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The Public Health Leadership Forum (PHLF) at RESOLVE teamed with the Health Care Transformation Task Force (HCTTF) to develop a framework that supports enhanced collaboration between health care and public health entities. Join a webinar on November 27th at 1pm CST to learn more about essential elements of the framework: Partnering to Catalyze Comprehensive Community Wellness: An Actionable Framework for Health Care and Public Health Collaboration. Register here
PURPOSE:
Provide credible estimates of the start-up and ongoing effort and incremental practice expenses for the Advancing Care Together (ACT) behavioral health and primary care integration interventions.
METHODS:
Expenditure data were collected from 10 practice intervention sites using an instrument with a standardized general format that could accommodate the unique elements of each intervention.
RESULTS:
Average start-up effort expenses were $44,076 and monthly ongoing effort expenses per patient were $40.39. Incremental expenses averaged $20,788 for start-up and $4.58 per patient for monthly ongoing activities. Variations in expenditures across practices reflect the differences in intervention specifics and organizational settings. Differences in effort to incremental expenditures reflect the extensive use of existing resources in implementing the interventions.
CONCLUSIONS:
ACT program incremental expenses suggest that widespread adoption would likely have a relatively modest effect on overall health systems expenditures. Practice effort expenses are not trivial and may pose barriers to adoption. Payers and purchasers interested in attaining widespread adoption of integrated care must consider external support to practices that accounts for both incremental and effort expense levels. Existing knowledge transfer mechanisms should be employed to minimize developmental start-up expenses and payment reform focused toward value-based, Triple Aim-oriented reimbursement and purchasing mechanisms are likely needed.
PURPOSE:
To examine the interrelationship among behavioral health clinician (BHC) staffing, scheduling, and a primary care practice's approach to delivering integrated care.
METHODS:
Observational cross-case comparative analysis of 17 primary care practices in the United States focused on implementation of integrated care. Practices varied in size, ownership, geographic location, and integrated care experience. A multidisciplinary team analyzed documents, practice surveys, field notes from observation visits, implementation diaries, and semistructured interviews using a grounded theory approach.
RESULTS:
Across the 17 practices, staffing ratios ranged from 1 BHC covering 0.3 to 36.5 primary care clinicians (PCCs). BHC scheduling varied from 50-minute prescheduled appointments to open, flexible schedules slotted in 15-minute increments. However, staffing and scheduling patterns generally clustered in 2 ways and enabled BHCs to be engaged by referral or warm handoff. Five practices predominantly used warm handoffs to engage BHCs and had higher BHC-to-PCC staffing ratios; multiple BHCs on staff; and shorter, more flexible BHC appointment schedules. Staffing and scheduling structures that enabled warm handoffs supported BHC engagement with patients concurrent with the identification of behavioral health needs. Twelve practices primarily used referrals to engage BHCs and had lower BHC-to-PCC staffing ratios and BHC schedules prefilled with visits. This enabled some BHCs to bill for services, but also made them less accessible to PCCs in when patients presented with behavioral health needs during a clinical encounter. Three of these practices were experimenting with open scheduling and briefer BHC visits to enable real-time access while managing resources.
CONCLUSION:
Practices' approaches to PCC-BHC staffing, scheduling, and delivery of integrated care mutually influenced each other and were shaped by the local context. Practice leaders, educators, clinicians, funders, researchers, and policy makers must consider these factors as they seek to optimize integrated systems of care.
INTRODUCTION:
Behavioral health (BH) integration has been proposed as an important strategy to help primary care practices meet the needs of their patient population, but there is little research on the ways in which practices are integrating BH services. This article describes the goals for BH integration at 30 high-performing primary care practices and strategies to operationalize these goals.
METHODS:
We conducted a qualitative analysis of BH integration at 30 US primary care practices that had been selected for the Learning from Effective Ambulatory Practices (LEAP) project following an interview-based assessment and rating process. Data collection included formal and informal interviews with practice leaders and staff, as well as observations of clinical encounters. We used a template analysis approach to thematically analyze data.
RESULTS:
Most LEAP practices looked to BH integration to help them provide timely BH care for all patients, share the work of providing BH-related care, meet the full spectrum of patient needs, and improve the capacity and functioning of care teams. Practices operationalized these goals in various ways, including universal BH screening and involving BH specialists in chronic illness care. As they worked toward their BH integration goals, LEAP practices faced common challenges related to staffing, health information technology, funding, and community resources.
DISCUSSION:
High-performing primary care practices share common goals for BH integration, as well as common challenges operationalizing these goals. As US residents increasingly receive BH services in primary care, it is critical to remove barriers to BH integration and support primary care practices in meeting a full spectrum of patient needs.
BACKGROUND:
The historic, cultural separation of primary care and behavioral health has caused the spread of integrated care to lag behind other practice transformation efforts. The Advancing Care Together study was a 3-year evaluation of how practices implemented integrated care in their local contexts; at its culmination, practice leaders ("innovators") identified lessons learned to pass on to others.
METHODS:
Individual feedback from innovators, key messages created by workgroups of innovators and the study team, and a synthesis of key messages from a facilitated discussion were analyzed for themes via immersion/crystallization.
RESULTS:
Five key themes were captured: (1) frame integrated care as a necessary paradigm shift to patient-centered, whole-person health care; (2) initialize: define relationships and protocols up-front, understanding they will evolve; (3) build inclusive, empowered teams to provide the foundation for integration; (4) develop a change management strategy of continuous evaluation and course-correction; and (5) use targeted data collection pertinent to integrated care to drive improvement and impart accountability.
CONCLUSION:
Innovators integrating primary care and behavioral health discerned key messages from their practical experience that they felt were worth sharing with others. Their messages present insight into the challenges unique to integrating care beyond other practice transformation efforts.
Leveraging Practice-Based Research Networks to Accelerate Implementation and Diffusion of Chronic Kidney Disease Guidelines in Primary Care Practices
Patients with existing disease or major risk factors should be prescribed statins unless contraindicated.
