Preparing behavioral health clinicians for success and retention in rural safety net practices.

PURPOSE: This study assesses how, among behavioral health clinicians working in rural safety net practices, the amount of exposure to care in rural underserved communities received during training relates to confidence in skills important in their work settings, successes in jobs and communities, and anticipated retention. METHODS: This study uses survey data from Licensed Clinical Social Workers, Licensed Professional Counselors, and Psychologists working in rural safety net practices in 21 states while receiving educational loan repayment support from the National Health Service Corps, from 2015 to April 2022. FINDINGS: Of the 778 survey respondents working in rural counties, 486 (62.5%) reported they had formal education experiences with medically underserved populations during their professional training, for a median of 47 weeks. In analyses adjusting for potential confounders, the estimated amount of rural training exposure was positively associated with a variety of indicators of clinicians' integration and fit with their communities as well as with longer anticipated retention within their rural safety net practices. The amount of training in care for rural underserved populations was not associated with clinicians' confidence levels in various professional skills or successes in their work, including connection with patients and work satisfaction. CONCLUSIONS: Formal training in care for underserved populations is a large part of the education of behavioral health clinicians who later work in rural safety net practices. More training in rural underserved care for these clinicians is associated with greater integration and fit in their communities and longer anticipated retention in their practices, but not with skills confidence or practice outcomes.

Harm reduction workforce, behavioral health, and service delivery in the USA: a cross-sectional study.

BACKGROUND: Despite recent financial and policy support for harm reduction in the USA, information on the types of workers within organizations who design, implement, and actualize harm reduction services remains nascent. Little is known about how variability in the harm reduction workforce impacts referrals and linkages to other community supports. This exploratory mixed-methods study asked: (1) Who constitutes the harm reduction workforce? (2) Who provides behavioral health services within harm reduction organizations? (3) Are referral services offered and by whom? (4) Do referrals differ by type of harm reduction worker? METHODS: Purposive sampling techniques were used to distribute an electronic survey to U.S.-based harm reduction organizations. Descriptive statistics were conducted. Multivariate binary logistic regression models examined the associations (a) between the odds of the referral processes at harm reduction organizations and (b) between the provision of behavioral health services and distinct types of organizational staff. Qualitative data were analyzed using a hybrid approach of inductive and thematic analysis. RESULTS: Data from 41 states and Washington, D.C. were collected (N = 168; 48% response rate). Four primary types of workers were identified: community health/peer specialists (87%); medical/nursing staff (55%); behavioral health (49%); and others (34%). About 43% of organizations had a formal referral process; among these, only 32% had follow-up protocols. Qualitative findings highlighted the broad spectrum of behavioral health services offered and a broad behavioral health workforce heavily reliant on peers. Unadjusted results from multivariate models found that harm reduction organizations were more than 5 times more likely (95% CI [1.91, 13.38]) to have a formal referral process and 6 times more likely (95% CI [1.74, 21.52]) to have follow-up processes when behavioral health services were offered. Organizations were more than two times more likely (95% CI [1.09, 4.46]) to have a formal referral process and 2.36 (95% CI [1.11, 5.0]) times more likely to have follow-up processes for referrals when behavioral health providers were included. CONCLUSIONS: The composition of the harm reduction workforce is occupationally diverse. Understanding the types of services offered, as well as the workforce who provides those services, offers valuable insights into staffing and service delivery needs of frontline organizations working to reduce morbidity and mortality among those who use substances. Workforce considerations within U.S.-based harm reduction organizations are increasingly important as harm reduction services continue to expand.

Pharmacists Colocated With Primary Care Physicians: Understanding Delivery of Interprofessional Primary Care.

BACKGROUND: While evidence supports interprofessional primary care models that include pharmacists, the extent to which pharmacists are working in primary care and the factors associated with colocation is unknown. OBJECTIVES: This study aimed to analyze the physical colocation of pharmacists with primary care providers (PCPs) and examine predictors associated with colocation. RESEARCH DESIGN: This is a retrospective cross-sectional study of pharmacists and PCPs with individual National Provider Identifiers in the National Plan and Provider Enumeration System's database. Pharmacist and PCP practice addresses of the health care professionals were geocoded, and distances less than 0.1 miles were considered physically colocated. SUBJECTS: In all, 502,373 physicians and 221,534 pharmacists were included. RESULTS: When excluding hospital-based pharmacists, 1 in 10 (11%) pharmacists were colocated with a PCP. Pharmacists in urban settings were more likely to be colocated than those in rural areas (OR=1.32, CI: 1.26-1.38). Counties with the highest proportion of licensed pharmacists per 100,000 people in the county had higher colocation (OR=1.38, CI: 1.32-1.45). Colocation was significantly higher in states with an expanded scope of practice (OR 1.37, CI: 1.32-1.42) and those that have expanded Medicaid (OR 1.07, CI: 1.03-1.11). Colocated pharmacists more commonly worked in larger physician practices. CONCLUSION: Although including pharmacists on primary care teams improves clinical outcomes, reduces health care costs, and enhances patient and provider experience, colocation appears to be unevenly dispersed across the United States, with lower rates in rural areas. As the integration of pharmacists in primary care continues to expand, knowing the prevalence and facilitators of growth will be helpful to policymakers, researchers, and clinical administrators.

Social workers roles in achieving health quality metrics in primary care: a quality improvement case study.

Value-based payment models may improve patient health by targeting quality of care over quantity of health services. Social workers in primary care settings are well-positioned to improve the quality of health services for vulnerable patients by identifying and addressing patients' social determinants of health. This case study describes a Plan Do Study Act (PDSA) quality improvement approach implemented and refined by social workers to proactively address clinical quality gaps in one family medicine practice. The studied program - entitled Gap Closure Day - was led by a team of social workers to improve quality outcomes of patients. Findings highlight the important roles of social workers as members of health care teams to improve the quality of health services and address health equity.

Examining the use of psychiatric collaborative care and behavioral health integration codes at federally qualified health centers: A mixed-methods study.

INTRODUCTION: Despite evidence to support the integration of behavioral health and physical health care, the adoption of Integrated Behavioral Health (IBH) has been stymied by a lack of reliable and sustainable financing mechanisms. This study aimed to provide information on the use of Psychiatric Collaborative Care Model (CoCM) and behavioral health integration (BHI) codes and the implementation of IBH in federally qualified health centers (FQHCs). METHOD: This cross-sectional, mixed-methods study involved an electronic survey of administrators and follow-up qualitative interviews from a subset of survey respondents. Quantitative data were analyzed using descriptive analysis and thematic coding was used to analyze qualitative data to identify salient themes. RESULTS: Administrators (N = 52) from 11 states completed the survey. Use of CoCM (13%) or BHI codes (17.4%) was low. Most administrators were not aware that CoCM (72%) or BHI codes (70%) existed. Qualitative interviews (n = 9) described barriers that further complicate IBH and code use like workforce shortages and insufficient reimbursement for the cost to deliver CoCM services. DISCUSSION: Although FQHCs are working to meet the needs of the communities they serve, a lack of billing clarity and awareness and workforce issues hinder the adoption of the CoCM. FQHCs face many demands to provide care to safety net populations, yet are not fully equipped with the resources, workflows, staffing, and payment structures to support CoCM/BHI billing. Increased financial and logistical support to build practice infrastructure is needed to reduce the administrative complexity and inadequate reimbursement mechanisms that currently hinder the implementation of the CoCM and integrated care delivery. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Are DEA-waivered buprenorphine prescribers colocated with behavioral health clinicians?

BACKGROUND AND OBJECTIVES: Medication for opioid use disorder (MOUD) in primary care includes a combination of medication, behavioral therapy, and/or other psychosocial services. This study assessed rates of colocation between waivered prescribers and behavioral health clinicians across the United States to understand if rates varied by provider type and geographic indicators. METHODS: Data from the DEA-Drug Addiction Treatment Act of 2000 provider list as of March 2022 and the National Plan and Provider Enumeration System's National Provider Identifier database were gathered, cleaned, and formatted in Stata. Data were geocoded with ESRI StreetMap® database and ArcGIS software. Covariates at individual, county, and state levels were examined and compared. Chi-square statistics and a mixed-effects logistic regression were analyzed. RESULTS: The sample (N = 71, 292 prescribers) included physicians (64%), nurse practitioners (29%), and physician assistants (7%). About 48% of prescribers were colocated with a behavioral health clinician. Physicians were the least likely to be colocated (47%), but differences between provider types were modest. We observed significant geographic differences in provider colocation by provider type. Mixed effects logistic regression identified significant predictors of colocation at individual, county, and state levels. DISCUSSION AND CONCLUSIONS: Optimally distributing the workforce providing MOUD is necessary to broadly ensure the provision of comprehensive MOUD care based on practice guidelines. SCIENTIFIC SIGNIFICANCE: Less than half of all waivered prescribers, outside of hospitals, are colocated with behavioral health clinicians. Findings offer greater clarity on where integrated MOUD is occurring, among which types of providers, and where it needs to be expanded to increase MOUD uptake.

Federally Qualified Health Centers Use of Telehealth to Deliver Integrated Behavioral Health Care During COVID-19.

Federally qualified health centers (FQHCs) that provide comprehensive health services, including integrated behavioral health (IBH), transitioned to deliver care via telehealth during the COVID-19 pandemic. This study explored how FQHCs adapted IBH services using telehealth. A mixed-method design was used, pairing a survey disseminated to FQHC administrators with a structured interview. Of the 46 administrators who participated in the survey, 14 (30.4%) reported delivering IBH using telecommunication prior to the pandemic. Since COVID-19, almost all of the FQHCs surveyed used telecommunication to deliver IBH (n = 44, 95.7%). Nine interviews with FQHC administrators resulted in the four themes: telehealth was essential; core components of IBH were impacted; payment parity and reimbursement were a concern; and telehealth addressed workforce issues. Findings confirm the necessity of telehealth for FQHCs during COVID-19. However due to the lack of co-location, warm-handoffs and other core components of IBH were limited.

Frontline, Essential, and Invisible: The Needs of Low-Wage Workers in Hospital Settings During COVID-19.

BACKGROUND: Frontline health care workers are particularly vulnerable to burnout and diminished well-being as they endure COVID-19 pandemic-related stressors. While physicians and nurses are the public face of those experiencing burnout in hospitals, these stressors also affect low-wage workers such as food and housekeeping/janitorial service workers whose roles largely remain "invisible" when conceptualizing the essential health workforce and understanding their needs. This study sought to understand the experiences of frontline essential workers to better support them and prevent burnout. METHODS: Using a semi-structured interview guide, we conducted 20 in-depth qualitative interviews with workers in three U.S. states. Thematic content analysis was conducted to code and analyze interviews. RESULTS: Workers had an average of 5.8 years in their jobs, which included food services, housekeeping/janitorial, and patient transport roles. Analysis revealed four prominent stressors contributing to worker burnout: changes in duties and staff shortages, fear of contracting or transmitting COVID-19, desire for recognition of their job-related risk, and unclear communication on safety precautions and resources. Protective factors included paid time-off, mental health supports, sense of workplace pride, and self-coping strategies. CONCLUSION/APPLICATION TO PRACTICE: As health systems continue to grapple with care delivery in the context of COVID-19, identifying best practices to support all workers and prevent burnout is vital to the functioning and safety of hospitals. Further consideration is warranted to create policies and multipronged interventions to meet workers' tangible needs while shifting the culture, so all members of the health workforce are seen and valued.

Improving the Health of Rural Communities Through Academic-Community Partnerships and Interprofessional Health Care and Training Models.

Health disparities between rural and urban areas are widening at a time when urban health care systems are increasingly buying rural hospitals to gain market share. New payment models, shifting from fee-for-service to value-based care, are gaining traction, creating incentives for health care systems to manage the social risk factors that increase health care utilization and costs. Health system consolidation and value-based care are increasingly linking the success of urban health care systems to rural communities. Yet, despite the natural ecosystem rural communities provide for interprofessional learning and collaborative practice, many academic health centers (AHCs) have not invested in building team-based models of practice in rural areas. With responsibility for training the future health workforce and major investments in research infrastructure and educational capacity, AHCs are uniquely positioned to develop interprofessional practice and training opportunities in rural areas and evaluate the cost savings and quality outcomes associated with team-based care models. To accomplish this work, AHCs will need to develop academic-community partnerships that include networks of providers and practices, non-AHC educational organizations, and community-based agencies. In this commentary, the authors highlight 3 examples of academic-community partnerships that developed and implemented interprofessional practice and education models and were designed around specific patient populations with measurable outcomes: North Carolina's Asheville Project, the Boise Interprofessional Academic Patient Aligned Care model, and the Interprofessional Care Access Network framework. These innovative models demonstrate the importance of academic-community partnerships to build teams that address social needs, improve health outcomes, and lower costs. They also highlight the need for more rigorous reporting on the components of the academic-community partnerships involved, the different types of health workers deployed, and the design of the interprofessional training and practice models implemented.

Prevalence and Characteristics of Providers' Care Coordination Communication With Schools.

OBJECTIVES: Care coordination between schools and medical providers promotes child health, particularly for children with physical, emotional, and behavioral challenges. The purpose of this study was to assess caregivers' reports of provider-school communication for their children. Further, the study assessed if communication rates varied by child demographic or health conditions. METHODS: This study was a cross-sectional analysis of the 2016-2017 National Survey of Children's Health focused on school-aged children (age 6-17 years; n = 18,160). Weighted frequencies overall and stratified by provider-school communication status are reported. Multivariable logistic regression examined associations of provider-school communication. RESULTS: Only 23.5% of the total sample reported provider-school communication. The highest caregiver-reported communication prevalence was for children with diabetes (68.0%). Behavioral/mental health conditions, chronic physical health conditions or having increased medical complexity and needs were significantly associated with increased communication compared to those without these conditions. Odds Ratio (OR) and 95% Confidence Intervals (CI) for children with a behavioral/mental health condition were OR: 1.28; CI: 1.02 to 1.61, for children with a chronic physical health condition were OR: 1.37; CI: 1.15 to 1.63 and for children with special health care needs or with medical complexity were OR: 2.15; CI: 1.75 to 2.64 and OR: 1.77; CI: 1.09 to 2.87, respectively. Significant communication differences existed for every health condition (P < 0.05) except for children who had a blood disorder (P = 0.365). CONCLUSIONS: Caregiver perception of provider-school communication is low and differences in reported rates existed between health conditions and complexity status. Further work is needed to support provider-school-family communication for children with physical, mental, behavioral, and complex health conditions.

What Do EHRs Tell Us about How We Deploy Health Professionals to Address the Social Determinants of Health.

The objective of this study was to determine how well Electronic Health Record (EHR) documentation identifies which health professionals act to address patient social determinants of health (SDOH) and what interventions are documented. The Electronic Medical Record Search Engine was used to identify food and housing insecurity EHR notes. From the notes, researchers randomly sampled 60 from each SDOH category. Of 120 notes, which contained a reference to food or housing insecurity, 72% also contained information on an intervention taken. Interventions were documented by social workers 63% of the time, followed by dietitians and physicians. Addressing patient SDOH is a crucial part of comprehensive healthcare. Findings contribute to a broader conversation on the documentation and interventions in healthcare settings to address patients' SDOH. Findings support the critical importance of standardizing SDOH documentation in the EHR across more members of the health workforce to ensure patient needs are met.

Using Latent Class Analysis to Understand Social Worker Roles in Integrated Health Care.

Purpose: Social work (SW) is a profession that fulfills important roles on integrated health teams, yet there remains a lack of clarity on SW's functions. The current study sought to identify typologies of SW's roles on integrated care teams using latent class analysis (LCA).Method: An electronic survey was developed, piloted, and administered to Masters level SW students and practitioners in integrated health care settings (N = 395) regarding weekly use of interventions. LCA was conducted to estimate latent sub-groups of respondents.Results: Respondents reported an average of 14.6 (SD = 4.7) interventions. Five classes of SW roles were identified and varied by setting and focus. One class (13%) completed a hybrid function providing behavioral health and social care interventions.Conclusions: Classes of SW roles on teams may reflect varying models of integrated care. A flexible SW on the team may adapt to patient and clinic needs, but increases the opportunity for role confusion.

Harnessing the electronic health record to advance integrated care.

INTRODUCTION: Integrated health care is utilized in primary care clinics to meet patients' physical, behavioral, and social needs. Current methods to collect and evaluate the effectiveness of integrated care require refinement. Using informatics and electronic health records (EHR) to distill large amounts of clinical data may help researchers measure the impact of integrated care more efficiently. This exploratory pilot study aimed to (a) determine the feasibility of using EHR documentation to identify behavioral health and social care components of integrated care, using social work as a use case, and (b) develop a lexicon to inform future research using natural language processing. METHOD: Study steps included development of a preliminary lexicon of behavioral health and social care interventions to address basic needs, creation of an abstraction guide, identification of appropriate EHR notes, manual chart abstraction, revision of the lexicon, and synthesis of findings. RESULTS: Notes (N = 647) were analyzed from a random sample of 60 patients. Notes documented behavioral health and social care components of care but were difficult to identify due to inconsistencies in note location and titling. Although the interventions were not described in detail, the outcomes of screening, referral, and brief treatment were included. The integrated care team frequently used EHR to share information and communicate. DISCUSSION: Opportunities and challenges to using EHR data were identified and need to be addressed to better understand the behavioral health and social care interventions in integrated care. To best leverage EHR data, future research must determine how to document and extract pertinent information about integrated team-based interventions. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Victimization and Adversity in Child Welfare Involved Youth: The Cumulative Influence on Child and Caregiver Reported Behavioral Health Symptoms.

Exposure to childhood victimization and adversity (CVA) is pervasive for child welfare (CW) involved youth. However, most research with CW samples has focused on types of maltreatment and fails to recognize the additive influence of exposure to CVA beyond maltreatment. A subsample aged 8 to 17 (n = 1,887) was drawn from the National Survey of Child and Adolescent Well-Being (NSCAW) II. CVA included six domains. Behavioral health was assessed using the Child Depression Inventory, Trauma Symptom Checklist, and the internalizing and externalizing subscales of the Child Behavior Checklist. Logistic regression was used to explore the association between the number of CVA reported and the risk of clinical-range behavioral health symptoms. Analyses were adjusted for the cluster-based sampling design and sampling weights were applied to provide nationally representative estimates. More than 60% of the sample experienced three or more CVA domains. The number of CVAs reported was associated with all four behavioral health outcomes (p < .001). Children exposed to five or more domains were more likely to report high depressive symptoms (odds ratio [OR] = 5.0), high trauma symptoms (OR = 7.0), and to have internalizing or externalizing symptoms reported by caregivers (OR = 18.0), as compared with children reporting one or less CVAs. Youth involved with CW are exposed to staggeringly high rates of CVA beyond maltreatment. For children who are already at great risk for behavioral health challenges, research to understand screening and interventions for CVA is needed to inform policy and practice initiatives to prevent and mitigate harm.

Mapping colocation: Using national provider identified data to assess primary care and behavioral health colocation.

INTRODUCTION: Evidence supports that integrated behavioral health care improves patient outcomes. Colocation, where health and behavioral health providers work in the same physical space, is a key element of integration, but national rates of colocation are unknown. We established national colocation rates and analyzed variation by primary care provider (PCP) type, practice size, rural/urban setting, Health and Human Services region, and state. METHOD: Data were from the Centers for Medicare & Medicaid Services' 2018 National Plan and Provider Enumeration System data set. Practice addresses of PCPs (family medicine, general practitioners, internal medicine, pediatrics, and obstetrician/gynecologists), social workers, and psychologists were geocoded to latitude and longitude coordinates. Distances were calculated; those < 0.01 miles apart were considered colocated. Bivariate and multivariate analyses were conducted, and maps were generated. RESULTS: Of the 380,690 PCPs, > 44% were colocated with a behavioral health provider. PCPs in urban settings were significantly more likely to be colocated than rural providers (46% vs. 26%). Family medicine and general practitioners were least likely to be colocated. Only 12% of PCPs who were the sole PCP at an address were colocated compared with 48% at medium-size practices (11-25 PCPs). DISCUSSION: Although colocation is modestly expanding in the United States, it is most often occurring in large urban health centers. Efforts to expand integrated behavioral health care should focus on rural and smaller practices, which may require greater assistance achieving integration. Increased colocation can improve access to behavioral health care for rural, underserved populations. This work provides a baseline to assist policymakers and practices reach behavioral health integration. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Investigating racial differences in clusters of adverse childhood experiences.

Many researchers have examined the cumulative effects of adverse childhood experiences (ACEs) and found that higher levels of ACEs increase the risk for worsening health conditions. Recent research has moved beyond the simple counting of ACEs, to develop a more nuanced understanding of the ways in which ACEs are experienced. Despite evidence that ACEs are experienced differentially by race, limited attention has been paid to these differences. The objective of the current study is to understand whether groupings of ACEs are experienced similarly across racial groups. A subsample of Latinx, Black, and White children were drawn from the National Survey of Children's Health 2016 data release was used as the sample (N = 43,711). The primary measure included in the study were 9 ACE indicators available in the survey. We use descriptive and latent class analysis to examine whether similar clusters of ACEs appear across racial groups. We found that White children had lower exposure to specific ACEs as well as total number of ACEs compared to non-Latinx Black and Latinx Children. In addition, there was not configural similarity between race/ethnic groups and the latent class structure of ACE exposure varies by child race/ethnicity, suggesting important differences by child race. Understanding the disparities in children's experiences can inform screening and intervention development. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Traumatic Experience, Polytraumatization, and Perinatal Depression in a Diverse Sample of Adolescent Mothers.

This study examines the prevalence of trauma subtypes, polytraumatization, and perinatal depression (PND) in a diverse sample of adolescent mothers to help inform PND prevention, screening, and treatment efforts. We conducted a secondary analysis of a sample (N = 210) of adolescent mothers aged 14 to 20 years from a prospective longitudinal study of PND. Participants were recruited from a county-based, public health prenatal clinic, and data were collected in the prenatal and postpartum periods. In this sample, 81% of adolescent mothers reported at least one trauma experience and 75% reported lifetime experience of intimate partner violence (IPV). The most prevalent trauma types among adolescent mothers reporting PND were sexual trauma prior to age 13 (11.9%), loss of a caregiver or sibling (28.3%), emotional adversity (17.1%), and polytraumatization (43%). Trauma is alarmingly prevalent among adolescent mothers. Results suggest standards of care for adolescent mothers should include screening adolescent mothers for trauma history and provision of appropriate referrals for IPV. Findings support the need for trauma-informed treatment in perinatal public health clinics to decrease potential health risks to both mother and baby.

Where are social workers co-located with primary care physicians?

Social workers are increasingly working in primary care clinics that provide Integrated Behavioral Healthcare (IBH) in which a patient's physical, behavioral, and social determinants of health are addressed on a collaborative team. Co-location, where care is housed in the same physical space, is a key element of IBH. Yet, little is known about the rate of social workers co-located with primary care physicians (PCPs). To identify national rates of social worker co-location, data were drawn from the Centers for Medicare and Medicaid (CMS) National Plan and Provider Enumeration System (NPPES; n = 232,021 social workers, n = 380,690 PCPs). Practice addresses were geocoded and straight-line distances between practice locations of social workers and PCPs were calculated. More than 26% of social workers were co-located with a PCP. However, in rural settings only 21% were co-located (p < .001). Co-location also varied by PCP practice size, specialty, and state. This study serves as a benchmark of the growth of IBH and continued monitoring of co-location is needed to ensure social work workforce planning and training are aligned with changing models of care. Further, identifying mechanisms to support social work education, current providers, and health systems to increase IBH implementation is greatly needed.