality, and obesity. Although equitable healthful food access is needed, the issue is exceedingly complicated. Understanding and operationalizing effective and efficient PSE approaches is in its infancy. More research is needed to better understand how to appropriately measure determinants of health (and how they relate to the conditions that ultimately promote obesity through food insecurity and compromises to dietary quality), implement deliberate interventions that address the underlying factors, and disseminate that information to policymakers and practitioners in the field. This special issue of Translational Behavioral Medicine includes articles that relay practical findings, measurement methods, and lessons learned related to PSE approaches such as federal food assistance programs (e.g., National School Lunch Program), systems-based interventions (e.g., clinic-community connections), and environmental modifications(e.g., food retail marketing). Although much more practical and action-oriented research is needed in this area, these articles will contribute to the evidence base supporting better future assessment and PSE interventions that address food security, dietary quality, and obesity.

Communicating With Leadership: Behavioral Health and HIPAA in the Field.

It can be challenging for a general medical officer to determine a patient's fitness for duty in the field. Communicating with commanding officers can be difficult given a general medical officer's loyalties as both a physician and medical officer. We present a case of a junior officer that highlights these issues.

Preventing and managing multimorbidity by integrating behavioral health and primary care.

Increasing specialization, underinvestment in primary care and behavioral health, and the growing prevalence of multiple chronic conditions (MCC) across all age groups have led to a substantial mismatch between the way health care is currently organized and delivered and the needs of people with MCC. People with multimorbidity are especially challenged in navigating fragmented health systems designed to treat diseases rather than people. The harms associated with this fragmentation, such as adverse events resulting from conflicting treatments and increased costs, have been well documented. As a result, there have been renewed calls for more patient-centered care, with a particular emphasis on the importance of the integration of primary care and behavioral health as fundamental for achieving this goal. There is an enormous opportunity to improve individual and population health by developing, implementing, evaluating, scaling, and spreading effective interventions to prevent and manage multimorbidity. This will require integration of behavioral health and primary care and broader efforts to create healthy communities, including efforts to address the social determinants of health, as well as the alignment of clinical medicine, public health, and community services to support these efforts. Evidence is needed for the most effective strategies to manage multimorbidity as well as for models of health care delivery and population health to foster health and well-being for all. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Standards for economic analyses of interventions for the field of health psychology and behavioral medicine.

Behavioral interventions can be offered within a wide range of contexts, including public health, medicine, surgery, physical rehabilitation, nutrition, and other health services. These differing services compete for the same resources and it is difficult to compare their value. Systematic standardized methodologies for valuing outcomes are available and are being applied by economists and health services researchers, but are not widely used in our field. With support from the Society for Health Psychology, the National Cancer Institute (NCI), and the Office for Behavioral and Social Sciences Research (OBSSR) at the National Institutes of Health, two working group meetings were held to consider the use of well-established cost-effectiveness methodologies for the evaluation of behavioral and public health interventions. In this special section, we acknowledge a wide range of variability in terms of behavioral interventions typically delivered in nonclinical versus more traditional clinical settings. Three articles address (1) standardizing methods for conducting cost-effectiveness and cost-utility analyses, (2) providing examples to illustrate progress in applying these methods to evaluate interventions delivered in whole or in part in clinical settings, and (3) providing nonclinical intervention examples selected to highlight the challenges and opportunities for evaluating the cost-effectiveness of interventions in more diverse settings. The ability of our field to communicate cost-effectiveness data to policy makers, employers, and insurers that incorporates implementation costs is central to the likelihood of our interventions being adopted by practitioners and reimbursed by payers. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Ke Ku'una Na'au: A Native Hawaiian Behavioral Health Initiative at The Queen's Medical Center.

Although acute care facilities have not typically focused on resolving the psychosocial determinants of health, new models are emerging. This article provides details of the Ke Ku'una Na'au (KKN) Native Hawaiian Behavioral Health Initiative implemented in 2016 at The Queen's Medical Center in Honolulu, Hawai'i. The program is focused on reducing hospital readmissions for socially and economically vulnerable Native Hawaiian adults and improving their health care outcomes after hospitalization. The program was piloted on 2 medical units to assist patients who identified as Native Hawaiian, were ages 18 and older, and living with chronic diseases, psychosocial needs, and/or behavioral health problems. The program model was developed using a team of Native Hawaiian community health workers referred to as navigators, who were supported by an advanced practice nurse and a project coordinator/social worker. Navigators met patients during their inpatient stay and then followed patients post discharge to support them across any array of interpersonal needs for at least 30 days post-discharge. Goals were to assist patients with attending a post-hospital follow-up appointment, facilitate implementation of the discharge plan, and address social determinants of health that were impacting access to care. In 2017, 338 patients received care from the KKN program, a number that has grown since that time. In 2015, the baseline readmission rate for Native Hawaiians on the 2 medical units was 16.6% (for 440 Native Hawaiian patients in total). In 2017, the readmission rate for Native Hawaiians patients on the two medical units was 12.6% (for 445 Native Hawaiian patients, inclusive of KKN patients) (P=.092). This decrease suggests that the KKN program has been successful at reducing readmissions for vulnerable patients and, thus, improving care for Native Hawaiians in the health system generally. The KKN program has offered relevant, culturally sensitive care meeting a complex, personalized array of needs for over 338 patients and has shown demonstrated success in its outcomes. This information will be useful to other acute care organizations considering similar programs.

Accountable Care Organizations' Performance in Depression: Lessons for Value-Based Payment and Behavioral Health.

Value-based payment initiatives, such as the Medicare Shared Savings Program (MSSP), offer the possibility of using financial incentives to drive improvements in mental health and substance use outcomes. In the past 2 years, Accountable Care Organizations (ACOs) participating in the MSSP began to publicly report on one behavioral health outcome-Depression Remission at Twelve Months, which may indicate how value-based payment incentives have impacted mental health and substance use, and if reforms are needed. For ACOs that meaningfully reported performance on the depression remission measure in 2017, the median rate of depression remission at 12 months was 8.33%. A recent meta-analysis found that the average rate of spontaneous depression remission at 12 months absent treatment was approximately 53%. Although a number of factors likely explain these results, the current ACO design does not appear to incentivize improved behavioral health outcomes. Four changes in value-based payment incentive design may help to drive better outcomes: (1) making data collection easier, (2) increasing the salience of incentives, (3) building capacity to implement new interventions, and (4) creating safeguards for inappropriate treatment or reporting.

Meeting the Behavioral Health Needs of LGBT Older Adults.

Lesbian, gay, bisexual, and transgender (LGBT) older adults face an increased risk of adverse behavioral health outcomes compared with the general population of older adults, yet little attention has been given to factors contributing to these disparities or to the ways in which clinicians can address these challenges. We present the case of a 75-year-old widowed lesbian woman with depression to illustrate how a lifetime of exposure to discrimination and stigma can produce high levels of stress and isolation while also fostering resilience. We then offer recommendations and resources for promoting psychological health among LGBT older adults by attending to the historical and cultural forces that affect LGBT health, and by implementing inclusive policies and programming. The article concludes with suggestions for advancing research and policy to help achieve greater health equity for LGBT older adults. J Am Geriatr Soc 67:1565-1570, 2019.

The Impact of Designated Behavioral Health Services on Resource Utilization and Quality of Care in Patients Requiring Constant Observation in a General Hospital Setting: A Quality Improvement Project.

Constant observation (CO) is a common economic burden on general hospitals. A quality improvement (QI) project focusing on behavioral health (BH) management of this population was piloted using a novel BH protocol for the proactive assessment and management of all patients requiring CO. The impact on CO-cost and length of stay (LOS) was assessed. Data on demographics, diagnoses, psychopharmacologic treatment, complications and clinical setting were collected and analyzed for all CO-patients over a 6-month period. Cost and LOS data were compared with a similar sequential group prior to project implementation. Out of the 533 patients requiring CO during the study period, 491 underwent the protocol. This QI-project resulted in a significant reduction in the average monthly CO-cost by 33.06% and a 15% reduction in LOS without any increase in complications.

Concordance of assessments of clients' mental and behavioral health with in vivo assessment of work performance.

BACKGROUND: Assessing functioning and disability among individuals with mental and behavioral health disorders has historically relied on deriving accurate psychiatric diagnoses and assessing symptoms. However, growing empirical evidence suggests that this approach is inadequate to determine real world performance, particularly with respect to work. OBJECTIVE: We examined a performance-based approach to the assessment of work functioning and its relationship to mental and behavioral health status. METHODS: A cross-sectional study was conducted at two mental health programs. Trained employment providers conducted performance-based assessments of work function and ratings of mental and behavioral health while study participants self-reported their mental/behavioral health functioning. We hypothesized that participant and provider ratings of mental/behavioral health would be moderately correlated with performance-based assessments of work function. RESULTS: We found no significant correlation between participants' self-report of their mental and behavioral health and performance-based assessments of work. Employment providers' ratings of participants' mental/behavioral health were moderately correlated with performance-based measures of work. Finally, we found low concordance between employment providers and study participants' with respect to ratings of their mental/behavioral health. CONCLUSIONS: Contrary to our hypotheses, ratings of mental/behavioral health were only moderately correlated with performance-based measures of work. Results confirm earlier research suggesting that it is difficult to predict work performance from participants' self-reports of their mental/behavioral health alone. Performance-based assessments of work capacity as well as ratings of mental and behavioral health may both be needed for a more complete and complimentary picture of the ability of individuals with mental and behavioral health disorders to function in the work place.

Lessons of Leading Organizational Change in Quality and Process Improvement Training.

Physicians operate in complex health care systems where leading change is an important competency, often practically implemented in process and quality improvements. This case describes a deployed junior officer leading change through a process improvement. It aligns the plan, do, study, act model with Kotter's model of leading organizational change.

Return to Duty Practices of Army Behavioral Health Providers in Garrison.

Introduction: While combat readiness is a top priority for the U.S. Army, there is concern that behavioral health (BH) return to duty (RTD) practices may under-represent the number of soldiers available for deployment. Profiling, the official administrative process by which medical duty limitations are communicated to commanders, was recently found to be significantly under-reporting BH readiness levels in one Army Division. This is a safety issue in addition to a readiness problem, and underscores the importance of better understanding RTD practices in order to offer solutions. This study sought to categorize the information and tools used by Army BH providers in garrison to make decisions about duty limitations that can affect BH readiness. Materials and Methods: A qualitative approach was used for this study. Fourteen semi-structured interviews and three focus groups were conducted with a diverse convenience sample of Army BH providers in October 2015, resulting in input from 29 practitioners. Results: Through thematic analysis, it was discovered that profile decisions are driven first by safety of the soldier and secondarily by the needs of the unit. To facilitate their clinical decision-making, providers consider an array of data including standardized scales, unit mission, consultation with unit leadership, meetings with other providers, and, when appropriate, discussion with the friends and family of the soldier. Conclusions: If the military is to address the concern of under-reporting behavioral health readiness levels in garrison, it is critical to develop more predictability in treatment planning and reporting, as well as access to necessary data to make these clinical decisions. The interviews and focus groups revealed that while the technical process for initiating a profile does not vary, there is great disparity about the amount and type of information that is taken into consideration when making profile decisions. Categorization of the information that supports RTD decisions can lead to a better understanding of the process and inform leadership about ways to improve the accuracy of BH readiness reporting.

Society of Behavioral Medicine (SBM) position statement: Increasing funding for the NIH OBSSR to promote timely and effective behavioral medicine research.

Chronic diseases are a leading cause of morbidity and mortality in the USA. Most chronic diseases have behavioral risk factors that can improve health and quality of life and reduce financial burdens. Improved methods of measurement and behavioral interventions are rapidly progressing. These changes require sufficient funding to maximize effectiveness. The National Institutes of Health (NIH) Office of Behavioral and Social Sciences Research (OBSSR) helps to coordinate and support behavioral and social science research initiatives that are designed to promote public health and reduce chronic disease burden throughout the NIH. OBSSR's budget has not increased for the past 5 years. The goals of this policy paper are to promote awareness of the OBSSR Strategic Plan FY 2017-2021's three priority areas and encourage increased and sustained funding for OBSSR to support these priority areas. Priority area 1 involves improving the quality and integration of behavioral and social science research, which can increase speed of funding natural experiments. Priority area 2 encourages the use and improvement of new technology to create methods and infrastructures to analyze big behavioral data, ensuring that health behavior interventions keep pace with the substantial data generated from new technology. Priority area 3 supports translational research between scientific data and real-world practice, ensuring the delivery of research findings to patients and populations. Adequate and sustained resources are needed to address these priority areas. Without such resources, disparities in health outcomes and the costs of treating preventable chronic diseases will continue to grow. Society of Behavioral Medicine (SBM) recommends and supports an increase for OBSSR's budget.

Does the U Stand for Useless? The Urine Drug Screen and Emergency Department Psychiatric Patients.

BACKGROUND: Behavioral emergencies account for a significant portion of emergency department (ED) visits in the United States. Substance abuse is common in this population and may precipitate or exacerbate preexisting psychiatric illness. Contrary to ED policy guidelines, many behavior health centers (BH) require a urine drug screen (UDS) in stable patients prior to transfer. OBJECTIVE: We sought to determine the role of the UDS in ED length of stay (LOS), cost, and charges to patients and inpatient psychiatric care. METHODS: We performed a retrospective chart review of all patients transferred to an in-network BH from September 1-30, 2014. Clinical data were extracted and analyzed from our electronic medical record, including records from both the ED visit and the BH stay. RESULTS: There were 205 patient encounters identified; 89 patients had a UDS performed in the ED and 89% were obtained after the ED medical clearance. LOS were similar between the two groups, however, time to ED departure from time of medical clearance was delayed in the UDS group. BH providers mentioned UDS results < 25% of the time and no confirmatory tests were performed. There was no difference in BH LOS or discharge diagnosis of substance-abuse disorder. Patient charges for UDS over the month totaled $21,093. CONCLUSION: The UDS did not seem to have any significant effect on inpatient psychiatric care; whereas ED LOS and cost were both negatively affected. Based on these results, the UDS seems to be of little-to-no benefit in the setting of acute psychiatric illness.

Purchased Behavioral Health Care Received by Military Health System Beneficiaries in Civilian Medical Facilities, 2000-2014.

Introduction: Behavioral health conditions are a significant concern for the U.S. military and the Military Health System (MHS) because of decreased military readiness and increased health care utilization. Although MHS beneficiaries receive direct care in military treatment facilities, a disproportionate majority of behavioral health treatment is purchased care received in civilian facilities. Yet, limited evidence exists about purchased behavioral health care received by MHS beneficiaries. This longitudinal study (1) estimated the prevalence of purchased behavioral health care and (2) identified patient and visit characteristics predicting receipt of purchased behavioral health care in acute care facilities from 2000 to 2014. Materials and Methods: Medical claims with Major Diagnostic Code 19 (mental disorders/diseases) or 20 (alcohol/drug disorders) as primary diagnoses and TRICARE as the primary/secondary payer were analyzed for MHS beneficiaries (n = 17,943) receiving behavioral health care in civilian acute care facilities from January 1, 2000, to December 31, 2014. The primary dependent variable, receipt of purchased behavioral health care, was modeled for select mental health and substance use disorders from 2000 to 2014 using generalized estimating equations. Patient characteristics included time, age, sex, and race/ethnicity. Visit types included inpatient hospitalization and emergency department (ED). Time was measured in days and visits were assumed to be correlated over time. Behavioral health care was described by both frequency of patients and visit type. The University of South Carolina Institutional Review Board approved this study. Results: From 2000 to 2014, purchased care visits increased significantly for post-traumatic stress disorder, adjustment, anxiety, mood, bipolar, tobacco use, opioid/combination opioid dependence, nondependent cocaine abuse, psychosocial problems, and suicidal ideation among MHS beneficiaries. The majority of care was received for mental health disorders (78.8%) and care was most often received in EDs (56%). Most commonly treated diagnoses included mood, tobacco use, and alcohol use disorders. ED visits were associated with being treated for anxiety (excluding post-traumatic stress disorder; Adjusted odds ratio [AOR]: 9.14 [95% confidence interval (CI): 8.26, 10.12]), alcohol use disorders (AOR = 1.67 [95% CI: 1.53, 1.83]), tobacco use (AOR = 1.16 [95% CI: 1.06, 1.26]), nondependent cocaine abuse (AOR = 5.47 [95% CI: 3.28, 9.12]), nondependent mixed/unspecified drug abuse (AOR = 7.30 [95% CI: 5.11, 10.44]), and psychosis (AOR = 1.38 [95% CI: 1.20, 1.58]). Compared with adults age 60 yr and older, adolescents (ages 12-17 yr), and adults under age 60 yr were more likely to be treated for suicidal ideation, adjustment, mood, bipolar, post-traumatic stress disorder, nondependent cocaine, and mixed/unspecified drug abuse. Adults under age 60 yr also had increased odds of being treated for tobacco use disorders, alcohol use disorders, and opioid/combination opioid dependence compared with adults age 60 yr and older. Conclusions: Over the past 15 yr, purchased behavioral health care received by MHS beneficiaries in acute care facilities increased significantly. MHS beneficiaries received the majority of purchased behavioral health care for mental health disorders and were treated most often in the ED. Receiving behavioral health care in civilian EDs raises questions about access to outpatient behavioral health care and patient-centered care coordination between civilian and military facilities. Given the influx of new Veterans Health Administration users from the MHS, findings have implications for military, veteran, and civilian facilities providing behavioral health care to military and veteran populations.