What was the research about?
Behavioral health integration, or BHI, is when clinics manage both physical and mental health care in the same place. The goal of BHI is to improve the coordination of services to better meet patients’ needs.
In this study, the research team wanted to learn if BHI improved patients’ experiences of care. The team looked at clinics that were using BHI and scored them on staff training, how well staff work together, and other aspects of BHI. Then the team looked at whether clinics with higher scores had better
- Patient-reported experiences of care
- Patient-reported experiences of being judged, or stigma, in a healthcare setting
- Quality of care
The team also looked at whether patients who felt stigma were less likely to get their healthcare needs met.
What were the results?
The study didn’t find a relationship between clinics’ scores on BHI and patients’ experiences of care or of stigma. In addition, overall scores on BHI didn’t relate to clinics’ quality of care. But the study found that
- Patients receiving care from clinics that had higher scores for training staff on BHI had fewer unnecessary emergency room visits.
- Clinics with higher scores for how well staff worked together did a better job of monitoring patients who took medicine for six months or longer.
- Clinics with higher scores for integrating their financial systems for physical and mental health services did a better job of following up with patients and monitoring those who took medicine for six months or longer.
Also, patients who experienced stigma were more likely to report that they didn’t get their healthcare needs met.
Who was in the study?
The study included 2,524 adult patients receiving care at 1 of 12 clinics in Oregon. Of these, 88 percent were white. The average age was 53, and 68 percent were women. In addition, 52 percent of patients had a mental health condition. All patients lived in Oregon and had a commercial, Medicaid, or Medicare Advantage insurance plan.
What did the research team do?
Staff at each clinic completed a survey. The survey asked about ways the clinic integrated physical and mental health care, including training and overall cooperation in managing the two kinds of services.
Patients completed a survey about their healthcare experiences during the study’s first year and again one year later. The survey asked how quickly patients got care, if the care was hassle free, and whether people felt stigma when they went to the clinic. To assess the quality of care that patients received, the research team looked at health records for 20,279 patients at the clinics.
Then the research team looked at the relationship between clinics’ scores for BHI and patients’ experiences.
A patient advisory team gave input on the study.
What were the limits of the study?
All clinics in the study used BHI. Results may differ if the research team had been able to compare clinics that were using BHI with those that weren’t.
Future research could compare patient experiences of care at clinics using BHI with clinics not using BHI.
How can people use the results?
Healthcare clinics can use these results when planning ways to help patients improve their mental and physical health.
To observe the effects of behavioral health integration (BHI) efforts on patient experience, perceived stigma, and claims-based quality of care
|Design||Cluster nonrandomized longitudinal observational study|
Survey: 2,524 patients in 12 clinics in OregonClaims data: 20,729 patients seen in 1 of 12 clinics in the past 21 months
|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.
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).
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.
Final Research Report
View this project's final research report.
Results of This Project
Related Journal Citations
Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.
The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments.
Peer reviewers commented, and the researchers made changes or provided responses. The comments and responses included the following:
- The reviewers asked for more details on the 12 practices involved in the study. The researchers responded that they had collected health-integration information but did not collect additional details about each practice, such as provider characteristics. In response to reviewers, they were able to add some information about patient characteristics, such as illness severity. The researchers explained that what interested them the most was the structural elements of care, rather than process or clinical characteristics.
- The reviewers asked for additional specific information about how the clinic audit tool described and measured behavioral health integration. The researchers expanded their description of the clinic audit tool and explained that the tool was specifically designed to measure changes in health-integration practices that Oregon state policy promoted. The researchers acknowledged that the tool has not been formally tested for reliability, but its use in the state-wide initiative made it the right tool to use if this study was going to influence state policy. The researchers also noted that they completed a series of cognitive interviews to gauge the tool’s face validity.
- Reviewers suggested the study design would have been more powerful with a control group of clinics that did not use behavioral health integration practices. The researchers agreed but said that because clinics generally used at least some behavioral health integration practices, they could not establish a control group. Instead, they compared clinics by stratifying them based on their level of behavioral health integration.
Conflict of Interest Disclosures
Study Registration Information
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