Literature Collection

OBJECTIVES: The opioid overdose epidemic is escalating. Increasing access to medications for opioid use disorder in primary care is crucial. The impact of the US Department of Health and Human Services' policy change removing the buprenorphine waiver training requirement on primary care buprenorphine prescribing remains unclear. We aimed to investigate the impact of the policy change on primary care providers' likelihood of applying for a waiver and the current attitudes, practices, and barriers to buprenorphine prescribing in primary care. METHODS: We used a cross-sectional survey with embedded educational resources disseminated to primary care providers in a southern US academic health system. We used descriptive statistics to aggregate survey data, logistic regression models to evaluate whether buprenorphine interest and familiarity correlate with clinical characteristics, and a χ(2) test to evaluate the effect of the educational intervention on screening. RESULTS: Of the 54 respondents, 70.4% reported seeing patients with opioid use disorder, but only 11.1% had a waiver to prescribe buprenorphine. Few nonwaivered providers were interested in prescribing, but perceiving buprenorphine to be beneficial to the patient population was associated with interest (adjusted odds ratio 34.7, P < 0.001). Two-thirds of nonwaivered respondents reported the policy change having no impact on their decision to obtain a waiver; however, among interested providers, it increased their likelihood of obtaining a waiver. Barriers to buprenorphine prescribing included lack of clinical experience, clinical capacity, and referral resources. Screening for opioid use disorder did not increase significantly after the survey. CONCLUSIONS: Although most primary care providers reported seeing patients with opioid use disorder, interest in prescribing buprenorphine was low and structural barriers remained the dominant obstacles. Providers with a preexisting interest in buprenorphine prescribing reported that removing the training requirement was helpful.

OBJECTIVE: Receiving mental health services as part of primary care in the Veterans Health Administration (VHA) might increase engagement in specialty mental health care. The authors reexamined the association between primary care-mental health integration (PCMHI) and continued engagement in specialty mental health care for VHA patients and assessed differences by race and ethnicity. METHODS: The study included 437,051 primary care patients with a first in-person specialty mental health encounter in 2015-2016 (no specialty mental health encounters in prior 12 months), including 46,417 patients with new PCMHI encounters in the year before the first specialty mental health encounter. Multivariable logistic regression assessed odds of follow-up specialty mental health care within 3 months of the first specialty mental health encounter. The dependent variable was care engagement (attending a second specialty mental health appointment); independent variables were whether patients were seen by PCMHI on the same day as the primary care appointment ("same-day access"), the time between PCMHI and first specialty mental health appointments, and race and ethnicity. RESULTS: PCMHI was associated with increased engagement in specialty mental health care for all patients, with a greater likelihood of engagement among non-Hispanic White patients. Same-day access to PCMHI was positively associated with care engagement, with no significant differences by race or ethnicity. PCMHI care within 3 months before a first specialty mental health encounter was associated with greater care engagement. CONCLUSIONS: PCMHI, especially same-day access to PCMHI care, may boost engagement in mental health care, although the study design precluded conclusions regarding causal relationships.

OBJECTIVES: We assessed how shared plans of care (SPoC), a care coordination tool, impact healthcare utilization of a cohort of children with special healthcare needs (CSHCN) and mental health conditions. METHODS: Data, including emergency department (ED) visits, hospitalizations, and primary care visits, were collected through chart review of CSHCN. A Poisson generalized linear mixed model was used to analyze healthcare utilization data for CSHCN. RESULTS: Our results showed a decrease in primary care visits, hospitalizations, and ED visits for CSHCN after SPoC implementation, though only primary care visits reached significance. Mental health care visits were specifically found to decrease by 39% following employment of SPoC. CONCLUSIONS FOR PRACTICE: The use of SPoCs in CSHCN had a positive impact on healthcare utilization suggesting widespread use of this tool improved care coordination in this population.

OBJECTIVE: Pediatric primary care providers (PCPs) work in challenging environments and are increasingly called to implement complex interventions, such as behavioral health (BH) service integration. We explore how perceived stressful practice climates (1) change over time in and (2) influence provider perceptions of collaborative care versus usual care, 2 models of integrated BH care. METHODS: Secondary exploratory analysis using hierarchical linear modeling was performed on an 18-month cluster-randomized trial of 8 pediatric primary care practices to Doctor-Office Collaborative Care (DOCC), where an on-site care manager delivered BH services in coordination with PCPs, or Enhanced Usual Care (EUC), where a care manager facilitated referrals to local BH providers. Various indicators of PCP perceptions of BH services, including satisfaction with practice, burdens and beliefs regarding psychosocial problems, and effectiveness in treating behavioral problems, were assessed as outcomes. Moderators were 2 domains of stressful climates, role conflict and role overload. RESULTS: Role conflict and role overload stayed stable in both conditions. Role conflict strengthened the positive effect of DOCC on PCP perceived effectiveness in treating behavioral problems (beta [SE], 0.04 [0.02]; p = 0.04) and improvement in managing oppositional/aggressive behavior (0.02 [0.01]; p = 0.02). Role overload strengthened the positive effect of DOCC on PCP-perceived improvement in managing attention-deficit hyperactivity disorder (0.03 [0.01]; p = 0.01). Stressful climates did not influence perceptions for EUC providers. CONCLUSIONS: Providers experiencing more stressful practice climates developed more positive perceptions of collaborative care. This may encourage stressed providers to make effective practice changes and promote practice integration of BH services.