Integrating Behavioral Health and Primary Care for Comorbid Behavioral and Medical Problems

Research Questions Does integration of behavioral health and primary care services, compared to simple co-location, improve patient-centered outcomes in patients with multiple morbidities? Aim 1: Determine if increased integration results in better patient-centered outcomes. Aim 2: Determine if protocolized process techniques are effective in increasing BH integration. Aim 3: Explore how contextual factors affect the implementation and patient-centeredness of integrated BH care.

Integrated Behavioral Health Shared space Shared records Evidence-based BH services Automatic systems for managing BH patients: Screening Scheduling Monitoring Follow-up Frequent communication among providers Stable reimbursement for BH services

What does it take to integrate? Tactics Protocolized Process Skills Institutional Support   A. Identification B. Assessment C. Treatment D. Surveillance Environmental and Organizational Context Clinical Tasks Care Structure Leadership Medical Services Behavioral Health Services Integrated Things that matter to patients and families Patient-Centered Outcomes

Intervention Online Skills training for BH providers, PCPs and staff A Toolkit of suggested tactics for integrating Protocolized Process for facilitated redesign of Primary Care practices Remote coaching of in-house facilitator 12 hour intensive team exercise to plan changes Toyota Production System LEAN method

Practices Family Practice or General Internal Medicine Commitment to having a BH clinician onsite for 5 years Willing to engage in integration efforts Electronic medical records Private practices, Federally Qualified Health Centers, Academic clinics, etc.

Practice Locations

Patients Adults Receive care in a participating practice for at least one year At least one chronic medical problem At least one Behavioral Health problem Identified by electronic medical records review Telephone consent

Subject Identification C. Study Subjects Panel: Medical and behavioral problems and consent to study (n=75)   A. Community panel of unselected adults (n=~1,000) B. Target medical and behavioral problems identified by EHR (n=~300) All patients in the practice.

Subject Identification A. Community Patient Panel   C. Study Subject Panel D. Identified and treated patients Co-location All patients in the practice (Group B not shown) Integration Subject Identification by Phase

Practice Outcomes Degree of integration achieved Did the intervention make changes in the practice? PIP What happened inside the practice? Qualitative analyses Surveys and focus groups Staff Providers Patients

Patient Outcomes PROMIS-29 (Symptoms & Functional Status) Communication Empathy Self-management Adherence Time lost to disability Emergency Room and hospital visits Disease specific outcomes (blood sugar control, blood pressure, etc.)

Design: Cluster Randomized Trial 20 practices randomized to integration 20 practices randomized to stay in co-location Recruit a random sample of 75 patients per practice Assess patients (and practices) at baseline and every 12 months Unit of randomization is the practice (n=40) Unit of analysis is the patient (n=3,000)

Practice Redesign Process Study Design Integration Eligible Practices Randomize Baseline Measures Practice Redesign Process Follow-up Measures Usual Care Co-location

Timeline