Contents: M.E. Maruish, Preface. Part I:General Considerations. M.E. Maruish, Introduction. C.J. Peek, R. Heinrich, Integrating Behavioral Health and Primary Care. M. Evers-Szostak, Integration of Behavioral Health Care Services in Pediatric Primary Care Settings. L.R. Derogatis, L.L. Lynn, II, Screening and Monitoring Psychiatric Disorder in Primary Care Populations. C.L. Ofstead, D.S. Gorban, D.L. Lum, Integrating Behavioral Health Assessment With Primary Care Services. Part II:Assessment Instruments. S.R. Hahn, K. Kroenke, J.B.W. Williams, R.L. Spitzer, Evaluation of Mental Disorders With the PRIME-MD. G.R. Grissom, K.I. Howard, Directions and COMPASS-PC. J. Shedler, The Shedler QPD Panel (Quick PsychoDiagnostics Panel): A Psychiatric "Lab Test" for Primary Care. L.R. Derogatis, K.L. Savitz, The SCL-90-R and Brief Symptom Inventory (BSI) in Primary Care. M.E. Maruish, Applications of the Symptom Assessment-45 Questionnaire (SA-45) in Primary Care Settings. P.J. Brantley, S.K. Jeffries, Daily Stress Inventory (DSI) and Weekly Stress Inventory (WSI). P.J. Brantley. D.J. Mehan, Jr., J.L. Thomas, The Beck Depression Inventory (BDI) and the Center for Epidemiologic Studies Depression Scale (CES-D). K.A. Kobak, W.M. Reynolds, The Hamilton Depression Inventory. T.L. Kramer, G.R. Smith, Tools to Improve the Detection and Treatment of Depression in Primary Care. F. Scogin, N. Rohen, E. Bailey, Geriatric Depression Scale. R.J. Ferguson, Using the Beck Anxiety Inventory in Primary Care. L.J. Davis, Self-Administered Alcoholism Screening Test (SAAST). G.J. Demakis, M.G. Mercury, J.J. Sweet, Screening for Cognitive Impairments in Primary Care Settings. H.P. Wetzler, D.L. Lum, D.M. Bush, Using the SF-36 Health Survey in Primary Care. A. Murray, D.G. Safran, The Primary Care Assessment Survey: A Tool for Measuring, Monitoring, and Improving Primary Care. S.R. Hahn, The Difficult Doctor Patient Relationship Questionnaire. Part III:Primary and Behavioral Health Care Integration Projects. P. Robinson, K. Strosahl, Improving Care for a Primary Care Population: Depression as an Example. A. Beck, C. Nimmer, A Case Study: The Kaiser Permanente Integrated Care Project. L. Goldstein, B. Bershadsky, M.E. Maruish, The INOVA Primary Behavioral Health Care Pilot Project. Part IV:Future Directions. K.A. Kobak, J.C. Mundt, D.J. Katzelnick, Future Directions in Psychological Assessment and Treatment in Primary Care Settings.

Assessment of Pain in Primary Care Settings

Background:
The NHS policy of constructing multispecialty community providers (MCPs) rests on a complex set of assumptions about how health systems can replace hospital use with enhanced primary care for people with complex, chronic or multiple health problems, while contributing savings to health-care budgets.

Objectives:
To use policy-makers’ assumptions to elicit an initial programme theory (IPT) of how MCPs can achieve their outcomes and to compare this with published secondary evidence and revise the programme theory accordingly.

Design:
Realist synthesis with a three-stage method: (1) for policy documents, elicit the IPT underlying the MCP policy, (2) review and synthesise secondary evidence relevant to those assumptions and (3) compare the programme theory with the secondary evidence and, when necessary, reformulate the programme theory in a more evidence-based way.

Data sources:
Systematic searches and data extraction using (1) the Health Management Information Consortium (HMIC) database for policy statements and (2) topically appropriate databases, including MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Applied Social Sciences Index and Abstracts (ASSIA). A total of 1319 titles and abstracts were reviewed in two rounds and 116 were selected for full-text data extraction. We extracted data using a formal data extraction tool and synthesised them using a framework reflecting the main policy assumptions.

Results:
The IPT of MCPs contained 28 interconnected context–mechanism–outcome relationships. Few policy statements specified what contexts the policy mechanisms required. We found strong evidence supporting the IPT assumptions concerning organisational culture, interorganisational network management, multidisciplinary teams (MDTs), the uses and effects of health information technology (HIT) in MCP-like settings, planned referral networks, care planning for individual patients and the diversion of patients from inpatient to primary care. The evidence was weaker, or mixed (supporting some of the constituent assumptions but not others), concerning voluntary sector involvement, the effects of preventative care on hospital admissions and patient experience, planned referral networks and demand management systems. The evidence about the effects of referral reductions on costs was equivocal. We found no studies confirming that the development of preventative care would reduce demands on inpatient services. The IPT had overlooked certain mechanisms relevant to MCPs, mostly concerning MDTs and the uses of HITs.

Limitations:
The studies reviewed were limited to Organisation for Economic Co-operation and Development countries and, because of the large amount of published material, the period 2014–16, assuming that later studies, especially systematic reviews, already include important earlier findings. No empirical studies of MCPs yet existed.

Conclusions:
Multidisciplinary teams are a central mechanism by which MCPs (and equivalent networks and organisations) work, provided that the teams include the relevant professions (hence, organisations) and, for care planning, individual patients. Further primary research would be required to test elements of the revised logic model, in particular about (1) how MDTs and enhanced general practice compare and interact, or can be combined, in managing referral networks and (2) under what circumstances diverting patients from in-patient to primary care reduces NHS costs and improves the quality of patient experience.

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From Programme Theory to Logic Models for Multispecialty Community Providers: A Realist Evidence Synthesis

Objective This paper examines how and why to improve care systems for disease management and health promotion for the growing population of cancer survivors with cardiovascular multi-morbidities. Method We reviewed research characterizing cancer survivors' and their multiple providers' common sense cognitive models of survivors' main health threats, preventable causes of adverse health events, and optimal coping strategies. Results Findings indicate that no entity in the health care system self-identifies as claiming primary responsibility to address longstanding unhealthy lifestyle behaviors that heighten survivors' susceptibility to both cancer and cardiovascular disease (CVD) and whose improvement could enhance quality of life. Conclusions To address this gap, we propose systems-level changes that integrate health promotion into existing survivorship services by including behavioral risk factor vital signs in the electronic medical record, with default proactive referral to a health promotionist (a paraprofessional coach adept with mobile technologies and supervised by a professional expert in health behavior change). By using the patient's digital tracking data to coach remotely and periodically report progress to providers, the health promotionist closes a gap, creating a connected care system that supports, reinforces, and maintains accountability for healthy lifestyle improvement. No comparable resource solely dedicated to treatment of chronic disease risk behaviors (smoking, obesity, physical inactivity, treatment nonadherence) exists in current models of integrated care. Integrating health promotionists into care delivery channels would remove burden from overtaxed PCPs and instantiate a comprehensive, actionable systems-level schema of health risks and coping strategies needed to have preventive impact with minimal interference to clinical work flow. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Toward a health-promoting system for cancer survivors: Patient and provider multiple behavior change.

INTRODUCTION Although there is a rapid increase in the integration of behavioral health services in primary care, few studies have evaluated the effectiveness of these services in real-world clinical settings, in part due to the difficulty of translating traditional mental health research designs to this setting. Accordingly, innovative approaches are needed to fit the unique challenges of conducting research in primary care. The development and implementation of one such approach is described in this article. METHOD A continuously populating database for psychotherapy services was implemented across 5 primary care clinics in a large health system to assess several levels of patient care, including service utilization, symptomatic outcomes, and session-by-session use of psychotherapy principles by providers. RESULTS Each phase of implementation revealed challenges, including clinician time, dissemination to clinics with different resources, and fidelity of data collection strategy across providers, as well as benefits, including the generation of useful data to inform clinical care, program development, and empirical research. DISCUSSION The feasible and sustainable implementation of data collection for routine clinical practice in primary care has the potential to fuel the evidence base around integrated care. The current project describes the development of an innovative approach that, with further empirical study and refinement, could enable health care professionals and systems to understand their population and clinical process in a way that addresses essential gaps in the integrated care literature. (PsycINFO Database Record

Development and implementation of a psychotherapy tracking database in primary care.

The reduction of mental health stigma (MHS) was an expected benefit of integrating behavioral health in primary care (IPC). However, unlike other barriers discussed in agency reports on IPC, discussions of MHS lack research support. To fill this gap, the authors conducted a literature review identifying seven studies. Given the dearth of research, we also examine general IPC research on probable indicators of MHS reduction in IPC, as well as, facets of IPC potentially influencing MHS related factors negatively associated with help-seeking. Using the data from these three types of research, the evidence suggests the potential of IPC to reduce MHS impact on care utilization, but indicates it is premature to draw firm conclusions. Given the possible benefits of primary care and the known benefits of decreased MHS, this review highlights the importance of further research examining this question and provides specific research and program development recommendations.

Reducing the Impacts of Mental Health Stigma Through Integrated Primary Care: An Examination of the Evidence.

Introduction There are benefits of integrating a behavioral health specialist in primary care; however, little is known about the physicians' perspectives. The purpose of this study was to explore primary care physicians' beliefs regarding the benefits of integrated care for both patients and themselves. Method Fifteen senior staff physicians and 78 residents completed surveys regarding their opinions of referring to a psychologist in a patient-centered medical home. Results The top reasons that physicians believed their patients followed through with a visit with an integrated psychologist included that they recommended it (79.5%) and that patients can be seen in the same primary care clinic (76.9%). The overwhelming majority of physicians were satisfied with having access to an integrated psychologist (97.4%). Physicians believed that integrated care directly improves patient care (93.8%), is a needed service (90.3%), and helps provide better care to patients (80.9%). In addition, physicians reported that having an integrated psychologist reduces their personal stress level (90.1%). Conclusion Primary care physicians may be motivated to integrate behavioral health services into their clinics knowing that other physicians believe that it directly and indirectly improves patient care and physician stress.

Vanessa Robinson

Papers

Benefits of integrated behavioral health services: The physician perspective.