Clinical Workflows and the Associated Tasks and Behaviors to Support Delivery of Integrated Behavioral Health and Primary Care.

Integrating primary care and behavioral health is an important focus of health system transformation. Cross-case comparative analysis of 19 practices in the United States describing integrated care clinical workflows. Surveys, observation visits, and key informant interviews analyzed using immersion-crystallization. Staff performed tasks and behaviors-guided by protocols or scripts-to support 4 workflow phases: (1) identifying; (2) engaging/transitioning; (3) providing treatment; and (4) monitoring/adjusting care. Shared electronic health records and accessible staffing/scheduling facilitated workflows. Stakeholders should consider these workflow phases, address structural features, and utilize a developmental approach as they operationalize integrated care delivery.

Demonstration of the Health Literacy Universal Precautions Toolkit: Lessons for Quality Improvement.

The Agency for Healthcare Research and Quality Health Literacy Universal Precautions Toolkit was developed to help primary care practices assess and make changes to improve communication with and support for patients. Twelve diverse primary care practices implemented assigned tools over a 6-month period. Qualitative results revealed challenges practices experienced during implementation, including competing demands, bureaucratic hurdles, technological challenges, limited quality improvement experience, and limited leadership support. Practices used the Toolkit flexibly and recognized the efficiencies of implementing tools in tandem and in coordination with other quality improvement initiatives. Practices recommended reducing Toolkit density and making specific refinements.

Improving the Effectiveness of Medication Review: Guidance from the Health Literacy Universal Precautions Toolkit.

BACKGROUND: Although routine medication reviews in primary care practice are recommended to identify drug therapy problems, it is often difficult to get patients to bring all their medications to office visits. The objective of this study was to determine whether the medication review tool in the Agency for Healthcare Research and Quality Health Literacy Universal Precautions Toolkit can help to improve medication reviews in primary care practices. METHODS: The toolkit's "Brown Bag Medication Review" was implemented in a rural private practice in Missouri and an urban teaching practice in California. Practices recorded outcomes of medication reviews with 45 patients before toolkit implementation and then changed their medication review processes based on guidance in the toolkit. Six months later we conducted interviews with practice staff to identify changes made as a result of implementing the tool, and practices recorded outcomes of medication reviews with 41 additional patients. Data analyses compared differences in whether all medications were brought to visits, the number of medications reviewed, drug therapy problems identified, and changes in medication regimens before and after implementation. RESULTS: Interviews revealed that practices made the changes recommended in the toolkit to encourage patients to bring medications to office visits. Evaluation before and after implementation revealed a 3-fold increase in the percentage of patients who brought all their prescription medications and a 6-fold increase in the number of prescription medications brought to office visits. The percentage of reviews in which drug therapy problems were identified doubled, as did the percentage of medication regimens revised. CONCLUSIONS: Use of the Health Literacy Universal Precautions Toolkit can help to identify drug therapy problems.

Parent and Provider Perspectives on Pediatric Readmissions: What Can We Learn About Readiness for Discharge?

BACKGROUND: Readmissions are an increasingly recognized quality metric that will likely affect payments to children's hospitals. Our aim was to inform future efforts to reduce readmissions by eliciting parent and provider perceptions of pediatric readmissions. METHODS: We interviewed English- and Spanish-speaking parents and inpatient providers of children with medical diagnoses who had unplanned readmissions (≤7 days). Parents were interviewed one-on-one during the readmission. Providers were interviewed in person or by phone within 1 week of the patient's second discharge. Interviewees were queried about their perceptions of the reason for readmission and whether the readmission was preventable. Interview transcripts were analyzed using qualitative content methods. Code categories were developed and emergent themes independently identified by 2 analysts. RESULTS: The study included 30 readmitted children (median age 17 months, 70% male, 80% White or Hispanic, and 66% publically insured). We interviewed 30 parents (23% Spanish speaking) and 27 discharging or readmitting providers. Parents and providers identified several major factors as causing readmissions, including child related (health and symptoms), parent/family related (adherence to recommended care), provider/team related (medical management), communication difficulties, home supports, and quality of discharge teaching. Parents and providers had differing interpretations of the role or magnitude of these factors. Lack of shared understanding between parents and providers emerged as a potentially important cause of readmissions. CONCLUSIONS: We identified lack of shared understanding and communication difficulties between parents and providers as potential causes of readmission. Further research is needed to determine if improvements in identifying and addressing such problems can reduce pediatric readmissions.

Using the Health Literacy Universal Precautions Toolkit to Improve the Quality of Patient Materials.

Patient materials are often written above the reading level of most adults. Tool 11 of the Health Literacy Universal Precautions Toolkit ("Design Easy-to-Read Material") provides guidance on ensuring that written patient materials are easy to understand. As part of a pragmatic demonstration of the Toolkit, we examined how four primary care practices implemented Tool 11 and whether written materials improved as a result. We conducted interviews to learn about practices' implementation activities and assessed the readability, understandability, and actionability of patient education materials collected during pre- and postimplementation site visits. Interview data indicated that practices followed many action steps recommended in Tool 11, including training staff, assessing readability, and developing or revising materials, typically focusing on brief documents such as patient letters and information sheets. Many of the revised and newly developed documents had reading levels appropriate for most patients and--in the case of revised documents--better readability than the original materials. In contrast, the readability, understandability, and actionability of lengthier patient education materials were poor and did not improve over the 6-month implementation period. Findings guided revisions to Tool 11 and highlighted the importance of engaging multiple stakeholders in improving the quality of patient materials.

Clinician Staffing, Scheduling, and Engagement Strategies Among Primary Care Practices Delivering Integrated Care.

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.

Electronic Health Record Challenges, Workarounds, and Solutions Observed in Practices Integrating Behavioral Health and Primary Care.

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.

Case study of a primary care-based accountable care system approach to medical home transformation.

We report a case study of a mature primary care-based accountable care organization that is both a health plan and a network of medical homes. Over 20 years, WellMed Inc (San Antonio, Texas) implemented many patient-centered services, experimenting to find which belong within clinics and which operate best as system functions. The adjusted mortality rate is half that of the state for people older than 65 years. Hospitalization and readmission rates and emergency department visits have not changed over time, but preventive services have improved. Phased implementation across the network makes it difficult to link improvements to specific processes but they seem to have improved outcomes collectively.

Measuring primary care expenses.

BACKGROUND: Significant investments and effort are being devoted to health care reform, yet little is known about the costs of improvements. Practical tools are needed to allow for systematic assessment of practice expenses. We report here a field trial of a standardized expenditure data collection instrument. METHODS: Combining economic and primary care practice consultation, an expenditure data collection instrument was created. The instrument underwent observed feasibility testing and was fielded by 10 practice-based research networks in 30 practices conducting 10 different health behavior change interventions. RESULTS: Start-up and operating expenses were successfully collected for 87% and 97% of the practices, respectively. Data collection time and effort were considerable but acceptable. Three elements were necessary to collect expenditure data: (1) an intervention-specific data collection instrument, (2) a field guide, and (3) economic oversight and assistance. Fully 90% of networks reported that they planned to collect expenditure data in the future and study participation increased the likelihood of their participation in a future expenditure study. CONCLUSIONS: It is feasible to systematically collect intervention-specific expenses in primary care using formal expenditure methods. However, most practices and researchers lack the knowledge, expertise, and resources to collect such data independently. Further assistance and education is necessary to obtain reliable information about the expenses to transform and improve primary care.

An electronic practice-based network for observational comparative effectiveness research.

The Distributed Ambulatory Research in Therapeutics Network (DARTNet) is a federated network of electronic health data from 8 organizations representing more than 500 clinicians and more than 400 000 patients. DARTNet was designed to increase knowledge of the comparative effectiveness of prescription medications and medical devices. Traditional observational comparative effectiveness research is conducted using large data sets, such as claims databases. Such databases do not provide important clinical information that is critical to understanding comparative effectiveness. By linking electronic health records, laboratory and imaging data, and administrative data from diverse and geographically disparate patients, DARTNet provides important new insight into the comparative effectiveness of oral diabetes medications, and it is ready for expansion to further enable effectiveness research.

Start-up and incremental practice expenses for behavior change interventions in primary care.

BACKGROUND: If behavior-change services are to be offered routinely in primary care practices, providers must be appropriately compensated. Estimating what is spent by practices in providing such services is a critical component of establishing appropriate payment and was the objective of this study. METHODS: In-practice expenditure data were collected for ten different interventions, using a standardized instrument in 29 practices nested in ten practice-based research networks across the U.S. during 2006-2007. The data were analyzed using standard templates to create credible estimates of the expenses incurred for both the start-up period and the implementation phase of the interventions. RESULTS: Average monthly start-up expenses were $1860 per practice (SE=$455). Most start-up expenditures were for staff training. Average monthly incremental costs were $58 ($15 for provision of direct care [SE=$5]; $43 in overhead [SE=$17]) per patient participant. The bulk of the intervention expenditures was spent on the recruitment and screening of patient participants. CONCLUSIONS: Primary care practices must spend money to address their patients' unhealthy behaviors--at least $1860 to initiate systematic approaches and $58 monthly per participating patient to implement the approaches routinely. Until primary care payment systems incorporate these expenses, it is unlikely that these services will be readily available.

Prescription for health: changing primary care practice to foster healthy behaviors.

PURPOSE: The leading causes of premature death in the United States are linked to 4 behaviors: smoking, unhealthy diet, physical inactivity, and risky alcohol use. We report lessons from 17 exploratory projects funded under Prescription for Health that tested the feasibility of innovative behavior change strategies for at least 2 of these behaviors in primary care practices. METHODS: Seventeen practice-based research networks (PBRNs) implemented and evaluated tools, cues, and techniques in 120 family medicine, internal medicine, pediatric, and nursing practices across an ethnically diverse sample of adults, children, and adolescents in rural and urban settings. We reviewed progress reports and notes from site visits and 3 meetings to generate overarching lessons. RESULTS: PBRNs successfully implemented their projects in diverse practices despite reported logistical challenges and practice constraints. The networks showed that distributing the effort across the care team and throughout the practice and community is possible. Although each behavior required specific attention, each did not require its own separate staff and system. Three models emerged as helpful guides for the comprehensive redesign of health behavior counseling, but they require adaptation for use in real-world primary care settings. Traditional methods of collaboration yielded mixed results, making obvious a need for dedicated collaboration funds and a better framework to identify and align high-yield opportunities. CONCLUSIONS: These projects confirm the feasibility of health behavior counseling in primary care practice. They also highlight the need for substantive practice redesign, and the value of models and frameworks to guide redesign and collaborative efforts.

Practical and relevant self-report measures of patient health behaviors for primary care research.

PURPOSE: With increasing evidence for the value of behavior change counseling, there is a need for health behavior measurements that can be implemented in primary care research. This article discusses criteria for and reviews self-report measures to briefly assess cigarette smoking, eating patterns, physical activity, and risky drinking across the life course. It then proposes pragmatic measures for use in practice-based research. METHODS: Drawing from literature reviews, previous multisite studies, personal communications with experts in the field, and guidance from an expert panel, we identified self-report behavior change measures and gave priority to items that addressed Healthy People 2010 goals, as well as those that were practical (ie, shorter, and easier to score and use for intervention), were sensitive to change, and produced results that could directly inform primary care intervention. RESULTS: Separate recommendations are described for measures for adults and for children/adolescents. We recommend a set of 22 items for adults and 16 items for adolescents to track succinctly their status on the 4 health behaviors above. Perfected measures remain elusive: newly developed measures of physical activity and eating patterns are recommended, and in general, the brief measures for adults are currently better validated than are the child measures. CONCLUSIONS: A set of totally satisfactory practical instruments for measuring behavior change in primary care settings does not yet exist. There is sufficient progress to encourage use of and further research on the proposed items. Use of a common set of items across different interventions and projects will help to advance clinical and behavioral research in primary care settings.