When Interruption Becomes Innovation: How Integrated Behavioral Health in Primary Care Adapted During COVID-19.

BACKGROUND AND OBJECTIVES: Integrated behavioral health (IBH) delivered in primary care is critical to addressing the growing behavioral health crisis in the United States. COVID-19 prompted changes to the core components of IBH, causing the model to shift. The specifics of how IBH teams adapted and what these adaptations mean for the future of IBH teams in primary care are uncertain. METHODS: We conducted individual interviews with IBH team members using a semistructured interview guide. A purposive convenience sample consisted of primary care clinicians (N=20) from nine states. We used qualitative thematic analysis to code and generate themes. RESULTS: Four themes emerged: (a) permanent changes to the physical structure of the team; (b) increased reliance on technology for team communication; (c) shift in team collaboration, often occurring asynchronously; and (d) telehealth embraced for IBH. CONCLUSIONS: COVID-19 interrupted the originally designed IBH model of team-based care. Changes to the physical proximity of team members disrupted all other components of IBH, requiring adapted workflows, communication via digital channels, virtual team building, asynchronous care coordination, and remote service delivery. Long-term evaluation of these innovations is needed to examine whether shifts in core components impact model efficacy. Training family medicine, primary care, and behavioral health clinicians for these adapted models of IBH will be needed.

Varying Estimates of Social Workers in the United States: Which Data Source to Use?

Behavioral health needs continue rise in the United States and constitute a key driver of health care utilization, costs, and outcomes. Social workers provide a wide range of services across health, behavioral health, and community settings, and while this heterogeneity in practice benefits care delivery, it complicates health workforce analyses. This analysis compares five commonly used national data sources and details similarities and differences in their estimates of the number, type, and practice characteristics of social workers. The analysis suggests that estimates vary significantly between data sets ranging from 282,425 to 1,022,859 social workers; as well as yield different findings of types of social workers in the United States, depending on the data set used. These differences have the potential to shape how researchers and policy makers assess the adequacy of the social work workforce and identify solutions to address the nation's behavioral health and social care needs.

How would a certification in harm reduction impact service delivery and the harm reduction workforce? A qualitative study.

INTRODUCTION: Harm reduction utilizes evidence-based strategies to reduce the negative health and social impacts of substance use. As harm reduction services expand across the U.S. without the requirement of professional certification, variation in how the workforce is regarded and trained on harm reduction principles and practices persists. This study explores the harm reduction workforce's perspectives on how certification would impact service delivery and their profession. METHODS: The study employed purposive sampling to identify and survey administrators within a publicly available syringe services program directory (N = 168). This sub-study utilized thematic analysis to evaluate 152 respondents' answers to one dichotomous closed-ended question, "Would a certification in the harm reduction field be helpful?" followed by an open-ended response to the follow-up statement, "Based on your answer to the previous question about a certification to work in harm reduction, please explain why or why not." Approximately 45 % of the respondents (n = 68) answered no, while 55 % (n = 84) answered yes. RESULTS: Seven themes emerged in total. Among those against harm reduction certification, the four themes were: (1) certification is exclusionary and creates barriers, (2) lived experience is more important than certification, (3) certification does not equate to skills, and (4) no regulatory body exists to oversee the certification process. The study identified three themes from individuals who indicated harm reduction certification was helpful: (1) certification helps standardize training, (2) certification validates/legitimizes the harm reduction field, and (3) low barriers to receiving certificates. CONCLUSIONS: The study presents participants' perspectives for and against harm reduction certification emphasizing implications for service delivery and the workforce. Despite varying perceptions on how certification may advance or hinder the field, the sample was unified in their commitment to harm reduction practices and endorsement of its integral role in confronting the U.S. drug use epidemic. This study highlights how certification can impact state and federal harm reduction service delivery and promotes future research on ways to address the needs of harm reduction organizations and their workforce.

Artificial Neural Network Analysis Examining Substance Use Problems Co-Occurring with Anxiety and Depressive Disorders Among Adults Receiving Mental Health Treatment.

Objective: The co-occurrence of anxiety disorders, depressive disorders, and substance use problems was examined. Methods: The Mental Health Client-Level Data dataset was used to conduct logistic regression models and an artificial neural network analysis. Logistic regression analyses were conducted among adults with anxiety (n = 547,473) or depressive disorders (n = 1,610,601) as their primary diagnosis who received treatment in a community mental health center. The artificial neural network analysis was conducted with the entire sample (N = 2,158,074). Results: Approximately 30% of the sample had co-occurring high-risk substance use or substance use disorder. Characteristics including region of treatment receipt, age, education, gender, race and ethnicity, and the presence of co-occurring anxiety and depressive disorders were associated with the co-occurring high-risk substance use or a substance use disorder. Conclusions: Findings from this study highlight the importance of mental health facilities to screen for and provide integrated treatment for co-occurring disorders.

Preparing behavioral health clinicians for success and retention in rural safety net practices.

PURPOSE: This study assesses how, among behavioral health clinicians working in rural safety net practices, the amount of exposure to care in rural underserved communities received during training relates to confidence in skills important in their work settings, successes in jobs and communities, and anticipated retention. METHODS: This study uses survey data from Licensed Clinical Social Workers, Licensed Professional Counselors, and Psychologists working in rural safety net practices in 21 states while receiving educational loan repayment support from the National Health Service Corps, from 2015 to April 2022. FINDINGS: Of the 778 survey respondents working in rural counties, 486 (62.5%) reported they had formal education experiences with medically underserved populations during their professional training, for a median of 47 weeks. In analyses adjusting for potential confounders, the estimated amount of rural training exposure was positively associated with a variety of indicators of clinicians' integration and fit with their communities as well as with longer anticipated retention within their rural safety net practices. The amount of training in care for rural underserved populations was not associated with clinicians' confidence levels in various professional skills or successes in their work, including connection with patients and work satisfaction. CONCLUSIONS: Formal training in care for underserved populations is a large part of the education of behavioral health clinicians who later work in rural safety net practices. More training in rural underserved care for these clinicians is associated with greater integration and fit in their communities and longer anticipated retention in their practices, but not with skills confidence or practice outcomes.

Harm reduction workforce, behavioral health, and service delivery in the USA: a cross-sectional study.

BACKGROUND: Despite recent financial and policy support for harm reduction in the USA, information on the types of workers within organizations who design, implement, and actualize harm reduction services remains nascent. Little is known about how variability in the harm reduction workforce impacts referrals and linkages to other community supports. This exploratory mixed-methods study asked: (1) Who constitutes the harm reduction workforce? (2) Who provides behavioral health services within harm reduction organizations? (3) Are referral services offered and by whom? (4) Do referrals differ by type of harm reduction worker? METHODS: Purposive sampling techniques were used to distribute an electronic survey to U.S.-based harm reduction organizations. Descriptive statistics were conducted. Multivariate binary logistic regression models examined the associations (a) between the odds of the referral processes at harm reduction organizations and (b) between the provision of behavioral health services and distinct types of organizational staff. Qualitative data were analyzed using a hybrid approach of inductive and thematic analysis. RESULTS: Data from 41 states and Washington, D.C. were collected (N = 168; 48% response rate). Four primary types of workers were identified: community health/peer specialists (87%); medical/nursing staff (55%); behavioral health (49%); and others (34%). About 43% of organizations had a formal referral process; among these, only 32% had follow-up protocols. Qualitative findings highlighted the broad spectrum of behavioral health services offered and a broad behavioral health workforce heavily reliant on peers. Unadjusted results from multivariate models found that harm reduction organizations were more than 5 times more likely (95% CI [1.91, 13.38]) to have a formal referral process and 6 times more likely (95% CI [1.74, 21.52]) to have follow-up processes when behavioral health services were offered. Organizations were more than two times more likely (95% CI [1.09, 4.46]) to have a formal referral process and 2.36 (95% CI [1.11, 5.0]) times more likely to have follow-up processes for referrals when behavioral health providers were included. CONCLUSIONS: The composition of the harm reduction workforce is occupationally diverse. Understanding the types of services offered, as well as the workforce who provides those services, offers valuable insights into staffing and service delivery needs of frontline organizations working to reduce morbidity and mortality among those who use substances. Workforce considerations within U.S.-based harm reduction organizations are increasingly important as harm reduction services continue to expand.

Pharmacists Colocated With Primary Care Physicians: Understanding Delivery of Interprofessional Primary Care.

BACKGROUND: While evidence supports interprofessional primary care models that include pharmacists, the extent to which pharmacists are working in primary care and the factors associated with colocation is unknown. OBJECTIVES: This study aimed to analyze the physical colocation of pharmacists with primary care providers (PCPs) and examine predictors associated with colocation. RESEARCH DESIGN: This is a retrospective cross-sectional study of pharmacists and PCPs with individual National Provider Identifiers in the National Plan and Provider Enumeration System's database. Pharmacist and PCP practice addresses of the health care professionals were geocoded, and distances less than 0.1 miles were considered physically colocated. SUBJECTS: In all, 502,373 physicians and 221,534 pharmacists were included. RESULTS: When excluding hospital-based pharmacists, 1 in 10 (11%) pharmacists were colocated with a PCP. Pharmacists in urban settings were more likely to be colocated than those in rural areas (OR=1.32, CI: 1.26-1.38). Counties with the highest proportion of licensed pharmacists per 100,000 people in the county had higher colocation (OR=1.38, CI: 1.32-1.45). Colocation was significantly higher in states with an expanded scope of practice (OR 1.37, CI: 1.32-1.42) and those that have expanded Medicaid (OR 1.07, CI: 1.03-1.11). Colocated pharmacists more commonly worked in larger physician practices. CONCLUSION: Although including pharmacists on primary care teams improves clinical outcomes, reduces health care costs, and enhances patient and provider experience, colocation appears to be unevenly dispersed across the United States, with lower rates in rural areas. As the integration of pharmacists in primary care continues to expand, knowing the prevalence and facilitators of growth will be helpful to policymakers, researchers, and clinical administrators.

Social workers roles in achieving health quality metrics in primary care: a quality improvement case study.

Value-based payment models may improve patient health by targeting quality of care over quantity of health services. Social workers in primary care settings are well-positioned to improve the quality of health services for vulnerable patients by identifying and addressing patients' social determinants of health. This case study describes a Plan Do Study Act (PDSA) quality improvement approach implemented and refined by social workers to proactively address clinical quality gaps in one family medicine practice. The studied program - entitled Gap Closure Day - was led by a team of social workers to improve quality outcomes of patients. Findings highlight the important roles of social workers as members of health care teams to improve the quality of health services and address health equity.

Examining the use of psychiatric collaborative care and behavioral health integration codes at federally qualified health centers: A mixed-methods study.

INTRODUCTION: Despite evidence to support the integration of behavioral health and physical health care, the adoption of Integrated Behavioral Health (IBH) has been stymied by a lack of reliable and sustainable financing mechanisms. This study aimed to provide information on the use of Psychiatric Collaborative Care Model (CoCM) and behavioral health integration (BHI) codes and the implementation of IBH in federally qualified health centers (FQHCs). METHOD: This cross-sectional, mixed-methods study involved an electronic survey of administrators and follow-up qualitative interviews from a subset of survey respondents. Quantitative data were analyzed using descriptive analysis and thematic coding was used to analyze qualitative data to identify salient themes. RESULTS: Administrators (N = 52) from 11 states completed the survey. Use of CoCM (13%) or BHI codes (17.4%) was low. Most administrators were not aware that CoCM (72%) or BHI codes (70%) existed. Qualitative interviews (n = 9) described barriers that further complicate IBH and code use like workforce shortages and insufficient reimbursement for the cost to deliver CoCM services. DISCUSSION: Although FQHCs are working to meet the needs of the communities they serve, a lack of billing clarity and awareness and workforce issues hinder the adoption of the CoCM. FQHCs face many demands to provide care to safety net populations, yet are not fully equipped with the resources, workflows, staffing, and payment structures to support CoCM/BHI billing. Increased financial and logistical support to build practice infrastructure is needed to reduce the administrative complexity and inadequate reimbursement mechanisms that currently hinder the implementation of the CoCM and integrated care delivery. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Are DEA-waivered buprenorphine prescribers colocated with behavioral health clinicians?

BACKGROUND AND OBJECTIVES: Medication for opioid use disorder (MOUD) in primary care includes a combination of medication, behavioral therapy, and/or other psychosocial services. This study assessed rates of colocation between waivered prescribers and behavioral health clinicians across the United States to understand if rates varied by provider type and geographic indicators. METHODS: Data from the DEA-Drug Addiction Treatment Act of 2000 provider list as of March 2022 and the National Plan and Provider Enumeration System's National Provider Identifier database were gathered, cleaned, and formatted in Stata. Data were geocoded with ESRI StreetMap® database and ArcGIS software. Covariates at individual, county, and state levels were examined and compared. Chi-square statistics and a mixed-effects logistic regression were analyzed. RESULTS: The sample (N = 71, 292 prescribers) included physicians (64%), nurse practitioners (29%), and physician assistants (7%). About 48% of prescribers were colocated with a behavioral health clinician. Physicians were the least likely to be colocated (47%), but differences between provider types were modest. We observed significant geographic differences in provider colocation by provider type. Mixed effects logistic regression identified significant predictors of colocation at individual, county, and state levels. DISCUSSION AND CONCLUSIONS: Optimally distributing the workforce providing MOUD is necessary to broadly ensure the provision of comprehensive MOUD care based on practice guidelines. SCIENTIFIC SIGNIFICANCE: Less than half of all waivered prescribers, outside of hospitals, are colocated with behavioral health clinicians. Findings offer greater clarity on where integrated MOUD is occurring, among which types of providers, and where it needs to be expanded to increase MOUD uptake.

Federally Qualified Health Centers Use of Telehealth to Deliver Integrated Behavioral Health Care During COVID-19.

Federally qualified health centers (FQHCs) that provide comprehensive health services, including integrated behavioral health (IBH), transitioned to deliver care via telehealth during the COVID-19 pandemic. This study explored how FQHCs adapted IBH services using telehealth. A mixed-method design was used, pairing a survey disseminated to FQHC administrators with a structured interview. Of the 46 administrators who participated in the survey, 14 (30.4%) reported delivering IBH using telecommunication prior to the pandemic. Since COVID-19, almost all of the FQHCs surveyed used telecommunication to deliver IBH (n = 44, 95.7%). Nine interviews with FQHC administrators resulted in the four themes: telehealth was essential; core components of IBH were impacted; payment parity and reimbursement were a concern; and telehealth addressed workforce issues. Findings confirm the necessity of telehealth for FQHCs during COVID-19. However due to the lack of co-location, warm-handoffs and other core components of IBH were limited.

Frontline, Essential, and Invisible: The Needs of Low-Wage Workers in Hospital Settings During COVID-19.

BACKGROUND: Frontline health care workers are particularly vulnerable to burnout and diminished well-being as they endure COVID-19 pandemic-related stressors. While physicians and nurses are the public face of those experiencing burnout in hospitals, these stressors also affect low-wage workers such as food and housekeeping/janitorial service workers whose roles largely remain "invisible" when conceptualizing the essential health workforce and understanding their needs. This study sought to understand the experiences of frontline essential workers to better support them and prevent burnout. METHODS: Using a semi-structured interview guide, we conducted 20 in-depth qualitative interviews with workers in three U.S. states. Thematic content analysis was conducted to code and analyze interviews. RESULTS: Workers had an average of 5.8 years in their jobs, which included food services, housekeeping/janitorial, and patient transport roles. Analysis revealed four prominent stressors contributing to worker burnout: changes in duties and staff shortages, fear of contracting or transmitting COVID-19, desire for recognition of their job-related risk, and unclear communication on safety precautions and resources. Protective factors included paid time-off, mental health supports, sense of workplace pride, and self-coping strategies. CONCLUSION/APPLICATION TO PRACTICE: As health systems continue to grapple with care delivery in the context of COVID-19, identifying best practices to support all workers and prevent burnout is vital to the functioning and safety of hospitals. Further consideration is warranted to create policies and multipronged interventions to meet workers' tangible needs while shifting the culture, so all members of the health workforce are seen and valued.

Improving the Health of Rural Communities Through Academic-Community Partnerships and Interprofessional Health Care and Training Models.

Health disparities between rural and urban areas are widening at a time when urban health care systems are increasingly buying rural hospitals to gain market share. New payment models, shifting from fee-for-service to value-based care, are gaining traction, creating incentives for health care systems to manage the social risk factors that increase health care utilization and costs. Health system consolidation and value-based care are increasingly linking the success of urban health care systems to rural communities. Yet, despite the natural ecosystem rural communities provide for interprofessional learning and collaborative practice, many academic health centers (AHCs) have not invested in building team-based models of practice in rural areas. With responsibility for training the future health workforce and major investments in research infrastructure and educational capacity, AHCs are uniquely positioned to develop interprofessional practice and training opportunities in rural areas and evaluate the cost savings and quality outcomes associated with team-based care models. To accomplish this work, AHCs will need to develop academic-community partnerships that include networks of providers and practices, non-AHC educational organizations, and community-based agencies. In this commentary, the authors highlight 3 examples of academic-community partnerships that developed and implemented interprofessional practice and education models and were designed around specific patient populations with measurable outcomes: North Carolina's Asheville Project, the Boise Interprofessional Academic Patient Aligned Care model, and the Interprofessional Care Access Network framework. These innovative models demonstrate the importance of academic-community partnerships to build teams that address social needs, improve health outcomes, and lower costs. They also highlight the need for more rigorous reporting on the components of the academic-community partnerships involved, the different types of health workers deployed, and the design of the interprofessional training and practice models implemented.

Prevalence and Characteristics of Providers' Care Coordination Communication With Schools.

OBJECTIVES: Care coordination between schools and medical providers promotes child health, particularly for children with physical, emotional, and behavioral challenges. The purpose of this study was to assess caregivers' reports of provider-school communication for their children. Further, the study assessed if communication rates varied by child demographic or health conditions. METHODS: This study was a cross-sectional analysis of the 2016-2017 National Survey of Children's Health focused on school-aged children (age 6-17 years; n = 18,160). Weighted frequencies overall and stratified by provider-school communication status are reported. Multivariable logistic regression examined associations of provider-school communication. RESULTS: Only 23.5% of the total sample reported provider-school communication. The highest caregiver-reported communication prevalence was for children with diabetes (68.0%). Behavioral/mental health conditions, chronic physical health conditions or having increased medical complexity and needs were significantly associated with increased communication compared to those without these conditions. Odds Ratio (OR) and 95% Confidence Intervals (CI) for children with a behavioral/mental health condition were OR: 1.28; CI: 1.02 to 1.61, for children with a chronic physical health condition were OR: 1.37; CI: 1.15 to 1.63 and for children with special health care needs or with medical complexity were OR: 2.15; CI: 1.75 to 2.64 and OR: 1.77; CI: 1.09 to 2.87, respectively. Significant communication differences existed for every health condition (P < 0.05) except for children who had a blood disorder (P = 0.365). CONCLUSIONS: Caregiver perception of provider-school communication is low and differences in reported rates existed between health conditions and complexity status. Further work is needed to support provider-school-family communication for children with physical, mental, behavioral, and complex health conditions.

What Do EHRs Tell Us about How We Deploy Health Professionals to Address the Social Determinants of Health.

The objective of this study was to determine how well Electronic Health Record (EHR) documentation identifies which health professionals act to address patient social determinants of health (SDOH) and what interventions are documented. The Electronic Medical Record Search Engine was used to identify food and housing insecurity EHR notes. From the notes, researchers randomly sampled 60 from each SDOH category. Of 120 notes, which contained a reference to food or housing insecurity, 72% also contained information on an intervention taken. Interventions were documented by social workers 63% of the time, followed by dietitians and physicians. Addressing patient SDOH is a crucial part of comprehensive healthcare. Findings contribute to a broader conversation on the documentation and interventions in healthcare settings to address patients' SDOH. Findings support the critical importance of standardizing SDOH documentation in the EHR across more members of the health workforce to ensure patient needs are met.

Harnessing the electronic health record to advance integrated care.

INTRODUCTION: Integrated health care is utilized in primary care clinics to meet patients' physical, behavioral, and social needs. Current methods to collect and evaluate the effectiveness of integrated care require refinement. Using informatics and electronic health records (EHR) to distill large amounts of clinical data may help researchers measure the impact of integrated care more efficiently. This exploratory pilot study aimed to (a) determine the feasibility of using EHR documentation to identify behavioral health and social care components of integrated care, using social work as a use case, and (b) develop a lexicon to inform future research using natural language processing. METHOD: Study steps included development of a preliminary lexicon of behavioral health and social care interventions to address basic needs, creation of an abstraction guide, identification of appropriate EHR notes, manual chart abstraction, revision of the lexicon, and synthesis of findings. RESULTS: Notes (N = 647) were analyzed from a random sample of 60 patients. Notes documented behavioral health and social care components of care but were difficult to identify due to inconsistencies in note location and titling. Although the interventions were not described in detail, the outcomes of screening, referral, and brief treatment were included. The integrated care team frequently used EHR to share information and communicate. DISCUSSION: Opportunities and challenges to using EHR data were identified and need to be addressed to better understand the behavioral health and social care interventions in integrated care. To best leverage EHR data, future research must determine how to document and extract pertinent information about integrated team-based interventions. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Using Latent Class Analysis to Understand Social Worker Roles in Integrated Health Care.

Purpose: Social work (SW) is a profession that fulfills important roles on integrated health teams, yet there remains a lack of clarity on SW's functions. The current study sought to identify typologies of SW's roles on integrated care teams using latent class analysis (LCA).Method: An electronic survey was developed, piloted, and administered to Masters level SW students and practitioners in integrated health care settings (N = 395) regarding weekly use of interventions. LCA was conducted to estimate latent sub-groups of respondents.Results: Respondents reported an average of 14.6 (SD = 4.7) interventions. Five classes of SW roles were identified and varied by setting and focus. One class (13%) completed a hybrid function providing behavioral health and social care interventions.Conclusions: Classes of SW roles on teams may reflect varying models of integrated care. A flexible SW on the team may adapt to patient and clinic needs, but increases the opportunity for role confusion.