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Research ArticleOriginal Research

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 and Larry A. Green
The Journal of the American Board of Family Medicine March 2017, 30 (2) 130-139; DOI: https://doi.org/10.3122/jabfm.2017.02.160234
Bijal A. Balasubramanian
From the Department of Epidemiology, Human Genetics and Environmental Sciences, University of Texas School of Public Health, Dallas, TX (BAB, KKJ); the Department of Family Medicine, Oregon Health and Science University, Portland (DJC, MD, RG, KG); and the Department of Family Medicine, University of Colorado School of Medicine, Denver (LMD, FVdG, BFM, LAG).
MBBS, PhD
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Deborah J. Cohen
From the Department of Epidemiology, Human Genetics and Environmental Sciences, University of Texas School of Public Health, Dallas, TX (BAB, KKJ); the Department of Family Medicine, Oregon Health and Science University, Portland (DJC, MD, RG, KG); and the Department of Family Medicine, University of Colorado School of Medicine, Denver (LMD, FVdG, BFM, LAG).
PhD
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Katelyn K. Jetelina
From the Department of Epidemiology, Human Genetics and Environmental Sciences, University of Texas School of Public Health, Dallas, TX (BAB, KKJ); the Department of Family Medicine, Oregon Health and Science University, Portland (DJC, MD, RG, KG); and the Department of Family Medicine, University of Colorado School of Medicine, Denver (LMD, FVdG, BFM, LAG).
MPH, PhD
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L. Miriam Dickinson
From the Department of Epidemiology, Human Genetics and Environmental Sciences, University of Texas School of Public Health, Dallas, TX (BAB, KKJ); the Department of Family Medicine, Oregon Health and Science University, Portland (DJC, MD, RG, KG); and the Department of Family Medicine, University of Colorado School of Medicine, Denver (LMD, FVdG, BFM, LAG).
PhD
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Melinda Davis
From the Department of Epidemiology, Human Genetics and Environmental Sciences, University of Texas School of Public Health, Dallas, TX (BAB, KKJ); the Department of Family Medicine, Oregon Health and Science University, Portland (DJC, MD, RG, KG); and the Department of Family Medicine, University of Colorado School of Medicine, Denver (LMD, FVdG, BFM, LAG).
PhD
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Rose Gunn
From the Department of Epidemiology, Human Genetics and Environmental Sciences, University of Texas School of Public Health, Dallas, TX (BAB, KKJ); the Department of Family Medicine, Oregon Health and Science University, Portland (DJC, MD, RG, KG); and the Department of Family Medicine, University of Colorado School of Medicine, Denver (LMD, FVdG, BFM, LAG).
MA
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Kris Gowen
From the Department of Epidemiology, Human Genetics and Environmental Sciences, University of Texas School of Public Health, Dallas, TX (BAB, KKJ); the Department of Family Medicine, Oregon Health and Science University, Portland (DJC, MD, RG, KG); and the Department of Family Medicine, University of Colorado School of Medicine, Denver (LMD, FVdG, BFM, LAG).
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Frank V. deGruy III
From the Department of Epidemiology, Human Genetics and Environmental Sciences, University of Texas School of Public Health, Dallas, TX (BAB, KKJ); the Department of Family Medicine, Oregon Health and Science University, Portland (DJC, MD, RG, KG); and the Department of Family Medicine, University of Colorado School of Medicine, Denver (LMD, FVdG, BFM, LAG).
MD, MSFM
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Benjamin F. Miller
From the Department of Epidemiology, Human Genetics and Environmental Sciences, University of Texas School of Public Health, Dallas, TX (BAB, KKJ); the Department of Family Medicine, Oregon Health and Science University, Portland (DJC, MD, RG, KG); and the Department of Family Medicine, University of Colorado School of Medicine, Denver (LMD, FVdG, BFM, LAG).
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Larry A. Green
From the Department of Epidemiology, Human Genetics and Environmental Sciences, University of Texas School of Public Health, Dallas, TX (BAB, KKJ); the Department of Family Medicine, Oregon Health and Science University, Portland (DJC, MD, RG, KG); and the Department of Family Medicine, University of Colorado School of Medicine, Denver (LMD, FVdG, BFM, LAG).
MD
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Article Figures & Data

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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.

Tables

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    Table 1.

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

    Practice IDPractice TypeSettingOwnershipIntegrated Care Approach
    1Primary careSuburbanClinician
    • ∙ 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

    2Primary careSuburbanClinician
    • ∙ 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.

    3CMHCRuralPrivate, 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.

    4Primary careUrbanClinician
    • ∙ 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.

    5CMHCSuburbanPrivate, 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.

    • View popup
    Table 2.

    Patient Eligibility for Study and Analysis

    Practice IDScreening 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)
    190.0675181104
    291.0842372103
    390.0539224179
    412.1807724
    52.271632365
    • ↵* 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.

    • View popup
    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 white366 (83.2)
        Non-Hispanic black6 (1.4)
        Hispanic50 (11.4)
        Other18 (4.1)
    Insurance type
        Private/commercial149 (31.4)
        Medicare57 (12.0)
        Medicaid104 (21.9)
        Self-pay49 (10.3)
        Unknown116 (24.4)
    Comorbidities
        Cancer10 (2.1)
        Diabetes70 (14.7)
        Hypertension111 (23.4)
        Heart disease46 (9.7)
        Thyroid80 (16.8)
        Asthma89 (18.7)
    • Data are n (%) unless otherwise indicated.

    • ↵* 0.2% missing.

    • ↵† 7.4% missing.

    • View popup
    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 IDPatients (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)
    At BaselineAfterUnadjustedAdjusted*
    11046.49 (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)†
    21037.41 (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)†
    31798.49 (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)†
    4249.26 (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)‡
    5656.20 (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.

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The Journal of the American Board of Family     Medicine: 30 (2)
The Journal of the American Board of Family Medicine
Vol. 30, Issue 2
March-April 2017
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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
The Journal of the American Board of Family Medicine Mar 2017, 30 (2) 130-139; DOI: 10.3122/jabfm.2017.02.160234

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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
The Journal of the American Board of Family Medicine Mar 2017, 30 (2) 130-139; DOI: 10.3122/jabfm.2017.02.160234
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