Longitudinal Outcomes After Brief Behavioral Health Intervention in an Integrated Primary Care Clinic

Nellis Air Force Base, NV, USA.
Families Systems & Health (Impact Factor: 1.13). 01/2012; 30(1):60-71. DOI: 10.1037/a0027029
Source: PubMed


The primary aim of the current study was to obtain information about the longitudinal clinical functioning of primary care patients who had received care from behavioral health consultants (BHCs) integrated into a large family medicine clinic. Global mental health functioning was measured with the 20-item self-report Behavioral Health Measure (BHM), which was completed by patients at all appointments with the BHC. The BHM was then mailed to 664 patients 1.5 to 3 years after receipt of intervention from BHCs in primary care, of which 70 (10.5%) were completed and returned (62.9% female; mean age 43.1 ± 12.7 years; 48.6% Caucasian, 12.9% African American, 21.4% Hispanic/Latino, 2.9% Asian/Pacific Islander, 10.0% Other, 4.3% no response). Mixed effects modeling revealed that patients improved from their first to last BHC appointment, with gains being maintained an average of 2 years after intervention. Patterns of results remained significant even when accounting for the receipt of additional mental health treatment subsequent to BHC intervention. Findings suggest that clinical gains achieved by this subset of primary care patients that were associated with brief BHC intervention were maintained approximately 2 years after the final appointment.

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    • "A majority of the items included on the PPAQ belong to the practice and session management, clinical scope, and interventions domains. This finding is not surprising because previously published CCC literature [6,43] focuses heavily on the population-based framework of the model that emphasizes providing easily accessible care to a large number of patients with a wide range of acute, chronic, and preventive medicine concerns [14]. Providing population-based care impacts BHP clinical behaviors directed toward a brief, time-limited treatment model compared to specialty mental health settings which do not follow that framework. "
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    ABSTRACT: Background The integration of behavioral health services into primary care is increasingly popular, yet fidelity of implementation in this area has been infrequently assessed due to the few measurement tools available. A sentinel indicator of fidelity of implementation is provider adherence, or utilization of prescribed procedures and engagement in model-specific behaviors. This study aimed to develop the first self-report measure of behavioral health provider adherence for co-located, collaborative care, a commonly adopted model of behavioral health service delivery in primary care. Methods A preliminary 56-item measure was developed by the research team to represent critical components of adherence among behavioral health providers. To ensure the content validity of the measure, a modified Delphi study was conducted using a panel of co-located, collaborative care model experts. During three rounds of emailed surveys, panel members provided qualitative feedback regarding item content while rating each item’s relevance for behavioral health provider practice. Items with consensus ratings of 80% or greater were included in the final adherence measure. Results The panel consisted of 25 experts representing the Department of Veterans Affairs, the Department of Defense, and academic and community health centers (total study response rate of 76%). During the Delphi process, two new items were added to the measure, four items were eliminated, and a high level of consensus was achieved on the remaining 54 items. Experts identified 38 items essential for model adherence, six items compatible (although not essential) for model adherence, and 10 items that represented prohibited behaviors. Item content addressed several domains, but primarily focused on behaviors related to employing a time-limited, brief treatment model, the scope of patient concerns addressed, and interventions used by providers. Conclusions This study yielded the first content valid self-report measure of critical components of collaborative care adherence for use by behavioral health providers in primary care. Although additional psychometric evaluation is necessary, this measure may assist implementation researchers in clarifying how provider behaviors contribute to clinical outcomes. This measure may also assist clinical stakeholders in monitoring implementation and identifying ways to support frontline providers in delivering high quality services.
    Implementation Science 02/2013; 8(1):19. DOI:10.1186/1748-5908-8-19 · 4.12 Impact Factor
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    ABSTRACT: To model typical trajectories for improvement among patients treated in an integrated primary care behavioral health service, multilevel models were used to explore the relationship between baseline mental health impairment level and eventual mental health functioning across follow-up appointments. Data from 495 primary care patients (61.1% female, 60.7% Caucasian, 37.141 ± 12.21 years of age) who completed the Behavioral Health Measure (Kopta & Lowry, 2002) at each primary care appointment were used for the analysis. Three separate models were constructed to identify clinical improvement in terms of number of appointments attended, baseline impairment severity level, and the interaction of these 2 variables. The data showed that 71.5% of patients improved across appointments, 56.8% of which (40.5% of the entire sample) was clinically meaningful and reliable. Number of appointments and baseline severity of impairment significantly accounted for variability in clinical outcome, with trajectories of change varying across appointments as a function of baseline severity. Patients with more severe impairment at baseline improved faster than patients with less severe baseline impairment. Patients treated within an integrated primary care behavioral health service demonstrate significant improvements in clinical status, even those with the most severe levels of distress at baseline.
    Journal of Consulting and Clinical Psychology 03/2012; 80(3):396-403. DOI:10.1037/a0027726 · 4.85 Impact Factor
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    ABSTRACT: Integrated behavioral health care is a complex, multifaceted healthcare delivery approach that is geared towards addressing mental and behavioral health concerns in primary care. There are a number of different models for integrated behavioral health care, with components that can be conceptualized as structures of care, processes of care, or principles of care. Common models include the IMPACT model (care management for depression), the three-component model (care management, enhanced mental health support, and a prepared practice), and the primary mental health care model of colocated collaborative care (on-site mental health specialists who collaborate with primary care providers), among others. Meta-analysis has shown that integrated behavioral health care improves health outcomes, although the extant evidence primarily pertains to depression. It is not well known which components of integrated behavioral health care are either necessary or sufficient for improving outcomes. There are many evidence gaps in collaborative care, including implementation and dissemination and the effects of integrated behavioral health care on disease contexts other than depression, behavioral medicine (i.e., lifestyle change in primary care), diverse populations, cost and sustainability outcomes. Multiple methodologies should be deployed to address these gaps, including quasi-experimental, mixed methods (quantitative and qualitative), and observational designs.
    Integrated Behavioral Health in Primary Care: Evaluating the Evidence, Identifying the Essentials, Edited by M. R. Talen, A. Burke Valeras, 01/2013: chapter 5: pages 65-98; Springer Science+Business Media.
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