Primary care does not reliably meet the needs of patients with mental health, substance abuse, or health behavior (MHSHB) problems, 43-60% of whom are treated solely by a primary care provider (PCP) (Kessler and Stafford 2008). Furthermore, between 50% - 90% of primary care referrals made to out-of- office mental health practitioners fail to result in a follow up appointment (Kessler and Stafford 2008). Although some primary care sites have explored integrating mental health services into their patient care processes, they have neither systematically resolved core issues nor addressed the broad range of needs (mental health, substance abuse, and health behavior issues) presented in primary care settings. The objective of this study is to refine an toolkit previously trialed in to primary care practices using an innovative, evidence-supported model for integrating primary care and behavioral health services. This study will pilot the toolkit in two sites, with the first conducted by an expert facilitator and the second with an on-site facilitator supported remotely. The toolkit is based on "Lean Management," a method of structured, analytically based problem solving focused on work processes. The broad goal of this work is to improve delivery of psychological services to patients who present in primary care settings.
Specific aims :
Aim 1 : Refine a preliminary toolkit based on Lean, by sequentially piloting it in two primary care sites and collecting user feedback on its value. We will use a concurrent, mixed methods approach to obtain provider and staff evaluations of the Toolkit. In the first pilot, an expert outside facilittor will use the toolkit to help a practice team plan the implementation of PCBH and follow activation of the plan. Practice members will provide feedback on the toolkit and on PCBH implementation. After further refinement of the toolkit, the outside expert facilitator will train staff member of a second primary care site as in-practice facilitator. The in-practice facilitator will use the toolkit with the practice to plan the implementation of PCBH. Practice members will again provide feedback on the Toolkit and on PCBH implementation.
Aim 2 : Evaluate the reach and effectiveness of the PCBH Toolkit. We will collect de-identified patient data using an electronic health record (EHR) in each pilot site to report study outcomes as measured by depression severity and, secondarily, access indicators such as treatment initiation and waiting time for scheduled appointments. We will compare measures among patients receiving PCBH services at baseline and 6 months post-implementation at each site. This work will provide a field-tested Toolkit to systematically support the integration of MHSHB within primary care. We anticipate a follow-on multi-site, multi-state study of underserved primary care populations using two large, national practice-based research networks.

Public Health Relevance

Integrating behavioral health clinicians in primary care offices may make it easier for patients to access the mental health, substance abuse, or health behavior services they need, either within the primary care practice or, if needed, in specialist offices elsewhere. Piloting a toolbox of methods to help launch this new primary care specialty in a study using qualitative and quantitative methods will help implement this care model smoothly in terms of clinical, operational, and financial processes that must be in place. The result may be improved patient outcomes, as measured by depression scores, as well as better access to care, as measured by a higher percentage of referrals scheduled, shorter wait times to date of first appointment, and more treatments started. Results can be further tested in larger, future studies.

National Institute of Health (NIH)
Small Research Grants (R03)
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Dissemination and Implementation Research in Health Study Section (DIRH)
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Chambers, David A
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University of Vermont & St Agric College
Family Medicine
Schools of Medicine
United States
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