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.

Shared Language for Shared Work in Population Health.

People working on behalf of population health, community health, or public health often experience confusion or ambiguity in the meaning of these and other common terms-the similarities and differences and how they bear on the tasks and division of labor for care delivery and public health. Shared language must be clear enough to help, not hinder people working together as they ultimately come to mutual understanding of roles, responsibilities, and actions in their joint work. Based on an iterative lexicon development process, the authors developed and propose a definitional framework as an aid to navigating among related population and community health terms. These terms are defined, similarities and differences clarified, and then organized into 3 categories that reflect goals, realities, and ways to get the job done. Goals include (a) health as well-being for persons, (b) population health as that goal expressed in measurable terms for groups, and (c) community health as population health for particular communities of interest, geography, or other defining characteristic-groups with shared identity and particular systemic influences on health. Realities are social determinants as influences, health disparities as effects, and health equity as both a goal and a design principle. Ways to get the job done include health care delivery systems for enrollees and public health in population-based civic activities-with a broad zone of collaboration where streams of effort converge in partnership with served communities. This map of terms can enable people to move forward together in a broad zone of collaboration for health with less confusion, ambiguity, and conflict.

An Adaptive, Contextual, Technology-Aided Support (ACTS) System for Chronic Illness Self-Management.

Policy Points Fundamental changes are needed in how complex chronic illness conditions are conceptualized and managed. Health management plans for chronic illness need to be integrated, adaptive, contextual, technology aided, patient driven, and designed to address the multilevel social environment of patients' lives. Such primary care-based health management plans are feasible today but will be even more effective and sustainable if supported by systems thinking, technological advances, and policies that create and reinforce home, work, and health care collaborations. CONTEXT: The current health care system is failing patients with chronic illness, especially those with complex comorbid conditions and social determinants of health challenges. The current system combined with unsustainable health care costs, lack of support for primary care in the United States, and aging demographics create a frightening probable future. METHODS: Recent developments, including integrated behavioral health, community resources to address social determinants, population health infrastructure, patient-centered digital-health self-management support, and complexity science have the potential to help address these alarming trends. This article describes, first, the opportunity to integrate these trends and, second, a proposal for an integrated, patient-directed, adaptive, contextual, and technology-aided support (ACTS) system, based on a patient's life context and home/primary care/work-setting "support triangle." FINDINGS: None of these encouraging trends is a panacea, and although most have been described previously, they have not been integrated. Here we discuss an example of integration using these components and how our proposed model (termed My Own Health Report) can be applied, along with its strengths, limitations, implications, and opportunities for practice, policy, and research. CONCLUSIONS: This ACTS system builds on and extends the current chronic illness management approaches. It is feasible today and can produce even more dramatic improvements in the future.

Without Wasting a Word: Extreme Improvements in Efficiency and Accuracy Using Computerized Adaptive Testing for Mental Health Disorders (CAT-MH).

PURPOSE OF REVIEW: We review recent literature on the adaptive assessment of complex mental health disorders and provide a detailed comparison of classical test theory and adaptive testing based on multidimensional item response theory. RECENT FINDINGS: Adaptive tests for a wide variety of mental health traits (e.g., depression, anxiety, mania, substance misuse, suicidality) are now available in a cloud-based environment. These tests have been validated in a variety of settings against lengthy structured clinical interviews with excellent results and even higher reliability than fixed-length tests. Applications include screening and assessments in emergency departments, psychiatric and primary care clinics, student health clinics, perinatal medicine clinics, child welfare settings, and the judicial system. The future of mental health measurement will be based on automated screening and assessments. Adaptive tests will provide increased precision of measurement and decreased burden of measurement. Integration into the electronic health record is important and now easily accomplished.

Using Telepsychiatry to Enrich Existing Integrated Primary Care.

Background: Integrated care is characterized by evolving heterogeneity in models. Using telepsychiatry to enhance these models can increase access, quality, and efficiencies in care. Introduction: The purpose of this report is to describe the process and outcomes of adapting telepsychiatry into an existing integrated care service. Materials and Methods: Telepsychiatry was implemented into an existing integrated care model in a high-volume, urban, primary care clinic in Colorado serving patients with complex physical and behavioral needs. Consultative, direct care, educational/training encounters, provider-to-provider communication, process changes, and patient-level descriptive measures were tracked as part of ongoing quality improvement. Results: Telepsychiatry was adapted into the existing behavioral health services using an iterative team meeting process within a stepped care model. Over 35% of the requests for psychiatry services were medication related-and medication changes (type/dose) were the most frequent referral outcome of psychiatric consultation. Forty percent of patients in the service had multiple behavioral health diagnoses, in addition to physical health diagnoses. Discussion: Telehealth will become an increasingly necessary component in building hybrid/blended integrated care teams. Examples of flexible model implementation will support clinics in tailoring effective applications for their unique patient panels. Conclusions: An adapted integrated care model leveraging telepsychiatry is successfully serving the complex deep end of a primary care patient population in Colorado. Lessons learned in implementing this model include the importance of team attitudes.

Primary care providers' experiences caring for complex patients in primary care: a qualitative study.

BACKGROUND: Complex patients are increasingly common in primary care and often have poor clinical outcomes. Healthcare system barriers to effective care for complex patients have been previously described, but less is known about the potential impact and meaning of caring for complex patients on a daily basis for primary care providers (PCPs). Our objective was to describe PCPs' experiences providing care for complex patients, including their experiences of health system barriers and facilitators and their strategies to enhance provision of effective care. METHODS: Using a general inductive approach, our qualitative research study was guided by an interpretive epistemology, or way of knowing. Our method for understanding included semi-structured in-depth interviews with internal medicine PCPs from two university-based and three community health clinics. We developed an interview guide, which included questions on PCPs' experiences, perceived system barriers and facilitators, and strategies to improve their ability to effectively treat complex patients. To focus interviews on real cases, providers were asked to bring de-identified clinical notes from patients they considered complex to the interview. Interview transcripts were coded and analyzed to develop categories from the raw data, which were then conceptualized into broad themes after team-based discussion. RESULTS: PCPs (N = 15) described complex patients with multidimensional needs, such as socio-economic, medical, and mental health. A vision of optimal care emerged from the data, which included coordinating care, preventing hospitalizations, and developing patient trust. PCPs relied on professional values and individual care strategies to overcome local and system barriers. Team based approaches were endorsed to improve the management of complex patients. CONCLUSIONS: Given the barriers to effective care described by PCPs, individual PCP efforts alone are unlikely to meet the needs of complex patients. To fulfill PCP's expressed concepts of optimal care, implementation of effective systemic approaches should be considered.

Value-based financially sustainable behavioral health components in patient-centered medical homes.

Because a high percentage of primary care patients have behavioral problems, patient-centered medical homes (PCMHs) that wish to attain true comprehensive whole-person care will find ways to integrate behavioral health services into their structure. Yet in today's health care environment, the incorporation of behavioral services into primary care is exceptional rather than usual practice. In this article, we discuss the components considered necessary to provide sustainable, value-added integrated behavioral health care in the PCMH. These components are to: (1) combine medical and behavioral benefits into one payment pool; (2) target complex patients for priority behavioral health care; (3) use proactive onsite behavioral "teams;" (4) match behavioral professional expertise to the need for treatment escalation inherent in stepped care; (5) define, measure, and systematically pursue desired outcomes; (6) apply evidence-based behavioral treatments; and (7) use cross-disciplinary care managers in assisting the most complicated and vulnerable. By adopting these 7 components, PCHMs will augment their ability to achieve improved health in their patients at lower cost in a setting that enhances ease of access to commonly needed services.

The future role of the family physician in the United States: a rigorous exercise in definition.

As the U.S. health care delivery system undergoes rapid transformation, there is an urgent need to define a comprehensive, evidence-based role for the family physician. A Role Definition Group made up of members of seven family medicine organizations developed a statement defining the family physician's role in meeting the needs of individuals, the health care system, and the country. The Role Definition Group surveyed more than 50 years of foundational manuscripts including published works from the Future of Family Medicine project and Keystone III conference, external reviews, and a recent Accreditation Council on Graduate Medical Education Family Medicine Milestones definition. They developed candidate definitions and a "foil" definition of what family medicine could become without change. The following definition was selected: "Family physicians are personal doctors for people of all ages and health conditions. They are a reliable first contact for health concerns and directly address most health care needs. Through enduring partnerships, family physicians help patients prevent, understand, and manage illness, navigate the health system and set health goals. Family physicians and their staff adapt their care to the unique needs of their patients and communities. They use data to monitor and manage their patient population, and use best science to prioritize services most likely to benefit health. They are ideal leaders of health care systems and partners for public health." This definition will guide the second Future of Family Medicine project and provide direction as family physicians, academicians, clinical networks, and policy-makers negotiate roles in the evolving health system.

Storylines of family medicine VIII: clinical approaches.

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'VIII: clinical approaches', authors address the following themes: 'Evaluation, diagnosis and management I-toward a working diagnosis', 'Evaluation, diagnosis and management II-process steps', 'Interweaving integrative medicine and family medicine', 'Halfway-the art of clinical judgment', 'Seamless integration in family medicine-team-based care', 'Technology-uncovering stories from noise' and 'Caring for patients with multiple long-term conditions'. May readers recognise in these essays the uniqueness of a family medicine approach to care.

Primary care physician perceptions on caring for complex patients with medical and mental illness.

BACKGROUND: Mental illness is common and associated with poor outcomes for co-occurring medical illness. Since primary care physicians manage the treatment of complex patients with both mental and medical illnesses, their perspectives on the care of these patients is vital to improving clinical outcomes. OBJECTIVE: To examine physician perceptions of patient, physician and system factors that affect the care of complex patients with mental and medical illness. DESIGN: Inductive, participatory, team-based qualitative analysis of transcripts of in-depth semi-structured interviews. PARTICIPANTS: Fifteen internal medicine physicians from two university primary care clinics and three community health clinics. RESULTS: Participant characteristics were balanced in terms of years in practice, practice site, and gender. Physicians identified contributing factors to the complexity of patient care within the domains of patient, physician and system factors. Physicians identified 1) type of mental illness, 2) acuity of mental illness, and 3) communication styles of individual patients as the principal patient characteristics that affected care. Physicians expressed concern regarding their own lack of medical knowledge, clinical experience, and communication skills in treating mental illness. Further, they discussed tensions between professionalism and emotional responses to patients. Participants expressed great frustration with the healthcare system centered on: 1) lack of mental health resources, 2) fragmentation of care, 3) clinic procedures, and 4) the national healthcare system. CONCLUSIONS: Physicians in this study made a compelling case for increased training in the treatment of mental illness and improvements in the delivery of mental health care. Participants expressed a strong desire for increased integration of care through collaboration between primary care providers and mental health specialists. This approach could improve both comfort in treating mental illness and the delivery of care for complex patients.

The Time Is Now: A Plan to Redesign Family Medicine Residency Education.

A new graduate medical education program in family medicine is urgently needed now. We propose an innovative plan to develop community-based, community-owned family medicine residency programs. The plan is founded on five guiding principles in which residencies will (1) transition to independent, community-owned organizations; (2) sustain comprehensiveness and generalism; (3) emphasize collaborative learning and interprofessional education; (4) develop local educators with national guidance; and (5) share resources, responsibilities, and learning. We describe actionable steps to begin the process of transforming residencies and strengthening primary care. As community-based and locally-run organizations, residencies will gain self-determination in how time is allocated, budgets are spent, and teams function. Building on the momentum of the National Academy of Medicine's 2021 primary care implementation plan and recommendations by family medicine organization leaders, we propose a Decade of Family Medicine Residency Transformation. We encourage individuals and organizations spanning disciplines, health care systems, and communities, to join forces to reimagine and recreate the preparation of outstanding personal physicians dedicated to individual and community health and well-being.

A step at a time.

In this issue of Families, Systems, and Health are two articles that inch us on our winding way forward as we try to help people become healthier. This article takes stock of where we are now, starting from the start, equipped with three of our foundational guiding principles, and sighting our polestar to see what our best next moves might be. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Nomination of Parinda Khatri for Don Bloch Award, 2020.

This article focuses on Parinda Khatri, PhD, who was nominated for the annual Don Bloch Award. This award is the quintessential organizational award for members who have advanced the field of collaborative care, and who show intellectual, behavioral, and relational qualities. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Attending to the whole person in the patient-centered medical home: the case for incorporating mental healthcare, substance abuse care, and health behavior change.

The foundation of the U.S. healthcare system is faulty, and the consequences have become inescapable (Committee of Quality of Health Care in America, 2001). We are first among nations in spending on healthcare, whether measured in absolute dollars, per capita expenditures, or proportion of our national budget. Yet our citizens are the least healthy in the developed world. (Anderson & Hussey, 2001) Our nation's healthcare system is simply not a high-quality system. This shortfall is serious enough to cause tens of thousands of unnecessary deaths each year and to compromise our capacity for further economic growth (Anderson & Hussey, 2001; Anderson, Frogner, Johns, & Reinhardt, 2006; Macinko, Starfield, & Shi, 2003), yet it ramifies into so many of our political, financial, and social institutions that change is difficult and fraught with serious unintended consequences.

Frequency of provider contact after FDA advisory on risk of pediatric suicidality with SSRIs.

OBJECTIVE: The Food and Drug Administration (FDA) issued a public health advisory in October 2003 on the risk of suicide in pediatric patients taking antidepressants and advised maintaining "close supervision" of such patients. In this study, the authors compared trends in the frequency of provider contacts for patients with depression before and after the advisory was issued. METHOD: Retrospective cohorts of children (N=27,370) and adults (N=193,151) with new episodes of depression treated with antidepressants were created from a national claims database of managed care plans (1998-2005). Two standards were used in measuring patient monitoring: the Health Plan Employer Data and Information Set (HEDIS) quality-of-care criterion calling for three contacts in 3 months and the FDA-recommended contact schedule totaling seven visits in 3 months. Time-series models compared postadvisory trends to the expected trend based on preadvisory measures. RESULTS: Less than 5% of all patients met FDA contact recommendations before the advisory, and the rate did not change after the advisory. A greater proportion of patients met the HEDIS contact criterion before the advisory (60% for children and 40% for adults), and the rate did not change after the advisory. A greater proportion of pediatric patients seen by a psychiatrist (80%) met the HEDIS criterion than those seen by a pediatrician (60%) or a non-pediatrician primary care physician (54%), and than adults seen by a psychiatrist (65%) or a primary care physician (37%). The proportions of pediatric patients who met the FDA recommendations did not differ by specialty. CONCLUSIONS: Contrary to expectations, the frequency of visits by patients with new episodes of depression treated with antidepressants did not increase after the October 2003 FDA advisory was issued.