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Families, Systems, & Health - Vol 35, Iss 2

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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
  • To clinician innovators: A special invitation.
    Our vision for this special issue was simple: to inspire clinician innovators working in integrated care to not only consume the literature but also contribute to it. Growing the research capacity of clinician innovators in integrated care is vital for at least three reasons. First and foremost, real-world clinicians have an excellent vantage on the processes and outcomes that relate to the reach or the extent to which the given intervention or model of care engages its intended audience (Klesges, Estabrooks, Dzewaltowski, Bull, & Glasgow, 2005). Second, policy changes within the Affordable Care Act have facilitated the rapid uptake of integrated care in recent years (Beacham, Kinman, Harris, & Masters, 2012; Nash, Khatri, Cubic, & Baird, 2013), but the growth of the published evidence base has not kept pace. Third, clinician innovators in integrated care are well positioned to contribute to the evidence base because of the growing emphasis on demonstrating outcomes in health care. Many of the articles in this special issue highlight specific recommendations that clinician innovators can make to transform a local evaluation into one that produces generalizable findings worthy of publication. Our hope is that this special issue can help dismantle the “research” stereotype and inspire future clinician innovators to become more active participants. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • The role of policy in supporting clinician-led research on behavioral health integration.
    In Best Care at Lower Cost, the Institute of Medicine laid out a vision for continuously learning health systems (Institute of Medicine of the National Academies, 2016). This issue of Families, Systems, & Health represents a substantial step toward this vision, with on-the-ground clinicians and administrators testing empirically informed hypotheses about practice transformation and population health management, and using those results to produce shared learning within and across systems. While the studies in this issue demonstrate that producing generalizable knowledge from clinician-led initiatives is feasible, they also demonstrate that the current system does not adequately support clinicians in doing so. To achieve the triple aim of better care, lower costs, and healthier people, health care will need innovation at all levels of payment and delivery (Berwick, Nolan, & Whittington, 2008), and to pursue the suggested fourth aim – “improving the work life of those who deliver care” – clinicians on the ground who lead innovations will need to be supported (Bodenheimer & Sinsky, 2014). This issue of Families, Systems, & Health demonstrates that health policy will need to adapt to better support and foster emerging clinician-innovators, who can be crucial partners in producing the knowledge necessary to improve our nation’s health care systems, bringing us closer to the triple aim. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Real-world program evaluation of integrated behavioral health care: Improving scientific rigor.
    Introduction: Designing systematic, scientifically rigorous program evaluations (PE) is 1 way to contribute to the significant need to build best practices and a stronger evidence base for integrated behavioral health care. However, there are many potential pitfalls when conducting PE in real-world settings, and many clinicians and administrators may be hesitant to engage in PE due to lack of training or resources. Rigorous PE can be achieved feasibly and efficiently. Method: This article discusses common challenges that arise when conducting PE in integrated behavioral health care settings and illustrates ways to increase the methodological quality of PE efforts using lessons learned from 2 real-world case examples. The first example included a PE of a training program for brief alcohol interventions, and the second example included a PE of a depression medication monitoring service. Results/Discussion: The case examples demonstrate the need for strategic planning beforehand, including the use of a conceptual framework as well as appropriate study designs/methodology, measurement, and the need for consistency to achieve a well-designed PE. Using the recommendations within this article, it is hoped that the quality of PEs can be improved resulting in more generalizable data that can be used to inform organizations and policymakers to improve health care delivery. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Using implementation science to guide the integration of evidence-based family interventions into primary care.
    This article is a demonstration of how an implementation-science (IS) framework can be coupled with the measurement of implementation outcomes to effectively integrate evidence-based family interventions in primary care. The primary care environment presents a number of challenges for successfully integrating such interventions. However, IS methods can improve the prospect of successfully implementing a new intervention while simultaneously and rigorously evaluating the impact on salient outcomes. We used our experiences across 2 pilot trials in which the family check-up (Smith, Montaño, Mauricio, Berkel, & Dishion, 2016), an evidence-based family intervention, was integrated into primary care. In these pilot trials, the exploration, preparation, implementation, and sustainment (EPIS) framework and the Proctor et al. taxonomy of implementation outcomes were used to guide the implementation and evaluate its success. Grounding our presentation in our pilot work offers an illustration of applying the EPIS framework and outcomes measurement to real-world problems and contexts. When embarking on new efforts to integrate behavioral interventions into health-care settings, the application of IS frameworks and measurement strategies can create generalizable knowledge that substantively contributes to a sparse literature. Today, those “in the trenches” who are translating evidence-based interventions to their setting can contribute to the corpus of research in integrated care by using IS methods to plan a new program and evaluate its feasibility, adoption, and reach. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • A systematic review of evaluation research in integrated behavioral health care: Operational and financial characteristics.
    Introduction: Integrated behavioral health care (IBHC) is an emerging solution for the delivery of behavioral health in primary care contexts. Although IBHC has been implemented and studied for more than 2 decades, little seems to be known about how it is best evaluated. This article illustrates a framework for IBHC evaluation based on the Three World view (with a focus on the operational and financial worlds) and delivers results from a systematic review on the operational and financial characteristics of existing IBHC research. Method: This study identified original reports of research that included an evaluation or assessment of the operational or financial success or sustainability of IBHC sites or programs. Results: A total of 3,386 articles were found through the selected databases and 46 articles were found to meet the inclusion criteria. From the 46 articles that contained an IBHC evaluation including operational or financial variables, 9 operational and 11 financial characteristics were identified as barriers or strengths to sustainability or success. The characteristics of the evaluation participants, IBHC settings, and method of evaluation were also coded and analyzed. Discussion: As a result of this systematic review of articles, evaluation of the success and sustainability of the operational and financial worlds can now be conceptualized at provider and practice levels. Collaboration and communication between medical and behavioral health providers was a significant operational characteristic related to success and sustainability. Financial characteristics indicated that continuous financial evaluation throughout implementation was important to success and sustainability. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Identifying trajectories of change to improve understanding of integrated health care outcomes on PTSD symptoms post disaster.
    Introduction: Addressing life stressors is an important function for integrated care, especially for health care homes located in disaster prone environments. This study evaluated trajectories of change for patients with postdisaster posttraumatic stress disorder (PTSD) who were seen in integrated care. In addition to describing the results, this article provides the methods of subgroup analyses as this may be useful for others working in real-world practice. Method: Patients (N = 340) receiving services at 5 rural health clinics self-reported PTSD symptoms as part of an ongoing evaluation to study the effectiveness of integrated health. Analysis of variance was used to assess differences overtime and trajectories were identified with cluster analyses. Disaster and trauma related factors associated with these trajectories were assessed using logistic regression. Results: Significant overall decreases in PTSD symptoms overtime were found; individual trajectories were identified and include stable low, steep declines, stable high symptoms, and increasing symptoms. Stress related to disaster and the number of other traumas patients experienced correctly classified trajectory membership. Discussion: Trajectories indicate that patients have differing treatment needs and cluster analysis as an evaluation technique may be useful in identifying what treatment works and for whom. The present study addresses a major concern for health care providers serving disaster prone communities and emphasizes the importance of identifying pre incident and disaster related risk vulnerabilities that contribute to mental health outcomes. Subgroup analyses are a useful tool for developing more targeted treatment within integrated care and may be an accessible research strategy for others working in such settings. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Integrated care in rural health: Seeking sustainability.
    Introduction: The increased awareness of the financial impact associated with social determinants of health coincides with expectations of the Affordable Care Act (HR 3590) to improve care while reducing costs. The integration of behavioral health providers (BHPs) into primary care has demonstrated improved clinical outcomes. This study was designed with 2 aims, including the evaluation of the financial viability of an integrated care model in a rural setting and the demonstration of incorporating practice-based research into clinical work. Method: A rural health plan caring for 22,000 members funded a pilot project placing BHPs in 3 clinics to provide integrated care. Patient utilization of medical services for 6 months following BHP services was compared with baseline utilization. Results: The BHPs treated 256 unique patients, with a total of 459 consultations. The percentage of patients receiving BHP services varied between clinics (Clinic A = 1.4%, Clinic B = 2.7%, and Clinic C = 3.9%). A between-clinic analysis showed differences in medical claims data between baseline and post-BH services. The overall effect sizes for reduced medical utilization for patients at clinics B and C were very large, Hedge’s g = −2.31 and −4.79, respectively. Utilization of 4 of the services (emergency, lab, outpatient, and primary care) showed the large reductions in their costs. In contrast, the data for Clinic A showed no change. Discussion: Patients receiving behavioral health services within the integrated care model may decrease utilization of medical services following treatment, resulting in cost offset. Potential reasons for variability between clinics are discussed. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Using standardized patients as a means of training and evaluating behavioral health consultants in primary care.
    Introduction: The Health Federation of Philadelphia, which hosts a network of Behavioral Health Consultants (BHC) operating within the Primary Care Behavioral Health model (PCBH), identified a need to systematically evaluate PCBH model fidelity and to rigorously evaluate the competency assessment process to further their workforce development. A simulated patient exercise was developed for evaluating BHC PCBH specific competencies. Method: A simulated BHC encounter was held at a clinical learning center using standardized patients, repeated twice over 2 years. A competency based rating scale was developed by the network for the simulation (BHC-ORS), patient feedback was captured using the Working Alliance Inventory (WAI), and BHC feedback was collected using a questionnaire. Dedicated consultants were hired to develop the internal process, as well as conduct the evaluation in a way that might make a contribution to research. Results: Targeted PCBH competencies generally improved after being identified as training needs in Year 1 of the simulation. Patient feedback showed average ratings for the majority of the BHCs. BHCs identified the experience as valid and useful. Important changes in methodology between Years 1 and 2 of the pilot limited a more complete analysis. Discussion: The use of simulated patients to evaluate BHC adherence to the PCBH model was helpful for training and adds to the workforce development literature. The authors suggest that doing practice based research will always entail unanticipated needs that interfere with quantitative research but that there are ways in which researchers can attempt to anticipate these changes. Review of possible applications to community PCBH practice is included. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Initial examination of characteristics of patients who are high utilizers of an established primary care behavioral health consultation service.
    Obective: Although much has been studied regarding high-utilizing patients of medical services, no studies have been published regarding high-utilizing patients of integrated primary care behavioral health (PCBH) services. The primary purpose of the current study was to examine characteristics of high-utilizing patients of PCBH services and model adherence. The secondary purpose was to describe the process of conducting this research by clinicians in integrated care. Method: Data were obtained from electronic health records retrospectively for the study’s time period, 2007–2013, for the sample of all patients who met with the behavioral health consultation team during that time. Variables include demographics, diagnoses, involvement in additional services, and scores on a patient-complexity scale for a subset of patients. Chi-square analyses, t tests and logistic regression analyses were performed. Results: The results demonstrate significant associations between key demographic characteristics, use of population-based augmentation services (i.e., consulting psychiatry, care management, substance-abuse consulting), and high-utilizing status. Model adherence was maintained over time. Logistic regression analysis, controlling for high-utilizing status and number of visits, demonstrated a significant relationship between more complex diagnostic categories and behavioral health issues. Discussion: There are differences between high-utilizing patients and nonhigh-utilizing patients suggestive of increased clinical severity and appropriate use of services while maintaining PCBH model integrity. The use of the population-based augmentation services is associated with high-utilizer status, and reflects the ability of these services to target those patients who most need the clinical care. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Need, access, and the reach of integrated care: A typology of patients.
    Introduction: This paper is a report on a study exploring a potential typology of primary care patients referred for integrated behavioral health care (IBHC) services. We considered whether primary care patients could be grouped into meaningful clusters based on perceived need for behavioral health services, barriers to accessing care, and past-year service utilization. We also described the development of a working partnership between our university-based research team and a federally qualified health center (FQHC). Method: A total of 105 adult primary care patients referred for same-day behavioral health appointments completed a brief self-report questionnaire assessing past-year behavioral health concerns, service utilization, and perceived barriers to utilization. Results: Hierarchical and k-means cluster analyses revealed 3 groups: (a) Well-Served patients, characterized by high perceived need for services, high service use, and low barriers to service use (40%); (b) Underserved patients, characterized by high perceived need, low service utilization, and high barriers to service use (20%); and (c) Subclinical patients, characterized by low perceived need, low service use, and low barriers to service use (20%). Clusters were reliably differentiated by age, primary language, insurance status, and global functioning. Discussion: We found primary care patients could be grouped into 3 categories and that 60% (Underserved and Subclinical) represented groups less commonly seen in traditional mental health (MH) settings. IBHC may be a promising approach for extending the reach of MH care, and partnerships between FQHCs and university-based research teams may be a promising approach for conducting research on the IBHC service-delivery model. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Development and implementation of a psychotherapy tracking database in primary care.
    Introduction: Although there is a rapid increase in the integration of behavioral health services in primary care, few studies have evaluated the effectiveness of these services in real-world clinical settings, in part due to the difficulty of translating traditional mental health research designs to this setting. Accordingly, innovative approaches are needed to fit the unique challenges of conducting research in primary care. The development and implementation of one such approach is described in this article. Method: A continuously populating database for psychotherapy services was implemented across 5 primary care clinics in a large health system to assess several levels of patient care, including service utilization, symptomatic outcomes, and session-by-session use of psychotherapy principles by providers. Results: Each phase of implementation revealed challenges, including clinician time, dissemination to clinics with different resources, and fidelity of data collection strategy across providers, as well as benefits, including the generation of useful data to inform clinical care, program development, and empirical research. Discussion: The feasible and sustainable implementation of data collection for routine clinical practice in primary care has the potential to fuel the evidence base around integrated care. The current project describes the development of an innovative approach that, with further empirical study and refinement, could enable health care professionals and systems to understand their population and clinical process in a way that addresses essential gaps in the integrated care literature. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Reducing hospital readmission through team-based primary care: A 7-week pilot study integrating behavioral health and pharmacy.
    Introduction: A team-based service delivery model was applied to provide patients with biopsychosocial care following hospital discharge to reduce hospital readmission. Most previous interventions focused on transitions of care occurred in the inpatient setting with attention to predischarge strategies. These interventions have not considered psychosocial stressors, and few have explored management in primary care settings. Method: A 7-week team-based service delivery model was implemented in a family medicine practice emphasizing a biopsychosocial approach. A physician, psychologist, pharmacist, care managers, and interdisciplinary trainees worked with 17 patients following hospital discharge. This comprehensive evaluation assessed patients’ mood, cognitive abilities, and self-management of health behaviors. Modifications were made to improve ease of access to outpatient care and to improve patient understanding of the therapeutic plan. This pilot study was conducted to determine the utility of the model. Results: Of 17 patients, 15 individuals avoided readmission at 30- and 90-day intervals. Other substantial benefits were noted, including reduced polypharmacy, engagement in specialty care, and reduction of environmental stressors to improve access to care. The clinic in which this was implemented is currently making efforts to maintain this model of care based on observed success. Discussion: Although this work only represents a small sample, results are encouraging. This model can be replicated in other primary care settings with specialty clinicians on site. Specifically, approaches that promote a team-based delivery in a primary care setting may support improved patient outcomes and reduced overall systems’ costs. Recommendations for research in a clinical setting are also offered. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Integrated behavioral health practice facilitation in patient centered medical homes: A promising application.
    Introduction: The purpose of this study was to assess the degree of behavioral health (BH) integration change in patient-centered medical homes (PCMHs) when using a practice facilitator (PF) specially trained in implementing integrated care and how a quasi-experimental design assists in this process. Method: Twelve PCMHs, 8 Federally Qualified Health Centers and 4 private practices, with varying degrees of BH services participated in this study. The degree of BH integration was assessed with a quasi-experimental design using the Maine Health Access Foundation’s Site Self Assessment (MeHAF SSA) at baseline and after implementing site-specific BH services. The sites tracked completion of unique objectively measured goals being implemented using the Goal Attainment Scale (GAS) score. Results: At the conclusion of the study, sites saw a statistically significant increase in the level of BH integration from a baseline of 2.73 (SD = 0.44) to a postintervention score of 3.49 (SD = 0.22) with improvements from mild-moderate overall integration to moderate-advanced overall integration (p <.001). In addition, 10 out of the 12 sites achieved successful implementation of unique goals with assistance from the PF. Discussion: This study provides the first quasi-experimental/pretest-posttest evidence utilizing real-world data that the practice facilitation method is an effective solution toward increasing the degree of BH integration. This paper describes the real-world efforts to evaluate the degree of BH integration change in PCMHs when using a PF with content expertise in BH integration within primary care. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Evaluating transformation with available resources: The influence of APEX on depression screening.
    Objective: The University of Colorado developed and piloted a team-based primary care delivery model called ambulatory process excellence (APEX) in a family medicine residency in 2015. We evaluated its impact on depression screening using found data and tools readily available to practice-based evaluators. Method: The APEX model calls for 5 medical assistants (MAs) supporting 2 providers. MAs have dedicated time to provide delegated care, including depression screening with 2 versions of the Patient Health Questionnaire: PHQ-2 and PHQ-9. Using an interrupted time-series-with-control design, we created longitudinal profiles of the pilot and a control practice using statistical process control charts. We obtained data from preexisting dashboards derived from the electronic medical record. Outcomes included PHQ-2 screening rates, patients screening positive, and the proportion of them completing a PHQ-9. Covariates included monthly visits and new-patient appointments. Using Microsoft Excel, we transformed all data into modified z scores, plotted them on a multivariate control chart for each practice, and assessed them for evidence of special cause variation. Key informants provided information about potentially confounding concurrent events. Results: Compared with baseline, the intervention practice significantly increased primary care medical visits and new-patient appointments, increased positive PHQ-2 patients, and improved PHQ-9 completion. High screening rates remained stable. In the control practice, new-patient appointments increased and PHQ2 screening improved. Discussion: APEX may contribute to better depression-screening processes. We have provided a detailed description of a real-world, practice-based, quasi-experimental evaluation model using common spreadsheet software (Microsoft Excel) to transform and analyze found data with multivariate statistical process-control charts. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Confronting the new epidemic: Integrated care for opioid use disorders.
    The inaugural Collaborative Family Health Care (CFHA) regional conference took place March 17, 2017, in St. Louis, Missouri. The conference theme was opioid use disorders and the potential of medication-assisted treatment using team-based care to address this epidemic. The conference ended with an emphasis on the importance of and strategies for self-care among caregivers working with this population and their families. This intensive meeting was crafted as a proof in concept for CFHA; however, the content was timely with regard to its importance in health care as well as compelling in the opportunity for collaborative care to offer an effective approach. In this article, the authors highlight five impotance topics: (1) opioid use disorders should be addressed in primary care; (2) a team is essential; (3) harm reduction; (4) sustaining self through mindful practice and self-compassion; and (5) medication-assisted treatment. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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