Case Report: Implementation of a Multi-Component Behavioral Health Integration Program in Obstetrics for Perinatal Behavioral Health

Despite growing research and policy attention, perinatal behavioral health conditions (i.e., mental health and substance use disorders) remain prevalent, burdensome for families, and largely untreated in the US. Researchers have documented an array of barriers to accurate detection, linkage with effective treatment, and improved outcomes for perinatal women with behavioral health disorders. It is clear that a multi-component approach that integrates evidence-based detection and management of perinatal behavioral health in the context of obstetrics care can be effective. This paper presents the initial development of a clinical quality improvement program that includes evidence-based components of behavioral health integration in obstetrics in the state of Florida in the US. The FL BH Impact (Improving Maternal and Pediatric Access, Care and Treatment for Behavioral Health) program, guided by the RE-AIM model for program implementation, has been developed over the past 2 years. Program components, initial implementation, and preliminary findings are presented. Following the implementation phase, the program has enrolled 12 obstetrics practices and 122 obstetrics providers in program engagement and training activities. The primary program component allows for obstetrics clinician telephone access to a statewide listing of behavioral health referral resources for patients and access to consultation with psychiatry. Since program implementation, the program has received a total of 122 calls to this line, with an expected increasing trajectory of calls over time. Results suggest this program is feasible to implement across a large geographic area. Challenges to implementation and future directions are discussed. These types of multi-component approaches to improved management and outcomes for perinatal behavioral health are promising and must be expanded and sustained in the US.

Assessing cross-sector stakeholder readiness to advance and sustain statewide behavioral integration beyond a State Innovation Model (SIM) initiative

Integrated care is recognized as a promising approach to comprehensive health care and reductions in health care costs. However, the integration of behavioral health and primary care is complex and often difficult to implement. Successful and sustainable integration efforts require coordination and alignment both within health care organizations and across multiple sectors. Furthermore, implementation progress and outcomes are shaped by the readiness of stakeholders to work together toward integrated care. In the context of a Colorado State Innovation Model (SIM) effort, we examined stakeholder readiness to advance and sustain partnerships for behavioral health integration beyond the period of grant funding. Partnership readiness was assessed using the Readiness for Cross-sector Partnerships Questionnaire (RCP) in spring 2019. Participants from 67 organizations represented seven sectors: government, health care, academic, practice transformation, advocacy, payer, and other. RCP analyses indicated a moderate level of readiness among Colorado stakeholders for partnering to continue the work of behavioral health integration initiated by SIM. Stakeholders indicated their highest readiness levels for general capacity and lowest for innovation-specific capacity. Five thematic categories emerged from the open-ended questions pertaining to partnership experiences: (a) collaboration and relationships, (b) capacity and leadership, (c) measurement and outcomes, (d) financing integrated care, and (e) sustainability of the cross-sector partnership. Partnering across sectors to advance integrated behavioral health and create more equitable access to services is inherently complex and nonlinear in nature. The RCP usefully identifies opportunities to strengthen the sustainability of integrated care efforts.

Integrating Behavioral Health and Primary Care (IBH-PC) to improve patient-centered outcomes in adults with multiple chronic medical and behavioral health conditions: study protocol for a pragmatic cluster-randomized control trial

Background Chronic diseases that drive morbidity, mortality, and health care costs are largely influenced by human behavior. Behavioral health conditions such as anxiety, depression, and substance use disorders can often be effectively managed. The majority of patients in need of behavioral health care are seen in primary care, which often has difficulty responding. Some primary care practices are providing integrated behavioral health care (IBH), where primary care and behavioral health providers work together, in one location, using a team-based approach. Research suggests there may be an association between IBH and improved patient outcomes. However, it is often difficult for practices to achieve high levels of integration. The Integrating Behavioral Health and Primary Care study responds to this need by testing the effectiveness of a comprehensive practice-level intervention designed to improve outcomes in patients with multiple chronic medical and behavioral health conditions by increasing the practice’s degree of behavioral health integration. Methods Forty-five primary care practices, with existing onsite behavioral health care, will be recruited for this study. Forty-three practices will be randomized to the intervention or usual care arm, while 2 practices will be considered “Vanguard” (pilot) practices for developing the intervention. The intervention is a 24-month supported practice change process including an online curriculum, a practice redesign and implementation workbook, remote quality improvement coaching services, and an online learning community. Each practice’s degree of behavioral health integration will be measured using the Practice Integration Profile. Approximately 75 patients with both chronic medical and behavioral health conditions from each practice will be asked to complete a series of surveys to measure patient-centered outcomes. Change in practice degree of behavioral health integration and patient-centered outcomes will be compared between the two groups. Practice-level case studies will be conducted to better understand the contextual factors influencing integration. Discussion As primary care practices are encouraged to provide IBH services, evidence-based interventions to increase practice integration will be needed. This study will demonstrate the effectiveness of one such intervention in a pragmatic, real-world setting. Trial registration ClinicalTrials.gov NCT02868983. Registered on August 16, 2016.