Patient and Provider Perspectives on Processes of Engagement in Outpatient Treatment for Opioid Use Disorder: A Scoping Review.

Effective treatment for opioid use disorder (OUD) is available, but patient engagement is central to achieving care outcomes. We conducted a scoping review to describe patient and provider-reported strategies that may contribute to patient engagement in outpatient OUD care delivery. We searched PubMed and Scopus for articles reporting patient and/or provider experiences with outpatient OUD care delivery. Analysis included: (1) describing specific engagement strategies, (2) mapping strategies to patient-centered care domains, and (3) identifying themes that characterize the relationship between engagement and patient-centered care. Of 3,222 articles screened, 30 articles met inclusion criteria. Analysis identified 14 actionable strategies that facilitate patient engagement and map to all patient-centered care domains. Seven themes emerged that characterize interpersonal approaches to OUD care engagement. Interpersonal interactions between patients and providers play a pivotal role in encouraging engagement throughout OUD treatment. Future research is needed to further evaluate promising engagement strategies.

Integrating Routine Screening for Opioid Use Disorder into Primary Care Settings: Experiences from a National Cohort of Clinics.

BACKGROUND: The U.S. Preventive Services Task Force recommends routine population-based screening for drug use, yet screening for opioid use disorder (OUD) in primary care occurs rarely, and little is known about barriers primary care teams face. OBJECTIVE: As part of a multisite randomized trial to provide OUD and behavioral health treatment using the Collaborative Care Model, we supported 10 primary care clinics in implementing routine OUD screening and conducted formative evaluation to characterize early implementation experiences. DESIGN: Qualitative formative evaluation. APPROACH: Formative evaluation included taking detailed observation notes at implementation meetings with individual clinics and debriefings with external facilitators. Observation notes were analyzed weekly using a Rapid Assessment Process guided by the Consolidated Framework for Implementation Research, with iterative feedback from the study team. After clinics launched OUD screening, we conducted structured fidelity assessments via group interviews with each site to evaluate clinic experiences with routine OUD screening. Data from observation and structured fidelity assessments were combined into a matrix to compare across clinics and identify cross-cutting barriers and promising implementation strategies. KEY RESULTS: While all clinics had the goal of implementing population-based OUD screening, barriers were experienced across intervention, individual, and clinic setting domains, with compounding effects for telehealth visits. Seven themes emerged characterizing barriers, including (1) challenges identifying who to screen, (2) complexity of the screening tool, (3) staff discomfort and/or hesitancies, (4) workflow barriers that decreased screening follow-up, (5) staffing shortages and turnover, (6) discouragement from low screening yield, and (7) stigma. Promising implementation strategies included utilizing a more universal screening approach, health information technology (HIT), audit and feedback, and repeated staff trainings. CONCLUSIONS: Integrating population-based OUD screening in primary care is challenging but may be made feasible via implementation strategies and tailored practice facilitation that standardize workflows via HIT, decrease stigma, and increase staff confidence regarding OUD.

A qualitative study of strategies and challenges in training behavioral health workforce for integrated primary care.

Context: COVID-19 has underscored the need to accelerate behavioral health (BH) integration in primary care, where many patients seek mental health services. Expanding BH integration requires a strong and sustainable BH workforce trained to work in primary care. Psychology internship is a critical period of development when doctorate-level therapists receive supervised clinical experiences with integrated primary care. Objective: To explore the strategies and challenges of teaching psychology trainees to practice BH in primary care. Study design: Qualitative study. Setting: Nine out of 11 psychology internship and postdoctoral fellowship programs across the Washington State that provide integrated primary care training were recruited. Response rate was 82%. Population studied: Twelve training leads and supervisors completed semi-structured interviews between December 2020 - March 2021. Outcome measures: Interviews focused on participant experiences with providing educational training and supervision to psychology trainees practicing integrated primary care. Data were analyzed using grounded theory approach. Results: Four strategies emerged - orient trainees with extensive onboarding to the culture, context, and function of primary care; provide a psychologically safe space for open dialogues that facilitate professional identity development; model the skills needed to collaborate with primary care teams; and create a structured environment for trainees to practice the skills. Training leads and supervisors also reported three challenges - strategies to address trainees' difficulties with acculturating to the culture of primary care; loss of opportunities to shadow and interact with primary care providers due to telemedicine during COVID-19; and limitations of the traditional supervision structure to accommodate the unpredictable and urgent crises experienced by trainees in fast-paced primary care settings. Conclusion: Future recommendations include early exposure to primary care during psychology graduate training, a hybrid model of fixed and flexible supervision schedules, and intentional efforts to define and balance in-person and remote teaching for different types of training needs.

Implementing collaborative care to reduce depression for rural native American/Alaska native people.

BACKGROUND: The purpose of this study was to identify the effects of Collaborative Care on rural Native American and Alaska Native (AI/AN) patients. METHODS: Collaborative Care was implemented in three AI/AN serving clinics. Clinic staff participated in training and coaching designed to facilitate practice change. We followed clinics for 2 years to observe improvements in depression treatment and to examine treatment outcomes for enrolled patients. Collaborative Care elements included universal screening for depression, evidence-based treatment to target, use of behavioral health care managers to deliver the intervention, use of psychiatric consultants to provide caseload consultation, and quality improvement tracking to improve and maintain outcomes. We used t-tests to evaluate the main effects of Collaborative Care and used multiple linear regression to better understand the predictors of success. We also collected qualitative data from members of the Collaborative Care clinical team about their experience. RESULTS: The clinics participated in training and practice coaching to implement Collaborative Care for depressed patients. Depression response (50% or greater reduction in depression symptoms as measured by the PHQ-9) and remission (PHQ-9 score less than 5) rates were equivalent in AI/AN patients as compared with White patients in the same clinics. Significant predictors of positive treatment outcome include only one depression treatment episodes during the study and more follow-up visits per patient. Clinicians were overall positive about their experience and the effect on patient care in their clinic. CONCLUSIONS: This project showed that it is possible to deliver Collaborative Care to AI/AN patients via primary care settings in rural areas.

Early Health System Experiences with Collaborative Care (CoCM) Billing Codes: a Qualitative Study of Leadership and Support Staff.

BACKGROUND: Although collaborative care (CoCM) is an evidence-based and widely adopted model, reimbursement challenges have limited implementation efforts nationwide. In recent years, Medicare and other payers have activated CoCM-specific codes with the primary aim of facilitating financial sustainability. OBJECTIVE: To investigate and describe the experiences of early adopters and explorers of Medicare's CoCM codes. DESIGN AND PARTICIPANTS: Fifteen interviews were conducted between October 2017 and May 2018 with 25 respondents representing 12 health care organizations and 2 payers. Respondents included dually boarded medicine/psychiatry physicians, psychiatrists, primary care physicians (PCPs), psychologists, a registered nurse, administrative staff, and billing staff. APPROACH: A semi-structured interview guide was used to address health care organization characteristics, CoCM services, patient consent, CoCM operational components, and CoCM billing processes. All interviews were recorded, transcribed, coded, and analyzed using a content analysis approach conducted jointly by the research team. KEY RESULTS: Successful billing required buy-in from key, interdisciplinary stakeholders. In planning for CoCM billing implementation, several organizations hired licensed clinical social workers (LICSWs) as behavioral health care managers to maximize billing flexibility. Respondents reported a number of consent-related difficulties, but these were not primary barriers. Workflow changes required for billing the CoCM codes (e.g., tracking cumulative treatment minutes, once-monthly code entry) were described as arduous, but also stimulated creative solutions. Since CoCM codes incorporate the work of the psychiatric consultant into one payment to primary care, organizations employed strategies such as inter-departmental ledger transfers. When challenges arose from variations in the local payer mix, some organizations billed CoCM codes exclusively, while others elected to use a mixture of CoCM and traditional fee-for-service (FFS) codes. For most organizations, it was important to demonstrate financial sustainability from the CoCM codes. CONCLUSIONS: With deliberate planning, persistence, and widespread organizational buy-in, successful utilization of newly available FFS CoCM billing codes is achievable.

The experience of primary care providers with an integrated mental health care program in safety-net clinics.

Primary care providers participating in a statewide implementation of an integrated mental health care program for "safety-net" patients in primary care clinics were surveyed to elicit their experiences and level of satisfaction. Quantitative analyses were performed to identify respondent characteristics and satisfaction with the program. Qualitative analyses were done to identify common themes in response to the question "How could psychiatric consultation [in the program] be improved?" Primary care providers were generally satisfied with the integrated mental health care program and raised several concerns that suggest important principles for successful future implementations of these types of programs.

Perceived Educational Needs of the Integrated Care Psychiatric Consultant.

OBJECTIVE: With the increased implementation of models that integrate behavioral health with other medical care, there is a need for a workforce of integrated care providers, including psychiatrists, who are trained to deliver mental health care in new ways and meet the needs of a primary care population. However, little is known about the educational needs of psychiatrists in practice delivering integrated care to inform the development of integrated care training experiences. METHOD: The educational needs of the integrated care team were assessed by surveying psychiatric consultants who work in integrated care. RESULTS: A convenience sample of 52 psychiatrists working in integrated care responded to the survey. The majority of the topics included in the survey were considered educational priorities (>50% of the psychiatrists rated them as essential) for the psychiatric consultant role. Psychiatrists' perspectives on educational priorities for behavioral health providers (BHPs) and primary care providers (PCPs) were also identified. Almost all psychiatrists reported that they provide educational support for PCPs and BHPs (for PCP 92%; for BHP 96%). CONCLUSIONS: The information provided in this report suggests likely educational needs of the integrated care psychiatric consultant and provides insight into the learning needs of other integrated care team members. Defining clear priorities related to the three roles of the integrated care psychiatric consultant (clinical consultant, clinical educator, and clinical team leader) will be helpful to inform residency training programs to prepare psychiatrists for work in this emerging field of psychiatry.

Teaching psychiatry residents to work at the interface of mental health and primary care.

The authors present examples of programs educating psychiatry residents to work in integrated healthcare settings.

Behavioral Health Workforce Development in Washington State: Addition of a Behavioral Health Support Specialist.

The mental and behavioral health workforce shortage has hindered access to care in the United States, resulting in long waitlists for persons who need behavioral health care. Global models for task sharing, combined with U.S.-led studies of nonspecialists delivering interventions for depression and anxiety, support the development of this workforce in a stepped care system. This Open Forum highlights an innovative effort in Washington State to initiate a bachelor's-level behavioral health support specialist curriculum leading to credentialing to expand the mental health workforce and improve access to care for people with depression and anxiety.

Care managers' experiences in a collaborative care program for high risk mothers with depression.

OBJECTIVES: The aim of this study was to understand care managers' experiences in caring for depressed mothers in an integrated behavioral health program. METHODS: As part of a quality improvement project, we conducted a focus group interview with six care managers caring for low income mothers with behavioral health needs in a safety net program in King County, WA. Using thematic analysis, codes were organized into themes that described the care managers' experiences. RESULTS: Two organizing themes along with associated themes emerged: (1) Assets for improving depression outcomes: patient-provider interactions, including the importance of engagement; program resources such as care coordination and (2) Barriers to improved depression outcomes: patient-provider interactions, including difficulty engaging patient; patient-related factors such as multiple stressors; program resources such as need for more psychiatric support; and difficulty accessing outside resources. CONCLUSIONS: Numerous potentially modifiable factors including levels of engagement, motivational interviewing, and increased psychiatric support were identified by care managers as affecting depression care and outcomes. Implications for care management training and approaches to psychiatric consultations are discussed.

Training Health Care Professionals in Suicide Assessment, Management, and Treatment.

Washington was the first state to require all licensed general medical and behavioral health care professionals (HCPs) to complete training in suicide assessment, management, and treatment. Results from pretest and posttest surveys of 873 HCPs participating in All Patients Safe, a 6-hour online training course, are presented. Improvements in knowledge and attitudes about suicide and confidence in treating at-risk individuals were observed, demonstrating the effectiveness of delivering large-scale training to HCPs to fulfill state requirements. Future work should examine the impact of training on clinical practices and the role of training in improving patient care.

Task Sharing to Expand Access to Care: Development of a Behavioral Health Support Specialist.

Task sharing improves access to mental health care in many countries, but little formative research has examined uptake in the United States. This Open Forum proposes the development of nonspecialist professional roles to deliver low-intensity behavioral interventions for common mental health conditions in U.S. settings such as primary care. Using data from a multilevel stakeholder assessment, the authors discuss findings and challenges associated with such a role. Key themes from stakeholder surveys concerned scope of practice, competencies, pragmatic concerns, and training needs. Although stakeholders generally found this role to be acceptable and feasible, the themes raised will be critical to developing and implementing such a role.

Making It to Sustainability: Evaluating Billing Strategies for Collaborative Care.

The collaborative care model (CoCM) is an effective strategy to manage common mental disorders in primary care. Despite the growing adoption of newer CoCM billing codes to support these programs, few studies have investigated the use of these codes. This column evaluated the implementation of CoCM billing codes by comparing clinics using different billing strategies and assessed the impact of CoCM code implementation on revenue and on clinical and process-of-care outcomes. Qualitative data were obtained to understand provider perspectives. The results indicate that CoCM billing code implementation is operationally feasible, does not adversely affect the delivery of patient care or revenue, and is acceptable to providers.

Integrating Opioid Use Disorder Treatment Into Primary Care Settings.

Importance: Medication for opioid use disorder (MOUD) (eg, buprenorphine and naltrexone) can be offered in primary care, but barriers to implementation exist. Objective: To evaluate an implementation intervention over 2 years to explore experiences and perspectives of multidisciplinary primary care (PC) teams initiating or expanding MOUD. Design, Setting, and Participants: This survey-based and ethnographic qualitative study was conducted at 12 geographically and structurally diverse primary care clinics that enrolled in a hybrid effectiveness-implementation study from July 2020 to July 2022 and included PC teams (prescribing clinicians, nonprescribing behavioral health care managers, and consulting psychiatrists). Survey data analysis was conducted from February to April 2022. Exposure: Implementation intervention (external practice facilitation) to integrate OUD treatment alongside existing collaborative care for mental health services. Measures: Data included (1) quantitative surveys of primary care teams that were analyzed descriptively and triangulated with qualitative results and (2) qualitative field notes from ethnographic observation of clinic implementation meetings analyzed using rapid assessment methods. Results: Sixty-two primary care team members completed the survey (41 female individuals [66%]; 1 [2%] American Indian or Alaskan Native, 4 [7%] Asian, 5 [8%] Black or African American, 5 [8%] Hispanic or Latino, 1 [2%] Native Hawaiian or Other Pacific Islander, and 46 [4%] White individuals), of whom 37 (60%) were between age 25 and 44 years. An analysis of implementation meetings (n = 362) and survey data identified 4 themes describing multilevel factors associated with PC team provision of MOUD during implementation, with variation in their experience across clinics. Themes characterized challenges with clinical administrative logistics that limited the capacity to provide rapid access to care and patient engagement as well as clinician confidence to discuss aspects of MOUD care with patients. These challenges were associated with conflicting attitudes among PC teams toward expanding MOUD care. Conclusions and Relevance: The results of this survey and qualitative study of PC team perspectives suggest that PC teams need flexibility in appointment scheduling and the capacity to effectively engage patients with OUD as well as ongoing training to maintain clinician confidence in the face of evolving opioid-related clinical issues. Future work should address structural challenges associated with workload burden and limited schedule flexibility that hinder MOUD expansion in PC settings.