Virtual Care for Behavioral Health Conditions.

The COVID-19 pandemic has highlighted the urgent need for behavioral health care services. A substantial portion of mental health care transitioned to virtual care during the COVID-19 pandemic, remains virtual today, and will continue that way in the future. Mental health needs continue to grow, and there has been growing evidence showing the efficacy of virtual health for behavioral health conditions at the system, provider, and patient level. There is also a growing understanding of the barriers and challenges to virtual behavioral health care.

Lessons Learned During COVID-19 That Can Move Telehealth in Primary Care Forward.

INTRODUCTION: Our university hospital-based primary care practices transitioned a budding interest in telehealth to a largely telehealth-based approach in the face of the COVID-19 pandemic. INITIAL WORK: Implementation of telehealth began in 2017. Health system barriers, provider and patient reluctance, and inadequate reimbursement prevented widespread adoption at the time. COVID-19 served as the catalyst to accelerate telehealth efforts. IMPLEMENTATION: COVID-19 resulted in the need for patient care with "social distancing." In addition, due to the pandemic, the Centers for Medicare and Medicaid Services and other insurers began expanded reimbursement for telehealth. More than 2000 providers received virtual health training in less than 2 weeks. In March 2020, we provided 2376 virtual visits, and in April 5293, which was more than 75 times the number provided in February; 73% of all visits in April were virtual (up from 0.5% in October 2019). As COVID-19 cases receded in May, June, and July, patient demand for virtual visits decreased, but 28% of visits in July were still virtual. LESSONS LEARNED: Several key lessons are important for future efforts regarding clinical implementation: (1) prepare for innovation, (2) cultivate an innovation mindset, (3) standardize (but not too much), (4) technological innovation is necessary but not sufficient, and (5) communicate widely and often.

Using Telepsychiatry to Enrich Existing Integrated Primary Care.

Background: Integrated care is characterized by evolving heterogeneity in models. Using telepsychiatry to enhance these models can increase access, quality, and efficiencies in care. Introduction: The purpose of this report is to describe the process and outcomes of adapting telepsychiatry into an existing integrated care service. Materials and Methods: Telepsychiatry was implemented into an existing integrated care model in a high-volume, urban, primary care clinic in Colorado serving patients with complex physical and behavioral needs. Consultative, direct care, educational/training encounters, provider-to-provider communication, process changes, and patient-level descriptive measures were tracked as part of ongoing quality improvement. Results: Telepsychiatry was adapted into the existing behavioral health services using an iterative team meeting process within a stepped care model. Over 35% of the requests for psychiatry services were medication related-and medication changes (type/dose) were the most frequent referral outcome of psychiatric consultation. Forty percent of patients in the service had multiple behavioral health diagnoses, in addition to physical health diagnoses. Discussion: Telehealth will become an increasingly necessary component in building hybrid/blended integrated care teams. Examples of flexible model implementation will support clinics in tailoring effective applications for their unique patient panels. Conclusions: An adapted integrated care model leveraging telepsychiatry is successfully serving the complex deep end of a primary care patient population in Colorado. Lessons learned in implementing this model include the importance of team attitudes.

Evaluating transformation with available resources: The influence of APEX on depression screening.

OBJECTIVE: The University of Colorado developed and piloted a team-based primary care delivery model called ambulatory process excellence (APEX) in a family medicine residency in 2015. We evaluated its impact on depression screening using found data and tools readily available to practice-based evaluators. METHOD: The APEX model calls for 5 medical assistants (MAs) supporting 2 providers. MAs have dedicated time to provide delegated care, including depression screening with 2 versions of the Patient Health Questionnaire: PHQ-2 and PHQ-9. Using an interrupted time-series-with-control design, we created longitudinal profiles of the pilot and a control practice using statistical process control charts. We obtained data from preexisting dashboards derived from the electronic medical record. Outcomes included PHQ-2 screening rates, patients screening positive, and the proportion of them completing a PHQ-9. Covariates included monthly visits and new-patient appointments. Using Microsoft Excel, we transformed all data into modified z scores, plotted them on a multivariate control chart for each practice, and assessed them for evidence of special cause variation. Key informants provided information about potentially confounding concurrent events. RESULTS: Compared with baseline, the intervention practice significantly increased primary care medical visits and new-patient appointments, increased positive PHQ-2 patients, and improved PHQ-9 completion. High screening rates remained stable. In the control practice, new-patient appointments increased and PHQ2 screening improved. DISCUSSION: APEX may contribute to better depression-screening processes. We have provided a detailed description of a real-world, practice-based, quasi-experimental evaluation model using common spreadsheet software (Microsoft Excel) to transform and analyze found data with multivariate statistical process-control charts. (PsycINFO Database Record

Designing Clinical Space for the Delivery of Integrated Behavioral Health and Primary Care.

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.

Outlining the scope of behavioral health practice in integrated primary care: dispelling the myth of the one-trick mental health pony.

Patient presentation in primary care ranges from psychosocial considerations to physical and mental health concerns including serious mental illness. To best prepare for addressing all aspects of health, integrated primary care practices should be equipped with the expertise and resources to appropriately treat the range of presentations. We conducted a literature review of research articles to determine the span of service types provided by behavioral health providers in primary care settings. Among 675 articles retrieved, only 17 addressed health behaviors, 64 examined both health behaviors and mental health, and 160 included only mental health topics. Within these groups, depression was the dominant screening, assessment, and treatment target, and only 42% of all studies included Method and Results sections. Literature supports that integrating behavioral health providers and services into primary care settings benefits patients, primary care providers, and the practice at large, resulting in improved care experiences. However, primary care practices appear to not use the full range of services behavioral health providers can offer. Increased health policy efforts and payment reform are needed to enable a more expansive view of what behavioral health providers could do in a primary care context.

Primary care, behavioral health, provider colocation, and rurality.

PURPOSE: The purpose of this study was to characterize the proximity of primary care and behavioral health service delivery sites in the United States and factors influencing their colocation. METHODS: We geocoded the practice addresses of primary care and behavioral health providers found in the Centers for Medicare & Medicaid Services' National Plan and Provider Enumeration System Downloadable File to report where colocation is occurring throughout the country. RESULTS: The extent to which primary care physicians are colocated with behavioral health providers is strongly associated with rurality. Specifically, 40.2% of primary care physicians in urban areas are colocated with behavioral health providers compared with 22.8% in isolated rural areas and 26.5% in frontier areas. However, when controlling for number of primary care physicians at a location, the odds of colocation actually are greater for physicians in a frontier area than those in urban areas (odds ratio, 1.289; P < .01). CONCLUSIONS: Our findings offer new insights into the overlap of the behavioral health and primary care workforce, where opportunities for integration may be limited because of practice size and the proximity of providers, and where new possibilities for integration exist.