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6.
J Am Board Fam Med ; 28 Suppl 1: S102-6, 2015.
Artículo en Inglés | MEDLINE | ID: mdl-26359467

RESUMEN

The articles in this supplement contain a wealth of practical information regarding the integration of behavioral health and primary care. This type of integration effort is complex and greatly benefits from support from outside organizations, as well as collaboration with other practices attempting similar work. This editorial extracts from these articles some of the key lessons learned regarding the integration of behavioral health and primary care for practices and for organizations that support practice transformation.


Asunto(s)
Servicios Comunitarios de Salud Mental/organización & administración , Prestación Integrada de Atención de Salud/organización & administración , Administración de la Práctica Médica/organización & administración , Atención Primaria de Salud/organización & administración , Registros Electrónicos de Salud , Humanos , Capacitación en Servicio , Trastornos Mentales/terapia , Grupo de Atención al Paciente , Mejoramiento de la Calidad , Calidad de la Atención de Salud , Derivación y Consulta/organización & administración , Estados Unidos
8.
J Am Board Fam Med ; 28 Suppl 1: S32-40, 2015.
Artículo en Inglés | MEDLINE | ID: mdl-26359470

RESUMEN

PURPOSE: To examine the interrelationship among behavioral health clinician (BHC) staffing, scheduling, and a primary care practice's approach to delivering integrated care. METHODS: Observational cross-case comparative analysis of 17 primary care practices in the United States focused on implementation of integrated care. Practices varied in size, ownership, geographic location, and integrated care experience. A multidisciplinary team analyzed documents, practice surveys, field notes from observation visits, implementation diaries, and semistructured interviews using a grounded theory approach. RESULTS: Across the 17 practices, staffing ratios ranged from 1 BHC covering 0.3 to 36.5 primary care clinicians (PCCs). BHC scheduling varied from 50-minute prescheduled appointments to open, flexible schedules slotted in 15-minute increments. However, staffing and scheduling patterns generally clustered in 2 ways and enabled BHCs to be engaged by referral or warm handoff. Five practices predominantly used warm handoffs to engage BHCs and had higher BHC-to-PCC staffing ratios; multiple BHCs on staff; and shorter, more flexible BHC appointment schedules. Staffing and scheduling structures that enabled warm handoffs supported BHC engagement with patients concurrent with the identification of behavioral health needs. Twelve practices primarily used referrals to engage BHCs and had lower BHC-to-PCC staffing ratios and BHC schedules prefilled with visits. This enabled some BHCs to bill for services, but also made them less accessible to PCCs in when patients presented with behavioral health needs during a clinical encounter. Three of these practices were experimenting with open scheduling and briefer BHC visits to enable real-time access while managing resources. CONCLUSION: Practices' approaches to PCC-BHC staffing, scheduling, and delivery of integrated care mutually influenced each other and were shaped by the local context. Practice leaders, educators, clinicians, funders, researchers, and policy makers must consider these factors as they seek to optimize integrated systems of care.


Asunto(s)
Servicios Comunitarios de Salud Mental/organización & administración , Prestación Integrada de Atención de Salud/organización & administración , Trastornos Mentales/terapia , Admisión y Programación de Personal/organización & administración , Administración de la Práctica Médica/organización & administración , Atención Primaria de Salud/organización & administración , Estudios Transversales , Teoría Fundamentada , Humanos , Derivación y Consulta , Estados Unidos
9.
J Am Board Fam Med ; 28 Suppl 1: S41-51, 2015.
Artículo en Inglés | MEDLINE | ID: mdl-26359471

RESUMEN

PURPOSE: To identify how organizations prepare clinicians to work together to integrate behavioral health and primary care. METHODS: Observational cross-case comparison study of 19 U.S. practices, 11 participating in Advancing Care Together, and 8 from the Integration Workforce Study. Practices varied in size, ownership, geographic location, and experience delivering integrated care. Multidisciplinary teams collected data (field notes from direct practice observations, semistructured interviews, and online diaries as reported by practice leaders) and then analyzed the data using a grounded theory approach. RESULTS: Organizations had difficulty finding clinicians possessing the skills and experience necessary for working in an integrated practice. Practices newer to integration underestimated the time and resources needed to train and organizationally socialize (onboard) new clinicians. Through trial and error, practices learned that clinicians needed relevant training to work effectively as integrated care teams. Training efforts exclusively targeting behavioral health clinicians (BHCs) and new employees were incomplete if primary care clinicians (PCCs) and others in the practice also lacked experience working with BHCs and delivering integrated care. Organizations' methods for addressing employees' need for additional preparation included hiring a consultant to provide training, sending employees to external training programs, hosting residency or practicum training programs, or creating their own internal training program. Onboarding new employees through the development of training manuals; extensive shadowing processes; and protecting time for ongoing education, mentoring, and support opportunities for new and established clinicians and staff were featured in these internal training programs. CONCLUSION: Insufficient training capacity and practical experience opportunities continue to be major barriers to supplying the workforce needed for effective behavioral health and primary care integration. Until the training capacity grows to meet the demand, practices must put forth considerable effort and resources to train their own employees.


Asunto(s)
Servicios Comunitarios de Salud Mental/organización & administración , Prestación Integrada de Atención de Salud/organización & administración , Capacitación en Servicio/organización & administración , Evaluación de Necesidades , Administración de la Práctica Médica/organización & administración , Atención Primaria de Salud/organización & administración , Humanos , Trastornos Mentales/terapia , Selección de Personal , Estados Unidos
10.
J Am Board Fam Med ; 28 Suppl 1: S21-31, 2015.
Artículo en Inglés | MEDLINE | ID: mdl-26359469

RESUMEN

PURPOSE: This paper sought to describe how clinicians from different backgrounds interact to deliver integrated behavioral and primary health care, and the contextual factors that shape such interactions. METHODS: This was a comparative case study in which a multidisciplinary team used an immersion-crystallization approach to analyze data from observations of practice operations, interviews with practice members, and implementation diaries. The observed practices were drawn from 2 studies: Advancing Care Together, a demonstration project of 11 practices located in Colorado; and the Integration Workforce Study, consisting of 8 practices located across the United States. RESULTS: Primary care and behavioral health clinicians used 3 interpersonal strategies to work together in integrated settings: consulting, coordinating, and collaborating (3Cs). Consulting occurred when clinicians sought advice, validated care plans, or corroborated perceptions of a patient's needs with another professional. Coordinating involved 2 professionals working in a parallel or in a back-and-forth fashion to achieve a common patient care goal, while delivering care separately. Collaborating involved 2 or more professionals interacting in real time to discuss a patient's presenting symptoms, describe their views on treatment, and jointly develop a care plan. Collaborative behavior emerged when a patient's care or situation was complex or novel. We identified contextual factors shaping use of the 3Cs, including: time to plan patient care, staffing, employing brief therapeutic approaches, proximity of clinical team members, and electronic health record documenting behavior. CONCLUSION: Primary care and behavioral health clinicians, through their interactions, consult, coordinate, and collaborate with each other to solve patients' problems. Organizations can create integrated care environments that support these collaborations and health professions training programs should equip clinicians to execute all 3Cs routinely in practice.


Asunto(s)
Servicios Comunitarios de Salud Mental/organización & administración , Prestación Integrada de Atención de Salud/organización & administración , Trastornos Mentales/terapia , Administración de la Práctica Médica/organización & administración , Atención Primaria de Salud/organización & administración , Toma de Decisiones Clínicas , Conducta Cooperativa , Estudios Transversales , Humanos , Estudios Longitudinales , Grupo de Atención al Paciente/organización & administración , Derivación y Consulta/organización & administración , Estados Unidos
11.
J Am Board Fam Med ; 28 Suppl 1: S52-62, 2015.
Artículo en Inglés | MEDLINE | ID: mdl-26359472

RESUMEN

PURPOSE: This study sought to describe features of the physical space in which practices integrating primary care and behavioral health care work and to identify the arrangements that enable integration of care. METHODS: We conducted an observational study of 19 diverse practices located across the United States. Practice-level data included field notes from 2-4-day site visits, transcripts from semistructured interviews with clinicians and clinical staff, online implementation diary posts, and facility photographs. A multidisciplinary team used a 4-stage, systematic approach to analyze data and identify how physical layout enabled the work of integrated care teams. RESULTS: Two dominant spatial layouts emerged across practices: type-1 layouts were characterized by having primary care clinicians (PCCs) and behavioral health clinicians (BHCs) located in separate work areas, and type-2 layouts had BHCs and PCCs sharing work space. We describe these layouts and the influence they have on situational awareness, interprofessional "bumpability," and opportunities for on-the-fly communication. We observed BHCs and PCCs engaging in more face-to-face methods for coordinating integrated care for patients in type 2 layouts (41.5% of observed encounters vs 11.7%; P < .05). We show that practices needed to strike a balance between professional proximity and private work areas to accomplish job tasks. Private workspace was needed for focused work, to see patients, and for consults between clinicians and clinical staff. We describe the ways practices modified and built new space and provide 2 recommended layouts for practices integrating care based on study findings. CONCLUSION: Physical layout and positioning of professionals' workspace is an important consideration in practices implementing integrated care. Clinicians, researchers, and health-care administrators are encouraged to consider the role of professional proximity and private working space when creating new facilities or redesigning existing space to foster delivery of integrated behavioral health and primary care.


Asunto(s)
Servicios Comunitarios de Salud Mental/organización & administración , Prestación Integrada de Atención de Salud/organización & administración , Arquitectura y Construcción de Instituciones de Salud/métodos , Administración de la Práctica Médica/organización & administración , Atención Primaria de Salud/organización & administración , Humanos , Trastornos Mentales/terapia , Estados Unidos
12.
J Am Board Fam Med ; 28 Suppl 1: S63-72, 2015.
Artículo en Inglés | MEDLINE | ID: mdl-26359473

RESUMEN

PURPOSE: This article describes the electronic health record (EHR)-related experiences of practices striving to integrate behavioral health and primary care using tailored, evidenced-based strategies from 2012 to 2014; and the challenges, workarounds and initial health information technology (HIT) solutions that emerged during implementation. METHODS: This was an observational, cross-case comparative study of 11 diverse practices, including 8 primary care clinics and 3 community mental health centers focused on the implementation of integrated care. Practice characteristics (eg, practice ownership, federal designation, geographic area, provider composition, EHR system, and patient panel characteristics) were collected using a practice information survey and analyzed to report descriptive information. A multidisciplinary team used a grounded theory approach to analyze program documents, field notes from practice observation visits, online diaries, and semistructured interviews. RESULTS: Eight primary care practices used a single EHR and 3 practices used 2 different EHRs, 1 to document behavioral health and 1 to document primary care information. Practices experienced common challenges with their EHRs' capabilities to 1) document and track relevant behavioral health and physical health information, 2) support communication and coordination of care among integrated teams, and 3) exchange information with tablet devices and other EHRs. Practices developed workarounds in response to these challenges: double documentation and duplicate data entry, scanning and transporting documents, reliance on patient or clinician recall for inaccessible EHR information, and use of freestanding tracking systems. As practices gained experience with integration, they began to move beyond workarounds to more permanent HIT solutions ranging in complexity from customized EHR templates, EHR upgrades, and unified EHRs. CONCLUSION: Integrating behavioral health and primary care further burdens EHRs. Vendors, in cooperation with clinicians, should intentionally design EHR products that support integrated care delivery functions, such as data documentation and reporting to support tracking patients with emotional and behavioral problems over time and settings, integrated teams working from shared care plans, template-driven documentation for common behavioral health conditions such as depression, and improved registry functionality and interoperability. This work will require financial support and cooperative efforts among clinicians, EHR vendors, practice assistance organizations, regulators, standards setters, and workforce educators.


Asunto(s)
Servicios Comunitarios de Salud Mental/organización & administración , Prestación Integrada de Atención de Salud/organización & administración , Registros Electrónicos de Salud/organización & administración , Administración de la Práctica Médica/organización & administración , Atención Primaria de Salud/organización & administración , Documentación/métodos , Humanos , Trastornos Mentales/terapia , Estados Unidos
13.
J Am Board Fam Med ; 28 Suppl 1: S7-20, 2015.
Artículo en Inglés | MEDLINE | ID: mdl-26359474

RESUMEN

PURPOSE: To provide empirical evidence on key organizing constructs shaping practical, real-world integration of behavior health and primary care to comprehensively address patients' medical, emotional, and behavioral health needs. METHODS: In a comparative case study using an immersion-crystallization approach, a multidisciplinary team analyzed data from observations of practice operations, interviews, and surveys of practice members, and implementation diaries. Practices were drawn from 2 studies of practices attempting to integrate behavioral health and primary care: Advancing Care Together, a demonstration project of 11 practices located in Colorado, and the Integration Workforce Study, a study of 8 practices across the United States. RESULTS: We identified 5 key organizing constructs influencing integration of primary care and behavioral health: 1) Integration REACH (the extent to which the integration program was delivered to the identified target population), 2) establishment of continuum of care pathways addressing the location of care across the range of patient's severity of illness, 3) approach to patient transitions: referrals or warm handoffs, 4) location of the integration workforce, and 5) participants' mental model for integration. These constructs intertwine within an organization's historic and social context to produce locally adapted approaches to integrating care. Contextual factors, particularly practice type, influenced whether specialty mental health and substance use services were colocated within an organization. CONCLUSION: Interaction among 5 organizing constructs and practice context produces diverse expressions of integrated care. These constructs provide a framework for understanding how primary care and behavioral health services can be integrated in routine practice.


Asunto(s)
Servicios Comunitarios de Salud Mental/organización & administración , Prestación Integrada de Atención de Salud/organización & administración , Trastornos Mentales/terapia , Administración de la Práctica Médica/organización & administración , Atención Primaria de Salud/organización & administración , Centros Comunitarios de Salud Mental , Vías Clínicas , Estudios Transversales , Humanos , Estudios Longitudinales , Derivación y Consulta , Estados Unidos
14.
J Am Board Fam Med ; 28 Suppl 1: S73-85, 2015.
Artículo en Inglés | MEDLINE | ID: mdl-26359475

RESUMEN

PURPOSE: This study reports REACH (the extent to which an intervention or program was delivered to the identified target population) of interventions integrating primary care and behavioral health implemented by real-world practices. METHODS: Eleven practices implementing integrated care interventions provided data to calculate REACH as follows: 1) Screening REACH defined as proportion of target patients assessed for integrated care, and 2) Integrated care services REACH-defined as proportion of patients receiving integrated services of those who met specific criteria. Difference in mean REACH between practices was evaluated using t test. RESULTS: Overall, 26.2% of target patients (n = 24,906) were assessed for integrated care and 41% (n = 836) of eligible patients received integration services. Practices that implemented systematic protocols to identify patients needing integrated care had a significantly higher screening REACH (mean, 70%; 95% CI [confidence interval], 46.6-93.4%) compared with practices that used clinicians' discretion (mean, 7.9%; 95% CI, 0.6-15.1; P = .0014). Integrated care services REACH was higher among practices that used clinicians' discretion compared with those that assessed patients systematically (mean, 95.8 vs 53.8%; P = .03). CONCLUSION: REACH of integrated care interventions differed by practices' method of assessing patients. Measuring REACH is important to evaluate the extent to which integration efforts affect patient care and can help demonstrate the impact of integrated care to payers and policy makers.


Asunto(s)
Servicios Comunitarios de Salud Mental/estadística & datos numéricos , Prestación Integrada de Atención de Salud/estadística & datos numéricos , Atención Primaria de Salud/estadística & datos numéricos , Servicios Comunitarios de Salud Mental/organización & administración , Prestación Integrada de Atención de Salud/organización & administración , Femenino , Humanos , Masculino , Trastornos Mentales/terapia , Administración de la Práctica Médica/organización & administración , Administración de la Práctica Médica/estadística & datos numéricos , Atención Primaria de Salud/organización & administración , Evaluación de Programas y Proyectos de Salud , Estados Unidos
15.
J Am Board Fam Med ; 28 Suppl 1: S86-97, 2015.
Artículo en Inglés | MEDLINE | ID: mdl-26359476

RESUMEN

PURPOSE: Provide credible estimates of the start-up and ongoing effort and incremental practice expenses for the Advancing Care Together (ACT) behavioral health and primary care integration interventions. METHODS: Expenditure data were collected from 10 practice intervention sites using an instrument with a standardized general format that could accommodate the unique elements of each intervention. RESULTS: Average start-up effort expenses were $44,076 and monthly ongoing effort expenses per patient were $40.39. Incremental expenses averaged $20,788 for start-up and $4.58 per patient for monthly ongoing activities. Variations in expenditures across practices reflect the differences in intervention specifics and organizational settings. Differences in effort to incremental expenditures reflect the extensive use of existing resources in implementing the interventions. CONCLUSIONS: ACT program incremental expenses suggest that widespread adoption would likely have a relatively modest effect on overall health systems expenditures. Practice effort expenses are not trivial and may pose barriers to adoption. Payers and purchasers interested in attaining widespread adoption of integrated care must consider external support to practices that accounts for both incremental and effort expense levels. Existing knowledge transfer mechanisms should be employed to minimize developmental start-up expenses and payment reform focused toward value-based, Triple Aim-oriented reimbursement and purchasing mechanisms are likely needed.


Asunto(s)
Servicios Comunitarios de Salud Mental/economía , Prestación Integrada de Atención de Salud/economía , Administración de la Práctica Médica/economía , Atención Primaria de Salud/economía , Colorado , Servicios Comunitarios de Salud Mental/organización & administración , Prestación Integrada de Atención de Salud/organización & administración , Gastos en Salud , Humanos , Trastornos Mentales/terapia , Administración de la Práctica Médica/organización & administración , Atención Primaria de Salud/organización & administración
16.
Med Care ; 52(11 Suppl 4): S39-47, 2014 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-25310637

RESUMEN

BACKGROUND: Integrated care focuses on care coordination and patient centeredness. Integrated care supports continuity of care over time, with care that is coordinated within and between settings and is responsive to patients' needs. Currently, little is known about care integration for rural patients. OBJECTIVE: To examine challenges to care integration in rural safety net clinics and strategies to address these challenges. RESEARCH DESIGN: Qualitative case study. PARTICIPANTS: Thirty-six providers and staff from 3 rural clinics in the Safety Net Medical Home Initiative. METHODS: Interviews were analyzed using the framework method with themes organized within 3 constructs: Team Coordination and Empanelment, External Coordination and Partnerships, and Patient-centered and Community-centered Care. RESULTS: Participants described challenges common to safety net clinics, including limited access to specialists for Medicaid and uninsured patients, difficulty communicating with external providers, and payment models with limited support for care integration activities. Rurality compounded these challenges. Respondents reported benefits of empanelment and team-based care, and leveraged local resources to support care for patients. Rural clinics diversified roles within teams, shared responsibility for patient care, and colocated providers, as strategies to support care integration. CONCLUSIONS: Care integration was supported by 2 fundamental changes to organize and deliver care to patients-(1) empanelment with a designated group of patients being cared for by a provider; and (2) a multidisciplinary team able to address rural issues. New funding and organizational initiatives of the Affordable Care Act may help to further improve care integration, although additional solutions may be necessary to address particular needs of rural communities.


Asunto(s)
Prestación Integrada de Atención de Salud/organización & administración , Grupo de Atención al Paciente/organización & administración , Atención Dirigida al Paciente/organización & administración , Administración de la Práctica Médica/organización & administración , Servicios de Salud Rural/organización & administración , Proveedores de Redes de Seguridad/organización & administración , Colorado , Investigación sobre Servicios de Salud , Humanos , Oregon , Estudios de Casos Organizacionales , Desarrollo de Programa , Evaluación de Programas y Proyectos de Salud , Investigación Cualitativa
19.
Zhongguo Zhen Jiu ; 34(2): 179-82, 2014 Feb.
Artículo en Chino | MEDLINE | ID: mdl-24796062

RESUMEN

The standardized management of acupuncture-moxibustion in Singapore General Hospital is introduced. With gradual improvement of outpatient infrastructure, re-training of medical staff, strict disinfection of manipulation, periodical inspection of medical instruments, unified management of writing, saving and processing in medical records and public education of TCM knowledge, a standardized management system in accordance with modernized hospital is gradually established. As a result, efficiency and quality of clinical treatment is continuously increasing. From April of 1998 to December of 2012, a total of 74 654 times of treatment were performed, and treatment amount per day is gradually increased. The unusual condition of acupuncture is avoided. Periodical strict inspection of joint committee authenticated by domestic and overseas medical health organization is repeatedly passed and accepted. Additionally, three clinical researches funded by Singapore Health-care Company are still in progress in acupuncture-moxibustion department.


Asunto(s)
Terapia por Acupuntura/normas , Hospitales Generales/normas , Moxibustión/normas , Administración de la Práctica Médica/normas , Hospitales Generales/organización & administración , Humanos , Administración de la Práctica Médica/organización & administración , Estándares de Referencia , Singapur , Recursos Humanos
20.
J Allergy Clin Immunol Pract ; 2(1): 34-9, 2014.
Artículo en Inglés | MEDLINE | ID: mdl-24565766

RESUMEN

For decades, health care policy experts have wrestled with ways to solve problems of access, cost, and quality in US health care. The current consensus is that the solution to all three lies in changing financial incentives for providers and delivering care through integrated systems. The currently favored vehicle for this, both in the public and private sectors, is through Accountable Care Organizations (ACOs). Medicare has several models and has fostered rapid growth in the number of operative ACOs. At least an equal number of private ACOs are in operation. Whether or not these organizations will fulfill their promise is unknown but there is reason for cautious optimism. Allergists can and should be part of the process of this transformation in our health care system. They can be integral to helping these organizations save money by reducing hospitalizations and improving the quality of allergy and asthma care in the populations served. In order to accomplish this, allergists must become more involved in their medical communities and hospitals.


Asunto(s)
Organizaciones Responsables por la Atención/organización & administración , Alergia e Inmunología/organización & administración , Reforma de la Atención de Salud/organización & administración , Administración de la Práctica Médica/organización & administración , Organizaciones Responsables por la Atención/economía , Organizaciones Responsables por la Atención/legislación & jurisprudencia , Alergia e Inmunología/economía , Alergia e Inmunología/legislación & jurisprudencia , Prestación Integrada de Atención de Salud/organización & administración , Planes de Aranceles por Servicios/organización & administración , Costos de la Atención en Salud , Reforma de la Atención de Salud/economía , Reforma de la Atención de Salud/legislación & jurisprudencia , Gastos en Salud , Accesibilidad a los Servicios de Salud/organización & administración , Humanos , Asociaciones de Práctica Independiente/organización & administración , Medicaid/organización & administración , Medicare/organización & administración , Modelos Organizacionales , Objetivos Organizacionales , Paquetes de Atención al Paciente , Patient Protection and Affordable Care Act/organización & administración , Atención Dirigida al Paciente/organización & administración , Administración de la Práctica Médica/economía , Administración de la Práctica Médica/legislación & jurisprudencia , Calidad de la Atención de Salud/organización & administración , Estados Unidos
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