Doing Qualitative Research

The patient-centered medical home (PCMH) is a promising framework for the redesign of primary care and more recently specialty care. As defined by the Agency for Healthcare Research and Quality, the PCMH framework has 5 attributes: comprehensive care, patient-centered care, coordinated care, accessible services, and quality and safety. Evidence increasingly demonstrates that for the PCMH to best achieve the Triple Aim (improved outcomes, decreased cost, and enhanced patient experience), treatment for behavioral health (including mental health, substance use, and life stressors) must be integrated as a central tenet. However, challenges to implementing the PCMH framework are compounded for real-world practitioners because payment reform rarely happens concurrently. Nowhere is this more evident than in attempts to integrate behavioral health clinicians into primary care. As behavioral health clinicians find opportunities to work in integrated settings, a comprehensive understanding of payment models is integral to the dialogue. This article describes alternatives to the traditional fee for service (FFS) model, including modified FFS, pay for performance, bundled payments, and global payments (i.e., capitation). We suggest that global payment structures provide the best fit to enable and sustain integrated behavioral health clinicians in ways that align with the Triple Aim. Finally, we present recommendations that offer specific, actionable steps to achieve payment reform, complement PCMH, and support integration efforts through policy. (PsycINFO Database Record

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Payment reform in the patient-centered medical home: Enabling and sustaining integrated behavioral health care.

Overuse of medical services is an increasingly recognized driver of poor-quality care and high cost. A practical framework is needed to guide clinical decisions and facilitate concrete actions that can reduce overuse and improve care. We used an iterative, expert-informed, evidence-based process to develop a framework for conceptualizing interventions to reduce medical overuse. Given the complexity of defining and identifying overused care in nuanced clinical situations and the need to define care appropriateness in the context of an individual patient, this framework conceptualizes the patient-clinician interaction as the nexus of decisions regarding inappropriate care. This interaction is influenced by other utilization drivers, including healthcare system factors, the practice environment, the culture of professional medicine, the culture of healthcare consumption, and individual patient and clinician factors. The variable strength of the evidence supporting these domains highlights important areas for further investigation. Journal of Hospital Medicine 2017;12:346-351.

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A Practical Framework for Understanding and Reducing Medical Overuse: Conceptualizing Overuse Through the Patient-Clinician Interaction.

Purpose: This paper sought to describe how clinicians from different backgrounds interact to deliver integrated behavioral and primary health care, and the contextual factors that shape such interactions. Methods: This was a comparative case study in which a multidisciplinary team used an immersion-crystallization approach to analyze data from observations of practice operations, interviews with practice members, and implementation diaries. The observed practices were drawn from 2 studies: Advancing Care Together, a demonstration project of 11 practices located in Colorado; and the Integration Workforce Study, consisting of 8 practices located across the United States. Results: Primary care and behavioral health clinicians used 3 interpersonal strategies to work together in integrated settings: consulting, coordinating, and collaborating (3Cs). Consulting occurred when clinicians sought advice, validated care plans, or corroborated perceptions of a patient9s needs with another professional. Coordinating involved 2 professionals working in a parallel or in a back-and-forth fashion to achieve a common patient care goal, while delivering care separately. Collaborating involved 2 or more professionals interacting in real time to discuss a patient9s presenting symptoms, describe their views on treatment, and jointly develop a care plan. Collaborative behavior emerged when a patient9s care or situation was complex or novel. We identified contextual factors shaping use of the 3Cs, including: time to plan patient care, staffing, employing brief therapeutic approaches, proximity of clinical team members, and electronic health record documenting behavior. Conclusion: Primary care and behavioral health clinicians, through their interactions, consult, coordinate, and collaborate with each other to solve patients9 problems. Organizations can create integrated care environments that support these collaborations and health professions training programs should equip clinicians to execute all 3Cs routinely in practice.

Integrating Behavioral Health and Primary Care: Consulting, Coordinating and Collaborating Among Professionals.

Integrated behavioral health in primary care has spread rapidly over the past three decades, although significant questions remain unanswered regarding best practices in clinical, financial and operational worlds. Two key models have emerged over time: care management and Primary Care Behavioral Health. Research to date has been promising; however, there is a significant need for more sophisticated multi-level scientific methodologies to fill in the gaps in current knowledge of integrated primary care. In this paper, we summarize current scientific knowledge about integrated primary care and critically evaluate the strengths and weaknesses of this knowledge base, focusing on clinical, financial and operational factors. Finally, we recommended priorities for future research, dissemination, real-world implementation, and health policy implications.

Integration of behavioral health and primary care: current knowledge and future directions

Purpose: To examine the interrelationship among behavioral health clinician (BHC) staffing, scheduling, and a primary care practice9s approach to delivering integrated care Methods: Observational cross-case comparative analysis of 17 primary care practices in the United States focused on implementation of integrated care Practices varied in size, ownership, geographic location, and integrated care experience A multidisciplinary team analyzed documents, practice surveys, field notes from observation visits, implementation diaries, and semistructured interviews using a grounded theory approach Results: Across the 17 practices, staffing ratios ranged from 1 BHC covering 03 to 365 primary care clinicians (PCCs) BHC scheduling varied from 50-minute prescheduled appointments to open, flexible schedules slotted in 15-minute increments However, staffing and scheduling patterns generally clustered in 2 ways and enabled BHCs to be engaged by referral or warm handoff Five practices predominantly used warm handoffs to engage BHCs and had higher BHC-to-PCC staffing ratios; multiple BHCs on staff; and shorter, more flexible BHC appointment schedules Staffing and scheduling structures that enabled warm handoffs supported BHC engagement with patients concurrent with the identification of behavioral health needs Twelve practices primarily used referrals to engage BHCs and had lower BHC-to-PCC staffing ratios and BHC schedules prefilled with visits This enabled some BHCs to bill for services, but also made them less accessible to PCCs in when patients presented with behavioral health needs during a clinical encounter Three of these practices were experimenting with open scheduling and briefer BHC visits to enable real-time access while managing resources Conclusion: Practices9 approaches to PCC-BHC staffing, scheduling, and delivery of integrated care mutually influenced each other and were shaped by the local context Practice leaders, educators, clinicians, funders, researchers, and policy makers must consider these factors as they seek to optimize integrated systems of care

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Clinician Staffing, Scheduling, and Engagement Strategies Among Primary Care Practices Delivering Integrated Care

Integrating primary care and behavioral health is an important focus of health system transformation. Cross-case comparative analysis of 19 practices in the United States describing integrated care clinical workflows. Surveys, observation visits, and key informant interviews analyzed using immersion-crystallization. Staff performed tasks and behaviors-guided by protocols or scripts-to support 4 workflow phases: (1) identifying; (2) engaging/transitioning; (3) providing treatment; and (4) monitoring/adjusting care. Shared electronic health records and accessible staffing/scheduling facilitated workflows. Stakeholders should consider these workflow phases, address structural features, and utilize a developmental approach as they operationalize integrated care delivery.

Clinical Workflows and the Associated Tasks and Behaviors to Support Delivery of Integrated Behavioral Health and Primary Care.

http://lib.ajaums.ac.ir/booklist/annals of family medicine_july-aug.sup_1.pdf

Maribel Cifuentes

Papers

Clinician Staffing, Scheduling, and Engagement Strategies Among Primary Care Practices Delivering Integrated Care

Clinical Workflows and the Associated Tasks and Behaviors to Support Delivery of Integrated Behavioral Health and Primary Care.

Cross-Project Analyses: