Pharmacists Colocated With Primary Care Physicians: Understanding Delivery of Interprofessional Primary Care.

BACKGROUND: While evidence supports interprofessional primary care models that include pharmacists, the extent to which pharmacists are working in primary care and the factors associated with colocation is unknown. OBJECTIVES: This study aimed to analyze the physical colocation of pharmacists with primary care providers (PCPs) and examine predictors associated with colocation. RESEARCH DESIGN: This is a retrospective cross-sectional study of pharmacists and PCPs with individual National Provider Identifiers in the National Plan and Provider Enumeration System's database. Pharmacist and PCP practice addresses of the health care professionals were geocoded, and distances less than 0.1 miles were considered physically colocated. SUBJECTS: In all, 502,373 physicians and 221,534 pharmacists were included. RESULTS: When excluding hospital-based pharmacists, 1 in 10 (11%) pharmacists were colocated with a PCP. Pharmacists in urban settings were more likely to be colocated than those in rural areas (OR=1.32, CI: 1.26-1.38). Counties with the highest proportion of licensed pharmacists per 100,000 people in the county had higher colocation (OR=1.38, CI: 1.32-1.45). Colocation was significantly higher in states with an expanded scope of practice (OR 1.37, CI: 1.32-1.42) and those that have expanded Medicaid (OR 1.07, CI: 1.03-1.11). Colocated pharmacists more commonly worked in larger physician practices. CONCLUSION: Although including pharmacists on primary care teams improves clinical outcomes, reduces health care costs, and enhances patient and provider experience, colocation appears to be unevenly dispersed across the United States, with lower rates in rural areas. As the integration of pharmacists in primary care continues to expand, knowing the prevalence and facilitators of growth will be helpful to policymakers, researchers, and clinical administrators.

Harm reduction workforce, behavioral health, and service delivery in the USA: a cross-sectional study.

BACKGROUND: Despite recent financial and policy support for harm reduction in the USA, information on the types of workers within organizations who design, implement, and actualize harm reduction services remains nascent. Little is known about how variability in the harm reduction workforce impacts referrals and linkages to other community supports. This exploratory mixed-methods study asked: (1) Who constitutes the harm reduction workforce? (2) Who provides behavioral health services within harm reduction organizations? (3) Are referral services offered and by whom? (4) Do referrals differ by type of harm reduction worker? METHODS: Purposive sampling techniques were used to distribute an electronic survey to U.S.-based harm reduction organizations. Descriptive statistics were conducted. Multivariate binary logistic regression models examined the associations (a) between the odds of the referral processes at harm reduction organizations and (b) between the provision of behavioral health services and distinct types of organizational staff. Qualitative data were analyzed using a hybrid approach of inductive and thematic analysis. RESULTS: Data from 41 states and Washington, D.C. were collected (N = 168; 48% response rate). Four primary types of workers were identified: community health/peer specialists (87%); medical/nursing staff (55%); behavioral health (49%); and others (34%). About 43% of organizations had a formal referral process; among these, only 32% had follow-up protocols. Qualitative findings highlighted the broad spectrum of behavioral health services offered and a broad behavioral health workforce heavily reliant on peers. Unadjusted results from multivariate models found that harm reduction organizations were more than 5 times more likely (95% CI [1.91, 13.38]) to have a formal referral process and 6 times more likely (95% CI [1.74, 21.52]) to have follow-up processes when behavioral health services were offered. Organizations were more than two times more likely (95% CI [1.09, 4.46]) to have a formal referral process and 2.36 (95% CI [1.11, 5.0]) times more likely to have follow-up processes for referrals when behavioral health providers were included. CONCLUSIONS: The composition of the harm reduction workforce is occupationally diverse. Understanding the types of services offered, as well as the workforce who provides those services, offers valuable insights into staffing and service delivery needs of frontline organizations working to reduce morbidity and mortality among those who use substances. Workforce considerations within U.S.-based harm reduction organizations are increasingly important as harm reduction services continue to expand.

Artificial Neural Network Analysis Examining Substance Use Problems Co-Occurring with Anxiety and Depressive Disorders Among Adults Receiving Mental Health Treatment.

Objective: The co-occurrence of anxiety disorders, depressive disorders, and substance use problems was examined. Methods: The Mental Health Client-Level Data dataset was used to conduct logistic regression models and an artificial neural network analysis. Logistic regression analyses were conducted among adults with anxiety (n = 547,473) or depressive disorders (n = 1,610,601) as their primary diagnosis who received treatment in a community mental health center. The artificial neural network analysis was conducted with the entire sample (N = 2,158,074). Results: Approximately 30% of the sample had co-occurring high-risk substance use or substance use disorder. Characteristics including region of treatment receipt, age, education, gender, race and ethnicity, and the presence of co-occurring anxiety and depressive disorders were associated with the co-occurring high-risk substance use or a substance use disorder. Conclusions: Findings from this study highlight the importance of mental health facilities to screen for and provide integrated treatment for co-occurring disorders.

Social workers roles in achieving health quality metrics in primary care: a quality improvement case study.

Value-based payment models may improve patient health by targeting quality of care over quantity of health services. Social workers in primary care settings are well-positioned to improve the quality of health services for vulnerable patients by identifying and addressing patients' social determinants of health. This case study describes a Plan Do Study Act (PDSA) quality improvement approach implemented and refined by social workers to proactively address clinical quality gaps in one family medicine practice. The studied program - entitled Gap Closure Day - was led by a team of social workers to improve quality outcomes of patients. Findings highlight the important roles of social workers as members of health care teams to improve the quality of health services and address health equity.

Are DEA-waivered buprenorphine prescribers colocated with behavioral health clinicians?

BACKGROUND AND OBJECTIVES: Medication for opioid use disorder (MOUD) in primary care includes a combination of medication, behavioral therapy, and/or other psychosocial services. This study assessed rates of colocation between waivered prescribers and behavioral health clinicians across the United States to understand if rates varied by provider type and geographic indicators. METHODS: Data from the DEA-Drug Addiction Treatment Act of 2000 provider list as of March 2022 and the National Plan and Provider Enumeration System's National Provider Identifier database were gathered, cleaned, and formatted in Stata. Data were geocoded with ESRI StreetMap® database and ArcGIS software. Covariates at individual, county, and state levels were examined and compared. Chi-square statistics and a mixed-effects logistic regression were analyzed. RESULTS: The sample (N = 71, 292 prescribers) included physicians (64%), nurse practitioners (29%), and physician assistants (7%). About 48% of prescribers were colocated with a behavioral health clinician. Physicians were the least likely to be colocated (47%), but differences between provider types were modest. We observed significant geographic differences in provider colocation by provider type. Mixed effects logistic regression identified significant predictors of colocation at individual, county, and state levels. DISCUSSION AND CONCLUSIONS: Optimally distributing the workforce providing MOUD is necessary to broadly ensure the provision of comprehensive MOUD care based on practice guidelines. SCIENTIFIC SIGNIFICANCE: Less than half of all waivered prescribers, outside of hospitals, are colocated with behavioral health clinicians. Findings offer greater clarity on where integrated MOUD is occurring, among which types of providers, and where it needs to be expanded to increase MOUD uptake.

Federally Qualified Health Centers Use of Telehealth to Deliver Integrated Behavioral Health Care During COVID-19.

Federally qualified health centers (FQHCs) that provide comprehensive health services, including integrated behavioral health (IBH), transitioned to deliver care via telehealth during the COVID-19 pandemic. This study explored how FQHCs adapted IBH services using telehealth. A mixed-method design was used, pairing a survey disseminated to FQHC administrators with a structured interview. Of the 46 administrators who participated in the survey, 14 (30.4%) reported delivering IBH using telecommunication prior to the pandemic. Since COVID-19, almost all of the FQHCs surveyed used telecommunication to deliver IBH (n = 44, 95.7%). Nine interviews with FQHC administrators resulted in the four themes: telehealth was essential; core components of IBH were impacted; payment parity and reimbursement were a concern; and telehealth addressed workforce issues. Findings confirm the necessity of telehealth for FQHCs during COVID-19. However due to the lack of co-location, warm-handoffs and other core components of IBH were limited.

Where are social workers co-located with primary care physicians?

Social workers are increasingly working in primary care clinics that provide Integrated Behavioral Healthcare (IBH) in which a patient's physical, behavioral, and social determinants of health are addressed on a collaborative team. Co-location, where care is housed in the same physical space, is a key element of IBH. Yet, little is known about the rate of social workers co-located with primary care physicians (PCPs). To identify national rates of social worker co-location, data were drawn from the Centers for Medicare and Medicaid (CMS) National Plan and Provider Enumeration System (NPPES; n = 232,021 social workers, n = 380,690 PCPs). Practice addresses were geocoded and straight-line distances between practice locations of social workers and PCPs were calculated. More than 26% of social workers were co-located with a PCP. However, in rural settings only 21% were co-located (p < .001). Co-location also varied by PCP practice size, specialty, and state. This study serves as a benchmark of the growth of IBH and continued monitoring of co-location is needed to ensure social work workforce planning and training are aligned with changing models of care. Further, identifying mechanisms to support social work education, current providers, and health systems to increase IBH implementation is greatly needed.

Social workers in integrated health care: Improving care throughout the life course.

Great strides have been made in highlighting the strengths of the social work profession as a workforce vital to improving the health and well-being of individuals, families, and communities. Nevertheless, substantially more work is needed to advance education, practice, and research involving social workers' potential and their contributions to improved care throughout the life course. This special issue offers exemplars of the power of social work in integrated settings with the capacity to address the scope of behavioral health, psychosocial, and physical health care needs. In today's rapidly evolving heath care context, integrated care represents a promising direction for the future of health services, and may be leveraged to improve population health across the life course. Papers selected for this special issue focused on two themes: (a) defining the expanding roles and functions social workers fulfill in integrated health settings, and (b) identifying organizational and system factors that affect social workers' delivery of interventions in integrated health models. This special issue further articulates the added-value of social workers on health care teams and the resulting improved outcomes for patients, families, and communities. Through increased evidence, such as the knowledge gained from this special issue, it is our hope that the profession continues to advance the boundary-spanning roles and capabilities of social workers in integrated health settings-both in the hospital and in community-based settings.

The role of social work in the opioid epidemic: office-based opioid treatment programs.

The opioid epidemic is a national emergency in the United States. To meet the needs of individuals diagnosed with Opioid Use Disorder (OUD) office-based opioid treatment programs (OBOT) are quickly expanding. However, social workers roles in OBOT programs are not clearly described. This paper will emphasize three roles social workers may fulfill in OBOT programs to combat the opioid crisis.

Adverse Childhood Experiences and Child Health Outcomes: Comparing Cumulative Risk and Latent Class Approaches.

Objectives This study seeks to further the work exploring adverse childhood experiences (ACEs) by proposing a novel approach to understanding the impact of ACEs through applying advanced analytical methods to examine whether combinations of ACEs differentially impact child health outcomes. Methods Using National Survey of Children's Health data, we use latent class analysis to estimate associations between classes of ACEs and child health outcomes. Results Class membership predicts child poor health, with differences found for specific ACE combinations. A subgroup of children exposed to poverty and parental mental illness are at higher risk for special healthcare needs than all other groups, including children exposed to 3 or more ACEs. Conclusions Different combinations of ACEs carry different risk for child health. Interventions tailored to specific ACEs and ACE combinations are likely to have a greater effect on improving child health. Our findings suggest children who experience specific ACE combinations (e.g., poverty and parental mental illness) are at particularly high risk for poor health outcomes. Therefore, clinicians should routinely assess for ACEs to identify children exposed to the most problematic ACE combinations; once identified, these children should be given priority for supportive interventions tailored to their specific ACE exposure and needs.

Is North Carolina's Workforce Prepared for Team-Based Care?

Evaluating the capacity of the health workforce to adopt team-based health care delivery models, nationally or in North Carolina, requires a nuanced approach that explores educational and clinical environments, payment, health systems, and regulatory levers. This paper discusses workforce challenges to team-based care and how best to train, prepare, and retool an equipped health workforce to meet the needs of team-based care.

The Accountable Care Workforce: Bridging the Health Divide in North Carolina.

Accountable care communities form as health care entities partner with communities to more fully address population health. This partnership requires an adaptable, boundary spanning, and diverse workforce, as well as flexible regulatory and governing structures that adapt to changing payment models, task shifting, and new roles in health care.

Varying Estimates of Social Workers in the United States: Which Data Source to Use?

Behavioral health needs continue rise in the United States and constitute a key driver of health care utilization, costs, and outcomes. Social workers provide a wide range of services across health, behavioral health, and community settings, and while this heterogeneity in practice benefits care delivery, it complicates health workforce analyses. This analysis compares five commonly used national data sources and details similarities and differences in their estimates of the number, type, and practice characteristics of social workers. The analysis suggests that estimates vary significantly between data sets ranging from 282,425 to 1,022,859 social workers; as well as yield different findings of types of social workers in the United States, depending on the data set used. These differences have the potential to shape how researchers and policy makers assess the adequacy of the social work workforce and identify solutions to address the nation's behavioral health and social care needs.

Behavioral Health Workforce Distribution in Socially Disadvantaged Communities.

This study sought to understand the geographic distribution of three behavioral health clinician (BHC) types in disadvantaged communities in the U.S. across a standardized index of area disadvantage. CMS National Plan and Provider Enumeration System's data were used to identify BHC practice addresses. Addresses were geocoded and mapped to census block groups across Area Disadvantage Index (ADI) scores. Differences in the proportion of BHCs per 100k people in a block group by ADI, clinician type, and rurality were compared. Zero-inflated negative binomial models assessed associations between ADI score with any amount, and expected count, of BHC type in a block group. The sample included 836,780 BHCs (51.5% counselors, 34.5% social workers, 14.0% psychologists). Results indicated there were fewer BHCs in areas of high disadvantage with 351 BHCs in the lowest need versus 267 BHCs in highest need areas, per 100k people. BHC type was differently associated with the rate of clinicians per 100k by ADI and block groups that were both rural and high ADI had the least BHCs located. Findings suggest the maldistribution of BHCs by ADI underscores how some BHCs may be better positioned to meet the needs of vulnerable communities. Increasing access to behavioral health care requires a workforce equitably positioned in high-need areas. Reforms to payment and practice regulations may support BHCs to deliver services in socially disadvantaged neighborhoods.

Preparing behavioral health clinicians for success and retention in rural safety net practices.

PURPOSE: This study assesses how, among behavioral health clinicians working in rural safety net practices, the amount of exposure to care in rural underserved communities received during training relates to confidence in skills important in their work settings, successes in jobs and communities, and anticipated retention. METHODS: This study uses survey data from Licensed Clinical Social Workers, Licensed Professional Counselors, and Psychologists working in rural safety net practices in 21 states while receiving educational loan repayment support from the National Health Service Corps, from 2015 to April 2022. FINDINGS: Of the 778 survey respondents working in rural counties, 486 (62.5%) reported they had formal education experiences with medically underserved populations during their professional training, for a median of 47 weeks. In analyses adjusting for potential confounders, the estimated amount of rural training exposure was positively associated with a variety of indicators of clinicians' integration and fit with their communities as well as with longer anticipated retention within their rural safety net practices. The amount of training in care for rural underserved populations was not associated with clinicians' confidence levels in various professional skills or successes in their work, including connection with patients and work satisfaction. CONCLUSIONS: Formal training in care for underserved populations is a large part of the education of behavioral health clinicians who later work in rural safety net practices. More training in rural underserved care for these clinicians is associated with greater integration and fit in their communities and longer anticipated retention in their practices, but not with skills confidence or practice outcomes.

When Interruption Becomes Innovation: How Integrated Behavioral Health in Primary Care Adapted During COVID-19.

BACKGROUND AND OBJECTIVES: Integrated behavioral health (IBH) delivered in primary care is critical to addressing the growing behavioral health crisis in the United States. COVID-19 prompted changes to the core components of IBH, causing the model to shift. The specifics of how IBH teams adapted and what these adaptations mean for the future of IBH teams in primary care are uncertain. METHODS: We conducted individual interviews with IBH team members using a semistructured interview guide. A purposive convenience sample consisted of primary care clinicians (N=20) from nine states. We used qualitative thematic analysis to code and generate themes. RESULTS: Four themes emerged: (a) permanent changes to the physical structure of the team; (b) increased reliance on technology for team communication; (c) shift in team collaboration, often occurring asynchronously; and (d) telehealth embraced for IBH. CONCLUSIONS: COVID-19 interrupted the originally designed IBH model of team-based care. Changes to the physical proximity of team members disrupted all other components of IBH, requiring adapted workflows, communication via digital channels, virtual team building, asynchronous care coordination, and remote service delivery. Long-term evaluation of these innovations is needed to examine whether shifts in core components impact model efficacy. Training family medicine, primary care, and behavioral health clinicians for these adapted models of IBH will be needed.

How would a certification in harm reduction impact service delivery and the harm reduction workforce? A qualitative study.

INTRODUCTION: Harm reduction utilizes evidence-based strategies to reduce the negative health and social impacts of substance use. As harm reduction services expand across the U.S. without the requirement of professional certification, variation in how the workforce is regarded and trained on harm reduction principles and practices persists. This study explores the harm reduction workforce's perspectives on how certification would impact service delivery and their profession. METHODS: The study employed purposive sampling to identify and survey administrators within a publicly available syringe services program directory (N = 168). This sub-study utilized thematic analysis to evaluate 152 respondents' answers to one dichotomous closed-ended question, "Would a certification in the harm reduction field be helpful?" followed by an open-ended response to the follow-up statement, "Based on your answer to the previous question about a certification to work in harm reduction, please explain why or why not." Approximately 45 % of the respondents (n = 68) answered no, while 55 % (n = 84) answered yes. RESULTS: Seven themes emerged in total. Among those against harm reduction certification, the four themes were: (1) certification is exclusionary and creates barriers, (2) lived experience is more important than certification, (3) certification does not equate to skills, and (4) no regulatory body exists to oversee the certification process. The study identified three themes from individuals who indicated harm reduction certification was helpful: (1) certification helps standardize training, (2) certification validates/legitimizes the harm reduction field, and (3) low barriers to receiving certificates. CONCLUSIONS: The study presents participants' perspectives for and against harm reduction certification emphasizing implications for service delivery and the workforce. Despite varying perceptions on how certification may advance or hinder the field, the sample was unified in their commitment to harm reduction practices and endorsement of its integral role in confronting the U.S. drug use epidemic. This study highlights how certification can impact state and federal harm reduction service delivery and promotes future research on ways to address the needs of harm reduction organizations and their workforce.