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

2. 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.

3. 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

4. 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

5. 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

6. 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.

7. Practice Locations

8. 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

9. 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.

10. 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

11. 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

12. 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.)

13. 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)

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

15. Timeline