Professional Abstract

Objective

To observe the effects of behavioral health integration (BHI) efforts on patient experience, perceived stigma, and claims-based quality of care

Study Design

Design Elements	Description
Design	Cluster nonrandomized longitudinal observational study
Population	Survey: 2,524 patients in 12 clinics in Oregon Claims data: 20,729 patients seen in 1 of 12 clinics in the past 21 months
Interventions/ Comparators	Level of integration of behavioral and physical health care in primary care clinics
Outcomes	Patient experience and perceived stigma, claims-based quality of care
Timeframe	Up to 2-year follow-up for study outcomes

In this prospective cluster nonrandomized longitudinal observational study, the research team examined whether there was an association between the integration of behavioral and physical health care in primary care clinics and three outcomes: patient experience, claims-based quality of care, and perceived stigma. The team also examined the relationship between stigma and patient experience and the impact of integration on this relationship.

The research team collected data in 12 primary care and safety net clinics. All clinics are part of Oregon’s Medicaid Accountable Care Organizations and were integrating physical and behavioral health care as part of a statewide policy initiative. Clinic staff completed a clinic audit tool that measured five BHI domains: integrated care staffing and training, data sharing between mental and physical health providers, workflow and collaboration, integrated financial arrangements, and overall BHI integration.

In the first and second year of the project, 2,524 adult patients receiving care at the clinics completed patient experience surveys. Of these, 88% were white, and the average age was 53. In addition, 68% were female, and 52% of respondents reported at least one behavioral health diagnosis. All patients were Oregon residents enrolled in a commercial, Medicaid, or Medicare Advantage insurance plan.

The research team used a survey to assess perceived stigma and four domains of the patient experience: all care needs met, timely access to care, hassle-free care, and provider-to-provider communication. The team measured quality of care using five items from Oregon’s All Payer All Claims data set. Data were from 20,279 patients receiving care at one of the 12 clinics over a 21-month period.

A patient advisory team assisted in study design and survey development.

Results

BHI scores were not associated with improved patient experience or reduced perceived stigma over time. Stigma was strongly associated with poor patient experience outcomes, but integration did not change this.

The research team also found no associations between overall BHI scores and any of the five quality of care indicators. However, three BHI domains were positively associated with quality of care indicators. Clinics with better integrated care training had a lower rate of avoidable emergency department visits (p<0.05); clinics with integrated workflows had better monitoring of patients on persistent medications (p<0.05); and integrated financing was associated with better patient follow-up within seven days of a mental health discharge (p<0.05) and better monitoring of patients on persistent medications (p<0.05).

Limitations

The research team measured the degree to which elements of structural integration were associated with patient outcomes, but the study cannot offer evidence of a causal relationship. The measure of clinic integration may not have been optimal for determining association. Other measures of integration may have yielded different results. Survey response rates were low; which may have affected results.

Conclusions and Relevance

At two-year follow-up, integrated care was not associated with patients’ quality of care or perceived stigma.

Future Research Needs

Future research could measure BHI differently or incorporate research designs better suited to test a causal relationship. Researchers could also explore further whether reducing stigma in clinical settings may improve the patient experience and enable BHI programs to have a stronger impact.