Pathways to Kindergarten Readiness: The Roles of Second Step Early Learning Curriculum and Social Emotional, Executive Functioning, Preschool Academic and Task Behavior Skills.

Efforts to improve the achievement gap between low-income children and their more affluent peers has led to the development of classroom interventions and curricula to increase executive functioning (EF) and social-emotional skills (SE), thought to be foundational for learning. The Second Step Early Learning (SSEL) curriculum is a commercially available curriculum designed to improve school readiness by building EF and SE skills. However, although widely used, it has not been widely studied. Modeling SSEL's underlying theory of change, structural equation modeling (SEM) was used to longitudinally examine the effects of the curriculum on low-income preschool children's kindergarten school readiness through the hypothesized mediating role of EF and SE skills in improving pre-academic skills and task behavior in preschool. In a cluster randomized trial, 972 children attending 63 preschool classrooms within 13 low-income Head Start or community preschools were individually tested at the beginning (T1) and end of preschool (T2, n = 836) and followed into kindergarten. Children's average age at T1 was 53 months, with 51% male, 42% Anglo-American, 26% African-American, and 40% Hispanic-American. Children's EF, social skills, pre-literacy/language, and pre-math skills were assessed by trained child assessors blind to study conditions at T1 and T2. Assessors also rated children's task behavior in the testing situation at T1 and T2. School records of children's kindergarten screening scores were obtained on 345 children at T3. It was expected that SSEL would have both direct and indirect effects on kindergarten readiness through improvements in children's SE and EF skills preschool academic skills and on-task behavior. We found no direct effects of SSEL on either pre-academic or on-task behavior outcomes in preschool, nor on later kindergarten readiness. However, SSEL significantly increased EF, and as expected by SSEL's theory of change, growth in EF predicted gains in both pre-academics (particularly pre-math), and on-task behavior in preschool. End-of-year pre-academic skills and on task behavior in turn predicted better kindergarten readiness. Further, SE (although not impacted by SSEL) had direct and indirect effects on kindergarten readiness. Thus, overall, our findings largely support SSEL's theory of change, particularly in relation to EF.

Homeless women's service use, barriers, and motivation for participating in substance use treatment.

BACKGROUND: Homeless women are at high risk for substance use disorder (SUD), and are a growing proportion of the homeless population. However, homeless women experience barriers to engaging in substance use services. OBJECTIVES: Among homeless women with SUD, to explore service use, motivation to change, service barriers, and willingness to have substance use and mental health problems addressed in primary health care. METHODS: Women with SUD were sampled from 11 Health Care for the Homeless (HCH) primary care clinics in 9 states, yielding 241 with either an alcohol or drug use disorder who then completed questions about SUD services. RESULTS: Over 60% of women with dual alcohol and drug use disorders used some type of SUD service in the past year, while 52% with a drug only disorder, and 44% with an alcohol only disorder used services. The most mentioned barrier to service use was depression, but cost, wait time, where to find treatment, and facilities located too far away, were also frequently noted. A large proportion across all groups indicated high motivation for treatment and willingness to discuss their SUD in a primary care setting. CONCLUSION: There are continued barriers to SUD service use for homeless women despite high motivation for treatment, and willingness to be asked about SUD and mental health problems in primary care. HCH primary care sites should more systematically ask about SUD and mental health issues and address women's expressed need for support groups and alternative therapies to more holistically address their SUD needs.

Postpartum outcomes of a pilot prenatal care-based psychosocial intervention for PTSD during pregnancy.

This study examines postpartum posttraumatic stress disorder (PTSD) symptoms and secondary outcomes including postpartum depression and birth outcomes for pregnant women who screened positive for PTSD and received a psychosocial education intervention compared to women with PTSD in the usual prenatal care setting. All women entering prenatal care at two federally qualified health centers were screened for symptoms of current PTSD; one site was selected randomly to have prenatal care advocates deliver eight Seeking Safety topics for women with clinical or subclinical PTSD. Women were not blind to condition. Baseline and postpartum interviews, including demographic characteristics and assessment of mental health, social support, and coping skills, were conducted. Medical record data was collected to document preterm delivery and low birth weight. Of the 149 participants at baseline, 128 (86%) participated in the postpartum interview. Intervention women, compared to controls, significantly decreased PTSD symptoms, and showed a non-significant trend for improved social support. However, depression, coping, and birth outcomes did not differ. This study suggests some initial support for the Seeking Safety intervention in prenatal care settings and requires further research to determine the best approaches to its implementation.

The Health Equity Scholars Program: Innovation in the Leaky Pipeline.

Despite attempts to increase enrollment of under-represented minorities (URMs: primarily Black/African American, Hispanic/Latino, and Native American students) in health professional programs, limited progress has been made. Compelling reasons to rectify this situation include equity for URMs, better prepared health professionals when programs are diverse, better quality and access to health care for UMR populations, and the need for diverse talent to tackle difficult questions in health science and health care delivery. However, many students who initiate traditional "pipeline" programs designed to link URMs to professional schools in health professions and the sciences, do not complete them. In addition, program requirements often restrict entry to highly qualified students while not expanding opportunities for promising, but potentially less well-prepared candidates. The current study describes innovations in an undergraduate pipeline program, the Health Equity Scholars Program (HESP) designed to address barriers URMs experience in more traditional programs, and provides evaluative outcomes and qualitative feedback from participants. A primary outcome was timely college graduation. Eighty percent (80%) of participants, both transfer students and first time students, so far achieved this outcome, with 91% on track, compared to the campus average of 42% for all first time students and 58-67% for transfers. Grade point averages also improved (p = 0.056) after program participation. Graduates (94%) were working in health care/human services positions and three were in health-related graduate programs. Creating a more flexible program that admits a broader range of URMs has potential to expand the numbers of URM students interested and prepared to make a contribution to health equity research and clinical care.

Prevalence and predictors of substance use disorders among homeless women seeking primary care: An 11 site survey.

BACKGROUND AND OBJECTIVES: Homeless women have shown high rates of substance use disorders (SUD), but many studies are more than a decade old, limited in geographic location, or focus only on women living outdoors or in shelters. The purpose of this study was to obtain a more current and representative sample of homeless women and the prevalence and predictors of substance use disorders among women seeking primary care at Health Care for the Homeless clinics across the US. METHODS: Eleven Health Care for the Homeless (HCH) clinics in nine states contributed proportionally to a sample of n = 780 female patients who completed a self-administered survey including demographics, housing history, health, mental health, and drug and alcohol use. RESULTS: Compared to the general population of women, rates were four times higher for an alcohol use disorder, and 12 times higher for a drug use disorder. DISCUSSION AND CONCLUSIONS: The findings indicate a significant need for SUD services, with an equally high need for mental health services. In addition, high rates of victimization and use of tobacco, and overall poor health status, indicate overall health disparities. SCIENTIFIC SIGNIFICANCE: Addressing barriers to full integration of substance use and mental health services, such as improving screening, reimbursement, clinician training, and addressing biases about motivation of this population to engage in treatment, are necessary to improve the health of women seeking care in HCH settings. (Am J Addict 2017;26:680-688).

Managing Depression Among Homeless Mothers: Pilot Testing an Adapted Collaborative Care Intervention.

OBJECTIVE: Although depression is common among homeless mothers, little progress has been made in testing treatment strategies for this group. We describe pilot test results of an adapted collaborative care model for homeless mothers with depression. METHOD: We conducted a pilot intervention study of mothers screening positive for depression in 2 randomly selected shelter-based primary care clinics in New York over 18 months in 2010-2012. Study participants completed a psychosocial, health, and mental health assessment at baseline, 3 months, and 6 months. RESULTS: One-third of women screened positive for depression (123 of 328 women). Sixty-seven women (63.2% of the eligible sample) enrolled in the intervention. At 6 months, compared to usual-care women, intervention group women were more likely to be receiving depression treatment (40.0% vs 5.9%, P = .01) and antidepressant medication (73.3% vs 5.9%, P = .001, respectively) and had more primary care physician and care manager visits at both 3 months (74.3% vs 53.3%, P = .009 and 91.4% vs 26.7%, P < .001, respectively) and 6 months (46.7% vs 23.5%, P = .003 and 70% vs 17.7%, P = .001, respectively). More women in the intervention group compared to usual-care women reported ≥ 50% improvement in depression symptoms at 6 months (30% vs 5.9%, P = .07). CONCLUSIONS: This pilot study found that implementing an adapted collaborative care intervention was feasible in a shelter-based primary care clinic and had promising results that require further testing. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02723058.

Using Prenatal Advocates to Implement a Psychosocial Education Intervention for Posttraumatic Stress Disorder during Pregnancy: Feasibility, Care Engagement, and Predelivery Behavioral Outcomes.

BACKGROUND: Pregnant women with posttraumatic stress disorder (PTSD) engage in more high-risk behavior and use less prenatal care. Although treating depression in pregnancy is becoming widespread, options for addressing PTSD are few. This study was designed to test the feasibility of implementing a manualized psychosocial PTSD intervention, Seeking Safety, delivered by prenatal advocates. METHODS: All women entering prenatal care at two federally qualified health centers were screened for current symptoms of PTSD. One site was selected randomly to have prenatal care advocates deliver eight Seeking Safety topics for women that indicated clinical or subclinical PTSD symptoms. Baseline and pre-delivery interviews were conducted, which collected background characteristics and assessed PTSD severity and coping skills. Medical records were collected to document care visits. Documentation of participation rates, fidelity to the treatment, and qualitative feedback from advocates and participants was collected. RESULTS: More than one-half (57.3%) of the intervention women received all Seeking Safety sessions and fidelity ratings of the session showed acceptable quality. Using an intent-to-treat analysis, intervention women participated in significantly more prenatal care visits (M = 11.7 versus 8.9; p < .001), and had a significantly higher rate of achieving adequate prenatal care (72.4% vs. 42.9%; p < .001). Although not significant when accounting for baseline differences, intervention women also reduced negative coping skills but not PTSD symptoms. CONCLUSIONS: Using prenatal care advocates to deliver Seeking Safety sessions to women screening positive for PTSD symptoms at entry to prenatal care is a promising intervention that seems to increase prenatal care participation and may reduce negative coping strategies.

Screening for Post-traumatic Stress Disorder in Prenatal Care: Prevalence and Characteristics in a Low-Income Population.

Objectives Investigate the feasibility of using a brief, 4-item PTSD screening tool (PTSD-PC) as part of routine prenatal care in two community health care settings serving ethnically and linguistically diverse low-income populations. Report prevalence and differences by sub-threshold and clinical levels, in demographic, health, mental health, risk behaviors, and service use. Methods Women were screened as part of their prenatal intake visit over a 2-year period. Those screening positive at clinical or sub-threshold levels were recruited if they spoke English, Spanish, Portuguese, Vietnamese or Arabic. Enrolled women were interviewed about psychosocial risk factors, prior traumas, PTSD symptoms, depression, anxiety, substance use, health and services, using validated survey instruments. Results Of 1362 women seen for prenatal intakes, 1259 (92 %) were screened, 208 (17 %) screened positive for PTSD at clinical (11 %) or sub-threshold levels (6 %), and 149 (72 % of all eligible women) enrolled in the study. Those screening positive were significantly younger, had more prior pregnancies, were less likely to be Asian or black, and were more likely to be non-English speakers. Enrolled women at clinical as compared to sub-threshold levels showed few differences in psychosocial risk, but had significantly more types of trauma, more trauma before age 18, more interpersonal trauma, and had greater depression, anxiety, and PTSD symptoms. Only about 25 % had received mental health treatment. Conclusions The PTSD-PC was a feasible screening tool for use in prenatal care. While those screening in at clinical levels were more symptomatic, those at subthreshold levels still showed substantial symptomology and psychosocial risk.

Preparing Future Leaders: An Integrated Quality Improvement Residency Curriculum.

BACKGROUND AND OBJECTIVES: The Accreditation Council for Graduate Medical Education (ACGME) has recognized the importance of quality improvement (QI) training and requires that accredited residencies in all specialties demonstrate that residents are "integrated and actively participate in interdisciplinary clinical quality improvement and patient safety activities." However, competing demands in residency training may make this difficult to accomplish. The study's objective is to develop and evaluate a longitudinal curriculum that meets the ACGME requirement for QI and patient safety training and links to patient-centered medical home (PCMH) practices. METHODS: Residents in the Worcester Family Medicine Residency (WFMR) participated in a faculty-developed quality improvement curriculum that included web-based tutorials, quality improvement projects, and small-group sessions across all 3 years of residency. They completed self-evaluations of knowledge and use of curricular activities annually and at graduation, and comparisons were made between two graduating classes, as well as comparison of end of PGY2 to end of PGY3 for one class. RESULTS: Graduating residents who completed the full 3 years of the curriculum rated themselves as significantly more skilled in nine of 15 areas assessed at end of residency compared to after PGY2 and reported confidence in providing future leadership in a focus group. Five areas were also rated significantly higher than prior-year residents. CONCLUSIONS: Involving family medicine residents in a longitudinal curriculum with hands-on practice in implementing QI, patient safety, and chronic illness management activities that are inclusive of PCMH goals increased their self-perceived skills and leadership ability to implement these new and emerging evidence-based practices in primary care.

A randomized control trial of a chronic care intervention for homeless women with alcohol use problems.

A clinician-randomized trial was conducted using the chronic care model for disease management for alcohol use problems among n = 82 women served in a health care for the homeless clinic. Women with problem alcohol use received either usual care or an intervention consisting of a primary care provider (PCP) brief intervention, referral to addiction services, and on-going support from a care manager (CM) for 6 months. Both groups significantly reduced their alcohol consumption, with a small effect size favoring intervention at 3 months, but there were no significant differences between groups in reductions in drinking or in housing stability, or mental or physical health. However, intervention women had significantly more frequent participation in substance use treatment services. Baseline differences and small sample size limit generalizability, although substantial reductions in drinking for both groups suggest that screening and PCP brief treatment are promising interventions for homeless women with alcohol use problems.

Homeless women and hazardous drinking: screening results in a primary health care setting.

BACKGROUND AND OBJECTIVES: Screening for alcohol use in primary care is underutilized, especially for women. The current study implemented systematic women's alcohol use screening in a health care for the homeless primary care program. METHODS: All women (n=541) seeking care over 12 months were screened. RESULTS: Of the 541 screening forms returned, 80 women refused to answer the alcohol use questions. Of 461 completed screens, over 40% reported no alcohol use, while 43.8% reported hazardous drinking. Hazardous drinking was significantly associated with younger age, African American race, and living on the street or in a shelter. DISCUSSION AND CONCLUSIONS: High rates of drinking were identified among women in different housing situations and use of systematic screening was beneficial to providers. SCIENTIFIC SIGNIFICANCE AND FUTURE DIRECTIONS: Health care settings are important sites to identify hazardous drinking as well as alcohol disorders among women with unstable housing histories. The growing integration of behavioral health care into primary care, and the medical home concept, both provide opportunities for brief interventions for at-risk drinkers, as well as treatment options for those with alcohol use disorders that may be particularly appealing to women. Findings support further investigation of the relationship of housing stability to drinking, and suggest African American women may need special attention.

Does experiencing homelessness affect women's motivation to change alcohol or drug use?

BACKGROUND AND OBJECTIVES: Homeless women are at high risk of drug and alcohol dependence and may receive less opportunity for treatment. Our objective was to examine the association between experiencing homelessness and motivation to change drug or alcohol use. METHODS: Women (n = 154) participants in a study of substance dependence at an urban medical center (69 with some homeless days in the last 90 days; 85 continuously housed at baseline) completed six items rating motivation to change alcohol or drug use (ie, importance, readiness, and confidence) at baseline and in 3-, 6-, and 12-month follow-up interviews. Unadjusted and longitudinal analyses controlling for covariates (eg, demographics, insurance status, substance use consequences, mental health status, and participation in treatment) were conducted. RESULTS: There were no significant differences between women experiencing homeless days versus continuously housed women in the odds of reporting high motivation to change alcohol or drug use, either in unadjusted baseline analyses or longitudinal analyses adjusted for covariates. Covariates that were significantly associated with high importance, readiness or confidence to change behavior were higher life time consequences of substance use, and participation in 12-step programs. DISCUSSION AND CONCLUSIONS: The findings suggest that clinicians should not make assumptions that homeless women have low motivation to change their substance use. SCIENTIFIC SIGNIFICANCE AND FUTURE DIRECTIONS: The same opportunities for addiction treatment should be offered to homeless as to housed women.

A pilot study of a primary prevention curriculum to address preschool behavior problems.

Behavior problems among preschool children are common. They are important targets for intervention because early externalizing problems and self-regulation issues tend to persist without appropriate attention, and can affect later mental health and school achievement outcomes. However, few preschool curricula addressing social and emotional development exist, and evidence for effects are mixed. In this study, the Second Step Pre/Kindergarten Social and Emotional Learning curriculum was adapted and tested in a small cluster randomized pilot study of community preschool classrooms to determine if it could improve outcomes in: (1) individual children's teacher-rated behavior problems and prosocial skills; (2) classroom climate (classroom interactions and two measures of disruptive behavior); and (3) teacher interaction skills. Year 1 outcomes were modest and were accounted for by baseline differences. In Year 2, classroom climate, measured by independent observers, differed significantly in intervention classrooms, largely because of declines in control classrooms, and there was some evidence for better teacher interaction skills in intervention classrooms. The pattern of effects suggests important impacts on classroom quality worth investigating in a larger study. Both fidelity and implementation rates, as well as positive teacher responses to the curriculum, indicate potential for widespread adoption.

Implementing a Primary Prevention Social Skills Intervention in Urban Preschools: Factors Associated with Quality and Fidelity.

RESEARCH FINDINGS: Preschool behavior problems are of increasing concern to early childhood educators. Preventive interventions are being developed, but implementation in under-resourced child care programs is challenging. This study describes the implementation of an adapted Second Step curriculum to increase children's social skills and decrease behavior problems in preschool classrooms. Teacher training/coaching, organizational supports, and procedures for sustainability are described. Measures included baseline classroom characteristics, lesson completion and fidelity, and teacher satisfaction. Teachers completed 88% of the lessons across two years. Follow-up monitoring in Year 3, once all training was terminated, found 95% of lessons were delivered with higher fidelity than the first two years. Teachers were satisfied with training, felt the curriculum improved children's social skills, and stated they would continue to use the curriculum. Lesson completion and fidelity were associated with various teacher characteristics, training attendance, classroom characteristics, teacher and child turnover, and the percent of children with developmental delays in the classroom. PRACTICE: Results support the implementation strategy and suggest that paying attention to teacher morale, general skill development, and a period of on-going support for training is important and will lead to sustainable and high implementation rates.

"They don't want anything to do with you": patient views of primary care management of chronic pain.

OBJECTIVE: Chronic pain is one of the most frequent complaints of patients in primary care, yet both patients and providers report low satisfaction with chronic pain care. This study was designed to explore the views held by a diverse sample of patients with chronic pain complaints about their care experiences to identify ways to improve care. DESIGN: Qualitative analysis of 17 patient focus groups (size 3-7 participants). Groups used structured questions and were tape recorded, transcribed, and coded using qualitative software. Eleven groups were conducted in English, six groups in Spanish. PATIENTS: Convenience sample of 72 adult patients (68% female, 44% Latino, mean age=48.1 years) recruited from four diverse primary care practices in Central Massachusetts. RESULTS: Across all 17 groups, and all gender, ethnicity, and age groups, most patients reported suboptimal interactions with their providers when seeking care for chronic pain. Subjects acknowledged feeling disrespected and distrusted, suspected of drug-seeking, and having their symptoms dismissed as trivial and/or not warranting medical care. Patients reported more satisfaction when they felt a provider listened to them, trusted them, was accessible to address pain concerns between visits, and used patient-centered approaches to establish goals and treatment plans. Patients also recommended some management techniques related to the chronic disease management model to improve pain care. CONCLUSIONS: Implementing patient-centered approaches in caring for individuals with chronic pain and using principles drawn from the chronic disease management model to improve care systems may improve both patient and provider satisfaction with chronic pain care.

A survey of primary care provider attitudes and behaviors regarding treatment of adult depression: what changes after a collaborative care intervention?

OBJECTIVE: To assess primary care provider (PCP) attitudes and self-reported behavior with regard to identifying and managing depression in adult patients before and after a chronic disease/collaborative care intervention. METHOD: A self-administered cross-sectional survey was conducted in 6 targeted practices among 39 family practice physicians, family nurse practitioners, and residents before and after implementation of a depression in primary care project. In this project, the sites received tools and training in depression screening and guideline-concordant treatment, facilitated referral services for patients to access mental health providers, psychiatric phone consultation, patient education materials, and services of a depression care manager. The project was conducted from June 2003 through June 2006. RESULTS: Comparison of responses prior to and after the intervention showed that significantly or nearly significantly larger proportions of PCPs endorsed the importance of depression as a patient presenting problem (p = .000), increased provision of supportive counseling (p = .13), more often identified counseling or therapy as effective (p = .07), and more often referred patients to mental health services (p = .001). PCPs also reduced their perception that treating depression is time consuming (p = .000). CONCLUSIONS: After a chronic disease/collaborative care approach to depression treatment in primary care was implemented, PCP attitudes and behaviors about depression treatment were significantly modified. More guideline-concordant care, and increased collaboration with mental health services, was reported. Implications for future primary care depression intervention activities and research are discussed.

Family medicine physicians' views of how to improve chronic pain management.

PURPOSE: To determine family practice provider views of how to improve chronic nonmalignant pain (CNMP) management in primary care. METHODS: Modified Delphi group process with providers randomly selected from 6 community practice sites: 3 federally qualified community health centers, 1 rural health center, and 2 hospital-owned practices. Providers gave structured written feedback in response to a report of provider and patient concerns about the quality of CNMP in their practice sites and participated in a facilitated discussion in 1 of 3 group meetings. RESULTS: 54% participation (n=14) of family physicians, 6 to 30 years out of residency, identified 4 major themes for improvement of CNMP treatment: (1) the need for provider practice guidelines; (2) changes in the monthly opioid prescription refill process; (3) provision of self-management support and access to alternative treatments for patients; and (4) the use of a nurse care manager. CONCLUSIONS: Family physicians identified multiple components of practice that would improve both provider and patient experiences during and outcomes of CNMP management. Recommendations lend themselves to consideration of CNMP as a chronic illness and use of the Chronic Care Model as an appropriate framework for quality improvement.

Primary care provider concerns about management of chronic pain in community clinic populations.

BACKGROUND: Chronic pain is a common patient complaint in primary care, yet providers and patients are often dissatisfied with treatment processes and outcomes. OBJECTIVE: To assess provider satisfaction with their training for and current management of chronic pain in community clinic settings. To identify perceived problems with delivering chronic pain treatment and issues with opioid prescribing for chronic pain. DESIGN: Mailed survey to primary care providers (PCPs) at 8 community clinics. RESULTS: Respondents (N=111) included attendings, residents, and nurse practioners (NPs)/physician assistants (PAs). They reported 37.5% of adult appointments in a typical week involved patients with chronic pain complaints. They attributed problems with pain care and opioid prescribing more often to patient-related factors such as lack of self-management, and potential for abuse of medication than to provider or practice system factors. Nevertheless, respondents reported inadequate training for, and low satisfaction with, delivering chronic pain treatment. CONCLUSIONS: A substantial proportion of adult primary care appointments involve patients with chronic pain complains. Dissatisfaction with training and substantial concerns about patient self-management and about opioid prescribing suggest areas for improving medical education and postgraduate training. Emphasis on patient-centered approaches to chronic pain management, including skills for assessing risk of opioid abuse and addiction, is required.

Challenges of implementing depression care management in the primary care setting.

Empirical evidence shows that care management is an effective tool for improving depression treatment in primary care patients. However, several conceptual and practical issues have not been sufficiently addressed. This article explores questions concerning the scope of care management services within the chronic illness care model; optimal ways to identify depressed patients in the primary care setting; responsibilities and desirable qualifications of depression care managers; the location and manner in which care managers interact with patients; costs of services provided by care managers; and the level of supervision by mental health specialists that is necessary to ensure quality care.

Crossing the divide: primary care and mental health integration.

This paper describes the views of primary care providers about treating depression among adult Medicaid patients and their experiences with managed behavioral health care. It also shows the outcomes of an intervention project that provides a care manager to facilitate connections among PCPs, patients, and behavioral health providers. Despite widespread initiatives to improve depression management in primary care and to manage behavioral health services, it appears that links between the two systems and the use of evidence-based approaches to managing patients are rare. A pilot project to initiate practice redesign, the use of a care manager to assist in patient support, and compliance with both medical and behavioral health treatment has been shown to improve communication and results in positive patient outcomes. Managed behavioral health care can result in incentive structures that create gaps between primary care and behavioral health systems. This project illustrates an initiative co-sponsored by the Massachusetts behavioral health program designed to strengthen links between behavioral health and primary care, and increase rates and effectiveness of depression treatment.