Gregory P. Beehler

Behavioral health providers' perspectives of delivering behavioral health services in primary care: a qualitative analysis

BackgroundCo-located, collaborative care (CCC) is one component of VA’s model of Integrated Primary Care that embeds behavioral health providers (BHPs) into primary care clinics to treat commonly occurring mental health concerns among Veterans. Key features of the CCC model include time-limited, brief treatments (up to 6 encounters of 30 minutes each) and emphasis on multi-dimensional functional assessment. Although CCC is a mandated model of care, the barriers and facilitators to implementing this approach as identified from the perspective of BHPs have not been previously identified.MethodsThis secondary data analysis used interview data captured as part of a quality improvement project in 2008. Fourteen BHPs (48% of providers in a regional VA network) agreed to participate in a 30-minute, semi-structured phone interview. The interview included questions about their perceived role as a CCC provider, depiction of usual practice styles and behaviors, and perceptions of typical barriers and facilitators to providing behavioral healthcare to Veterans in CCC. Interviews were transcribed verbatim into a text database and analyzed using grounded theory.ResultsSix main categories emerged from the analysis: (a) Working in the VA Context, (b) Managing Access to Care on the Front Line, (c) Assessing a Care Trajectory, (d) Developing a Local Integrated Model, (e) Working in Collaborative Teams, and (f) Being a Behavioral Health Generalist. These categories pointed to system, clinic, and provider level factors that impacted BHP’s role and ability to implement CCC. Across categories, participants identified ways in which they provided Veteran-centered care within variable environments.ConclusionsThis study provided a contextualized account of the experiences of BHP’s in CCC. Results suggest that these providers play a multifaceted role in delivering clinical services to Veterans while also acting as an interdependent component of the larger VA behavioral health and primary care systems. Based on the inherent challenges of enacting this role, BHPs in CCC may benefit from additional implementation support in their effort to promote health care integration and to increase access to patient-centered care in their local clinics.

Moving toward integrated behavioral intervention for treating multimorbidity among chronic pain, depression, and substance-use disorders in primary care.

Introduction:The importance of using integrated treatment for multimorbidity has been increasingly recognized. One prevalent cluster of health conditions is multimorbidity of chronic pain, depression, and substance-use disorders, a common triad of illnesses among primary care patients. This brief report brings attention to an emerging treatment method of an integrated behavioral approach to improve health outcomes for individuals with these 3 conditions in the outpatient setting, particularly primary care. Methods:A multidatabase search was conducted to identify studies of behavioral interventions targeting co-occurrence or multimorbidity among the 3 health conditions in the adult outpatient setting. An independent screening of the articles was accomplished by all authors with consensus on the final inclusion for review. Results:Three studies met formal inclusion criteria for this review. The included studies evaluated cognitive behavioral therapy or combined motivational interviewing with cognitive behavioral therapy. Key findings from other reviews and additional studies are also included in this review to further inform the development of a common approach for treating this triad of conditions in primary care. Conclusions:Although there has been increased recognition for more effective and practical behavioral treatments for patients with multiple chronic health conditions, the evidence-base to inform practice remains limited. The findings from this review suggest that a common approach, rather than a distinct intervention for chronic pain, depression, or substance-use disorders, is indicated and that best care can be provided within the context of a coordinated, interdisciplinary, and patient-centered primary care team.

Hormonally active agents in the environment and children's behavior: assessing effects on children's gender-dimorphic outcomes.

Background. Early sex hormone exposure contributes to gender-dimorphic behavioral development in mammals, including humans. Environmental toxicants concentrated in contaminated sport fish can interfere with the actions of sex steroids. Methods. This study developed an outcome variable by combining gender-dimorphic behaviors that differentiates boys and girls. Offspring of participants in the New York State Angler Cohort Study (NYSACS) were targeted in a parent-report postal survey. Instruments were selected based on findings of gender differences in the general population. Results. A linear discriminant function model incorporating three gender behavior scales correctly classified the sex of 97.7% of children (252 boys and 234 girls) from a random NYSACS sample. The discriminant function was cross-validated by correctly classifying the sex of 98.4% of children (457 boys and 425 girls) from the remaining NYSACS cases and 97.6% of children (154 boys and 142 girls) from an independent school sample. Within-sex stepwise multiple regression analyses revealed that masculine behavior increased among boys with age and with the number of years of maternal sport fish consumption. In girls, older age and previous live-born siblings were associated with more masculine behavior, whereas feminine behavior increased with the duration of breast feeding. These associations were replicated in an independent sample. Conclusions. A linear discriminant function effectively transformed the binary classification of sex (male-female) to a bipolar continuum of gender (masculinity-femininity). Findings from this study are consistent with the hypothesis that environmental contaminants contribute to shifts in gender-role behavior. Future investigations will need to account for competing explanations of this effect.

Health service and medication use among veterans with persistent postconcussive symptoms.

Abstract Persistent postconcussive symptoms (PPCS) are noted when a series of cognitive, emotional, and somatosensory complaints persist for months after a concussion. Clinical management of PPCS can be challenging in the veteran population because of the nonspecific nature of symptoms and co-occurrence with affective disturbances such as posttraumatic stress disorder (PTSD) and chronic pain. In this study, we compared health service and medication use patterns in a sample of 421 veterans with PPCS with an age-matched cohort of case controls. The results suggest that the veterans with PPCS showed high rates of medical and mental health service utilization during a mean treatment period of 2 years. Although chronic pain commonly co-occurs with PPCS in veterans, service use and medication prescribing trends seem to have been influenced more by the presence of PTSD than chronic pain. Our findings reinforce the overlap among PPCS, PTSD, and chronic pain and demonstrate the complexity inherent in treating these conditions in veterans.

Patient exit interviews for assessing fidelity to the VA VISN 2 Integrated Primary Care Model: Results from a pilot feasibility study

Veterans Integrated Service Network 2 Integrated Primary Care (VISN 2 IPC) is a population-based model of health services delivery that incorporates behavioral health providers (BHPs) into primary ...

Identifying measurement-based care practices of VHA co-located collaborative care providers.

The use of measurement-based care (MBC) is a routinely accepted practice in medical settings as a means to assess health status and guide evidence-based interventions. The continued expansion of integrated primary care within the Veterans Health Administration (VHA) offers ongoing opportunities for co-located collaborative care (CCC) providers to implement MBC. The present study aimed to identify and describe the degree to which MBC is used by CCC providers across VHA clinics in Upstate New York. A retrospective chart review of 448 CCC encounters was evaluated for evidence of MBC practices, including the use of quantitative mental health symptom screening tools, brief mental health symptom measures, and standardized functional assessment tools. Evidence of nonstandardized, idiographic assessments was also recorded. Providers’ use of measurement data to guide treatment initiation, modification, and termination was coded when available. Descriptive statistics were calculated for variables of interest. Results indicated that approximately 61% of patients were formally screened or completed mental health measures at least once during their course of care, though repeat administrations were rare. Detailed chart reviews found overall limited use of mental health screens and brief symptom measures (9.8% and 9.2% of all encounters, respectively), with measurement data infrequently (8.5%) linked to specific documented treatment decisions. Consistent with prior studies, CCC providers typically did not evidence use of standardized measures but did routinely record estimates of subjective distress and global functioning, lethality risk, and idiographic functional assessments. Obstacles and facilitators to the broader promotion and use of MBC among CCC providers are discussed.

Narrative Review of Provider Behavior in Primary Care Behavioral Health: How Process Data Can Inform Quality Improvement

Objective: Primary care behavioral health (PCBH) is a population-based approach to delivering mental and behavioral health care in the primary care setting. Implementation of the PCBH model varies across practice settings, which can impact how PCBH providers deliver services to patients and in turn may predict a variety of important outcomes. This article aims to characterize PCBH provider engagement in key processes of integrated care as demonstrated in results from empirical studies of real-world clinical practice. Method: For this narrative review of published studies on PCBH provider engagement in processes of care, PubMed and PsycINFO databases were searched from January 1990 through May 2016 to identify relevant articles. Results: Provider adherence to the brief, time-limited treatment model appears suboptimal. Common mental health conditions, such as depression, were often the primary focus of provider attention, with less consistent emphasis on behavioral medicine concerns. Whereas providers regularly conducted qualitative functional assessments with patients, routine use of standardized measures was low. Engagement in interprofessional collaboration with the primary care team was also low, but engagement in behaviors that fostered therapeutic relationships was high. Discussion: This review identified several strengths and weaknesses of typical PCBH provider practices. Results are discussed in relation to their value as areas for future quality improvement initiatives that can improve PCBH service delivery and, ultimately, patient outcomes.

Qualitative exploration of traumatic brain injury-related beliefs among U.S. military veterans.

Purpose/Objective: Explore cognitive, affective, and experiential factors that inform veterans’ traumatic brain injury (TBI)-related beliefs. Research Method/Design: Qualitative descriptive study of 22 veterans who received care for TBI at a VA Medical Center in the Northeastern United States using directed content analysis. Measures included a semistructured interview, demographic survey, the Alcohol Use Disorders Identification Test-Consumption Items (AUDIT-C), Patient Health Questionnaire-9 (PHQ-9), PTSD Checklist (PCL), Neurobehavioral Symptom Inventory (NSI), and Insomnia Severity Index (ISI). Results: Results were organized according to Leventhal et al.’s (1997) illness perception model, including veterans’ self-reports regarding: (a) knowledge of TBI, labels, and symptoms (identity); (b) etiology (cause); (c) the biopsychosocial impact of TBI (consequences); (d) symptom chronicity (timeline); and (e) recovery expectancy and management strategies (controllability). Participants identified common causes of TBI, as well as acute symptoms. Uncertainty was present with regard to TBI nomenclature, recovery expectancies and trajectories, and the impact of co-occurring mental health diagnoses. Conclusions/Implications: Opportunity exists to improve TBI-related education in the course of routine, patient-centered care. Clinicians should take into account the subjective beliefs and experiences, including co-occurring mental health conditions, that inform patients’ illness representations to improve patient-provider communication and the quality of TBI care.

Facilitators and Barriers to Seeking Mental Health Care Among Primary Care Veterans With Posttraumatic Stress Disorder: Facilitators and Barriers to Seeking PTSD Care

Although posttraumatic stress disorder (PTSD) is common in primary care patients, many do not seek mental health treatment. Existing research on barriers and facilitators to receiving PTSD treatment are not specific to primary care patients. In this study, we sought to understand the psychosocial concerns, treatment barriers, and treatment facilitators among non-treatment-seeking primary care veterans with PTSD who reside in both rural and urban settings. Using a concurrent triangulation design, we collected qualitative focus group and quantitative self-report data concurrently, analyzed them separately, and merged the results for interpretation. In total, 27 veteran primary care patients with PTSD participated in 1 of 4 focus groups. A modified conventional content analysis approach was used. Team-based coding began with three broad primary codes (psychosocial concerns, barriers, and facilitators) and subcodes were allowed to emerge from the data. Self-report measures were used to collect clinical characteristics and barriers to care. The results expanded upon existing models of PTSD treatment initiation by (a) specifying treatment preferences, such as patient-centered care, peer support services, and open access scheduling, and (b) presenting concerns, such as anger and core symptoms of PTSD. Results also indicated that a commonly used quantitative barriers measure may offer an incomplete picture of why veterans do not seek treatment as it does not assess how past negative treatment experiences may affect utilization. Strategies to help veterans overcome barriers to care may benefit from a focus on negative treatment-seeking beliefs and tailoring based on a veterans rural or urban status.

Patient outcomes associated with primary care behavioral health services: A systematic review

OBJECTIVE This systematic review focused on Primary Care Behavioral Health (PCBH) services delivered under normal clinic conditions that included the patient outcomes of: 1) access/utilization of behavioral health services, 2) health status, and 3) satisfaction. METHOD Following PRISMA guidelines, comprehensive database searches and rigorous coding procedures rendered 36 articles meeting inclusion criteria. The principle summary measures of odd ratios or Cohens d effect sizes were reported. RESULTS Due to significant limitations in the methodological rigor of reviewed studies, robust findings only emerged for healthcare utilization: PCBH is associated with shorter wait-times for treatment, higher likelihood of engaging in care, and attending a greater number of visits. Several small, uncontrolled studies report emerging evidence that functioning, depression, and anxiety improve overtime. There was no evidence of greater improvement in patient health status when PCBH was compared to other active treatments. The limited available evidence supports that patient satisfaction with PCBH services is high. CONCLUSIONS The implementation of PCBH services is ahead of the science supporting the usefulness of these services. Patient outcomes for PCBH are weaker than outcomes for Collaborative Care. More rigorous investigations of patient outcomes associated with PCBH are needed to allow for optimization of services.