Macaran A. Baird

National Institutes of Health State-of-the-Science Conference Statement: Family History and Improving Health

The role of obtaining family history information in the primary care setting, the validity of such information, and whether the information affects health outcomes must be clarified. Accordingly, t...

Health and behavior: the interplay of biological, behavioral, and social influences: summary of an Institute of Medicine report.

An Institute of Medicine committee was convened to explore the links between biological, psychosocial, and behavioral factors and health and to review effective applications of behavioral interventions. Based on the evidence about interactions of the physiological responses to stress, behavioral choices, and social influences, the committee encouraged additional research efforts to explore the integration of these variables and to evaluate their mechanisms. An understanding of the social factors influencing behavior is growing and should be considered in programs and policies for public health, in addition to individual behavior and physiological status. Interventions to change behaviors have been directed toward individuals, communities, and society. Many intervention trials have documented the capacity of interventions to modify risk factors. However, more trials that include measures of morbidity and mortality to determine if the strategy has the desired health effects are needed. Behavior can be changed and new behaviors can be taught. Maintaining behavior changes is a greater challenge. Although short-term changes in behavior following interventions are encouraging, long-duration efforts are needed to improve health outcomes and to provide long-term assessments of effectiveness. Interventions aimed at any level can influence behavior change; however, existing research suggests that concurrent interventions at multiple levels are most likely to sustain behavior change and should be encouraged.

Predicting persistently high primary care use.

PURPOSE We wanted to identify risk factors for persistently high use of primary care. METHODS We analyzed outpatient office visits to practitioners in family medicine, general internal medicine, general pediatrics, and obstetrics for 1997–1999 among patients in a small Midwestern city covered by a fee-for-service insurance plan with no co-payments for physician visits and no requirement for referral to specialty care. Logistic regression was used to predict which patients with 10 or more primary care visits in 1997 would repeat high use in 1998 based on demographic and diagnostic categories (adjusted clinical groups [ACGs]). A confirmatory data set (high primary care use in 1998 persistent into 1999) was used to evaluate the model. RESULTS Two percent of the 54,074 patients had 10 or more primary care visits in 1997, and of these, almost 19% had 10 or more visits in the next year. Among adults, 4 ambulatory diagnosis groups (ADGs) were simultaneously positive predictors of repeated high primary care visits: unstable chronic medical conditions, see and reassure conditions, minor time-limited psychosocial conditions, and minor signs and symptoms. Meanwhile, pregnancy was negatively associated. The area under the receiver operating characteristic (ROC) curve was 0.794 for adults in the developmental data set and 0.752 in the confirmatory data set, indicating a moderately accurate assessment. A satisfactory model was not developed for pediatric patients. CONCLUSIONS Many persistently high primary care users appear to be overserviced but underserved, with underlying problems not addressed by a medical approach. Some may benefit from psychosocial support, whereas others may be good candidates for disease management interventions.

Advancing Medical Family Therapy Through Qualitative, Quantitative, and Mixed-Methods Research

To survive in today’s healthcare climate, stakeholders across all behavioral health disciplines must work to produce empirical evidence that earns their fields’ regard by educators, providers, and policy makers. As the field of medical family therapy (MedFT) answers this call, it will be important for researchers to clearly define, characterize, and assess MedFT practice across clinical, operational, and financial arenas of care. In this chapter, the authors propose a common lexicon from which to do this, highlighting the following core tenets of MedFT: systems theory, biopsychosocial–spiritual sensitivity in practice, agency, communion, interdisciplinary collaboration, and the three-world model of healthcare. We conclude by offering concrete ways to advance the MedFT research agenda using qualitative, quantitative, and mixed-method approaches.

Prevention in College Health: Counseling Perspectives

Such problems as sexually transmitted diseases, alcohol and other drug use, and acquaintance rape require college health professionals to function in primary and secondary preventive roles. In this article, the authors draw upon counseling literature and college health practice to identify the central elements of preventive programs, highlight specific intervention formats used in preventive work, and describe how interventions are assembled into coherent programs of prevention. To illustrate the structure and process of long-range, institutionalized preventive efforts, the authors describe an initiative addressing the primary, secondary, and tertiary prevention of substance use at a health sciences campus.

Integrated care clinic: Creating enhanced clinical pathways for integrated behavioral health care in a family medicine residency clinic serving a low-income, minority population.

Introduction: Research examining the implementation and effectiveness of integrated behavioral health (BH) care in family medicine/primary care is growing. However, research identifying ways to consistently use integrated BH in busy family medicine/primary care settings with underserved populations is limited. This study describes 1 family medicine clinic’s transformation into a fully integrated BH care clinic through the development of an Integrated Care Clinic (ICC) and enhanced clinical pathways to promote regular use of behavioral health clinicians (BHCs). Method: We implemented the ICC at the Broadway Family Medicine Clinic serving a low-income (<

Patient Relationships and the Personal Physician in Tomorrow's Health System: A Perspective from the Keystone IV Conference

25,000 annual income/year) and minority population (>70% African American) in Minnesota. We conducted a pre- and postevaluation of the ICC during regular clinic activity. Results: Pilot findings indicated that the creation of ICC and the use of enhanced clinical pathways (e.g., 5–2–1–0 obesity prevention messages, Transitional Care Management, postpartum depression screening visits, warm hand-offs) to facilitate regular use of integrated BH care resulted in 6 integrated care visits per BHC per clinic half-day. In addition, changes in the behavioral/mental health therapy appointment time slot (from 60 to 30 min) reduced therapy no-show rates. Transitional Care Management (TCM) visits also showed improved pre- and postchanges in patient and clinician satisfaction and reductions in patient hospital readmission rates. Discussion: The transformation into a fully integrated BH family medicine clinic through the creation of ICC and enhanced clinical pathways to facilitate regular integrated BH care showed promising pilot results. Future research is needed to examine associations between ICC and patient outcomes (e.g., weight, depressive symptoms).

Families and Health

A group of senior leaders from the early generation of academic family medicine reflect on the meaning of being a personal physician, based on their own clinical experiences and as teachers of residents and students in academic health centers. Recognizing that changes in clinical care and education at national and local systems levels have added extraordinary demands to the role of the personal physician, the senior group offers examples of how the discipline might go forward in changing times. Differently organized care such as the Family Health Team model in Ontario, Canada; value-based payment for populations in large health systems; and federal changes in reimbursement for populations can have positive effects on physician satisfaction. These changes and examples of changes in medical student and residency education also have the potential to positively affect the primary care workforce. The authors conclude that, without substantive educational and health system reform, the ability to truly serve as a personal physician and adhere to the values of continuity, responsibility, and accountability will continue to be threatened.

Working with Complexity in Integrated Behavioral Health Settings

Family medicine has long held as fundamental components of its specialty the importance of both understanding family dynamics as well as treating patients in the context of their families.1 Family medicine endeavors to implement a bio-psychosocial model as it continues to confront educational and practice dilemmas in pursuit of knowledge of how families influence health and illness and how members of the health care team can work constructively with families to maximize the health of both individuals and families. As medical treatment increasingly moves out of the hospital and into ambulatory and home settings, it becomes even more important to understand the family’s role in health and health care. This chapter reviews: (a) principles of health-related family dynamics, (b) the family life cycle, (c) the family’s influence on health-related behavior, (d) studies on the family and health, (e) the changing nature of American families, and (f) implications for the future of family medicine.

The Patient-Center Medical Home and Managed Care: Times Have Changed, Some Components Have Not

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.