INTEGRATED BEHAVIORAL/PHYSICAL HEALTH: A REALIST EVALUATION APPROACH

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Alvin Tucker
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1 GR BHVR/HYSC HH: RS VU RCH Susan Grantham,, h.. *, ugenie Coakley,, H *, lec ckinney, B *, atalie ruesdell, B, H *, elina Ward, B *, Becky Hayes-Boober,, h..^, Barbara eonard, H^ * John Snow, nc., ^aine Health ccess Foundation ntroduction: o enhance service coordination and address inter-related medical and behavioral health needs, 14 provider organizations (representing 32 service locations) sought to better integrate behavioral and physical health care. Using a realist evaluation approach 1, we describe the interplay across mechanism, context, and outcomes related to reach, adoption, and implementation of these efforts. Contextual factors are categorized based on the Consolidated Framework for mplementation Research (CFR) 2. ethods: he R- (Reach, fficacy/ffectiveness, doption, mplementation, aintenance) framework 3,4 was used to guide a mixed methods approach. he CFR provides common language and definitions for describing contextual factors. ocuments review, site visits, and group and individual interviews comprise qualitative data sources. Site-level patient data on demographics, service use, follow up, and referrals has been collected over seven quarters. Qualitative analysis was iterative with evaluation team members and other stakeholders agreeing on evolving themes from field work, supplemented with a qualitative software analysis program. Consensus emerged over time on reported findings. Findings: ver 4000 patients were assessed for integrated services over a 1.75 year period. pproximately 62 percent of patients are referred for additional integrated services. f those referred, approximately 60 percent engaged in one or more behavioral health visits within 90 days, with the majority having more than one visit. Key mechanisms driving reach, adoption, and implementation were formal screening for behavioral health needs, perception of value added, leadership commitment, provider buy-in, willingness to invest time and resources, adapting behavioral health practice to C setting, and provider communication. he majority of contextual factors influencing these mechanisms were inner setting (e.g., learning organization, BH/C culture), individual characteristics (e.g., flexibility and adaptability, team-based experience), and process (e.g., engaging leaders, overlap of C/H staff hours). uter setting and intervention characteristics played a lesser role. Source of Funding: aine Health ccess Foundation CR KY: KG CXU FCRS S CHRCRSCS F VUS R SG UR SG RCSS RV CHRCRSCS * RFRC: Consolidated Framework for mplementing Research, amschroder et al., awson R, illey. Realistic valuation. ondon, ngland: Sage ublications td; amschroder J et al. Fostering implementation of health services research findings into practice: consolidated framework for advancing implementation science. mplementation Science 2009, 4: accessed on ovember 11, Glasgow, R. R-ing research for application: ways to improve evidence for family medicine. JBF. Jan-Feb Vol. 19, o. 1; th nnual H Conference on the Science of issemination and mplementation: olicy and ractice 1

2 CHS CXU FCRS SR UC rimary care provider willingness to screen R C H Formal Screening for Health eeds erceived availability of time to conduct screening Satisfaction with screening tools rganizational capacity to integrate screening tools into clinic flow Capacity to address needs identified atients with integrated care needs systematically identified rganizational assessment and definition of population needs Quick and easy to use screening tools CHS CXU FCRS SR UC erception of Value dded Capacity to measure value ; therefore, to justify cost vs. value dequate funding to cover start-up costs Concept and process of fits with organizational mission and values evel of patient need for revious organizational experience with ractices and providers willing to engage in 4 th nnual H Conference on the Science of issemination and mplementation: olicy and ractice 2

3 CHS CXU FCRS SR UC eadership Commitment ntegration set as organizational priority earning organization culture Stable leadership over course of planning and implementation Strong relationship between lead organization and service delivery sites (if different agencies) Benefits of perceived to outweigh costs ractices and providers willing to engage in CHS CXU FCRS SR UC rimary care providers willing to share responsibilities for holistic care rimary Care rovider Buy-n rimary care providers previous challenges with referrals to specialty lh lh rimary care providers experience in providing team based care vailability of referral mental health services in community eam-oriented organizational culture rovider retention (behavioral health specialists & primary care providers) health specialist available when needed by primary care providers Strong, engaged physician "champion" (especially the edical irector) ractices and providers willing to engage in mplementation planning processes included providers xternal, credible change agent 4 th nnual H Conference on the Science of issemination and mplementation: olicy and ractice 3

4 CHS CXU FCRS SR UC Health Specialists Willingness to dapt to rimary Care Setting ble and willing to change practice style (i.e., provide shorter visits and limit care to shorter engagements of care) penness to culture of primary care raining and belief in brief interventions irection/training/guidance present for behavioral health specialists to operate in primary care practice ractices and providers willing to engage in CHS CXU FCRS SR UC Willingness to nvest ime and Resources Clear leadership and buy-in ntegration set as organizational priority eadership perception that organization has the capacity to absorb start-up and non-reimbursable costs Well-established learning organization culture vailability of external resources Capacity to absorb non-reimbursable training costs Capacity and planning to provide on-going trainings to sustain and nurture nternal implementation leader identified Understanding of how to accomplish organizational change health and primary care are integrated at the clinical, 4 th nnual H Conference on the Science of issemination and mplementation: olicy and ractice 4

5 CHS Health Specialist and rimary Care rovider Communication and Collaboration CXU FCRS health specialists willing to change note style to be more succinct & more efficient for primary care provider to read health specialists able to build their credibility over time "earning organization" culture Shared records (w/hrs a benefit but not a necessity) health specialists considered part of clinical team (attend clinical meetings & interact directly with medical providers) Regulations concerning sharing of mental health and medical records are not a barrier (or perceived as a barrier) health specialists sharing common co-located hours with primary care providers SR UC health and primary care are integrated at the clinical, CHS Working out Reimbursement echanisms CXU FCRS roblem solving organizational culture ccess to resources that are knowledgeable about reimbursement dministrative capacity to work on reimbursement issues Capacity to overcome lack of reimbursement for training, meetings/case conferences, case/care management, patient advocacy Understanding state policies regarding credentialing/licensure issues FQHC status SR UC health and primary care are integrated at the clinical, 4 th nnual H Conference on the Science of issemination and mplementation: olicy and ractice 5

CHS CXU FCRS SR UC dapting Health ractice to C Setting health specialists willingness to adapt their practice earning organization culture eadership perception that resulted in better patient care

6 CHS CXU FCRS SR UC dapting Health ractice to C Setting health specialists willingness to adapt their practice earning organization culture eadership perception that resulted in better patient care Clinical & management leadership buy-in vailability of on-going trainings and staff development bility to overcome differences in culture of behavioral health vs. primary care ntegration is made an organizational priority ppropriate service population is defined Guidance/support provided to behavioral health specialists about primary care practice ntegration is operationalized (e.g., incorporated into hiring decisions, part of staff Structure in place and opportunities for behavioral health and primary care providers to build relationships Strong relationship and communication between lead organization & service delivery sites (when different organizations) health and primary care are integrated at the clinical, Use of data for reflection & evaluation Contact nformation Susan Grantham,, h.. John Snow, nc. 44 Farnsworth Street Boston, el: (617) sgrantham@jsi.com 4 th nnual H Conference on the Science of issemination and mplementation: olicy and ractice 6

Assessing and Increasing Readiness for Patient-Centered Medical Home Implementation 1

EVALUATION Assessing and Increasing Readiness for Patient-Centered Medical Home Implementation 1 Research Summary No. 9 March 2012 Introduction The current model of primary care in the United States is