Literature Collection

OBJECTIVE: To determine whether the presence of integrated behavioral health care (IBH) in a pediatric practice is associated with improved implementation of Safe Environment for Every Kid (SEEK), an evidence-based approach to prevention of child maltreatment. METHODS: Pediatric primary care practices across the United States (n = 44) expressed interest in participating in a longitudinal multisite trial. Half of the practices included IBH. Semi-structured interviews were conducted at different points in time with 49 practice leaders, primary care professionals, behavioral health professionals, and nursing and administrative staff. Quantitative data on implementation stage and phase, proportion of activities completed at each stage, and length of time to complete each stage were collected by the Stages of Implementation Completion measure. RESULTS: Qualitative data revealed several instances in which IBH facilitated the adoption and implementation of SEEK and where SEEK supported IBH. However, apart from a longer duration devoted to program startup among IBH practices, none of the quantitative differences in rate of program startup, better completion of implementation activities, more tasks completed within each stage, and greater competency were statistically significant. CONCLUSION: Integrated behavioral health care in pediatric primary care settings may help to facilitate the implementation of interventions like SEEK designed to address social determinants of health and reduce the risk of child maltreatment. However, the current study did not find evidence, based on quantitative analyses, that IBH significantly affected the uptake of Project SEEK and that more research may be warranted.

The Arizona Department of Health Services joined with the Milbank Memorial Fund to sponsor a forum on January 25 and 26, 2011 in Chandler, AZ, for policy makers in both the mental health and community health center fields. The public forum webpage provides links to a dozen presentations from the event.

Given the prevalence of behavioral health disorders in children and adolescents, and ongoing access gaps, clinicians and policymakers have pushed to expand integrated care models in pediatric primary care settings. Despite the evidence surrounding the efficacy of integrated behavioral health models for pediatric populations, uptake has been slow. Practices report many implementation barriers, including stand-up costs, training needs, and inadequate administrative support. In this Commentary, we argue that, perhaps even more fundamentally, ongoing financial challenges are restricting model adoption, scale, and sustainability, particularly for independent and smaller pediatric group practices. Two real-world case studies illustrate several key financial challenges and opportunity costs for such practices, including administrative barriers and lag times in contracting and credentialing behavioral health providers, reimbursement rates that fail to cover the costs of care delivery, opportunity costs for practice revenue, and persistent coding and billing restrictions. Policies aiming to fulfill the clinical promise of integrated behavioral health care must account for these fiscal realities, prioritizing billing and payment alignment with pediatric practices' bottom dollar.

BACKGROUND: People with diabetes, vascular disease, and asthma often struggle to maintain stability in their chronic health conditions, particularly those in rural areas, living in poverty, or racially or ethnically minoritized populations. These groups can experience inequities in healthcare, where one group of people has fewer or lower-quality resources than others. Integrating behavioral healthcare services into primary care holds promise in helping the primary care team better manage patients' conditions, but it involves changing the way care is delivered in a clinic in multiple ways. Some clinics are more successful than others in fully integrating behavioral health models as shown by previous research conducted by our team identifying four patterns of implementation: Low, Structural, Partial, and Strong. Little is known about how this variation in integration may be related to chronic disease management and if IBH could be a strategy to reduce healthcare inequities. This study explores potential relationships between IBH implementation variation and chronic disease management in the context of healthcare inequities. METHODS: Building on a previously published latent class analysis of 102 primary care clinics in Minnesota, we used multiple regression to establish relationships between IBH latent class and healthcare inequities in chronic disease management, and then structural equation modeling to examine how IBH latent class may moderate those healthcare inequities. RESULTS: Contrary to our hypotheses, and demonstrating the complexity of the research question, clinics with better chronic disease management were more likely to be Low IBH rather than any other level of integration. Strong and Structural IBH clinics demonstrated better chronic disease management as race in the clinic's location became more White. CONCLUSIONS: IBH may result in improved care, though it may not be sufficient to resolve healthcare inequities; it appears that IBH may be more effective when fewer social determinants of health are present. Clinics with Low IBH may not be motivated to engage in this practice change for chronic disease management and may need to be provided other reasons to do so. Larger systemic and policy changes are likely required that specifically target the mechanisms of healthcare inequities.