C. J. Peek

The Economics of Behavioral Health Services in Medical Settings: A Summary of the Evidence

The health care system in the United States, plagued by spiraling costs, unequal access, and uneven quality, can find its best chance of improving the health of the population through the improvement of behavioral health services. It is in this area that the largest potential payoff in reduction of morbidity and mortality and increased cost-effectiveness of care can be found. A review of the evidence shows that many forms of behavioral health services, particularly when delivered as part of primary medical care, can be central to such an improvement. The evidence supports many but not all behavioral health services when delivered in settings in which people will accept these services under particular administrative and fiscal structures.

What Does It Mean to “Employ” the RE-AIM Model?:

Many grant proposals identify the use of a given evaluation model or framework but offer little about how such models are implemented. The authors discuss what it means to employ a specific model, RE-AIM, and key dimensions from this model for program planning, implementation, evaluation, and reporting. The authors report both conceptual and content specifications for the use of the RE-AIM model and a content review of 42 recent dissemination and implementation grant applications to National Institutes of Health that proposed the use of this model. Outcomes include the extent to which proposals addressed the overall RE-AIM model and specific items within the five dimensions in their methods or evaluation plans. The majority of grants used only some elements of the model (less than 10% contained thorough measures across all RE-AIM dimensions). Few met criteria for “fully developed use” of RE-AIM and the percentage of key issues addressed varied from, on average, 45% to 78% across the RE-AIM dimensions. The results and discussion of key criteria should help investigators in their use of RE-AIM and illuminate the broader issue of comprehensive use of evaluation models.

The 5 R’s: An Emerging Bold Standard for Conducting Relevant Research in a Changing World

Research often fails to find its way into practice or policy in a timely way, if at all. Given the current pressure and pace of health care change, many authors have recommended different approaches to make health care research more relevant and rapid. An emerging standard for research, the “5 R’s” is a synthesis of recommendations for care delivery research that (1) is relevant to stakeholders; (2) is rapid and recursive in application; (3) redefines rigor; (4) reports on resources required; and (5) is replicable. Relevance flows from substantive ongoing participation by stakeholders. Rapidity and recursiveness occur through accelerated design and peer reviews followed by short learning/implementation cycles through which questions and answers evolve over time. Rigor is the disciplined conduct of shared learning within the specific changing situations in diverse settings. Resource reporting includes costs of interventions. Replicability involves designing for the factors that may affect subsequent implementation of an intervention or program in different contexts. These R’s of the research process are mutually reinforcing and can be supported by training that fosters collaborative and reciprocal relationships among researchers, implementers, and other stakeholders. In sum, a standard is emerging for research that is both rigorous and relevant. Consistent and bold application will increase the value, timeliness, and applicability of the research enterprise.

Research and evaluation in the transformation of primary care.

Across the United States, primary care practices are engaged in demonstration projects and quality improvement efforts aimed at integrating behavioral health and primary care. Efforts to make sustainable changes at the frontline of care have identified new research and evaluation needs. These efforts enable clinics and larger health care communities to learn from demonstration projects regarding what works and what does not when integrating mental health, substance use, and primary care under realistic circumstances. To do this, implementers need to measure their successes and failures to inform local improvement processes, including the efforts of those working on integration in separate but similar settings. We review how new research approaches, beyond the contributions of traditional controlled trials, are needed to inform integrated behavioral health. Illustrating with research examples from the field, we describe how research traditions can be extended to meet these new research and learning needs of frontline implementers. We further suggest that a shared language and set of definitions for the field (not just for a particular study) are critical for the aggregation of knowledge and learning across practices and for policymaking and business modeling.

Integrating care for persons, not only diseases

Integrated care is geared toward enhancing usual care and decision-making for common combinations of medical and mental health conditions, including the behavioral health and behavioral change aspects. Yet even with comprehensive and well-integrated care for health conditions and well-coordinated teamwork in place, some patients do not engage or respond to care in the way clinicians would like or predict. This troubles patients and clinicians alike and may be chalked up informally to things like medical complexity (multiple co-existing conditions), mental health conditions (that complicate care), or simply the case being considered complex or difficult. It also raises the question of how to address person-specific factors that interfere with care of whatever conditions the patient may have, and invites behavioral health clinicians in medical settings to look beyond care of conditions to the care of persons, and to look beyond disease-specific care management protocols to master generic practices of care management across whatever conditions the person may have. This person-centered emphasis is intrinsic to the concept of the “patient-centered medical home” which has burst into animated discussion and demonstration among providers, health plans, government plans, employer purchasers, and professional associations across public and private entities. This represents an opportunity for collaborative care clinicians to help shape the national state of the art in medical home and includes a range of person-oriented (rather than disease-oriented) practices for care management, including working systematically with complex patients and difficult patient–clinician relationships.

Integrated Behavioral Health and Primary Care: A Common Language

The field of integrated behavioral health has been around for decades, but until recently in the hands of pioneers in their own particular settings, using their own distinctive language and concepts. That work was generally successful and gathered around it considerable energy in this era of patient-centered medical home and primary care transformation. Mainstream application requires the field to coalesce enough in language and concept to be consistently understood by implementers, health systems, researchers, policymakers, purchasers—and of course patients themselves. Unifying a field with consistently understood concepts and definitions is a normal stage in the development of emerging fields. Inconsistently understood concepts and definitions—including what constitutes the essential functions of integrated behavioral health—have been a practical concern and source of confusion in the field. Even authors writing about different topics in the same book have encountered such ambiguities and confusions. The response to this practical problem was to employ published methods from the field of Descriptive Psychology to create a consensus lexicon or operational definition for behavioral health integrated in primary care. This work sponsored by the Agency for Healthcare Research and Quality—on behalf of the field—resulted in a lexicon described here and employed by chapter authors to move toward using consistently understood terms and functional descriptions of integrated behavioral health.

Seeking a wider lens for scientific rigor in emerging fields: The case of the primary care behavioral health model.

In response to widespread recognition of the need to blend biomedical and psychosocial health care efforts, the primary care behavioral health (PCBH) model has achieved rapid uptake across the United States. Reports of its application come from military sectors, community health centers, and a variety of health care systems, large and small. Examining the PCBH models appeal, evidence, and design forces us to confront important questions. These questions and much more are addressed in this issue of Families, Systems, & Health. (PsycINFO Database Record

Don Bloch's vision for collaborative family health care: Progress and next steps

BACKGROUND Don Bloch is the central figure in the origin story for the field of collaborative family health care; the journal Families, Systems, & Health; and for the Collaborative Family Healthcare Association (CFHA). He exerted extraordinary intellectual and practical leadership for all 3. He convened a national working session in 1994 that took stock of the field and set out next steps, one of which was to create the interprofessional organization dedicated to collaborative family health care that is now CFHA. PURPOSE As part of honoring Don Blochs contributions to the field and this journal, this article sets out tenets of his original vision and traces next steps toward this vision generated by national groups between 1994 and 2014, showing what is the same or different over these 20 years, and especially what this means for the field going forward. METHOD Precepts of Don Blochs original vision are drawn from his writings, including the briefing papers he prepared for the national Wingspread group convened in 1994, which also set out next steps for the field. These steps are then compared with next developmental steps for the field generated by CFHA conference attendees in 2004 and again in 2014, after reviewing the history of the organization and the field. CONCLUSION Much of Don Blochs vision has remained relevant to health care transformation, with a number of areas showing significant accomplishment and acceptance, whereas others remain aspirational, and a few others arguably being more difficult to achieve now than when Don articulated them.

From Our Practices to Yours: Key Messages for the Journey to Integrated Behavioral Health

Background: The historic, cultural separation of primary care and behavioral health has caused the spread of integrated care to lag behind other practice transformation efforts. The Advancing Care Together study was a 3-year evaluation of how practices implemented integrated care in their local contexts; at its culmination, practice leaders (“innovators”) identified lessons learned to pass on to others. Methods: Individual feedback from innovators, key messages created by workgroups of innovators and the study team, and a synthesis of key messages from a facilitated discussion were analyzed for themes via immersion/crystallization. Results: Five key themes were captured: (1) frame integrated care as a necessary paradigm shift to patient-centered, whole-person health care; (2) initialize: define relationships and protocols up-front, understanding they will evolve; (3) build inclusive, empowered teams to provide the foundation for integration; (4) develop a change management strategy of continuous evaluation and course-correction; and (5) use targeted data collection pertinent to integrated care to drive improvement and impart accountability. Conclusion: Innovators integrating primary care and behavioral health discerned key messages from their practical experience that they felt were worth sharing with others. Their messages present insight into the challenges unique to integrating care beyond other practice transformation efforts.

Working with Complexity in Integrated Behavioral Health Settings

This chapter provides a practical approach for understanding and dealing with patient “complexity” in a health care context. Complexity is defined as the interaction of patient, provider, and care delivery variables, which intermingle to create situations where usual treatments are not working—or not working as well as patients and clinicians are expecting. These situations can only be understood by looking at the complex interaction of those variables and adopting new models of understanding and implementing new care-giving strategies. The chapter begins with a review of different approaches to dealing with complexity within the USA and in Europe. A particular method and clinical checklist is described in detail. A “real world” application, the Complex Continuity Clinic, using this and other methods of engaging patients in complex situations, is outlined, with clinical examples. Finally, the important implications of a complexity approach to emerging health care reform is described, shedding light on how effective approaches that embrace complex biopsychosocial health issues can result in greater quality and reduced costs.