Daniel Mullin

Care that Matters: Quality Measurement and Health Care.

Barry Saver and colleagues caution against the use of process and performance metrics as health care quality measures in the United States.

Challenges in developing primary care physicians' motivational interviewing skills

INTRODUCTION Motivational interviewing (MI) skills are relevant for primary care providers (PCPs) who are responsible for caring for patients with diseases affected by behavior. There are significant challenges associated with developing PCPs MI skills. We report on an effort to document the acquisition of MI skills by PCPs using an objective measure of MI competence, the Motivational Interviewing Treatment Integrity (MITI) coding system. METHOD Eleven PCPs volunteered to participate in 6 MI workshops over a period of 6 months and to submit work samples between each of these workshops to be assessed with the MITI coding system. RESULTS Thirteen of the expected 55 work samples were submitted before the final workshop. A revised approach was implemented in which each participant completed 2 simulated patient encounters. None of the providers reached the MITIs Beginning Proficiency threshold of MI skill. DISCUSSION Six MI workshops were not sufficient to help motivated PCPs achieve Beginning Proficiency as measured by the MITI. Participants failed to submit most of the work samples for feedback on their MI practice, which may have contributed to their limited acquisition of MI skills. Helping PCPs develop MI skills likely requires more than participation in a series of workshops totaling 18 h. Questions remain about the feasibility of training PCPs to be competent in MI. Approaches such as use of simulated patients, peer observation, or specific protected time for obtaining work samples may be required. (PsycINFO Database Record

Ethical matters in rural integrated primary care settings

Integrated primary care is particularly valuable to rural communities. Behavioral health care is often in short supply, and small or close-knit communities can intensify the stigma of seeking specialty mental health in rural settings. These and other barriers result in reduced access to needed behavioral health care. Nonetheless, rural practice of integrated primary care presents unique challenges to practitioners of multiple disciplines, including issues of competence, confidentiality, and dual relationships. This article provides an illustrative vignette to describe ethical issues in the rural practice of integrated primary care. It will review discipline-specific guidance in approaching these challenges and will offer recommendations for addressing disparities in the approaches of various disciplines engaged in the practice of integrated primary care.

Development and validation of a measure of primary care behavioral health integration.

INTRODUCTION We developed the Practice Integration Profile (PIP) to measure the degree of behavioral health integration in clinical practices with a focus on primary care (PC). Its 30 items, completed by providers, managers, and staff, provide an overall score and 6 domain scores derived from the Lexicon of Collaborative Care. We describe its history and psychometric properties. METHOD The PIP was tested in a convenience sample of practices. Linear regression compared scores across integration exemplars, PC with behavioral services, PC without behavioral services, and community mental health centers without PC. An additional sample rated 4 scenarios describing practices with varying degrees of integration. RESULTS One hundred sixty-nine surveys were returned. Mean domain scores ran from 49 to 65. The mean total score was 55 (median 58; range 0-100) with high internal consistency (Cronbachs alpha = .95). The lowest total scores were for PC without behavioral health (27), followed by community mental health centers (44), PC with behavioral health (60), and the exemplars (86; p < .001). Eleven respondents rerated their practices 37 to 194 days later. The mean change was + 1.5 (standard deviation = 11.1). Scenario scores were highly correlated with the degree of integration each scenario was designed to represent (Spearmans ρ = -0.71; P = 0.0005). DISCUSSION These data suggest that the PIP is useful, has face, content, and internal validity, and distinguishes among types of practices with known variations in integration. We discuss how the PIP may support practices and policymakers in their integration efforts and researchers assessing the degree to which integration affects patient health outcomes. (PsycINFO Database Record

Implementing Clinical Interventions in Integrated Behavioral Health Settings: Best Practices and Essential Elements

The dissemination of Patient-Centered Medical Homes provides an opportunity for primary care practices to attend to the behavioral health and health behavior needs of its patients. This will often include the development of an integrated behavioral health care practice that expands the team membership and develops routines for anticipating and following patients, with a focus on managing a broad range of conditions. Implementation of a successful integrated behavioral health care practice requires attention to building a team, hiring and training that team, developing sustainable workflows, identifying empirically based interventions to include within a clinical pathway, and establishing processes for insuring quality care. This chapter will provide guidance to administrators and review empirical evidence when it exists on all of these topics.

The Practice Integration Profile: Rationale, development, method, and research.

Insufficient knowledge exists regarding how to measure the presence and degree of integrated care. Prior estimates of integration levels are neither grounded in theory nor psychometrically validated. They provide scant guidance to inform improvement activities, compare integration efforts, discriminate among practices by degree of integration, measure the effect of integration on quadruple aim outcomes, or address the needs of clinicians, regulators, and policymakers seeking new models of health care delivery and funding. We describe the development of the Practice Integration Profile (PIP), a novel instrument designed to measure levels of integrated behavioral health care within a primary care clinic. The PIP draws upon the Agency for Health care Research & Qualitys (AHRQ) Lexicon of Collaborative Care which provides theoretic justification for a paradigm case of collaborative care. We used the key clauses of the Lexicon to derive domains of integration and generate measures corresponding to those key clauses. After reviewing currently used methods for identifying collaborative care, or integration, and identifying the need to improve on them, we describe a national collaboration to describe and evaluate the PIP. We also describe its potential use in practice improvement, research, responsiveness to multiple stakeholder needs, and other future directions. (PsycINFO Database Record

Confronting the new epidemic: Integrated care for opioid use disorders.

The inaugural Collaborative Family Health Care (CFHA) regional conference took place March 17, 2017, in St. Louis, Missouri. The conference theme was opioid use disorders and the potential of medication-assisted treatment using team-based care to address this epidemic. The conference ended with an emphasis on the importance of and strategies for self-care among caregivers working with this population and their families. This intensive meeting was crafted as a proof in concept for CFHA; however, the content was timely with regard to its importance in health care as well as compelling in the opportunity for collaborative care to offer an effective approach. In this article, the authors highlight five impotance topics: (1) opioid use disorders should be addressed in primary care; (2) a team is essential; (3) harm reduction; (4) sustaining self through mindful practice and self-compassion; and (5) medication-assisted treatment. (PsycINFO Database Record