Literature Collection

Chronic kidney disease (CKD) is a common condition and important cardiovascular risk factor. However, CKD remains underdiagnosed and evidence-based medicines underutilized. In most healthcare systems, most CKD is managed in primary care. Optimal management in this setting can only be achieved with integration of care including early identification, prioritization, and use of the tools and skill mix available. This narrative review focuses on the importance of screening and identification in primary care, looking at innovative solutions and methods from other long-term conditions, particularly cardio-renal-metabolic conditions. Integrated care virtual multidisciplinary reviews, have demonstrated clinical and economic benefits, improved medication optimization, and reduced unnecessary referrals. However, implementation remains inconsistent, and prescribing of both established and novel therapies remains sub-optimal. Optimizing CKD care requires a system-wide approach that reinforces primary-secondary care collaboration, prioritizes early detection, and facilitates timely, evidence-based interventions. The inclusion of urine albumin: creatinine ratio testing, integrated digital tools, and shared accountability frameworks must be urgently adopted to realize improved outcomes and reduce the burden of CKD on individuals and healthcare systems alike.

BACKGROUND: Pharmacists remain an underutilized resource in the treatment of opioid use disorder (OUD). Although studies have engaged pharmacists in dispensing medications for OUD (MOUD), few studies have evaluated collaborative care models in which pharmacists are an active, integrated part of a primary care team offering OUD care. METHODS: This study seeks to implement a pharmacist integrated MOUD clinical model (called PrIMO) and evaluate its feasibility, acceptability, and impact across four diverse primary care sites. The Consolidated Framework for Implementation Research is used as an organizing framework for study development and interpretation of findings. Implementation Facilitation is used to support PrIMO adoption. We assess the primary outcome, the feasibility of implementing PrIMO, using the Stages of Implementation Completion (SIC). We evaluate the acceptability and impact of the PrIMO model at the sites using mixed-methods and combine survey and interview data from providers, pharmacists, pharmacy technicians, administrators, and patients receiving MOUD at the primary care sites with patient electronic health record data. We hypothesize that it is feasible to launch delivery of the PrIMO model (reach SIC Stage 6), and that it is acceptable, will positively impact patient outcomes 1 year post model launch (e.g., increased MOUD treatment retention, medication regimen adherence, service utilization for co-morbid conditions, and decreased substance use), and will increase each site's capacity to care for patients with MOUD (e.g., increased number of patients, number of prescribers, and rate of patients per prescriber). DISCUSSION: This study will provide data on a pharmacist-integrated collaborative model of care for the treatment of OUD that may be feasible, acceptable to both site staff and patients and may favorably impact patients' access to MOUD and treatment outcomes. TRIAL REGISTRATION: The study was registered on Clinicaltrials.gov (NCT05310786) on April 5, 2022, https://www.clinicaltrials.gov/study/NCT05310786?id=NCT05310786&rank=1 

BACKGROUND: Despite the high prevalence of alcohol use disorders (AUDs), in 2016, only 7.8% of individuals meeting diagnostic criteria received any type of AUD treatment. Developing options for treatment within primary care settings is imperative to increase treatment access. As part of a trial to implement AUD pharmacotherapy in primary care settings, this qualitative study analyzed pre-implementation provider interviews using the Consolidated Framework for Implementation Research (CFIR) to identify implementation barriers. METHODS: Three large Veterans Health Administration facilities participated in the implementation intervention. Local providers were trained to serve as implementation/clinical champions and received external facilitation from the project team. Primary care providers received a dashboard of patients with AUD for case identification, educational materials, and access to consultation from clinical champions. Veterans with AUD diagnoses received educational information in the mail. Prior to the start of implementation activities, 24 primary care providers (5-10 per site) participated in semi-structured interviews. Transcripts were analyzed using common coding techniques for qualitative data using the CFIR codebook Innovation/Intervention Characteristics, Outer Setting, Inner Setting, and Characteristics of Individuals domains. Number and type of barriers identified were compared to quantitative changes in AUD pharmacotherapy prescribing rates. RESULTS: Four major barriers emerged across all three sites: complexity of providing AUD pharmacotherapy in primary care, the limited compatibility of AUD treatment with existing primary care processes, providers' limited knowledge and negative beliefs about AUD pharmacotherapy and providers' negative attitudes toward patients with AUD. Site specific barriers included lack of relative advantage of providing AUD pharmacotherapy in primary care over current practice, complaints about the design quality and packaging of implementation intervention materials, limited priority of addressing AUD in primary care and limited available resources to implement AUD pharmacotherapy in primary care. CONCLUSIONS: CFIR constructs were useful for identifying pre-implementation barriers that informed refinements to the implementation intervention. The number and type of pre-implementation barriers identified did not demonstrate a clear relationship to the degree to which sites were able to improve AUD pharmacotherapy prescribing rate. Site-level implementation process factors such as leadership support and provider turn-over likely also interacted with pre-implementation barriers to drive implementation outcomes.

INTRODUCTION: Older adults experience several transitions in care, which can be challenging and stressful. Transitional care ensures continuity of care by addressing patients' healthcare needs before discharge and providing ongoing community support. Although transitional care improves patient outcomes and reduces hospital readmissions, its role in addressing mental health (MH) needs in older adults remains underexplored. This scoping review describes the literature on the integration of allied healthcare (AHC) professionals in transitional care for older adults with MH needs. METHOD: Following PRISMA-ScR guidelines, we analyzed 14 peer-reviewed articles (2010-2024) on transitions for older adults with cognitive impairment, dementia, depression, or suicide risk. Thematic analysis identified key roles, lessons, and patient needs in transitional care provided by AHC professionals. RESULTS: AHC professionals, including social workers, occupational therapists, pharmacists, and physical therapists, contributed through discharge planning, physiotherapy, medication reviews, MH counseling, and resource navigation. For caregivers, they provided education on dementia care, behavior management, and psychosocial support, improving caregiver well-being and interactions with persons with dementia. Transitional care interventions reduced caregiver stress and, in some cases, hospital readmissions. Challenges included suboptimal medication management for persons with dementia. Key facilitators were flexible delivery methods (e.g., telehealth), tailored interventions, and dementia-specific education. CONCLUSION: AHC professionals are vital to transitional care for older adults with MH needs, offering tailored support to patients and caregivers. Enhanced integration, interdisciplinary collaboration, caregiver education, and addressing systemic barriers could improve care quality. Future research should focus on standardizing interventions and optimizing medication management.

OBJECTIVE: A rural primary care clinic implemented an advance practice providers, including nurse practitioner (APRN)-led integrated behavioral health program to facilitate holistic health care delivery. METHODS: Implementation was facilitated by Health Resources and Services Administration Grant funding to a state University College of Nursing. The College formed an academic-practice partnership with a Federally Qualified Health Center (FQHC) to implement integrated care in a rural satellite clinic administered by the FQHC. An interdisciplinary team (two family APRNs, a psychiatric APRN, a licensed behavioral health provider, and the Grant Project Director who is a Psychiatric APRN and a licensed Psychologist) provided the integrated care based on the University of Washington's Collaborative Care Model. RESULTS: This brief report describes the implementation of integrated care during the clinic's first year, services provided, lessons learned, community response, and improvement in anxiety and depressive symptoms for patients who were treated for behavioral health problems. An exemplar illustrates how collaborative care addressed one patient's behavioral health and primary care needs. CONCLUSIONS: APRN-led collaborative care can expand access to holistic, affordable care in rural areas to improve mental health. Adaptation and flexibility in traditional roles may be necessary and determining post-grant access to funding for services will be necessary for sustainability.

OBJECTIVE: A rural primary care clinic implemented an advance practice providers, including nurse practitioner (APRN)-led integrated behavioral health program to facilitate holistic health care delivery. METHODS: Implementation was facilitated by Health Resources and Services Administration Grant funding to a state University College of Nursing. The College formed an academic-practice partnership with a Federally Qualified Health Center (FQHC) to implement integrated care in a rural satellite clinic administered by the FQHC. An interdisciplinary team (two family APRNs, a psychiatric APRN, a licensed behavioral health provider, and the Grant Project Director who is a Psychiatric APRN and a licensed Psychologist) provided the integrated care based on the University of Washington's Collaborative Care Model. RESULTS: This brief report describes the implementation of integrated care during the clinic's first year, services provided, lessons learned, community response, and improvement in anxiety and depressive symptoms for patients who were treated for behavioral health problems. An exemplar illustrates how collaborative care addressed one patient's behavioral health and primary care needs. CONCLUSIONS: APRN-led collaborative care can expand access to holistic, affordable care in rural areas to improve mental health. Adaptation and flexibility in traditional roles may be necessary and determining post-grant access to funding for services will be necessary for sustainability.

IMPORTANCE: Sleep is crucial for healthy growth, academic success, executive functioning, and mental health. However, sleep is not consistently and rigorously addressed in pediatric primary care. OBJECTIVE: To describe the development and reach, adoption, implementation, effectiveness, and maintenance of a well-child visit, electronic sleep screener with educational resources in a large primary care network. DESIGN, SETTING, AND PARTICIPANTS: In this case-control study of primary care practices in Pennsylvania and New Jersey, retrospective, observational electronic health records and implementation data were drawn for preimplementation (November 1, 2018, to September 30, 2019), phased-scaling (October 1, 2019, to June 30, 2021), implementation (July 1, 2021, to June 30, 2022), and maintenance (July 1, 2022, to June 30, 2023) periods. Multivariate logistic regression examined the effectiveness by comparing implementation vs preimplementation rates of sleep disorder diagnosis, polysomnogram orders, and sleep-related referrals. Patients were seen for a well-child visit during the preimplementation and implementation periods, without exclusions. Data were analyzed from October 10, 2023, to May 2, 2025. EXPOSURE: An age-based, electronic sleep screener assessing infant bed sharing, frequent snoring (≥3 nights/week), perceived sleep problems, insufficient sleep duration, and adolescent daytime sleepiness. MAIN OUTCOMES AND MEASURES: The Reach, Effectiveness, Adoption, Implementation, and Maintenance framework guided the outcomes including sleep screener use, results, and primary care clinician (PCC)-rendered sleep disorder diagnosis, polysomnogram orders, and sleep-related referrals at the well-child visit. RESULTS: A total of 409 217 well-child visits for 288 307 unique patients aged 18 years or younger (51.2% male; 49.9% White non-Hispanic or Latine) were included in the preimplementation and implementation periods. During implementation, 204 872 unique patients in 31 practices completed the screener, with adoption in 89.5% of all well-child visits. Overall, 9.7% of patients endorsed frequent snoring, 12.2% sleep problems, and 34.4% insufficient sleep. Infant bed sharing was endorsed in 6.5% of infants, whereas 14.7% of adolescents endorsed daytime sleepiness. Compared with the preimplementation period, at well-child visits with a completed sleep screener, PCCs were significantly more likely to render a sleep disorder diagnosis (odds ratio, 1.64 [95% CI, 1.56-1.73]), order a polysomnogram (odds ratio, 2.67 [95% CI, 2.32-3.20]), and refer to sleep (odds ratio, 6.48 [95% CI, 5.03-8.34]) or otolaryngology (odds ratio, 4.46 [95% CI, 3.95-5.02]) clinics. Minimal adaptations occurred during implementation, and adoption was high and persistent (92.5% of well-child visits) during the maintenance period. CONCLUSIONS AND RELEVANCE: In this case-control study, a brief, electronic well-child visit sleep screener was widely adopted and maintained in a sociodemographically diverse primary care network and was associated with increased recognition and management of sleep problems.

PURPOSE: Rural communities often have a high incidence of medical and behavioral health problems along with more limited access to care. This paper describes an innovative approach to providing integrated care in rural school-based health clinics in which graduate students serve as behavioral health interns. The purpose of this manuscript is 1) to describe a model for providing school-based integrated health services in a rural community and 2) to evaluate services provided by graduate interns embedded in school-based clinics. MATERIALS AND METHODS: Graduate interns completed a session checklist to track services provided in each session and collected data from participating students who received behavioral health services. Students completed the Outcome Rating Scale (ORS) after each session. Repeated measures MANOVAs were used to analyze the data for changes over time. RESULTS: Services provided most often by interns included assessment, engagement, positive reinforcement, coping skills, goal setting, and clinical intervention. The data suggest that students receiving at least three sessions improved over time on self-reported wellbeing. DISCUSSION: The results demonstrate the feasibility of providing integrated health care via school-based clinics that rely on graduate internships for behavioral health services. Challenges to implementing and sustaining school-based integrated health clinics are discussed. CONCLUSION: The ongoing challenges to meeting the medical and behavioral health needs of rural communities call for innovative approaches to providing integrated care. The clinics described here responded to these challenges through teamwork and strong university-community partnerships.