Literature Collection

OBJECTIVE: Rapid patient referral to epilepsy centers may facilitate subsequent disease-modifying surgical and non-surgical treatments. Delays of 15-18 years have been reported from time of epilepsy diagnosis to surgical evaluation in some settings, though patterns for timely guideline-concordant referrals within integrated care models are not well known and could inform strategies for optimizing guideline-concordant access. METHODS: We performed a retrospective cohort study of 1088 patients undergoing epilepsy center evaluation from January 1, 2008 through June 30, 2023 in a Northern California integrated healthcare delivery system (IDS) with a Level 4 Epilepsy Center. Using electronic health record (EHR) data, we summarized time from diagnosis and other major care time points until first visit at the epilepsy center. A multivariate linear model was used to evaluate the relationship of select demographic, socioeconomic, and clinical characteristics with the time to first epilepsy center visit. RESULTS: The mean times to epilepsy center visit from first prescription of an anti-seizure medication (ASM), diagnosis of epilepsy or seizures, and first visit with a general neurologist, were 3.9 years (SD = 4.5), 3.2 years (SD = 3.2) and 2.7 years (SD = 3.2), respectively, for the full cohort of patients prescribed any number of ASMs. Comparable time frames were seen for patients prescribed two or more ASMs at the time of first visit. Significantly longer time to epilepsy center visit was seen in patients with multiple ASMs prescribed, a concordant diagnosis of developmental delay, and those age 40 and above. Longer times to epilepsy center visit were not seen among patients with psychiatric comorbidities, public health insurance coverage, and among patients in traditionally underserved groups. CONCLUSIONS: Patients evaluated at an epilepsy clinic within an IDS system did so within less than four years of diagnosis and initial treatment, with few disparities by demographics or comorbidities. Future studies can identify specific health system features that are key to shorter time frames to test transferable strategies to reduce time to epilepsy centers.

INTRODUCTION: Existing models of medical-dental integration, as well as those from behavioral health care integrated with primary medical treatment, provide a basis for a truly synthesized and expanded model incorporating medical, dental, and behavioral components. Such a comprehensive model allows for collaborative health care serving patients seamlessly without disciplinary silos, promoting optimal whole-person health. This innovative approach is consistent with recent developments in the behavioral and social oral health sciences that include an imperative for their full inclusion in dental health care, research, and education. METHODS: Existing models of medical-dental integration are described, along with current models from integrated primary medical and behavioral health care. Using these existing approaches as a basis, a new multilevel model is proposed to include social and cultural determinants of health. RESULTS: Contemporary approaches to providing health care across disciplines include referral to a geographically separate entity, co-location of services, and integrated, side-by-side care. Integration of electronic health records and interoperability are necessary (but not sufficient) factors that affect transdisciplinary health care. Effective communication among health care providers and the need for interprofessional education, comprehensive training, and ongoing cross-disciplinary consultation also are noted as crucial factors in truly collaborative care. Evidence for existing models varies greatly depending on the target population and type of services provided. CONCLUSIONS: A fully integrated, transdisciplinary model of health care is possible, theoretically and practically. Combining aspects of extant integrated models and extending them provides opportunity for a greater focus on systemic factors and more emphasis on prevention. Consistent with this new model, medical and dental home concepts can be expanded to that of a person-centered health care home that includes interprofessional practice. This transdisciplinary approach contributes to greater health equity given the multilevel approach. Multidirectional integration of diverse disciplines representing the various realms of medicine, dentistry, and behavioral health care is essential for optimal health of all. KNOWLEDGE TRANSFER STATEMENT: This article can be used by clinicians, scientists, administrators, and policy makers in developing and implementing integrated systems of care that provide for patients' medical, dental, and behavioral health needs.