Project Summary
Behavioral problems are part of many of the chronic diseases that cause the majority of illness, disability, and death. Tobacco use, diet, physical inactivity, alcohol abuse, drug abuse, failure to take treatment, sleep problems, anxiety, depression, and stress are major issues, especially when chronic medical problems such as heart disease, lung disease, diabetes, or kidney disease are also present. These behavioral problems can often be helped, but the current healthcare system doesn’t do a good job of getting the right care to these patients.
Behavioral health includes mental health care, substance abuse care, health behavior change, and attention to family and other psychological and social factors. Many people with behavioral health needs present to primary care and may be referred to mental health or substance abuse specialists, but this method is often unacceptable to patients. Two newer ways have been proposed for helping these patients. In co-location, a behavioral health clinician (such as a psychologist or social worker) is located in or near the primary practice to increase the chance that the patient will make it to treatment. In Integrated Behavioral Health (IBH), a behavioral health clinician is specially trained to work closely with the medical provider as a full member of the primary treatment team. Although it is clear that the current system is not acceptable, we don’t know which of the two new ideas is best.
Our research question is: Does increased integration of evidence-supported behavioral health and primary care services, compared to simple co-location of providers, improve outcomes? The key decisions affected by the research are those made at the practice level: whether and how best to use behavioral health services. For patients, whether to seek out or accept offered behavioral health services will be influenced by the manner they are made available.
Aim 1: Compare co-location and IBH to see which one has better outcomes for patients
Aim 2: See if a structured process to help practices offer IBH helps them succeed
Aim 3: Explore how the type of practice and the healthcare system influence how well integration works
We plan to do a study of 30 practices that will each start off using co-location. Over time, each one will convert to IBH using a practice improvement method that has helped in other settings. We will measure the health status of patients in each practice before and after they start using IBH.
The “active arm” of this study is IBH. It includes training for the doctors and staff in the practices, a management facilitator to help them restructure their practice to make IBH run smoothly, and a “toolkit” containing 24 different things they can do to make IBH work in their practice. The “control” is co-location of a behavioral specialist within or near the primary clinic, but without increased integration.
We plan to study adults who each have both medical and behavioral problems, and get their care in Family Medicine clinics, General Internal Medicine practices, and Community Health Centers. We will study 30 practices from around the country. From each practice, we will randomly select 60 patients with behavioral health needs for a total of 1,800 patients followed for five years.
The main outcome is patient health and functioning. We will also measure how the patients feel about their care and whether their medical problems have changed. We also plan to measure how well the practices did at integrating behavioral health services by asking staff and providers to fill out a survey. Finally, we plan to do a series of interviews, focus groups, and surveys of patients, staff, and doctors to understand what went well and what went wrong.
Our research team includes scientists, doctors, nurses, psychologists, and patients. At every step, the patients have been full members of the team and have had equal input into how we ask this question, how we plan to answer it, and how to make sure that the answers are important to patients and families. In the end, we hope to be able to say whether integrating behavioral health services into primary care is a good idea and how to make it happen.
Kessler RS, Auxier A, Hitt JR, et al., Development and validation of a measure of primary care behavioral health integration, Families, Systems & Health (December 2016).
Macchi CR, Kessler R, Auxier A, et al., The Practice Integration Profile: Rationale, development, method, and research, Families, Systems & Health (December 2016).
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