Interventions for Integrating Behavioral Health into HIV Settings for US Adults: A Narrative Review of Systematic Reviews and Meta-analyses, 2010-2020.

Mental health and substance use disorders can negatively affect physical health, illness management, care access, and quality of life. These behavioral health conditions are prevalent and undertreated among people with HIV and may worsen outcomes along the entire HIV Care Continuum. This narrative review of tested interventions for integrating care for HIV and behavioral health disorders summarizes and contextualizes findings from systematic reviews and meta-analyses conducted in the past decade. We sought to identify gaps in research that hinder implementing evidence-based integrated care approaches. Using terms from the Substance Abuse and Mental Health Services Administration-Health Resources & Services Administration standard framework for integrated health care, we searched PubMed and PsycInfo to identify peer-reviewed systematic reviews or meta-analyses of intervention studies to integrate behavioral health and HIV published between 2010 and 2020. Among 23 studies identified, only reviews and meta-analyses that described interventions from the United States designed to integrate BH services into HIV settings for adults were retained, leaving six studies for narrative review by the study team. Demonstrated benefits from the relatively small literature on integrated care interventions include improved patient- and service-level outcomes, particularly for in-person case management and outreach interventions. Needed are systems-level integration interventions with assessments of long-term outcomes on behavioral health symptoms, HIV viral suppression, HIV transmission rates, and mortality. HIV, primary care, and other providers must include behavioral health as a part of overall healthcare and must play a central role in behavioral health care delivery. Research is needed to guide their way.

A Qualitative Examination of Perceptions of Mindfulness Among Arab, Middle Eastern, and North African Americans: Implications for Cultural Adaptation of Mindfulness-Based Interventions.

Background: Mindfulness-based interventions (MBIs) are well-positioned to address health disparities among racial-ethnic minority communities, given their focus on stress reduction and potential for greater accessibility and acceptability than conventional mental health treatments. Yet, there are currently no peer-reviewed studies of MBIs in an Arab, Middle Eastern, or North African (MENA) American sample. Addressing this gap in the literature is critical for advancing integrative health equity, given the high burden of stress and high prevalence of stress-related health conditions among Arab/MENA Americans. Objective: The present study sought to explore perceptions of mindfulness among Arab/MENA Americans and identify potential cultural adaptations to MBIs for this population. Methods: 4 focus groups were conducted with 26 Arab/MENA American adults who had participated in an introductory mindfulness workshop. Participants were asked about their experience learning mindfulness skills, the usefulness of mindfulness for problems they face, the alignment of mindfulness with their cultural values and practices, and suggestions for adapting mindfulness programs. Qualitative coding of focus group session transcriptions was conducted to identify themes in the data. Conclusion: The participants in this study described experiencing high levels of stress and identified micro- and macro-level stressors related to their Arab/MENA American identity, including discrimination, exclusion, historical and intergenerational trauma, and protracted sociopolitical crises in their heritage countries. They viewed mindfulness as a potentially useful approach to coping with stress. At the same time, participants identified aspects of mindfulness that could be adjusted to better align with their cultural values and experiences. Potential adaptations to MBIs for Arab/MENA Americans were identified based on suggestions from participants and issues they raised while discussing cultural strengths, stressors they face, and perceived barriers and facilitators to engaging in mindfulness practice.

Integrated Care Model by the Village Health Volunteers to Prevent and Slow down Progression of Chronic Kidney Disease in a Rural Community, Thailand.

INTRODUCTION: Chronic kidney disease (CKD) is a major health problem in Thailand and health behaviors are central to its risk and progression. Because of the shortage of healthcare personnel, village health volunteers (VHVs) have been collaborating in the primary health care system. However, the contribution of VHVs to CKD reduction has not been evaluated yet. This study aimed to evaluate the efficacy of the VHV-integrated model in preventing and slowing down CKD and its risk factors. METHODS: The population-based cohort study was conducted in a rural community of Thailand between 2017 and 2019. Baseline clinical and behavioral characteristics including CKD, diabetes, hypertension, and other high-risk factors of the participants were collected. The integrated care model was initiated by the multidisciplinary care team that facilitated, empowered, and trained VHVs targeting risk factors of CKD, health literacy, and health promotion. Then the participants were educated and trained for lifestyle modification and were monitored continuously for 18 months by VHVs. Changes in the CKD risk factors, and kidney functions before and after the application of integrated care model were compared. RESULTS: A total of 831 subjects participated in the study with an average age of 57.5 years, and 69.5% were female. Among them, 222 participants (26.7%) were diagnosed as having CKD, the vast majority (95%) of which were in the early stages (G1-G3 and A1-A2). CKD risk factors such as high salt intake, smoking, alcohol consumption, self-NSAID (non-steroidal anti-inflammatory drugs) use were significantly decreased after application of the care model. Also, hemoglobin A1c was significantly reduced in diabetic patients, and blood pressure was controlled better than before in the hypertensive patients. Most importantly, a decline of estimated glomerular filtration rate of the CKD group was improved and lower than the non-CKD group. CONCLUSION: The integrated care model through VHV significantly attenuated the risk factors associated with CKD in the general and high-risk population and effectively slowed down the progression of CKD.

Board-Certified Psychiatric Pharmacists and Their Potential Role in Addressing Behavioral Health Workforce Shortages.

Board-certified psychiatric pharmacists (BCPPs) are doctorate-level, board-certified experts in managing medications for people living with psychiatric disorders, including substance use disorders. BCPPs work as part of an integrated health care team that provides comprehensive medication management focused on optimizing medication-related outcomes and ensuring the safety of the prescribed medications. The authors describe BCPP education and training, settings in which BCPPs practice, and in what roles. Current policies that limit BCPP involvement in behavioral health care and proposed solutions to support the role of BCPPs in addressing behavioral health workforce shortages are discussed.

Integrated Behavioral Health Adaptations During the COVID-19 Pandemic.

INTRODUCTION: COVID-19 pandemic lockdowns threatened standard components of integrated behavioral health (IBH) such as in-person communication across care teams, screening, and assessment. Restrictions also exacerbated pre-existing challenges to behavioral health (BH) access. METHODS: Semistructured interviews were completed with clinicians from family medicine residency programs on the impact of the pandemic on IBH care delivery along with adaptations employed by care teams to ameliorate disruption. RESULTS: Participants (n = 41) from 14 family medicine residency programs described the rapid shift to virtual care, creating challenges for IBH delivery and increased demand for BH services. With patients and care team members at home, virtual warm handoffs and increased attention to communication were necessary. Screening and measurement were more difficult, and referrals to appropriate services were challenging due to higher demand. Tele-BH facilitated continued access to BH services but was associated with logistic challenges. Participants described adaptations to stay connected with patients and care teams and discussed the need to increase capacity for both in-person and virtual care. DISCUSSION: Most practices modified their workflows to use tele-BH as COVID-19 cases increased. Participants shared key learnings for successful implementation of tele-BH that could be applied in future health care crises. CONCLUSION: Practices adapted readily to challenges posed by pandemic restrictions and their ability to sustain key elements of IBH during the COVID-19 pandemic demonstrates innovation in maintaining access when in-person care is not possible, informing strategies applicable to other scenarios.

Integrated Behavioral Health Implementation and Training in Primary Care: A Practice-Based Research Network Study.

INTRODUCTION: Integrating behavioral health services into primary care has a strong evidence base, but how primary care training programs incorporate integrated behavioral health (IBH) into care delivery and training has not been well described. The goal of this study was to evaluate factors related to successful IBH implementation in family medicine (FM) residency programs and assess perspectives and attitudes on IBH among program leaders. METHODS: FM residency programs, all which are required to provide IBH training, were recruited from the American Academy of Family Physicians National Research Network. After completing eligibility screening that included the Integrated Practice Assessment Tool (IPAT) questionnaire, 14 training programs were included. Selected practices identified 3 staff in key roles to be interviewed: medical director or similar, behavioral health professional (BHP), and chief medical officer or similar. RESULTS: Forty-one individuals from 14 FM training programs were interviewed. IPAT scores ranged from 4 (Close Collaboration Onsite) to 6 (Full Collaboration). Screening, outcome tracking, and treatment differed among and within practices. Use of curricula and trainee experience also varied with little standardization. Most participants described similar approaches to communication and collaboration between primary care clinicians and BHPs and believed that IBH should be standard practice. Participants reported space, staff, and billing support as critical for sustainability. CONCLUSIONS: Delivery and training experiences in IBH varied widely despite recognition of the value and benefits to patients and care delivery processes. Standardizing resources and training and simplifying and assuring reimbursement for services may promote sustainable and high quality IBH implementation.

Conceptualizing the Biopsychosocial-Spiritual Health Influences of Adverse Childhood Experiences and the Application of Primary Care Behavioral Health for Their Treatment.

Adverse Childhood Experiences (ACEs) are common and affect the overall functioning of adults, but there is a need to understand how to better address the health impact of ACEs on adults in primary healthcare settings. A narrative review was utilized to extract data from seminal articles to (1) operationalize the influence of ACEs on health outcomes, (2) assess the primary care behavioral health (PCBH) model as a mechanism to address the influence of ACEs, and (3) identify mechanisms to expand the PCBH model to explicitly address spiritual determinants of health. The extracted data revealed that ACEs influence the biological, psychological, social, and spiritual health of patients providing a rationale for integrating psychosocial and spiritual treatment within primary healthcare settings. Simultaneously, the PCBH model integrates psychosocial interventions into existing primary care services but does not explicitly address spiritual determinants. Recommendations for expansion include (1) training for clinicians on evidence-based interventions to address spirituality, (2) spiritual screening tools in PCBH settings, and (3) consultation with chaplains as needed.

Referral Patterns and Sociodemographic Predictors of Adult and Pediatric Behavioral Health Referrals in a Federally Qualified Health Center.

Federally Qualified Health Centers (FQHCs) provide comprehensive care to medically underserved populations whose access to behavioral health services may be limited. The goal of the current study was to examine referral patterns to specialty mental health and subsequent treatment initiation in an FQHC. In a 13-month period from March 2017 to March 2018, 1201 patients received a specialty mental healthcare referral. Of these patients, 37% reported scheduling an appointment with this referral, 44% refused the referral, 4% reported improvement in symptoms and not needing a referral, and 5% were not able to be reached due to a contact number being out of service. Common referral reasons among adults were depression, anxiety, and stress, and the most prevalent pediatric referral reasons were behavioral problems, depression, attention deficit hyperactivity disorder (ADHD), and anxiety. These data suggest that of the patients who received a specialty mental health referral, only one-third scheduled an appointment. The study also suggested that anxiety problems may be underrecognized in both adult and pediatric patients. Although significant attention has been put on increasing access to behavioral health services, there is still an unmet need. Universal mental health screening and increased coordination with specialty mental health providers in the community may better address this need.

Providing Behavioral Health Care in PACE - A Review of Federal and State Manual Regulations.

OBJECTIVES: Present analysis of the federal and state regulations that guide The Program of All-Inclusive Care for the Elderly (PACE) operations and core clinical features for direction on behavioral health (BH). DESIGN: Review and synthesize the federal (Centers for Medicare and Medicaid Services [CMS]) and all publicly available state manuals according to the BH-Serious Illness Care (SIC) model domains. SETTING AND PARTICIPANTS: The 155 PACE organizations operating in 32 states and the District of Columbia. METHODS: A multipronged search was conducted to identify official state and federal manuals guiding the implementation and functions of PACE organizations. The CMS PACE website was used to identify the federal PACE manual. State-level manuals for 32 states with PACE programs were identified through several sources, including official PACE websites, contacts through official websites, the National PACE Association (NPA), and public and academic search engines. The manuals were searched according to the BH-SIC model domains that pertain to integrating BH care with complex care individuals. RESULTS: According to the CMS Manual, the interdisciplinary team is responsible for holistic care of PACE enrollees, but a BH specialist is not a required member. The CMS Manual includes information on BH clinical functions, BH workforce, and structures for outcome measurement, quality, and accountability. Eight of 32 PACE-participating states offer publicly available state PACE manuals; of which 3 offer information on BH clinical functions. CONCLUSIONS AND IMPLICATIONS: Regarding BH, federal and state manual regulations establish limited guidance for comprehensive care service delivery at PACE organizations. The absence of clear directives weakens BH care delivery due to a limiting the ability to develop quality measures and accountability structures. This hinders incentivization and accountability to truly all-inclusive care. Clearer guidelines and regulatory parameters regarding BH care at federal and state levels may enable more PACE organizations to meet rising BH demands of aging communities.

Patient-Centered Care Through Nurse Practitioner-Led Integrated Behavioral Health: A Case Study.

Integrated behavioral health can improve primary care and mental health outcomes. Access to behavioral health and primary care services in Texas is in crisis because of high uninsurance rates, regulatory restrictions, and lack of workforce. To address gaps in access to care, a partnership formed among a large local mental health authority in central Texas, a federally designated rural health clinic, and the Texas A&M University School of Nursing to create an interprofessional team-based health care delivery model led by nurse practitioners in rural and medically underserved areas of central Texas. Academic-practice partners identified 5 clinics for an integrated behavioral health care delivery model. From July 1, 2020, through December 31, 2021, a total of 3183 patient visits were completed. Patients were predominantly female (n = 1719, 54%) and Hispanic (n = 1750, 55%); 1050 (33%) were living at or below the federal poverty level; and 1400 (44%) were uninsured. The purpose of this case study was to describe the first year of implementation of the integrated health care delivery model, barriers to implementation, challenges to sustainability, and successes. We analyzed data from multiple sources, including meeting minutes and agendas, grant reports, direct observations of clinic flow, and interviews with clinic staff, and identified common qualitative themes (eg, challenges to integration, sustainability of integration, outcome successes). Results revealed implementation challenges with the electronic health record, service integration, low staffing levels during a global pandemic, and effective communication. We also examined 2 patient cases to illustrate the success of integrated behavioral health and highlighted lessons learned from the implementation process, including the need for a robust electronic health record and organizational flexibility.

Integrated Primary Care and Health Behavior Support: A Survey of Behavioral Health Providers.

OBJECTIVES: Many behavioral health providers (BHPs) in primary care practices spend a majority of their time addressing mental health rather than behavior change. We wanted to better understand the practice of BHPs in integrated primary care. METHODS: Survey of BHPs from practices participating in the Colorado State Innovation Model (SIM) initiative. The survey measured what diagnoses BHPs receive referrals to treat, what they treat regardless of referral reason, which techniques they use, and think are most effective for mental health diagnoses and behavior change/weight management support, and their interest in providing support for weight management. Results were analyzed using descriptive statistics and Spearman correlations. RESULTS: We received 79 surveys representing 64 out of 248 SIM practices (practice response rate of 26%). BHPs reported addressing health-related behaviors with patients referred to them for mental health diagnoses. They expressed interest in health behavior and believed the techniques they use for traditional mental health diagnoses also support behavior change. Most reported using cognitive behavioral therapy (89%), mindfulness (94%), and relaxation/stress management (94%). Time in practice was associated with receiving more referrals for weight management (rho(76) = .271, P = .018) and with addressing diet (rho(75) = .339, P = .003) and weight management (rho(75) = .323, P = .005). BHPs in practices that had care managers were more likely to report receiving referrals for weight management than BHPs in practices that did not employ a case manager (rτ(76) = .222, P = .038); practices employing a health coach were more likely to receive referrals for physical activity than practices without a health coach (rτ(76) = .257, P = .015). CONCLUSIONS: BHPs are interested in and frequently address health related behavior. Formalizing health behavior services from BHPs in primary care may provide opportunities to better support patients with behavior change and subsequently improve health outcomes.

Safety of a prehospital emergency medical services protocol for an alternative destination for pediatric behavioral emergencies in Alameda County.

Background: Pediatric patients with behavioral health emergencies (BHEs) are often transported to an emergency department (ED) by emergency medical services (EMS), despite having no physical medical complaints, to await psychiatric evaluation and treatment. This process leads to significant delays in their care. We examined the safety of directly transporting pediatric patients with BHEs from the field to an alternative destination of a psychiatric emergency service (PES) facility using an EMS protocol. Methods: A retrospective review from November 1, 2011, to November 1, 2016, was conducted for pediatric EMS encounters using EMS data from Alameda County, California. Our primary outcome was the safety of a prehospital alternative destination protocol. We identified the proportion of patients who required retransport to an ED within 24 h after arriving at PES (defined as a failed diversion). We also describe the mortality of all patients being transported for a BHE. Results: There were 38,241 total pediatric encounters, with 20.1% for BHEs. A total of 3122 (41%) BHE encounters met protocol criteria and were transported directly to the PES. Only 16 (0.5%) patients had a secondary transport (failed diversion) to an ED within 24 h of arrival. No patients with a BHE transported to the PES died within 30 days of the EMS encounter. Conclusion: Death and adverse clinical outcomes are extremely rare in pediatric patients using a prehospital alternative destination protocol. This information could significantly improve the care of children with BHEs.

Effects of Virtual Care and Same-Day Access to Integrated Care on Specialty Mental Health Engagement in the Veterans Health Administration.

BACKGROUND: In the Veterans Health Administration (VA), Primary Care-Mental Health Integration (PC-MHI) clinics offer mental health services embedded in primary care, a strategy shown to reduce overall specialty mental health clinic burden while facilitating prompt referrals when indicated. Among newly initiated patients, same-day access to PC-MHI from primary care increases subsequent specialty mental health engagement. However, the impact of virtual care on the association between same-day access to PC-MHI and subsequent mental health engagement remains unclear. OBJECTIVE: To examine the effects of same-day access to PC-MHI and virtual care use on specialty mental health engagement. METHODS: We used administrative data from 3066 veterans who initiated mental health care at a large, California VA PC-MHI clinic during 3/1/2018 to 2/28/2022 and had no previous mental health visits for at least 2 years prior to the index appointment. We conducted Poisson regression analyses to examine the effects of same-day access to PC-MHI, virtual access to PC-MHI and their combined effect on subsequent specialty mental health engagement. RESULTS: Same-day access to PC-MHI from primary care was positively associated with specialty mental health engagement (IRR = 1.19; 95% CI 1.14-1.24). Virtual access to PC-MHI was negatively associated with specialty mental health engagement (IRR = 0.83; 95% CI 0.79-0.87). The positive effect of same-day access on specialty mental health engagement was smaller among patients who initiated PC-MHI in a virtual visit (IRR = 1.07) compared to in-person visits (IRR = 1.29; 95% CI 1.22-1.36). CONCLUSIONS: Although same-day access to PC-MHI increased overall specialty mental health engagement, the magnitude of this effect varied between in-person and virtual modalities. More research is needed to understand mechanisms of the association between virtual care use, same-day access to PC-MHI, and specialty mental health engagement.

Factors Associated with Implementing the Integrated Behavioral Health Care Model and Iraqi Refugees in the USA.

The aim was to identify which factors facilitate providing integrated behavioral health care for Iraqi refugees in nationally recognized community health center in Northern USA. The social-ecological model (SEM) framework guided this qualitative case study exploring the experience of 11 professional staff. Data were collected from June through August 2021 through individual interviews. Eight themes emerged based on the SEM levels: Intrapersonal-gender-driven engagement; interpersonal-the need for discretion and trusting relationship; community-collaboration with community resources and integrator from the community; organizational-holistic care, and long-term care; and policy-insufficient educational preparation. The results highlight components for clinical practice and policymakers regarding a population that is a big consumer of mental health care. Future research should explore other vulnerable populations, the effect of social groups, and the incorporation of community resources as part of the integrated care team.

Evaluating Occupant Light Exposure and Usage Patterns in an Inpatient Behavioral Health Unit.

OBJECTIVE: To (1) evaluate the use case for tunable lighting in inpatient behavioral health, (2) describe differences in staff lighting exposures between static and tunable lighting conditions using wearable sensors, and (3) document occupant lighting control usage patterns. BACKGROUND: Tunable lighting fixtures can vary the amount of light and spectral content, so have been offered as a way to address light and health considerations. Before we can understand potential health benefits of tunable lighting, it is helpful to understand how occupant exposures under tunable lighting differ from those under more traditional lighting systems. METHODS: Tunable lighting benefits and challenges for inpatient behavioral health were carefully detailed during design. Light exposure measurements were recorded at an old site with static fluorescent lighting and a new site with tunable light-emitting diode (LED) lighting. Behavioral health inpatient unit staff participants voluntarily wore a light measurement device to estimate light exposure. At the new site, controls usage data were recorded each time a button was pressed on a lighting control station. RESULTS: While general observations can be made about the data between sites, there is notable variation at both sites depending on the day and hour. Button press data revealed that occupants used the full capability of the tunable lighting system to support different activities and needs. CONCLUSION: Understanding the relationship between occupant well-being and light requires a holistic research approach including thoughtful design accounting for real-world constraints, detailed measurement of light exposure, and understanding how occupants interact and make use of new technology.

Everybody Copes: An Interprofessional Workshop on Stress, Coping, and Helping Primary Care Patients Manage Medical Stressors.

Introduction: The value of psychological principles has become apparent in medical settings, especially with the rise of patient-centered care. We aimed to provide a curriculum informing medical providers about the theoretical basis and clinical utility of the social-cognitive model of stress and coping. Methods: This workshop was delivered to an interprofessional team of faculty and trainees. Our initial pedagogical approach was to relate the concepts of cognitive appraisals and coping strategies to participants' own stress responses. We then used didactic presentation and small-group activities to explore ways to promote adaptive coping with patients to improve health outcomes. Learners participated in a mindfulness exercise, conceptualized coping strategies given a hypothetical case scenario, and, in small groups, role-played a patient encounter to construct an effective coping repertoire for the patient. Participants completed a prework self-assessment and workshop evaluation form. Results: The 2.5-hour workshop had 48 participants from five professions (medicine, education, physician assistant, pharmacology, psychology). We received 35 evaluations (73% response rate). Learners reported increased real-world skills (M = 8.0 out of 10) and feeling better prepared for working in interprofessional settings (M = 7.6 out of 10). Qualitative feedback suggested that participants recognized the importance of individual differences in coping with stress and felt they could categorize strategies into emotion- or problem-focused coping. Discussion: This workshop provided participants with basic knowledge about the social-cognitive model of stress and coping and allowed them to practice newly learned skills in a role-play as an interprofessional medical care team.

Associations between life-course household wealth mobility and adolescent physical growth, cognitive development and emotional and behavioral problems: A birth cohort in rural western China.

Background: Parental household wealth has been shown to be associated with offspring health conditions, while inconsistent associations were reported among generally healthy population especially in low- and middle- income countries (LMICs). Whether the household wealth upward mobility in LMICs would confer benefits to child health remains unknown. Methods: We conducted a prospective birth cohort of children born to mothers who participated in a randomized trial of antenatal micronutrient supplementation in rural western China. Household wealth were repeatedly assessed at pregnancy, mid-childhood and early adolescence using principal component analysis for household assets and dwelling characteristics. We used conditional gains and group-based trajectory modeling to assess the quantitative changes between two single-time points and relative mobility of household wealth over life-course, respectively. We performed generalized linear regressions to examine the associations of household wealth mobility indicators with adolescent height- (HAZ) and body mass index-for-age and sex z score (BAZ), scores of full-scale intelligent quotient (FSIQ) and emotional and behavioral problems. Results: A total of 1,188 adolescents were followed, among them 59.9% were male with a mean (SD) age of 11.7 (0.9) years old. Per SD conditional increase of household wealth z score from pregnancy to mid-childhood was associated with 0.11 (95% CI 0.04, 0.17) SD higher HAZ and 1.41 (95% CI 0.68, 2.13) points higher FSIQ at early adolescence. Adolescents from the household wealth Upward trajectory had a 0.25 (95% CI 0.03, 0.47) SD higher HAZ and 4.98 (95% CI 2.59, 7.38) points higher FSIQ than those in the Consistently low subgroup. Conclusion: Household wealth upward mobility particularly during early life has benefits on adolescent HAZ and cognitive development, which argues for government policies to implement social welfare programs to mitigate or reduce the consequences of early-life deprivations. Given the importance of household wealth in child health, it is recommended that socioeconomic circumstances should be routinely documented in the healthcare record in LMICs.

Prevalence and predictors of team-based care activities between primary care providers and embedded behavioral health providers: a national survey.

Primary care (PC) settings increasingly use team-based care activities with embedded behavioral health providers (BHPs) to enhance patient care via group medical visits, conjoint appointments, team huddles, and warm handoffs. Aim 1 was to describe the variation of team-based care activities within integrated PC clinics. Aim 2 was to explore whether factors associated with the BHP (e.g., gender, training, and experience) and the PC setting (e.g., perceived teamwork) predict engagement in team-based activities. A national sample of eligible BHPs (n = 345; 14.2% response rate) completed an anonymous survey assessing the presence/intensity of team-based care activities. 90% of BHPs reported regularly engaging in team-based care activities with PC teams. Most engagement occurred when providing feedback to PC providers (90.4% at least daily) and during warm handoffs (90.4% at least once daily). Engagement in team-based care was predicted by the level of teamwork occurring within the PC clinic (ßs = .41-.47; ps < .001) and BHP characteristics, such as the number of years spent in PC (ßs = .24-.26, ps < .001). Although these data are promising, with many BHPs reportedly engaging in team-based activities with PC teams, there is significant variation. Researchers should continue to explore whether the engagement in these team-based care activities enhances patient care.

Broad and Adaptive Integrated Health Psychology Services: Engaging BIPOC Veterans in VA Healthcare.

Clinical health psychologists provide adaptive, evidenced-based interventions that incorporate behavioral medicine and behavioral health strategies, with the potential to integrate broadly across the medical system. Veterans Affairs (VA) healthcare strives to meet the needs of an increasingly diverse patient population with complex behavioral health needs. This conceptual paper describes an example of health psychology at one VA healthcare system, with a focus on adaptive and culturally responsive services reaching Black, Indigenous and People of Color/Veterans of Color (BIPOC). The clinical health psychology services and cases described aim to reach Veterans who may not participate in, or benefit as fully from, traditional disease self-management or mental health services. The authors offer recommendations, to secure the value and sustainability of these integrated health psychology services, and hopefully contribute to addressing healthcare inequities.

Measuring Behavioral Health Integration in Primary Care.

Behavioral health integration (BHI) within primary care settings is shown to improve outcomes. However, achieving BHI requires identifying best practices and a reliable tool that can be used to measure existing levels and progress toward BHI. The objective of this study was to develop and apply a conceptual framework to measure BHI, test the approach, and examine challenges to achieving BHI. Surveys and interviews were conducted with key informants within 17 designated public hospitals in California at the midpoint of participating in a 5-year project to establish BHI. A framework and coding methodology were developed to assess BHI best practices at each hospital. BHI status was assessed in the domains of infrastructure and process. Each domain included 5 themes such as electronic health record integration and functionality (infrastructure) and interprovider communication (process). Themes were assessed using a 6-point scale for various activities under a theme and associated weights. Theme-specific values were standardized from 0% to 100% to compare BHI scores between hospitals. Overall progress toward BHI ranged from scores of 52% to 83% (mean 63%) and indicated greater contribution of infrastructure versus process implementation. Within the infrastructure domain, scores were higher for having institutional and provider support, but lagged in establishing provider proximity. Within the process domain, scores were highest for implementation of behavioral health screening, but were frequently lower for other themes such as use of care coordination and referral processes. Further research is needed to test the robustness of this approach in other settings.