Cost Analysis of Integrated Behavioral Health in a Large Primary Care Practice.

A residency-based Family Medicine outpatient clinic chose to implement an integrated behavioral health care program in a large primary care clinic in the Southeast to improve patient access to behavioral health care. We hypothesized that embedding a BHP in a primary care setting would be a cost neutral intervention. We implemented a prospective cohort design and included expenses from both inpatient and outpatient visits. We implemented a mixed effects linear regression model to evaluate pre- and post-BHP exposure costs. A total of 1256 patients were identified in the post-BHP exposure period that had more than one-year post-exposure. After applying exclusion criteria, there were 926 patients included in analysis. These patient had an average total cost during the one-year pre-BHP exposure period of $5113 (SD = 7712) and one-year post-BHP exposure period of $5462 (SD = 7813). Our analysis shows a relatively cost neutral impact following the introduction of BHPs in a primary care setting. The results of this study provide a gauge for future planning of services.

Opioid Use Disorder and Assessment of Patient Interactions Among Family Medicine Residents, Medical Students, and Physician Assistant Students.

Introduction: In light of the opioid overdose epidemic in the US and the necessity of developing training to conduct difficult conversations around opioid dependence, three case-based videos were created to demonstrate providers using motivational interviewing (MI) with patients who have opioid use disorder (OUD). These vignettes displayed a primary care provider interacting with a patient seeking opioids. Methods: Learners-including third-year medical and physician assistant (PA) students, and family medicine residents-viewed three videos set in a family medicine clinic and assessed clinician use of MI when interacting with patients with OUD. The patients were at different levels of acknowledging their need to change their opioid use behaviors and/or pursue treatment. Learners rated each video with an MI rating scale, and a facilitator debriefed strengths, weaknesses, and omissions regarding MI. Results: Medical and PA students, and resident family physicians provided 572 ratings. Analysis of variance of mean percent incorrect was lower in residents than in all groups combined, but failed to reach statistical significance (47% + 12.0 vs 53% + 15.0, p = .43). Discussion: These case-based videos with MI ratings afforded students and residents the opportunity to assess clinician use of MI techniques with patients with OUD. The MI rating scale had clinical significance (residents scored +5 points and had more training) despite lacking statistical significance. These scenarios allowed learners to recognize how to use MI when having a difficult conversation with patients who misuse opioids. We envision individual use or use for group discussion.

Patient Views of Behavioral Health Providers in Primary Care: A Qualitative Study of 2 Southeastern Clinics.

BACKGROUND: Limited research is available around patient experience of integrated behavioral health care in primary care settings. OBJECTIVE: We sought to identify the major themes through which patients described their integrated behavioral health care experiences as a means of informing and improving clinic processes of integrated health care delivery. METHODS: We captured viewpoints from 16 patients who experienced an integrated behavioral health care model from 2 primary care clinics and completed at least 3 visits with a behavioral health provider (BHP). Using grounded theory analyses, we coded and analyzed transcriptions for emergent themes. ANALYSIS: The interview process yielded 3 major themes related to the BHP including (a) the BHPs' clinic presence made behavioral health care more convenient and accessible, (b) BHPs worked within time and program limitations, and (c) BHPs helped with coping, wellness, and patient-care team communication. CONCLUSION: The BHPs serving in a large primary care practice and a Federally Qualified Health Center played an important role in connecting patients with behavioral health care and improving care team collaboration, both in terms of communication within the team and between the team and the patient/family.

Patient experience of an integrated care model in a family practice clinic & FQHC.

In order to investigate the patient experience of integrated behavioral health care in primary care settings, we implemented a patient cohort model from a combined site sample (N = 727) consisting of a family practice clinic and a Federally Qualified Health Center. Patient experience was measured using 12 questions from a validated measure, the Agency for Healthcare Research and Quality's Consumer Assessment of Health Care Providers and Systems (CAHPS®), Home and Community Based Services version, and six additional questions about interactions with an integrated behavioral health care team. We assessed bivariate relationships between satisfaction with integration and the clinic practice and self-reported physical health or self-reported mental/emotional health. We also utilized multiple regression to evaluate this relationship. Our analyses showed a statistically significant and small to moderate direct correlation between patients' self-reported health (both physical and mental/emotional health) and their ratings of the practice as a whole (p = .0003), such that patients who rated their physical and/or mental/emotional health as better were more likely to rate their overall satisfaction with the practice higher. The results of this study suggest that primary care patients with only mild to moderate health conditions (physical and/or mental/emotional) may experience greater satisfaction with integrated behavioral health care than patients with multiple and/or severe health conditions. In contrast, patients with multiple and/or severe health conditions may experience lower satisfaction with integrated behavioral health care and may be better served through higher levels of care.

Using Standardized Patient Assessments to Evaluate a Health Literacy Curriculum.

BACKGROUND AND OBJECTIVES: Patients' health literacy is a growing concern as patients are expected to perform more self-care. While many US schools implement health literacy in their curricula, time spent on the topic ranges from 0 to 8 hours and is largely didactic. Evaluation of health literacy skills is not well defined. The effectiveness of a health literacy curriculum for third-year medical students was evaluated by two standardized patients assessments (SPAs). METHODS: All third-year medical students complete a required 4-week clerkship in family medicine. After participating in seminars on patient-centered communication, health literacy, mindfulness, implicit bias, and chronic disease management, students complete SPA-1. Students also work in two team-based teaching clinics with chronic disease patients with limited health literacy and receive faculty feedback. At week 4, students complete SPA-2. Six raters evaluated all video-recorded SPA performances using the Common Ground validated instrument and a tailored health literacy skills checklist. RESULTS: Using SPAs and reliably-trained nonclinical raters is an effective method for training and evaluating students about health literacy. Two classes (2013 and 2015) had significant improvement in Common Ground core skills from SPA-1 to SPA-2. For all classes, a small but significant increase in student use of health literacy checklist was seen from SPA-1 to SPA-2. CONCLUSIONS: Didactic sessions prepare students to demonstrate competence on Common Ground and health literacy skills. Improvements in students' health literacy and communication skills are feasible in a 4-week clerkship utilizing the curriculum and evaluation process described.

Perceptions of culturally competent diabetes management in a primary care practice.

To evaluate whether clinicians consider the impact of culture on diabetes management, a survey was mailed to 300 randomly selected patients > or = 50 years with type 2 diabetes and 153 surveys were returned. Data were correlated with A1C values. African Americans (AA) and non-Hispanic whites (NHW), (91.9%, 97.0%) respectively, reported clinicians discussed benefits of controlling blood sugar but did not discuss effects of cultural issues on glucose control (< or = 50%). AAs perceived clinicians were more accommodating of their cultural preferences than did NHWs (49.2% versus 30.6%) (P < .05). Females (51.9%) (P < .01) reported that clinicians acknowledged the importance of their cultural beliefs with a slightly higher percentage for African American females (54.8%) versus non-Hispanic White females (48.6%). Understanding the patient's and clinician's views of cultural beliefs as they relate to diabetes self-management can provide perspectives to guide care.

Are medical students aware of their anti-obesity bias?

PURPOSE: Anti-obesity prejudices affect the quality of care obese individuals receive. The authors sought to determine the prevalence of weight-related biases among medical students and whether they were aware of their biases. METHOD: Between 2008 and 2011, the authors asked all third-year medical students at Wake Forest School of Medicine to complete the Weight Implicit Association Test (IAT), a validated measure of implicit preferences for "fat" or "thin" individuals. Students also answered a semantic differential item assessing their explicit weight-related preferences. The authors determined students' awareness of their biases by examining the correlation between students' explicit preferences and their IAT scores. RESULTS: Of 354 medical students, 310 (88%) completed valid surveys and consented to participate. Overall, 33% (101/310) self-reported a significant ("moderate" or "strong") explicit anti-fat bias. No students self-reported a significant explicit anti-thin bias. According to the IAT scores, over half of students had a significant implicit weight bias: 39% (121/310) had an anti-fat bias and 17% (52/310) an anti-thin bias. Two-thirds of students (67%, 81/121) were unaware of their implicit anti-fat bias. Only male gender predicted an explicit anti-fat bias (odds ratio 3.0, 95% confidence interval 1.8-5.3). No demographic factors were associated with an implicit anti-fat bias. Students' explicit and implicit biases were not correlated (Pearson r = 0.03, P = .58). CONCLUSIONS: Over one-third of medical students had a significant implicit anti-fat bias; few were aware of that bias. Accordingly, medical schools' obesity curricula should address weight-related biases and their potential impact on care.

Standardized patient instructors' and physician assistant students' evaluation of diabetes counseling skills.

PURPOSE: Standardized patient instructors (SPIs) have been used in medical and physician assistant (PA) teaching and have been shown to be a valuable resource for assessing interviewing and clinical skills. This study evaluated the agreement between SPI ratings and student self-ratings in the assessment of counseling skills. METHODS: PA students in three graduating classes (2009-2011) participated in this study. SPIs received specialized training to simulate a patient with diabetes. SPIs provided feedback during simulated encounters using the Diabetes Risk Factor Interview Scale (DRFIS). The DRFIS provides a criteria-based scale for student assessment. Students completed the DRFIS as a self-assessment prior to receiving SPI feedback. Agreement between SPI evaluation and student self-evaluation using the DRFIS were evaluated. RESULTS: The total DRFIS score was generally comparable between all three graduation classes. SPI ratings of students by individual DRFIS items for all three classes indicate the highest scores occurred for Rapport and Empathy items while the lowest scores were evident for items including Reinforce Effort and Reframing Failure. The percent agreement between SPI and student self-rating was within one point for greater than 70% for all 12 DRFIS items for the cohort of three graduation classes. CONCLUSION: PA students rated themselves on average lower on the DRFIS than SPIs but within an acceptable overall percentage range. Using an evaluation scale that is focused around patient counseling skills is a viable teaching tool for students and SPIs. Acceptable agreement between students and SPI was found. The DRFIS provides an effective criteria-based scale for student assessment.

Commentary: Identifying attitudes towards empathy: an essential feature of professionalism.

Preserving and promoting empathy are ethical imperatives in medical education. The authors of this commentary propose that the "hidden curriculum" and mixed messages learners frequently receive during clinical rotations may erode humanistic traits essential to high-quality care. Three articles in this issue focus on assessing attitude towards empathy in the health care setting using the Jefferson Scale of Physician Empathy. The authors discuss salient points from these reports, reinforce the concept of empathy as a cognitive attribute, and offer recommendations for teaching and nurturing empathy in health professionals. In the reports, construct validity and reliability of the instrument were confirmed and were comparable with previous results, thus providing medical educators with a sound instrument to measure empathic attitudes in the context of patient care. The authors agree with the distinctions made in the three studies between empathy (described as a cognitive attribute) and sympathy (described as an emotional attribute) and believe that empathy as a cognitive skill can be role modeled, taught, and assessed. Barriers to empathic practice (lack of sufficient role models, failing to teach empathy as a cognitive skill, negative experiences, time pressures, overreliance on technology) can be remedied in medical education through interprofessional education and practice and institutional promotion of relationship-centered care, which maintains the centrality of the patient-clinician relationship while recognizing the importance of relationships with self and others.

Working effectively with interpreters: a model curriculum for physician assistant students.

BACKGROUND: Effective patient-provider communication is crucial to achieving good health care outcomes. To accomplish this with patients of limited English proficiency, learning to work effectively with interpreters is essential. AIMS: The primary goal of this study was to determine if physician assistant students could effectively use interpreters to communicate with Spanish speaking patients after implementation of a cultural competency and Medical Spanish curriculum. METHOD: In year one of a three year implementation process, a module for teaching students to work effectively with interpreters was developed and implemented in the Wake Forest University School of Medicine Department of Physician Assistant Studies. After four hours of orientation, practice and role play, students were observed and recorded during a standardized patient assessment and evaluated by clinicians as well as by trained, bi-lingual evaluators. RESULTS: In the Class of 2007, 94% (43 students) and in the Class of 2008, 96% (47 students) demonstrated competence. CONCLUSIONS: Our findings highlight the feasibility and usefulness of training students to work effectively with interpreters. Evaluation and feedback from students and faculty have been positive. Cost for this curriculum enhancement was reasonable, making it feasible to introduce the training into a wide variety of medical and allied health programs.

Training and evaluating tobacco-specific standardized patient instructors.

BACKGROUND AND OBJECTIVES: A comprehensive training program to develop tobacco-specific standardized patient instructors (SPIs) was implemented and evaluated at Wake Forest University. METHODS: Descriptive statistics were used to assess SPIs' experience with the training program and medical students' perceptions of the SPI-student interaction. Two standardized scales, used to assess student performance on counseling (Tobacco Intervention Risk Factor Interview Scale [TIRFIS]) and cultural competency (Tobacco Beliefs Management Scale-Tobacco Cultural Concerns Scale [TBMS-TCCS]), were tested for internal and interrater reliability and sensitivity to varied student performance. Costs of the program were measured. RESULTS: SPIs highly rated the content, organization, and presenters of the training program. Medical students positively evaluated their experience with the SPIs. The TIRFIS and TBMS-TCCS subscales demonstrated good internal reliability, and inconsistencies in ratings by different SPIs were minimal. In addition, a range of scores on both measures attest to the sensitivity of the instruments to assess variations in student performance. Significant start-up costs are associated with developing this training program, although costs decline when SPIs are retained long term. CONCLUSIONS: The SPI training program was effective in developing a cohort of knowledgeable and reliable SPIs to train medical students in ways to improve their tobacco intervention counseling skills. Retaining SPIs long term should be a primary goal of implementing a cost-effective, successful training program.

Applying theory to the design of cultural competency training for medical students: a case study.

Although literature suggests that providing culturally sensitive care promotes positive health outcomes for patients, undergraduate medical education currently does not provide adequate cultural competency training. At most schools, cultural competency, as a formal, integrated, and longitudinal thread within the overall curriculum, is still in its infancy. In this article, the authors summarize the current practice of cultural competency training within medical education and describe the design, implementation, and evaluation of a theoretically based, year-long cultural competency training course for second-year students at Wake Forest University School of Medicine. Evaluation of the results indicate that the course was successful in improving knowledge, attitudes, and skills related to cultural competence as well as bringing about positive changes in the medical school's approach to cultural competency training. Also discussed are the implications of the outcomes for the development of culturally competent physicians and how using appropriate theory can help achieve desired outcomes.