Outcomes of Integrated Behavioral Health with Primary Care

Bijal A. Balasubramanian; Deborah J. Cohen; Katelyn K. Jetelina; L. Miriam Dickinson; Melinda Davis; Rose Gunn; Kris Gowen; Frank V. deGruy; Benjamin F. Miller; Larry A. Green

doi:10.3122/jabfm.2017.02.160234

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Figure 1.
Clinically relevant change in the 9-item Patient Health Questionnaire score for patients receiving care among Advancing Care Together (ACT) practices.

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Table 1.

Practice Characteristics and Description of Integrated Care Approach Implemented at Each Advancing Care Together Practice

Practice ID	Practice Type	Setting	Ownership	Integrated Care Approach
1	Primary care	Suburban	Clinician	∙ Primary care practice partnered with a CMHC to hire a BHC and also expanded health-coaching services ∙ Systematically screened patients in the waiting room for medical and behavioral conditions ∙ Provided brief and intensive BH counseling and health coaching in the practice
2	Primary care	Suburban	Clinician	∙ Primary care practice affiliated with multiple primary care practices in the region; the BHC hired to serve patients across these practices is colocated in some practices but not others. ∙ Front desk staff systematically screened patients using a Web-enabled tablet to identify BH needs. ∙ BHC provided traditional therapy. Patients in need of more intensive mental health and substance use services were referred out.
3	CMHC	Rural	Private, not for profit	∙ Primary care team (PCP/MA team) and a BHC were embedded in this CMHC to provide primary care and BH services to all patients. ∙ Systematically screened patients in the waiting room for medical and BH conditions. ∙ Provided brief and intensive BH counseling and primary care in the practice.
4	Primary care	Urban	Clinician	∙ Private primary care practice expanded their partnership with a private mental health agency to provide integrated care. ∙ Screened patients with diabetes and hypertension for depression. ∙ BHCs provided brief counseling and referred patients to a partnering mental health agency for intensive counseling.
5	CMHC	Suburban	Private, not for profit	∙ CMHC hired PA and MA team to serve its patients and to expand its services to a non-SPMI population. ∙ Systematically screened patients to identify physical and BH needs among those without a PCP. ∙ The PA, health navigator, or health coach treats patients who are identified with mild to moderate BH needs and who are seeing the primary care team, whereas therapists in the clinic treat patients with SPMI and substance use needs.

BH, behavioral health; BHC, behavioral health clinician; CMHC, community mental health center; MA, medical assistant; PA, physician assistant; PCP, primary care physician; SPMI, serious and persistent mental illness.

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Table 2.

Patient Eligibility for Study and Analysis

Practice ID	Screening REACH,²³ (%)^*	Patients Who Screened Positive for ACT Intervention (n)	Patients with a PHQ-9 Score ≥10 at Baseline (n)	Patients with a PHQ-9 Score ≥10 at Baseline and >1 Visit (n)
1	90.0	675	181	104
2	91.0	842	372	103
3	90.0	539	224	179
4	12.1	80	77	24
5	2.2	716	323	65

↵* Screening REACH is defined as the percentage of target patients who were assessed for integrated care over a 3-month period.
ACT, Advancing Care Together; PHQ-9, 9-item Patient Health Questionnaire.

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Table 3.

Characteristics of Patients with a 9-Item Patient Health Questionnaire Score ≥10

	Patients (n = 475)
Male sex^*	146 (30.7)
Age (years), mean (SD)	43.9 (14.2)
Race/ethnicity^{^†}
Non-Hispanic white	366 (83.2)
Non-Hispanic black	6 (1.4)
Hispanic	50 (11.4)
Other	18 (4.1)
Insurance type
Private/commercial	149 (31.4)
Medicare	57 (12.0)
Medicaid	104 (21.9)
Self-pay	49 (10.3)
Unknown	116 (24.4)
Comorbidities
Cancer	10 (2.1)
Diabetes	70 (14.7)
Hypertension	111 (23.4)
Heart disease	46 (9.7)
Thyroid	80 (16.8)
Asthma	89 (18.7)

Data are n (%) unless otherwise indicated.
↵* 0.2% missing.
↵† 7.4% missing.

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Table 4.

Effect of Implementing Integrated Care Strategies on Mean Change in the 9-Item Patient Health Questionnaire for Patients Receiving Care in Advancing Care Together Practices

Practice ID	Patients (n)	Months in the Study, Mean (SD)	No. of Visits, Mean (SD)	PHQ-9 Score, Mean (SD)		Before/After Change in PHQ-9 Score, Mean (SE)		Adjusted⁺ Change in PHQ-9 Score over 6 Months, Mean (SE)
Practice ID	Patients (n)	Months in the Study, Mean (SD)	No. of Visits, Mean (SD)	At Baseline	After	Unadjusted	Adjusted^*	Adjusted⁺ Change in PHQ-9 Score over 6 Months, Mean (SE)
1	104	6.49 (4.6)	3.46 (2.6)	17.20 (4.1)	10.34 (7.1)	−6.87 (0.7)^{^†}	−6.46 (0.7)^{^†}	−3.19 (0.6)^{^†}
2	103	7.41 (4.7)	2.87 (1.8)	16.19 (4.3)	10.58 (8.3)	−5.61 (0.8)^{^†}	−4.97 (1.1)^{^†}	−3.25 (1.1)^{^†}
3	179	8.49 (4.6)	3.55 (1.6)	17.02 (4.3)	12.72 (6.8)	−4.30 (0.5)^{^†}	−3.89 (0.5)^{^†}	−2.03 (0.4)^{^†}
4	24	9.26 (3.7)	2.31 (0.5)	18.20 (3.1)	14.15 (4.2)	−4.06 (1.3)^{^†}	−4.47 (1.5)^{^†}	−3.12 (1.2)^{^‡}
5	65	6.20 (4.1)	2.82 (1.1)	18.06 (4.2)	15.09 (6.4)	−2.97 (0.8)^{^†}	−2.72 (0.7)^{^†}	−1.50 (0.5)^{^§}

↵* Adjusted for race (non-Hispanic white, non-Hispanic black, Hispanic, other), age (continuous), payer source (private, Medicare, Medicaid, self-pay, other), and sex.
↵† P < .001.
↵§ P < .01.
↵‡ P < .05.
SD, standard deviation; SE, standard error; PHQ-9, 9-item Patient Health Questionnaire.