Implementing a Hybrid-Collaborative Care Model: Practical Considerations for Nurse Practitioners.

Access to mental health care is a considerable problem for individuals suffering from a mental illness. Of the 44.7 million adults, aged 18 or older, experiencing a mental illness in 2016 only 43.1% reported receiving treatment. Utilizing integrated and collaborative models can enhance identification and treatment for individuals in need of mental health. The purpose of this paper is threefold: (a) to describe the process of implementing hybrid-collaborative care model (hybrid-CCM) in a practice setting, (b) to discuss the similarities and differences in a hybrid-CCM when compared to a traditional collaborative care model, and (c) to discuss practical considerations for nurse practitioners fulfilling the psychiatric consultant role in a hybrid-CCM or traditional collaborative care model. Implementing collaborative care presents challenges. Understanding implementation efforts can enhance the adoption of collaborative types of care and likely enhance the effectiveness of these strategies. Nurse practitioners can serve as psychiatric consultants within these delivery models, but appropriate training should take place prior to doing so to ensure they are prepared to fulfill this role. Continuing to identify ways we can expand implementation of collaborative models or hybrid versions of collaborative care models need to be explored.

Adaptation of digital navigation training for integrated behavioral health providers: Interview and survey study.

Despite effective treatment options, people who experience mental health conditions often do not receive needed care. E-mental health, for instance the use of mobile apps, is emerging as a way to increase access to and extend care. However, little formal training is available to increase the digital literacy level among behavioral healthcare providers (BHPs), seeking to employ such technology. The purpose of this study was to explore the acceptability and usability of an adapted in-person Digital Navigation Training (DNT) curriculum into e-Learning modules focused on the integrated environment for BHPs. BHP confidence to serve as digital navigators was also explored. E-Learning modules were adapted from an existing in-person DNT. A purposeful sampling strategy was used to recruit BHPs (n = 8) to complete the modules. Acceptability, usability, and confidence were assessed via survey and semi-structured interviews. Descriptive statistics were calculated for survey data and qualitative data were analyzed using a directed content analysis approach. BHPs who completed the training (n = 8) felt the modules were usable, enjoyed the structure, and felt the amount of time to complete the modules was acceptable. All participants thought the structure of the training worked well and enjoyed learning new information. While participants' confidence in their digital navigation skills increased, they desired more information and/or experience with screening apps prior to increasing their use of apps within their care. E-Learning modules were an acceptable method of educating BHPs with digital navigation skills. Future research is needed to explore incentives needed for training along with if participating in these modules can increase use of quality mobile apps to augment care within BHP treatment plans.

Supporting the use of technology in the integrated primary care environment, where patients often seek care for mental health conditions requires training. Behavioral Health Providers (BHPs) are members of the integrated team. BHPs are prime candidates to promote engagement of mobile apps within this model of care. Understanding how providing training in an online format to BHPs which supports their ability to incorporate apps into this unique environment is needed. The purpose of this article is to explore the acceptability and usability, and subsequent confidence to serve as a digital navigator, of an adapted in-person Digital Navigation Training consisting of E-Learning modules. E-Learning module content includes education pertaining to digital skills, shared-decision making and mobile app evaluation to facilitate knowledge among BHPs as well as their confidence in digital navigation. Our findings suggest that the online training is acceptable and usable by those who completed the training and improves their confidence to serve as a digital navigator. BHPs suggested quality improvement changes to the training which are being undertaken to include creating a checklist and adding to the mobile app evaluation content. The training can be accessed at https://www.unmc.edu/bhecn/education/m-health-digital-navigation-training-for-integrated-behavioral-health/index.html.

Methods for Navigating the Mobile Mental Health App Landscape for Clinical Use.

There are over 10,000 mental health and wellness apps on the market. Apps offer the opportunity to increase access to mental health care. However, with many apps to choose from and an app landscape that is largely unregulated, it can be difficult to incorporate this technology into clinical practice. The first step towards achieving this goal is to identify clinically relevant and appropriate apps. The purpose of this review is to discuss app evaluation, raise awareness of considerations involved in implementing mental health apps into clinical care, and provide an example of how apps can be used effectively in the clinical space. We discuss the current regulatory environment for health apps, how to evaluate apps, and implement them into clinical practice. We also showcase a digital clinic where apps are integrated into the clinical workflow and discuss barriers to app implementation. Mental health apps have the potential to increase access to care if they are clinically effective, easy to use, and protect patient privacy. Learning how to find, evaluate, and implement quality apps into practice is key in harnessing this technology for the benefit of patients.

Improving Integrated Mental Health Care Through an Advanced Practice Registered Nurse-Led Program: Challenges and Successes.

Integrated and collaborative care delivery models have demonstrated efficacy for the management of psychiatric conditions in the primary care environment, yet organizations struggle with implementation of integrated efforts in clinical practice. Delivering care with a population focus versus face-to-face encounters with individual patients requires financial investment and adjustment in care delivery. We discuss the early implementation process of an advanced practice registered nurse (APRN)-led integrated behavioral health care program, including the challenges, barriers, and successes in the first 9 months of the program (January-September 2021), for an academic institution in the Midwest. A total of 161 Patient Health Questionnaire 9 (PHQ-9) and 162 Generalized Anxiety Disorder (GAD-7) rating scales were completed on 86 patients. The mean PHQ-9 score at the initial visit was 11.3 (moderate depression); after 5 visits, it decreased significantly to 8.6 (mild depression) (P < .001). The mean GAD-7 score at the initial visit was 10.9 (moderate anxiety); after 5 visits, it decreased significantly to 7.6 (mild anxiety) (P < .001). A survey completed by 14 primary care physicians 9 months after program launch revealed improvements in satisfaction with collaboration but, most notably, in perception of access to and overall satisfaction with behavioral health consultation/patient care services. Program challenges included adapting the environment to enhance leadership roles for the program and adjusting to virtual availability of psychiatric support. A case example highlights the value of integrated care along with improved depression and anxiety-related outcomes. Next steps should include efforts that capitalize on nursing leadership strengths while also promoting equity among integrated populations.

How to Transition Patients Back From Psychiatric Care to Primary Care: An Access Initiative Protocol Development.

This column describes the initial steps to develop a bidirectional access initiative between outpatient psychiatric and primary care clinics within an academic medical center. The authors analyzed electronic health record data (N=2,837 patients), interviewed psychiatric and primary care providers, assembled a work group, and identified five patient tracks (treatment optimization, psychiatric continuity, specialty clinic, psychotherapy, and community referral). Over 16 months, the number of patients scheduled for new psychiatric diagnostic evaluations with medical services increased from 62.5 to 116.0 per month without significant change in the no-show rate for evaluations within the psychiatric outpatient clinic.

Addressing and evaluating health literacy in mHealth: a scoping review.

Background: Recent surveys have revealed many adults have basic or below basic health literacy, which is linked to medical errors, increased illness, and compromised public health. Health literacy as a concept is multi-faceted extending beyond the individual to include social structures and the context in which health information is being accessed. Delivering health information via mobile devices (mHealth) expands the amount of information available while presenting challenges to ensuring these materials are suitable for a variety of literacy needs. The aims of this study are to discover how health literacy is addressed and evaluated in mHealth app development. Methods: A scoping review of 5 peer-reviewed databases was conducted. Eligible articles were written in English, addressed general literacy or mHealth/digital/eHealth literacy, and collected literacy information in order to incorporate literacy into the design and/or modification of an app or collected literacy information to describe the population being studied. The "Health Literacy Online" (HLO) United States (U.S.) government guide was used as a framework. Results: Thirty-two articles were reviewed. Articles included health literacy recommendations for all HLO categories and some recommendations not aligned with these categories. Most articles addressed health literacy using specific HLO categories though none incorporated every HLO category. The most common categories addressed engagement and testing of mHealth content. Though several studies addressed health literacy through a formal assessment tool, most did not. Evaluation of health literacy in mHealth was end-user focused and did not extensively evaluate content for fit to a variety of individuals with limited health literacy. Conclusions: The recommendations seen consistently in our results in conjunction with formal HLO categories can act as beginning steps towards development of a health literacy evaluation tool for mHealth apps themselves. It is clear efforts are being made to reduce barriers to using mHealth for those with literacy deficits, however, it was also clear that this space has room to be more pragmatic in evaluation of mHealth tools for literacy. End user engagement in design and testing is necessary in future mHealth literacy tool development.

Telehealth Simulation With Graduate Nurse Practitioner Students.

BACKGROUND: Integration of telehealth preparation for nurse practitioner (NP) students varies across programs. PROBLEM: Nurse practitioner students had gaps in the preparation for using telehealth technology to deliver care and manage specific disorders. APPROACH: The purpose of this article is to describe the development and implementation of a telehealth simulation training experience for NP students to prepare them for practice in rural settings. OUTCOMES: Nurse practitioner students from various specialties completed the telehealth simulation training experience. The change in presimulation/postsimulation confidence and readiness scores were statistically significant. CONCLUSION: This telehealth simulation training experience provided an opportunity for NP students to engage in activities to enhance their knowledge and preparation in providing care via telehealth in a rural setting.

Mental Health App Evaluation: Updating the American Psychiatric Association's Framework Through a Stakeholder-Engaged Workshop.

The app evaluation framework of the American Psychiatric Association (APA) has emerged as an adaptable tool for those seeking to navigate the ever-growing space of mental health apps. The authors describe a meeting convened in December 2019 to refine the APA framework. The expert panel comprised 16 individuals across health care fields, with representation from psychiatry, psychology, social work, nursing, clinical informatics, peer support specialists, and individuals with lived mental health experience. This meeting resulted in an update to the APA framework with the addition of clearer question descriptions and the release of an eight-question screener that may be useful in clinical settings.

Actionable health app evaluation: translating expert frameworks into objective metrics.

As use and availability of mobile health apps have increased, so too has the need for a thorough, accessible framework for app evaluation. The American Psychiatric Association's app evaluation model has emerged as a way to critically assess an app by considering accessibility, privacy and security, clinical foundation, engagement, and interoperability; however, there is no centralized database where users can view how various health apps perform when assessed via the APA model. In this perspective, we propose and outline our effort to translate the APA's model for the evaluation of health apps into a set of objective metrics that can be published online, making the framework actionable and accessible to a broad audience. The questions from the APA model were operationalized into 105 objective questions that are either binary or numeric. These questions serve as the foundation of an online database, where app evaluation consists of answering these 105 questions and can be crowdsourced. While the database has yet to be published and crowdsourced, initial internal testing demonstrated excellent interrater reliability. The database proposed here introduces a public and interactive approach to data collection that is guided by the APA model. The published product enables users to sort through the many mobile health apps and filter them according to individual preferences and priorities, making the ever-growing health app market more navigable.

How a Health Center Eliminated the Waiting List for Psychiatric Services.

A quality improvement project was delivered by a federally qualified health center to improve patient access to psychiatric services. The effort was supported by training and technical assistance provided by the American Psychiatric Association Support and Alignment Network. Over a 3-year period, the collaborative care model (CoCM) and other integrated consultative strategies were implemented. As a result, the waitlist was reduced from 350 patients to 1 patient. The use of the CoCM and other integrated care strategies was successful in eliminating a psychiatric service waitlist in this primary care setting.

Systematic Review: Feasibility, Reliability, and Validity of Maternal/Caregiver Attachment and Bonding Screening Tools for Clinical Use.

INTRODUCTION: Infant-caregiver attachment is crucial for an infant's immediate and long-term social-emotional development and health. Despite advocacy by the National Institute of Children's Health Quality for infant social-emotional development screening, there is a lack of identified tools for use in primary care. Therefore, we conducted a systematic review to identify caretaker-infant attachment self-report screening tools that would be feasible, reliable, and valid for use in primary care. METHOD: A systematic search identified 340 abstracts/articles, which were screened using inclusion and exclusion criteria. Twelve articles and six self-report attachment tools were examined for reliability, validity, and feasibility characteristics. RESULTS: Six caregiver-infant attachment self-report tools were identified. Establishment of feasibility, reliability, and validity are in the early stages. DISCUSSION: Potential infant-caretaker attachment screening tools were identified for use in primary care practices. Suggestions for research and practice include informal screening, additional psychometric testing, and development of policies supporting implementation of screening.

Postpartum Depression Screening for New Mothers at Well Child Visits.

BACKGROUND: Postpartum depression (PPD) is a debilitating emotional experience that can affect mothers and their infants. Screening for PPD is encouraged during pediatric well-child visits (WCVs); however, the frequency, referral process, and documentation relative to screening in clinical practice require further study. OBJECTIVES: There were three purposes to this study: 1) determine prevalence of mothers who scored in the at-risk range using the Edinburgh Postnatal Depression Scale (EPDS) at each of the 2-, 4-, and 6-month WCVs in a pediatric outpatient practice; 2) examine feasibility factors relative to extending the current standard of care for PPD screening; and 3) examine visit documentation for at-risk mothers. DESIGN: A prospective cohort study design was used to screen mothers during their infants' 6-month WCV for PPD using the EPDS. Feasibility in adding the 6-month time frame was assessed using an investigator-designed clinical team survey. Visit documentation content was obtained through medical record review. RESULTS: Forty-three postpartum women were included in the study. Prevalence rates among participants were 10%, 12.5%, and 14% for 2-month, 4-month, and 6-month WCVs, respectively. The clinical team found the additional screening at the 6-month visit to be feasible. Documentation for mothers identified to be at-risk varied greatly. CONCLUSIONS: Prevalence of PPD among participants is consistent with previously reported rates. Areas identified for improved clinical practice include the content of the visit that is documented in the medical record and reviewed with mothers identified to be at-risk, time allotted for the clinical team to screen new mothers, and appropriate referral to outside sources.