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Families, Systems, & Health - Vol 35, Iss 3

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Families, Systems, & Health Acting as a vehicle to express the voices of change in the healthcare system with a focus on family, the biopsychosocial model, and collaboration; and to participate in making those changes more humane for patients, families, and healthcare professionals. Families, Systems, & Health is a peer-reviewed, multidisciplinary journal that publishes clinical research, training, and theoretical contributions in the areas of families and health, with particular focus on collaborative family healthcare.
Copyright 2017 American Psychological Association
  • Seeking a wider lens for scientific rigor in emerging fields: The case of the primary care behavioral health model.
    In response to widespread recognition of the need to blend biomedical and psychosocial health care efforts, the primary care behavioral health (PCBH) model has achieved rapid uptake across the United States. Reports of its application come from military sectors, community health centers, and a variety of health care systems, large and small. Examining the PCBH model’s appeal, evidence, and design forces us to confront important questions. These questions and much more are addressed in this issue of Families, Systems, & Health. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Narrative review of provider behavior in primary care behavioral health: How process data can inform quality improvement.
    Objective: Primary care behavioral health (PCBH) is a population-based approach to delivering mental and behavioral health care in the primary care setting. Implementation of the PCBH model varies across practice settings, which can impact how PCBH providers deliver services to patients and in turn may predict a variety of important outcomes. This article aims to characterize PCBH provider engagement in key processes of integrated care as demonstrated in results from empirical studies of real-world clinical practice. Method: For this narrative review of published studies on PCBH provider engagement in processes of care, PubMed and PsycINFO databases were searched from January 1990 through May 2016 to identify relevant articles. Results: Provider adherence to the brief, time-limited treatment model appears suboptimal. Common mental health conditions, such as depression, were often the primary focus of provider attention, with less consistent emphasis on behavioral medicine concerns. Whereas providers regularly conducted qualitative functional assessments with patients, routine use of standardized measures was low. Engagement in interprofessional collaboration with the primary care team was also low, but engagement in behaviors that fostered therapeutic relationships was high. Discussion: This review identified several strengths and weaknesses of typical PCBH provider practices. Results are discussed in relation to their value as areas for future quality improvement initiatives that can improve PCBH service delivery and, ultimately, patient outcomes. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Understanding integrated mental health care in “real-world” primary care settings: What matters to health care providers and clients for evaluation and improvement?
    Purpose: The integration of mental health specialists into primary care has been widely advocated to deliver evidence-based mental health care to a defined population while improving access, clinical outcomes, and cost efficiency. Integrated care has been infrequently and inconsistently translated into real-world settings; as a result, the key individual components of effective integrated care remain unclear. Method: This article reports findings from a qualitative study that explored provider and client experiences of integrated care. We conducted in-depth interviews with integrated care providers (n = 13) and clients (n = 9) to understand their perspectives and experiences of integrated care including recommended areas for quality measurement and improvement. The authors used qualitative content and reflexive thematic analytic approaches to synthesize the interview data. Results: Clients and integrated care providers agreed regarding the overarching concepts of the what, how, and why of integrated care including co-location of care; continuity of care; team composition and functioning; client centeredness; and comprehensive care for individuals and populations. Providers and clients proposed a number of dimensions that could be the focus for quality measurement and evaluation, illuminating what is needed for successful context-sensitive spreading and scaling of integrated care interventions. Conclusion: With a mounting gap between the empirical support for integrated care approaches and the implementation of these models, there is a need to clarify the aims of integrated care and the key ingredients required for widespread implementation outside of research settings. This study has important implications for future integrated care research, and health care provider and client engagement in the quality movement. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Integrated care clinic: Creating enhanced clinical pathways for integrated behavioral health care in a family medicine residency clinic serving a low-income, minority population.
    Introduction: Research examining the implementation and effectiveness of integrated behavioral health (BH) care in family medicine/primary care is growing. However, research identifying ways to consistently use integrated BH in busy family medicine/primary care settings with underserved populations is limited. This study describes 1 family medicine clinic’s transformation into a fully integrated BH care clinic through the development of an Integrated Care Clinic (ICC) and enhanced clinical pathways to promote regular use of behavioral health clinicians (BHCs). Method: We implemented the ICC at the Broadway Family Medicine Clinic serving a low-income (70% African American) in Minnesota. We conducted a pre- and postevaluation of the ICC during regular clinic activity. Results: Pilot findings indicated that the creation of ICC and the use of enhanced clinical pathways (e.g., 5–2–1–0 obesity prevention messages, Transitional Care Management, postpartum depression screening visits, warm hand-offs) to facilitate regular use of integrated BH care resulted in 6 integrated care visits per BHC per clinic half-day. In addition, changes in the behavioral/mental health therapy appointment time slot (from 60 to 30 min) reduced therapy no-show rates. Transitional Care Management (TCM) visits also showed improved pre- and postchanges in patient and clinician satisfaction and reductions in patient hospital readmission rates. Discussion: The transformation into a fully integrated BH family medicine clinic through the creation of ICC and enhanced clinical pathways to facilitate regular integrated BH care showed promising pilot results. Future research is needed to examine associations between ICC and patient outcomes (e.g., weight, depressive symptoms). (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Mixed methods evaluation of a collaborative care implementation using RE-AIM.
    Introduction: Application of the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework using mixed methods to evaluate a collaborative care practice implementation can inform the literature on real-world collaborative care experiences. Method: Two primary care practices serving Niagara Falls, NY, implemented collaborative care. Adults age 18 and over were screened at least annually for depression, anxiety, and alcohol use using the 9-item Patient Health Questionnaire (PHQ-9), the 7-item Generalized Anxiety Disorder questionnaire (GAD-7), and the AUDIT alcohol consumption questionnaire (AUDIT-C). Primary care clinicians referred patients screening positive to the on-site behavioral health care manager (BHCM) with warm handoffs; the BHCM used a mixed therapeutic approach, initiated consultations with a psychiatrist and a community resource liaison as needed, in collaboration with the clinician. External evaluators used mixed methods to assess collaborative care services’ RE-AIM. Results: Nearly 40% of patients screened positive for at least one behavioral healthcare (BH) concern or were referred to BH services upon clinician judgment. Of these patients, 43% were referred to integrated BH services, of whom 86% accepted and 54% actually participated in services. There were no differences in changes in symptoms between those who did and did not participate in services. Patients reported the services were valuable and helped build skills for coping with complex health conditions and psychosocial issues. Discussion: Evaluation of collaborative care using the RE-AIM framework may help others systematically evaluate programs, identify local improvement opportunities, and contribute to the broad literature on integrated care dissemination and implementation. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Where’s the LGBT in integrated care research? A systematic review.
    Introduction: Lesbian, gay, bisexual, and transgender (LGBT) individuals experience more negative health outcomes compared with their heterosexual peers. The health disparities are often related to family and social rejection of the LGBT individuals. Integrated care, and Medical Family Therapy in particular, may aid in addressing the systemic nature of the negative health outcomes. Method: To better understand the current state of the integrated care literature on addressing the health needs of LGBT individuals, a systematic review of the research literature was conducted from January 2000 to January 2016 for articles including integrated health care interventions for LGBT populations. Independent reviewers coded identified articles. Results: Only 8 research articles met criteria for inclusion out of the 2,553 initially identified articles in the search. Results indicated a lack of integrated care research on health care and health needs of LGBT individuals, and none of the articles addressed the use of family or systemic-level interventions. Discussion: Implications for future research and the need for better education training are discussed. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Community health workers in diabetes care: A systematic review of randomized controlled trials.
    Introduction: Maintaining optimal self-care in managing Type 2 diabetes is a common struggle for patients due to several barriers, including access to quality services, financial insecurity and/or lack of insurance, and emotional distress. Consequently, morbidity and mortality rates are high, alongside rising health care costs. Alternative approaches that address common barriers require further investigation. This systematic review of randomized controlled trials examines the effectiveness of using community health workers (CHWs) in Type 2 diabetes care. This effort is warranted to orient practitioners and researchers to the state of existing knowledge, and to direct clinical practice and future research. Method: Data were extracted from 17 peer-reviewed articles; they were examined with respect to theory integration, CHW intervention design, outcome variables, and findings. Results: Approximately one-third of articles explicitly integrated theory into their research conceptualization and design. There was great variation across intervention dosages, attrition rates, and methods of CHW training. Main foci across studies’ findings suggest that a CHW intervention has significant impacts on physical health outcomes, diabetes knowledge, self-care behaviors, and emotional distress and well-being. Discussion: Principal implications relate to the need for more research regarding CHW intervention types and methods, and further investigation about the mechanisms of change within a CHW-delivered intervention. Findings support the case for more CHWs in treatment teams to bridge patients with the medical system. This research will serve to better equip providers in the support of patients managing Type 2 diabetes and advance the Triple Aim of health care. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Promoting Resilience in Stress Management for Parents (PRISM-P): An intervention for caregivers of youth with serious illness.
    Introduction: It is well-known that parental stress and coping impacts the well-being of children with serious illness. The current study aimed to evaluate the feasibility and satisfaction of a novel resilience promoting intervention, the Promoting Resilience in Stress Management Intervention for Parents (PRISM-P) among parents of adolescents and young adults with Type 1 diabetes or cancer. Secondary analyses explored the effect of the PRISM-P on parent-reported resilience and distress. Method: The PRISM-P includes 4 short skills-based modules, delivered in either 2 or 4 separate, individual sessions. English-speaking parents of adolescents with cancer or Type 1 diabetes were eligible. Feasibility was conservatively defined as a completion rate of 80%; satisfaction was qualitatively evaluated based upon parent feedback regarding intervention content, timing, and format. Resilience and distress were assessed pre- and postintervention with the Connor Davidson Resilience Scale and the Kessler-6 Psychological Distress Scale. Results: Twelve of 24 caregivers of youth with diabetes (50%) and 13 of 15 caregivers of youth with cancer (87%) agreed to participate. Nine of 12 (75%) and 9 of 13 (64%) completed all PRISM-P modules, respectively. Among those who completed the intervention, qualitative satisfaction was high. Parent-reported resilience and distress scores improved after the intervention. Effect sizes for both groups indicated a moderate intervention effect. Discussion: Ultimately, the PRISM-P intervention was well accepted and impactful among parents who completed it. However, attrition rates were higher than anticipated, suggesting alternative or less time-intensive formats may be more feasible. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Integrated behavioral health training for primary care clinicians: Five lessons learned from a negative study.
    Introduction: There are very few studies examining the effectiveness of integrated behavioral health training for primary care clinicians. The purpose of this article is to review the findings of a negative study examining the effectiveness of medical resident training in integrated behavioral health and offer specific ideas for future research in workforce development. Methods: Twenty-three family medicine residents from a community-based residency program in the mid-Atlantic region completed a required rotation in which they consulted with behavioral health in primary care, observed psychotherapy, read behavioral medicine books, and received individual instruction. Fourteen residents completed a survey pre- and postrotation, and all 23 residents completed a semistructured interview postrotation. Results: Survey findings demonstrate that resident attitudes about collaboration and behavioral health consultants did not significantly change as a result of the rotation. Findings also show that internal referral orders for behavioral health services dropped sharply after the rotation. Qualitative data suggest that residents value integrated behavioral health. Discussion: There are five lessons to learn from this negative study: learning outcomes should match learning activities, residents benefit from direct observation, longitudinal data help measure change over time, collaborative care curriculum evaluation deserves collaborative partnership with other training sites, and evaluating the resident and the behavioral health provider offers a systems viewpoint and new insights. Future research should identify core knowledge and skills for primary care clinicians working in settings with integrated behavioral health and evaluate the long-term effectiveness of a curriculum based on those competencies. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Group education sessions for women veterans who experienced sexual violence: Qualitative findings.
    Introduction: The impact of sexual violence (SV) on mental health, self-care, and interpersonal relationships is profound and poses special challenges to health care delivery. Reproductive health care merits special attention because the care required may be linked to reminders of past abuse. We explored facilitators and barriers affecting the use of reproductive health services among women veterans with a history of SV. Method: Between June and September 2015, we conducted 2 focus groups and 3 general education sessions with 27 female veterans with a history of SV at 1 medical center. We analyzed transcripts according to applied thematic analysis and used Nvivo software for data management and retrieval. Results: Three main themes emerged from the focus groups and education sessions. Participants: (a) expressed a desire for greater agency in relation to the control they have over their bodies and medical care; (b) described how posttraumatic stress symptoms are retriggered during medical care; and (c) expressed needs for additional education, peer and provider support within the medical system. Discussion: For women with a history of SV, multiple individual and systemic barriers complicate how they utilize reproductive health services. Group education sessions were an effective mode of support, information and connection to other women within the Veterans Health Administration. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Accelerating delivery of trauma-sensitive care: Using multilevel stakeholder engagement to improve care for women veterans.
    Engaging women Veterans with trauma histories in the design of innovations for their own care in partnership with providers and staff and other multilevel stakeholders holds promise for accelerating delivery of trauma-sensitive care. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Can brief behavioral health interventions reduce suicidal and self-harm ideation in primary care patients?
    Objective: We examined whether brief behavioral health visits reduced suicidal and self-harm ideation among primary care patients and compared the effectiveness of interventions that targeted ideation directly (i.e., safety planning) with those that targeted ideation indirectly through management of underlying mental illness (e.g., behavioral activation). Method: We examined first- and last-visit data from 31 primary care patients with suicidal or self-harm ideation seen by behavioral health consultants. Results: Patients reported significantly lower frequencies of suicidal and self-harm ideation at their final visit than at their initial visit. Patients whose ideation was targeted directly showed greater improvements than patients whose ideation was targeted indirectly. Discussion: Although preliminary, results suggest mild to moderate suicidal ideation could be addressed in primary care through integration of behavioral health consultants into the medical team. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • A good daddy.
    This personal narrative presents the imagined inner dialogue of my father, when caring for me as a young sickly child. It is a compassionate exercise in attempting to understand the remote inner emotional world of my father, a Holocaust survivor, as he contended with my ongoing medical challenges that perhaps triggered his traumatic memories from the war. I am the daughter who eventually grew up to be a physician herself. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Finding a voice in integrated pediatric primary care.
    This narrative essay follows a psychology fellow discovering her role in an integrated pediatric primary care practice and the patient-centered care that manifests therein. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • “Back-up heart."
    Presents a 55-word story on the experience of providing an emergency procedure to keep a patient's heart pumping. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • De-prescription.
    Deprescribing is the removal or reduction of medications to improve patient function and quality of life. Despite potential benefits, patients who have received medications from trusted clinicians may resist deprescription, as they fear return of medical problems, use medications to cope, or view them as instruments to benefit health or prolong life. Deprescribing clinicians often struggle with opposition and patient distress as they seek to enhance patient well-being. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Review of Integrated behavioral health in primary care: Step-by-step guidance for assessment and intervention (Second edition).
    Reviews the book, Integrated Behavioral Health in Primary Care: Step-By-Step Guidance for Assessment and Intervention (Second Edition) by Anne C. Dobmeyer, Mark S. Oordt, Jeffrey L. Goodie, and Christopher L. Hunter (see record 2016-59132-000). This comprehensive book is well organized and covers many of the complex issues faced within the Primary Care Behavioral Health (PCBH) model and primary care setting: from uncontrolled type II diabetes to posttraumatic stress disorder. Primary care has changed since the initial release of this book, and the second edition covers many of these changes with up-to-date literature such as population health and the patient-centered medical home. The book is organized into three parts. The first three chapters describe the foundation of integrated behavioral consultation services. The next 12 chapters address common behavioral health issues that present in primary care. Last, the final two chapters focus on special topics such suicidal behavior and designing clinical pathways. This was an enjoyable read and worth the investment— especially if you are a trainee or a seasoned professional new to the practice of integrated behavioral health in primary care. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • An interview with Neftali Serrano, PsyD: Collaborative family healthcare association’s new executive director.
    The Collaborative Family Healthcare Association (CFHA) is continually evolving along with policies, funding, and models of healthcare in the U.S. With a vision of integrated healthcare for all as the standard of care, the new executive director of CFHA describes his perspective on how we can move closer towards this vision, the remaining barriers, models of integration, and why CFHA is a unique and necessary professional organization for those with a passion for delivering whole-person comprehensive healthcare. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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