The Agency for Healthcare Research and Quality (AHRQ) defines integrated behavioral health as: The care a patient experiences as a result of a team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population. Cost-effectiveness studies of HOPE’s approach would be very useful in understanding the feasibility of such models in similar clinics. With experience performing the behavior, the behavior will become habitual for the individual. 4, 2020, p. 15. In adjusted analyses, the intervention and control groups differed significantly on depressive symptoms at 12-months; the groups were similar on HbA1c, blood pressure, and BMI (Table 3). In conclusion, implementing an integrated care model with a focus on collaboration and communication between primary care and behavioral health providers in a free and charitable clinic setting can improve depressive symptoms after 12 months for individuals who are low-income or uninsured living in the border region of southern Texas. 1977; 2(8041): 734–737. 2010; 33(4): 706–713. Those who agreed to participate underwent an informed consent process including the study overview, information about the randomization process, and an understanding that voluntary participation included taking a baseline and all follow-up assessments. DOI: https://doi.org/10.1370/afm.843, Foy R, Hempel S, Rubenstein L, Suttorp M, Seelig M, Shanman R, et al. The clinic is staffed with volunteer primary care providers and employed behavioral health counselors. Our results demonstrate the positive impact integrated care can have on health outcomes. Guide to Community Preventive Services. TEAMcare: An Integrated Multicondition Collaborative Care Program for Chronic Illnesses and Depression. With behavioral health clinicians and community health workers (CHWs) available to provide comprehensive behavioral health services as part of routine medical care, the TEAM UP model focuses on meeting … The chronic care management visits focused on enabling patients to understand their chronic conditions (e.g. Many times there is a lot of frustration that can arise from miscommunication in the non-integrated models. Results: After 12 months, intervention participants (n = 172) were more likely to have a lower PHQ-9 score than control participants (n = 198) (β = –1.67, p = 0.01). Because primary and sensitivity analyses produced similar results, effect modification analyses were conducted using the intent-to-treat sample. DOI: https://doi.org/10.1037/lat0000009. This result has the potential to respond to the literature that has identified difficulties in treating depression in older adults and the need for approaches targeting symptoms in an older population [33, 34]. Chair, Research and Evaluation. Integrating Primary Care and Behavioral Health With Four Special Populations: Children with Special Needs, People With Serious Mental Illness, Refugees, and Deaf People. Analyses of these four outcomes employed the MIANALYZE procedure in SAS. Journal of Latina/o Psychology. DOI: https://doi.org/10.1056/NEJM200107123450205. DOI: https://doi.org/10.1146/annurev.clinpsy.032408.153621, Licht-Strunk E, Van Marwijk HWJ, Hoekstra T, Twisk JWR, De Haan M, Beekman ATF. When primary care physicians work closely with behavioral health professionals such as social workers and psychologists, they are, together, better able to respond to patient needs. DOI: https://doi.org/10.1046/j.1525-1497.2001.016009606.x, Gonen B, Rubenstein A, Rochman H, Tanega SP, Horwitz DL. Clinical use of antidepressant therapy and associated cardiovascular risk. Psychiatric Services. Watt T. A Process and Outcome Evaluation of Two Integrated Behavioral Health Care Models: People’s Community Clinic and Lone Star Circle of Care. 2015; 51(4): 385–392. Collaborative care for the treatment of depression in primary care with a low-income, Spanish-speaking population: Outcomes from a community-based program evaluation. 2014; 69(4): 377–387. DOI: https://doi.org/10.1007/s10597-014-9750-7, Ell K, Katon W, Xie B, Lee PJ, Kapetanovic S, Guterman J, et al. However, sensitivity analyses suggested the impact of contamination was minimal and did not bias study results. Accessed July 8, 2019, Liebschutz JM, Xuan Z, Shanahan CW, LaRochelle Keosaian J, Beers D, Guara G, et al. Diagnosed Diabetes. The results of sensitivity analyses were like the intent-to-treat analyses (Table 4). DOI: https://doi.org/10.1037/a0036220, Bedoya CA, Traeger L, Trinh NHT, Chang TE, Brill CD, Hails K, et al. The PHQ-9 assessment was administered through provider interview. The resulting multi-level behaviour change framework – the Integrated Behavioural Model for Water, Sanitation, and Hygiene (IBM – WASH) was presented at the 2011 Oklahoma University International WaTER Conference, and at participatory workshops and lectures at iccdr,b in Dhaka and Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland. Over the past several decades, examples of coordinated care service delivery models—that connect behavioral and physical health—have led to promising approaches of integration and collaboration. 688 patients were identified as eligible to participate via pre-screening of records; 585 agreed to participate when approached by clinic staff and were allocated 1:1 to the intervention and control groups. The results from this study can have funding … Waterfall Community Health Center operates in an Integrated Behavioral Health model of Primary Care. Washington, DC: SAMHSA-HRSA Center for Integrated Health Solutions; 2014 Mar. Integrated behavioral health care teams and services do not have to be present or delivered in the same physical location to meet the definition of integrated care. Retention rates for both groups were lower than anticipated which may have limited our ability to see effects in some outcomes; however, no differential attrition was detected. As part of the intervention, participants received a care plan developed collaboratively by providers of different services. UK NCGC. There is a multitude of theories that can be used, but the question is what to do with so many theories. Enhanced Integrated Behavioral Health Model Improves Depressive Symptoms in a Low-Income, Uninsured, Primarily Hispanic Population Served by a Free and Charitable Clinic. Poverty is pervasive, placing residents at high risk for poor health; they are more likely to be exposed to environmental hazards and have higher rates of chronic physical and mental health concerns [3, 4, 5]. Impact of a culturally focused psychiatric consultation on depressive symptoms among Latinos in primary care. Due to clinical staff and volunteer providers treating both intervention and control participants, there was concern about contamination of the control group. 2020;20(4):15. Outcome of depression in later life in primary care: Longitudinal cohort study with three years’ follow-up. DOI: https://doi.org/10.1037/lat0000067, Fiske A, Wetherell JL, Margaret G. Depression and Older Adults. Improvement in Depressive Symptoms Among Hispanic/Latinos Receiving a Culturally Tailored IMPACT and Problem-Solving Intervention in a Community Health Center. The effects demonstrated in the trial occurred despite a lack of feasibility to implement two planned program components: psychiatry consultation and volunteer primary care provider engagement. 2017; 177(9): 1265–1272. DOI: http://doi.org/10.5334/ijic.5421, Flynn A and others, ‘Enhanced Integrated Behavioral Health Model Improves Depressive Symptoms in a Low-income, Uninsured, Primarily Hispanic Population Served by a Free and Charitable Clinic’ (2020) 20 International Journal of Integrated Care 15 DOI: http://doi.org/10.5334/ijic.5421, Flynn, Amy, Erika Gaitan, Rebecca Stocker, Elizabeth Showalter, and Karen Sautter Errichetti. Arizona State University. Presence of “warm hand-offs”. J Ambul Care Manage. UK: National Institute for Health and Care Excellence; 2014. http://www.ncbi.nlm.nih.gov/pubmed/25535639. The program achieved results typically seen only in controlled clinical trials. All HOPE patients are uninsured and living at or below 200% of the FPL as eligibility criteria for either primary care or behavioral health services at the clinic. 2010. In Austin, Texas for example, People’s Community Clinic used an IBH model to enable adult primary care patients diagnosed with depression and anxiety to receive psychiatric medication, counseling, and education. This randomized trial evaluated whether patients receiving enhanced integrated behavioral health (IBH) care at a southern Texas free and charitable were more likely to improve health outcomes after 12 months compared to patients receiving standard care. Behavioral intention is determined by attitude, perceived norms, and personal agency (self-efficacy / perceived power). Similarly, Bridges et al. Outcomes of Integrated Behavioral Health with Primary Care. I am often asked how this model can be funded. Centers for Disease Control and Prevention. 2006; 166(21): 2314–2321. 2017; 30(2): 130–139. Effect of IBH Intervention on Health Outcomes at 12 Months, Intent-to-Treat Analyses. The intervention group had a significantly higher mean PHQ-9 score (7.1) than the control group (5.0) at baseline (p = 0.001). 2018. 2012; 14(6). The finding that depressive symptoms changed but physical outcomes such as blood pressure did not is interesting and notable. KSE was employed by Health Resources in Action and this manuscript was completed during paid work hours. DOI: https://doi.org/10.2105/AJPH.93.3.467, Diez Roux AV, Merkin SS, Arnett D, Chambless L, Massing M, Nieto FJ, et al. International Journal of Integrated Care 20 (4): 15. 2009; 5: 363–389. Intention or decision to perform the behavior, Knowledge and skills to perform a behavior, An indication of an individual's readiness or decision to perform the behavior, The most important predictor a desired behavior will actually occur, A function of attitudes toward a behavior and perceived norms and personal agency toward that behavior, Attitude, Experiential Attitude, Instrumental Attitude, Perceived norm, Injunctive norm, Descriptive norm, Personal agency, Perceived control, Self-efficacy. All participants enrolled had complete baseline sociodemographic data collected. While the trial significantly improved mental health despite this, it is possible that physical health outcomes may have improved with more direct engagement of these providers. The IBH model improved patients’ mental health outcomes with a minimal investment of resources [19]. We are all aware of the general lack of behavioral health resources, due in part to the fact that many plans and insurers do not adequately reimburse these providers for their services. Participants enrolled in the study were followed for approximately 12 months and assessed for physical and behavioral health outcomes at baseline, 6- and 12-months. Lancet (London, England). The behavior should be salient to the individual (that is, important to the person and at the forefront of their thoughts). The primary care practitioner reviews the screenings and refers patients with qualifying scores to the PBH provider for an on-the-s… Baseline sociodemographic data were collected from HOPE’s data system. Participants randomized to the intervention group received enhanced integrated primary care and behavioral health services (Table 1). A limited number of patient characteristics were available for equivalence testing, and unmeasured differences between groups is possible. Flynn A, Gaitan E, Stocker R, Showalter E, Errichetti KS. RS was employed by Hope Family Health Center and this manuscript was completed during paid work hours. Behavioral intention is determined by attitude, perceived norms, and personal agency (self-efficacy / perceived power). An individual needs the knowledge and skills to carry out the behavior. Background: Residents living in US-Mexico border communities have some of the worst health outcomes nationally. a adjusted for age, marital status, baseline systolic blood pressure, and number of comorbidities at baseline b adjusted for age, baseline diastolic blood pressure, and number of comorbidities at baseline c adjusted for baseline HbA1c level d adjusted for baseline BMI e adjusted for baseline PHQ-9 score. 2009; 338(7692): 463–466. The grant also provided funds for travel for in-person meetings. In sex-stratified models, the intervention was not statistically associated with blood pressure or HbA1c level for either sex (not shown). Secondary outcomes were diastolic blood pressure, HbA1c, BMI, and depressive symptoms. However, external referrals were not coordinated by the care coordinator and these participants did not receive warm-handoffs to other HOPE providers from the care coordinator. Heath B, Wise RP, Reynolds K. A Review and Proposed Standard Framework for Levels of Integrated Healthcare. 2016. Community Mental Health Journal. No statistically significant differences were identified between the intervention and control groups in terms of observed sociodemographic measures or health outcomes at baseline, except for PHQ-9 score (Table 2). Accessed July 8, 2019. Control participants with evidence of having received care coordination (n = 38) and intervention participants with no evidence of care coordination (n = 45) were removed from the sample for these sensitivity analyses. The primary outcome was systolic blood pressure. revealed that Latinos participating in IBH care had significant improvements in symptoms and expressed high satisfaction with IBH treatment [20]. We collected participant sociodemographic measures at baseline including age, sex (male; female), ethnicity (Hispanic; non-Hispanic), employment (employed; unemployed), marital status (married; not married, which included those who were divorced, partnered, separated, single, or widowed), and primary language spoken (English or Spanish). This model combines a multidisciplinary team that integrates treatment, program structure, systems of programs, and payment to provide whole person care rather than treating isolated symptoms or diagnosis. A 2016 update on research on integration of behavioral health and primary care emphasized the increasing strength of evidence highlighting the success of these approaches [8]. International Journal of Integrated Care, 20(4), p.15. DOI: http://doi.org/10.5334/ijic.5421, Flynn, Amy, Erika Gaitan, Rebecca Stocker, Elizabeth Showalter, and Karen Sautter Errichetti. The integrated behavioral health model of care starts with screening for behavioral health problems during primary care appointments. Haemoglobin A1: An indicator of the metabolic control of diabetic patients. Contamination occurred within the trial due to implementation challenges and the single clinic setting. 2020;20(4):15. Randomized Trial of an Integrated Behavioral Health Home: The Health Outcomes Management and Evaluation (HOME) Study. DOI: https://doi.org/10.1016/j.jadohealth.2016.11.013, Druss BG, von Esenwein SA, Glick GE, Deubler E, Lally C, Ward MC, et al. HOPE adapted the collaborative care model in December 2015 (Figure 2) [19, 21, 24, 25]. Similarities in constructs across TRA / TPB, IBM, Intention or decision to perform a behavior. Second, literature suggests that patients on anti-depressant drugs have increased risk of cardiovascular disease particularly if there is pre-existing cardiovascular disease [35]. 20, no. Ann Intern Med. The unique characteristics of our population and service setting may limit the generalizability of these results. DOI: http://doi.org/10.5334/ijic.5421. 2017; 60(3): 261–269. A rural Federally Qualified Health Center (FQHC) in Virginia is co-located with the Behavioral Health Services of the Shenandoah Valley Medical System, which offers consultations via a Primary Behavioral Health (PBH) service. Collaborative care for depression: A cumulative meta-analysis and review of longer-term outcomes. In addition, HOPE’s program activities were adapted for their unique border community, including bilingual programming and psychoeducation. Bogner HR, de Vries HF. Integrated Behavior Model . JAMA Intern Med. An integrated theoretical model using constructs from multiple behavioral models was applied to understand and predict condom use among a sample of injecting drug users, commercial sex workers, men who have sex with men, and multipartnered heterosexuals. The study has several limitations. Secondary outcomes were HbA1c (a measure of glucose control), body mass index (BMI), and depressive symptoms (assessed through PHQ-9 score) [27]. Control participants could be referred to additional specialty and community-based services. US Census. 2012; 4: 93–101. In practice, providers saw both intervention and control participants. We subsequently explored the potential for effect modification by baseline health condition (e.g., baseline depression as an effect modifier for impact on PHQ-9 score at 12 months), age (below versus equal to or above the mean study age of 51 years), and sex. There are five components that directly affect behavior: Similar to TRA / TPB, the most important determinant is intention. HOPE’s primary care providers are exclusively volunteers. Effect sizes for statistically significant results were calculated using the Cohen’s d statistic. International Journal of Integrated Care, vol. Neighborhood physical conditions and health. 2013 Mar. Wholly novel approaches to integrate care are significantly less common. Availability of Services for Usual and Integrated Care Participants. Without intention to do so, an individual is unlikely to carry out a behavior. Retrieved June 12, 2015, from http://www.thecommunityguide.org/mentalhealth/collab-care.html. Integrated behavioral health care blends care in one setting for medical conditions and related behavioral health factors that affect health and well-being. Ann Fam Med. No single model of IBH can be applied universally to health or social service settings; however, each approach is team-based and involves collaboration between multidisciplinary health and social service providers to achieve shared patient and community outcomes [6]. 2001; 16(9): 606–613. For these analyses, intervention receipt was operationally defined as any evidence of care coordination in the medical record. 2014; 2(1): 37–53. In age-stratified models, intervention participants aged 51 years or older had a PHQ-9 score 2.08 points lower than those in the control group (p = 0.01, d = 0.34, Table 5) on average; however, the intervention effect was not significant among participants under 51 years of age. After the informed consent process, participants were allocated to the intervention or control group through simple random assignment using a computer-generated random number calculator and participant selection of number from individual, unmarked envelopes. These plans included at least one visit with a behavioral health specialist (BHS) and chronic care management visits with a transitional nurse. Without intention to do so, an individual is unlikely to carry out a behavior. Funding an integrated behavioral health model. The model, which evolved to its current iteration in 2012, has roots dating back to 1998. Hypertension. Retrieved from: https://gis.cdc.gov/grasp/diabetes/DiabetesAtlas.html Accessed on: August 30, 2019. Intervention participants also received services from a care coordinator who made warm-handoffs to either the BHS, transitional nurse, internal pharmacy services, or coordinated referrals to other support services available in the community. QuickFacts: Willacy County, Texas; Starr County, Texas; Hidalgo County, Texas; Cameron County, Texas. What is Integrated Behavioral Health Care: A model agnostic view of the core elements. After assignment, participants were seen by a nurse manager to complete baseline assessment, including the PHQ-9. Additionally, volunteer providers’ variable schedules posed a challenge to implementing this aspect of the study design. AF, EG, and ES are employed by Health Resources in Action and this manuscript was completed during paid work hours. Integration of Depression and Hypertension Treatment: A Pilot, Randomized Controlled Trial. Drug Healthc Patient Saf. This list of resources, put forth by the SAMHSA-HRSA Center for Integrated Health Solutions (CIHS), assists providers in integrating primary and behavioral health services to better address the needs of individuals with mental health and substance use conditions, whether seen in specialty behavioral health or primary care provider settings. J Gen Intern Med. HOPE’s approach included activities from the Sanchez and Watt model that have been linked to improved health outcomes, including care management and access to behavioral health specialists [19]. International Journal of Integrated Care, 20(4), 15. DOI: http://doi.org/10.5334/ijic.5421, Flynn A, Gaitan E, Stocker R, Showalter E, Errichetti KS. Control group participants received HOPE’s usual care including primary care services and behavioral health counseling co-located within the clinic, but unlike the intervention participants, they were not offered the enhanced services from the transitional nurse or BHS. Rates of chronic disease such as obesity, diabetes, and related mortality in the RGV exceed those in most other regions of Texas and the nation [1, 2]. Professional shortages are common in areas served by free and charitable clinics, and engagement of mental health professionals in an IBH intervention may improve feasibility and sustainability of the approach; however, additional research is needed to validate this finding and guide other clinics working to provide similar programming. Results suggest that psychiatric consultation was not necessary to improve depressive symptoms in a charitable clinic setting. DOI: https://doi.org/10.1097/JAC.0b013e31820ef6a4, Balasubramanian BA, Cohen DJ, Jetelina KK, Dickinson LM, Davis M, Gunn R, et al. IBH has been effective in various populations [9, 10, 11, 12] with some studies focusing on specialty populations such as adolescents and those with substance use disorders or severe mental illness, which may need tailored and focused integrated care [13, 14, 15]. View Record in Scopus Google Scholar. Missing data for outcome measures blood pressure, BMI, and depressive symptoms ranged 1–21% at baseline and 11–19% at 12 months. New York, NY: Millbank Memorial Fund; 2016 May. Integrating care between primary care and behavioral health services is a complex process. This trial demonstrated that a behavioral health and care coordination intervention implemented in a free and charitable clinic with voluntary care providers can reduce depressive symptoms in uninsured patients living at or below the 200% FPL compared to standard care. Patients were excluded if they were pregnant or did not meet the eligibility criteria (Figure 1). 2014; 65(10): 1256–1262. These results align with findings from previous studies of IBH and its effect on mental health [31, 32]. The AIMS Center is most widely known for its work in spreading the Collaborative Care Model (CoCM) but many of the practices we work with incorporate CoCM into a “blended” or stepped model that combines other behavioral health interventions and strategies. We present the Integrated Behavior Change Model, a comprehensive multitheory model outlining the psy ... Health Psychology and Behavioral Medicine Research Group, School of Psychology and Speech Pathology, Faculty of Health Sciences, Curtin University, GPO Box U1987, Perth 6845, Western Australia, Australia (E-mail: [email protected]). Physicians appreciate having behavioral staff immediately available for their clients and a personal introduction by the physician often results the tran… Research Professor, School for the Science of Health Care Delivery . Effect of IBH Intervention on Health Outcomes at 12 Months, Per Protocol Analysis. The intervention and control groups had the same rate of retention (63%; p = 0.95), indicating no differential attrition. International Journal of Integrated Care. Use of a screening tool to identify mental health problems. Prior to analysis, we multiply imputed the missing outcome data with the mi procedure in SAS using all available baseline sociodemographic and health data, generating 10 datasets. TEAM UP for Children is a pediatric integrated behavioral health initiative co-developed by Boston Medical Center and seven community health centers across eastern Massachusetts. Because HbA1c level was not universally collected from participants, multiple imputation was not applied to the primary model of this outcome. 2 | Equip and educate affiliated primary care practices with evidence-based behavioral health screening and assessment tools to use during each patient care visit. The primary care behavioral health (PCBH) consultation model is a psychological approach to population-based clinical health care that is simultaneously co-located, collaborative, and integrated within the primary care clinic. Despite the promise of integrated care strategies in improving physical and mental health, key gaps exist in evidence of the generalizability of these approaches in diverse populations. Pearson correlation coefficients were calculated to identify collinearity among variables in each model. HOPE intended for intervention participants to receive care from a group of volunteer primary care providers separate from those treating the usual care participants. BMI was measured using a clinical scale and height tool [29]. Quercia RG, Bates LK. Gerrity M. Evolving Models of Behavioral Health Integration: Evidence Update 2010–2015. However, covariates included in our final models encompass biological and social factors known to be influential for health outcomes; additionally, randomization was successful based on the measured covariates, supporting the credibility of our results. We hypothesized that integrated care would reduce blood pressure, HbA1c, body mass index, and depressive symptoms among adult patients with chronic illness living at or below the 200% FPL. Obesity. 2008; 6(4): 295–301. 2012; 9(8). Health Resources in Action used grant funds from Methodist Healthcare Ministries who received federal funding for this project from the Corporation for National and Community Service, Social Innovation Fund for this project to pay for time used to conduct the study and prepare this manuscript. Enhanced Integrated Behavioral Health Model Improves Depressive Symptoms in a Low-Income, Uninsured, Primarily Hispanic Population Served by a Free and Charitable Clinic. DOI: https://doi.org/10.1136/bmj.a3079, Waring WS. First, there may have been insufficient time to observe a difference given the single year of follow up, and it is possible that physical changes may have occurred over a longer intervention period. T-tests were conducted to test within-group differences across time (baseline to endpoint) and between groups at study baseline and endpoint for each of the continuous outcomes. There were no statistically significant findings for other outcomes. The transitional nurse served as an additional resource to services addressing nutrition, exercise, smoking cessation, and support groups. To begin developing a proper Integrated Behavior Model for a particular population, interviews should be conducted on individuals present in that population to obtain information related to the behavioral, normative, efficacy, and control beliefs for the identified behavior. Patients flagged as potentially eligible were then assessed for eligibility in person at their next visit. In conclusion, implementing an integrated care model with a focus on collaboration and communication between primary care and behavioral health providers in a free and charitable clinic setting can improve depressive symptoms after 12 months for individuals who are low-income or uninsured living in the border region of southern Texas. DOI: http://doi.org/10.5334/ijic.5421, Flynn, A., et al.. “Enhanced Integrated Behavioral Health Model Improves Depressive Symptoms in a Low-income, Uninsured, Primarily Hispanic Population Served by a Free and Charitable Clinic”. Meta-analysis: Effect of Interactive Communication Between Collaborating Primary Care Physicians and Specialists. DOI: https://doi.org/10.3122/jabfm.2017.02.160234, Richardson LP, McCarthy CA, Radovic A, Suleiman BS. 2001; 345(2): 99–106. Integrated behavioral health care, a part of “whole-person care,” is a rapidly emerging shift in the practice of high-quality health care. This shift in design was primarily due to capacity of providers and HOPE’s priority to ensure patient care continuity. International Journal of Integrated Care. We compared the proportion of participants who were lost to follow-up in the intervention versus control groups using a Chi-square test. Similarly, HOPE planned to engage volunteer primary care providers more directly in the intervention, but the episodic character of provider work at the clinic made this impossible. This study builds on prior work promoting breast cancer screenings among Asian women by applying constructs from the Health Belief Model (HBM) and the Integrated Behavioral Model (IBM) to investigate why Asian-American women are less inclined to donate their healthy breast tissue than non-Asian women and how this population may be motivated to donate in the future. 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