Impact of Primary Care-Mental Health Care Integration on Mental Health Care Engagement Across Racial and Ethnic Groups.

OBJECTIVE: Receiving mental health services as part of primary care in the Veterans Health Administration (VHA) might increase engagement in specialty mental health care. The authors reexamined the association between primary care-mental health integration (PCMHI) and continued engagement in specialty mental health care for VHA patients and assessed differences by race and ethnicity. METHODS: The study included 437,051 primary care patients with a first in-person specialty mental health encounter in 2015-2016 (no specialty mental health encounters in prior 12 months), including 46,417 patients with new PCMHI encounters in the year before the first specialty mental health encounter. Multivariable logistic regression assessed odds of follow-up specialty mental health care within 3 months of the first specialty mental health encounter. The dependent variable was care engagement (attending a second specialty mental health appointment); independent variables were whether patients were seen by PCMHI on the same day as the primary care appointment ("same-day access"), the time between PCMHI and first specialty mental health appointments, and race and ethnicity. RESULTS: PCMHI was associated with increased engagement in specialty mental health care for all patients, with a greater likelihood of engagement among non-Hispanic White patients. Same-day access to PCMHI was positively associated with care engagement, with no significant differences by race or ethnicity. PCMHI care within 3 months before a first specialty mental health encounter was associated with greater care engagement. CONCLUSIONS: PCMHI, especially same-day access to PCMHI care, may boost engagement in mental health care, although the study design precluded conclusions regarding causal relationships.

Legally involved individuals in state hospitals and community mental health settings: Introduction to the special section.

Over the past several years, individuals with serious mental illness (SMI) have become involved with the legal system at an increasing rate. State psychiatric hospitals and community mental health programs have seen a high number of referrals and admissions at a time when resources and staffing have been challenges. Individuals with SMI continue to be highly represented among those incarcerated in jails and prisons, often for minor charges. This article serves as an introduction to a special section of Psychological Services on innovations in assessment and treatment of legally involved patients in state hospitals and community mental health settings. Data are presented on the prevalence of legal involvement among individuals with serious mental illness, including the exponential growth in individuals evaluated and found incompetent to stand trial. A brief summary of the articles in the special section is presented, broken down by themes of assessment, treatment, and policy. We hope that the studies described in this issue will lead to further exploration of problems, barriers, and potential solutions for individuals with SMI who become involved with the legal system. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Patients' perspectives of brief cognitive behavioral therapy for chronic pain: Treatment satisfaction, perceived utility, and global assessment of change.

Introduction: Brief Cognitive Behavioral Therapy for Chronic Pain (Brief CBT-CP) is a biopsychosocial treatment designed to improve access to nonpharmacological pain care in primary care. Results from a clinical demonstration project in Veterans Health Administration (VHA) clinics showed rapid improvement in pain outcomes following Brief CBT-CP treatment in Primary Care Behavioral Health (PCBH). As part of this larger project, the current work aimed to understand patients' perspectives of Brief CBT-CP via a self-report survey completed posttreatment. Method: Thirty-four primary care patients received Brief CBT-CP as part of their usual VHA care and subsequently completed an anonymous survey that included questions regarding treatment modality, intervention content, utility, and satisfaction, as well as global assessment of change in pain-related functioning. Results: Participants reported that Brief CBT-CP content was useful (91%) and that they were satisfied with the intervention overall (89%), including appointment length, frequency of encounters, and comprehensibility of content. On average (M = 4.50, SD = 1.71), participants reported "somewhat better" to "moderately better" pain-related functioning following treatment. Exploratory descriptive analysis indicated that self-reported change in function following treatment may vary by patient characteristics, including gender and opioid use history. Discussion: Patients were receptive to Brief CBT-CP, were satisfied with their experience during treatment, and reported benefit in pain-related functioning after treatment. Further development and evaluation of Brief CBT-CP as a feasible biopsychosocial treatment option for pain in primary care clinics using the PCBH model of integration is warranted. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Addressing Suicide in the Veteran Population: Engaging a Public Health Approach.

Suicide is a national public health issue in America, and it disproportionately affects those who are serving or who have served in the United States military. The US Department of Veterans Affairs (VA) has made suicide prevention its number one clinical priority. VA is committed to prevent suicide among the entire population of those who have served our country in the military, regardless of whether they make use of any VA services or benefits. Suicide can be prevented through the application of a public health strategy embracing partners at all levels. Following a national strategy, VA has embarked on an effort involving the application of a public health strategy combining both clinically-based and community-focused interventions. This paper describes several examples of these efforts and steps forward.

Measurement-based care and psychological assessment: Using measurement to enhance psychological treatment.

This special issue highlights new research in psychological assessment and measurement-based care. Psychological assessment has historically been central to the field of psychology. Measurement-based care, considered an evidence-based practice, is a special type of applied psychological assessment in which patient-reported outcome measures are used to track progress in care as part of a clinical process. We discuss how the knowledge from these two distinct but related fields can synergistically advance mental health treatment. The articles in this special issue demonstrate ways to practically implement measurement-based care, the application of measurement-based care in special populations, as well as feature advances in psychological assessment that support the practice of measurement-based care. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Global approaches to integrated care: Best practices and ongoing innovation.

The integration of behavioral health in primary care is critical for addressing worldwide concerns for access to, and quality of, health care services for physical and mental health promotion, prevention, and disease management. Clearly, promoting knowledge exchange internationally is critical to progress. In late 2015, the American Psychological Association convened an interdisciplinary summit on global approaches to integrated health care, bringing together 82 health care professionals (nurses, primary care physicians, psychologists, psychiatrists, and social workers) and scholars from diverse disciplines in medicine, psychology, economics, health policy, public health, and demography; participants came from 10 countries. The Global Summit provided an opportunity to share best practices and innovation in patient-centered integrated health care internationally. In this article, Global Summit participants from different countries reflect on the recommendations for future interprofessional endeavors across the following themes: build international interprofessional communities for change; advocate for, and promote social equity with, a population health and patient focus; advance research and program evaluation in integrated care; advance interprofessional training and education in integrated care; and develop financially sustainable models for integrated primary care. Building upon these recommendations and reflecting on current advancement in health care policy and integrated care research, new directions are suggested for clinicians, researchers, administrators, and policymakers working toward the advancement of integrated care to improve health care services globally. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Brief Cognitive Behavioral Therapy For Chronic Pain: Results From a Clinical Demonstration Project in Primary Care Behavioral Health.

OBJECTIVES: Although cognitive behavioral therapy is an effective intervention for chronic pain, it is a lengthy treatment typically applied only in specialty care settings. The aim of this project was to collect preliminary effectiveness data for Brief Cognitive Behavioral Therapy for Chronic Pain (Brief CBT-CP), an abbreviated, modular form of treatment designed for use in primary care. METHODS: A clinical demonstration project was conducted in which Brief CBT-CP was delivered to primary care patients by 22 integrated care providers practicing in the Primary Care Behavioral Health model of Veterans Health Administration primary care clinics. Brief measures were used at each appointment to collect patient-reported clinical outcomes. RESULTS: One hundred eighteen patients provided sufficient data for analysis (male, 75%; mean age, 51.4 y). Multilevel modeling suggested that a composite measure of pain intensity and functional limitations showed statistically significant improvements by the third appointment (Cohen's d=0.65). Pain-related self-efficacy outcomes showed a similar pattern of results but of smaller effect size (Cohen's d=0.22). The exploratory analysis identified that Brief CBT-CP modules addressing psychoeducation and goal setting, pacing, and relaxation training were associated with the most significant gains in treatment outcomes. DISCUSSION: These findings provide early support for the effectiveness of Brief CBT-CP when delivered by providers in every day Primary Care Behavioral Health settings. Results are discussed in relation to the need for additional research regarding the potential value of employing safe, population-based, nonpharmacological approaches to pain management in primary care.

Review of Integrating behavioral health into the medical home: A rapid implementation guide.

Reviews the book, Integrating Behavioral Health into the Medical Home: A Rapid Implementation Guide by Kent A. Corso, Christopher L. Hunter, Owen Dahl, Gene A. Kallenberg, and Lesley Manson (see record 2016-51034-000). This practical how-to book is written specifically for an audience working to implement integrated primary care (IPC) from the ground up, moving beyond the clinical competencies required for success in these settings to the business operational requirements to facilitate implementation. The book is divided into three sections, beginning with an introduction to key concepts and tools for successfully IPC practices. Section II is focused on the business practices needed for success, including strategic plan development, return on investment analyses, business cases analyses, hiring, billing, personnel training, and outcome monitoring. The last section is a series of case studies of successful programs from Cherokee Health Systems to Intermountain Health. This is particularly priceless because it provides evidence that IPC can thrive in a multitude of diverse settings, describing practical guidance of what to do and what to avoid. The authors, with more than 84 years of combined IPC experience, offer the reader sage advice, which can be applied readily. Each chapter begins with a Bottom Line, Up Front section, offering bulleted points of specific direction for the lay reader hoping to advance their journey into integration. A nice bonus surprise to the book is the wittiness of this esteemed group, offering refreshing pieces of humor, which is welcomed when thinking through the specific demands of IPC implementation. The book is also an excellent resource manual to delve more deeply into the IPC literature, with each chapter providing a host of references for further study. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Adapting Coordinated Anxiety Learning and Management for Veterans Affairs Community-Based Outpatient Clinics: Iterative Approach.

BACKGROUND: A national priority at the US Department of Veterans Affairs (VA) is to increase the availability and accessibility of evidence-based psychotherapies (EBPs) across all VA medical facilities. Yet many veterans, particularly those who use remote outpatient VA clinics, still do not receive much needed evidence-based treatment. Strategies are needed for supporting mental health providers at rural VA community-based outpatient clinics (CBOCs) as they translate their clinical training to routine practice. The Coordinated Anxiety Learning Management (CALM) program is a computer-delivered program that supports the delivery of cognitive behavioral therapy (CBT) by providers in outpatient settings to patients with depression and anxiety, including posttraumatic stress disorder. OBJECTIVE: The objectives of our study were to (1) adapt an existing computer-based program to rural VA CBOCs through feedback from key stakeholder focus groups; (2) develop a prototype of the adapted program; and (3) determine the adapted program's acceptability and feasibility. Mental health stakeholders included VA leaders (n=4) in the implementation of EBPs, VA experts (n=4) in CBT, VA CBOC mental health providers (n=8), and veterans (n=8) diagnosed with a mental health condition treated using the CALM program and receiving treatment in a VA CBOC. METHODS: An iterative approach comprising 3 waves of focus group discussions was used to develop a modified prototype of CALM. Following each wave of focus group discussions, template analysis was used to rapidly communicate stakeholder recommendations and feedback to the design team. The original program was first adapted through a process of data collection, design modification, and product development. Next, a prototype was developed. Finally, the redesigned program was tested for acceptability and feasibility through a live demonstration. RESULTS: Key stakeholders suggested modifications to the original CALM program that altered its modules' appearance by incorporating veteran-centric content. These modifications likely have no impact on the integrity of the original CALM program, but have altered its content to reflect better the demographic characteristics and experiences of rural veterans. Feedback from stakeholder groups indicates that changes will help VA patients identify with the program content, potentially enhancing their treatment engagement. CONCLUSIONS: The development model was effective for economically gathering actionable recommendations from stakeholders to adapt a computer-based program, and it can result in the development of an acceptable and feasible computer-delivered intervention. Results have implications for developing computer-based programs targeting behavior change more broadly and enhancing engagement in EBP.

The Integrated Care Team Approach of the Department of Veterans Affairs (VA): Geriatric Primary Care.

Historically, integrated mental and behavioral healthcare in the Department of Veterans Affairs (VA) commenced with initiatives in geriatrics. Innovation and system-wide expansion has occurred over decades and culminated in a unified vision for training and practice in the VA medical home model: Patient Aligned Care Team or PACT approach. In one VA hospital, the integration of neuropsychological services in geriatric primary care is pivotal and increases access for patients, as well as contributing to timely and effective care on an interprofessional team. The development and innovative use of an algorithm to identify problems with cognition, health literacy, and mental and behavioral health has been pragmatic and provides useful information for collaborative treatment planning in GeriPACT, VA geriatric primary care. Use of the algorithm also assists with decision-making regarding brief versus comprehensive neuropsychological assessment in the primary care setting. The model presented here was developed by supervising neuropsychologists as part of a postdoctoral residency program in geropsychology. However, postdoctoral residency programs in neuropsychology, as well as neuropsychological clinics, can also use this model to integrate neuropsychological assessment and interventions in geriatric primary care settings.

Psychosocial approaches to improving the military-to-civilian transition process.

This special issue of Psychological Services provides a glimpse of some of the most recent work in the arena of psychosocial interventions for military service members who are reintegrating into civilian society and becoming veterans. The psychological effects that can occur as members go through the military-to-civilian transition as they leave the military have been extensively recorded and treated. While psychosocial interventions have been utilized throughout history, we are seeing a new interest and recent renaissance in their use. These psychosocial interventions will help our veterans reintegrate into civilian society not just by focusing on reducing the symptoms from their visible and invisible wounds but by taking a more holistic and integrative perspective that works to improve the veterans' functioning in their surrounding social environments through community reengagement, treatment of the individual and their social environment, and functional improvement. The articles in this special issue illustrate how clinicians and researchers are validating new techniques to improve functioning among those learning to change careers as warriors in their new civilian occupations. (PsycINFO Database Record

Envisioning Transformation in VA Mental Health Services Through Collaborative Site Visits.

This column reviews the unique contributions of multiple partners in establishing a standardized site visit process to promote quality improvement in mental health care at the Veterans Health Administration. Working as a team, leaders in policy and operations, staff of research centers, and regional- and facility-level mental health leaders developed a standardized protocol for evaluating mental health services at each site and using the data to help implement policy goals. The authors discuss the challenges experienced and lessons learned in this systemwide process and how this information can be part of a framework for improving mental health services on a national level.

Achieving same-day access in integrated primary care.

Same-day access to behavioral health services is a critical feature of integrated primary care. Despite the benefits of same-day access, implementing and sustaining this key feature has been a challenge for multiple health care settings. Further, there is relatively little practical guidance on how to implement this practice management feature. Diverse program design solutions for same-day access are implemented in clinics across the Veterans Health Administration. The authors identified innovative approaches, developed in local facilities, with demonstrated success in same-day access that can be implemented in any setting. The purpose of this article is to describe five approaches for providing same-day access within integrated care. The authors discuss key considerations (staffing, space, program maturity), potential challenges and facilitators, and provide practical recommendations for implementation. (PsycINFO Database Record

Mental health productivity monitoring in the Veterans Health Administration: Challenges and lessons learned.

Achieving quality outcomes and cost efficiency within mental health are overarching objectives of the Veterans Health Administration (VHA). The mental health care workforce has long been oriented toward the goal of high quality outcomes; however, cost efficiency has only recently been elevated into this important value equation. With increased demand for access to mental health services within the VHA, leadership sought to advance methods of determining and improving mental health provider productivity. Monitoring of productivity data may also provide data signaling the potential need for additional staffing to keep up with demand for services. This article outlines VHA's development and specification of mental health productivity policy, implementation strategies, and a discussion of challenges and lessons learned for other systems to consider in implementing productivity monitoring. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

A quarter century of psychological practice in mental health and health care: 1990-2016.

Powerful forces have shaped professional psychology over the past 25 years, including significant changes in health policy and health care delivery systems. Examples include managed care cost containment, rapid growth of nondoctoral mental health providers, federal mental health parity legislation, and passage of the Affordable Care Act of 2010, with its emphasis on primary care-behavioral health integration and alternatives to fee-for-service reimbursement. This article considers these factors for psychology as a mental health profession and as a health profession more broadly defined, and describes the American Psychological Association's advocacy about the value of psychology in each domain. While challenging to psychology's traditional models of care, these changes offer significant promise for the future of psychology in health care. (PsycINFO Database Record

Homelessness as a public mental health and social problem: New knowledge and solutions.

Homelessness is a major public health problem that has received considerable attention from clinicians, researchers, administrators, and policymakers in recent years. In 2016, 550,000 individuals were homeless in the United States (U.S. Department of Housing and Urban Development, 2016) with 4.2% of individuals in the United States experiencing homelessness for over 1 month sometime in their lives and 1.5% experiencing homelessness in the last year (Tsai, 2017). Homelessness remains a recalcitrant problem and a ripe area for study, particularly in addressing needs of individuals at high risk for homelessness and those from understudied populations. New and innovative measurement approaches, interventions, and study methodologies are presented in this special issue to shed light on how psychology can help benefit and improve homeless services. (PsycINFO Database Record

Measurement-based management of mental health quality and access in VHA: SAIL mental health domain.

We outline the development of a Mental Health Domain to track accessibility and quality of mental health care in the United States Veterans Health Administration (VHA) as part of a broad-based performance measurement system. This domain adds an important element to national performance improvement efforts by targeting regional and facility leadership and providing them a concise yet comprehensive measure to identify facilities facing challenges in their mental health programs. We present the conceptual framework and rationale behind measure selection and development. The Mental Health Domain covers three important aspects of mental health treatment: Population Coverage, Continuity of Care, and Experience of Care. Each component is a composite of existing and newly adapted measures with moderate to high internal consistency; components are statistically independent or moderately related. Development and dissemination of the Mental Health Domain involved a variety of approaches and benefited from close collaboration between local, regional, and national leadership and from coordination with existing quality-improvement initiatives. During the first year of use, facilities varied in the direction and extent of change. These patterns of change were generally consistent with qualitative information, providing support for the validity of the domain and its component measures. Measure maintenance remains an iterative process as the VHA mental health system and potential data resources continue to evolve. Lessons learned may be helpful to the broader mental health-provider community as mental health care consolidates and becomes increasingly integrated within healthcare systems. (PsycINFO Database Record

Capturing Psychologists' Work in Integrated Care: Measuring and Documenting Administrative Outcomes.

With the expansion of integrated primary care and the increased focus on fiscal sustainability, it is critical for clinical managers of these innovative systems to have practical methods for measuring administrative outcomes. Administrative outcomes will assist leadership in the development of efficient, streamlined clinics to provide services to the primary care population. Additionally, administrative measures can be utilized to provide information to assist in guiding resource utilization and management decisions. Several administrative outcomes are suggested for integrated primary care managers to consider for application, including: clinic utilization measures, integrated care administrative measures, wait time and access metrics, and productivity monitors. Effective utilization of these measures can help office managers and clinic leadership not only to maximize patient care, but also to enhance essential business operations, which increase the long-term sustainability of integrated primary care programs.

Establishing Measurement-based Care in Integrated Primary Care: Monitoring Clinical Outcomes Over Time.

Full implementation of the patient-centered medical home requires the identification and treatment of patients with behavioral health concerns, leading to improved patient outcomes and reduced health care costs. Measurement-based care (MBC) for mental health conditions is an essential step in achieving these goals. Integrated primary care (IPC) administrators and providers are key leaders in MBC that spans initial screening for conditions to monitoring clinical outcomes over time. The purpose of this article is to assist IPC leaders, in partnership with their primary care team, in developing standard operating procedures for screening and follow up evaluations in order to lay a foundation for assessing program outcomes and improving quality of care in their unique settings.