Literature Collection

BACKGROUND: Patients with mental illness are frequently treated in primary care, where Primary Care Providers (PCPs) report feeling ill-equipped to manage their care. Team-based models of care improve outcomes for patients with mental illness, but multiple barriers limit adoption. Barriers include practical issues and psychosocial factors associated with the reorganization of care. Practice facilitation can improve implementation, but does not directly address the psychosocial factors or gaps in PCP skills in managing mental illness. To address these gaps, we developed Relational Team Development (RELATED). METHODS: RELATED is an implementation strategy combining practice facilitation and psychology clinical supervision methodologies to improve implementation of team-based care. It includes PCP-level clinical coaching and a team-level practice change activity. We performed a preliminary assessment of RELATED with a convergent parallel mixed method study in 2 primary care clinics in an urban Federally Qualified Health Center in Southwest, USA, 2017-2018. Study participants included PCPs, clinic staff, and patient representatives. Clinic staff and patients were recruited for the practice change activity only. Primary outcomes were feasibility and acceptability. Feasibility was assessed as ease of recruitment and implementation. Acceptability was measured in surveys of PCPs and staff and focus groups. We conducted semi-structured focus groups with 3 participant groups in each clinic: PCPs; staff and patients; and leadership. Secondary outcomes were change in pre- post- intervention PCP self-efficacy in mental illness management and team-based care. We conducted qualitative observations to better understand clinic climate. RESULTS: We recruited 18 PCPs, 17 staff members, and 3 patient representatives. We ended recruitment early due to over recruitment. Both clinics developed and implemented practice change activities. The mean acceptability score was 3.7 (SD=0.3) on a 4-point Likert scale. PCPs had a statistically significant increase in their mental illness management self-efficacy [change = 0.9, p-value= <.01]. Focus group comments were largely positive, with PCPs requesting additional coaching. CONCLUSIONS: RELATED was feasible and highly acceptable. It led to positive changes in PCP self-efficacy in Mental Illness Management. If confirmed as an effective implementation strategy, RELATED has the potential to significantly impact implementation of evidence-based interventions for patients with mental illness in primary care.

PURPOSE: Practice transformation initiatives have the potential to promote collaborations between public health, primary care, and behavioral health, but limited empirical evidence is available on how these programs affect participating clinical practices. OBJECTIVE: To report the findings from a mixed-methods program evaluation of the Washington Practice Transformation Support Hub (Hub), a publicly funded, multicomponent practice transformation initiative in Washington State. DESIGN: We used quantitative and qualitative methods to evaluate the impact of Hub activities on participating primary care and behavioral health practices. Pre- and posttest survey data were combined with administrative program data to understand the effect of program components. Qualitative interviews contextualized findings. SETTING: Urban and rural primary care and behavioral health practices in Washington State. PARTICIPANTS: One hundred seventy-five practices that were recruited to receive Hub coaching and facilitation from 8 coaches; of these, 13 practices and all coaches participated in key informant interviews. INTERVENTION: Practice coaching and facilitation supported by an online resource portal, from January 2017 through January 2019. MAIN OUTCOME MEASURES: Self-reported progress in specific activities in 3 practice-level domains: bidirectional integration of physical and behavioral health care (care integration); alignment with community-based services for whole-person care (clinical-community linkages); and value-based payment. RESULTS: Participation in Hub activities was associated with improvements in care integration and clinical-community linkages but not with progress toward value-based payment. Qualitative results indicated that practice progress was influenced by communication with practices, the culture of the practice, resource constraints (particularly in rural areas), and perceptions about sustainability. CONCLUSIONS: This statewide practice transformation initiative was successful in strengthening primary care and behavioral health integration and clinical-community linkages among participating practices but not value-based payment. Future practice transformation efforts may benefit from addressing barriers posed by communication, limited application of value-based payment, culture change, competing priorities, and resource limitations, particularly for rural communities.

IMPORTANCE: The demand for medications for opioid use disorder (MOUD) in rural US counties far outweighs their availability. Novel approaches to extend treatment capacity include telemedicine (TM) and mobile treatment on demand; however, their combined use has not been reported or evaluated. OBJECTIVE: To evaluate the use of a TM mobile treatment unit (TM-MTU) to improve access to MOUD for individuals living in an underserved rural area. DESIGN, SETTING, AND PARTICIPANTS: This quality improvement study evaluated data collected from adult outpatients with a diagnosis of OUD enrolled in the TM-MTU initiative from February 2019 (program inception) to June 2020. Program staff traveled to rural areas in a modified recreational vehicle equipped with medical, videoconferencing, and data collection devices. Patients were virtually connected with physicians based more than 70 miles (112 km) away. Data analysis was performed from June to October 2020. INTERVENTION: Patients received buprenorphine prescriptions after initial teleconsultation and follow-up visits from a study physician specialized in addiction psychiatry and medicine. MAIN OUTCOMES AND MEASURES: The primary outcome was 3-month treatment retention, and the secondary outcome was opioid-positive urine screens. Exploratory outcomes included use of other drugs and patients' travel distance to treatment. RESULTS: A total of 118 patients were enrolled in treatment, of whom 94 were seen for follow-up treatment predominantly (at least 2 of 3 visits [>50%]) on the TM-MTU; only those 94 patients' data are considered in all analyses. The mean (SD) age of patients was 36.53 (9.78) years, 59 (62.77%) were men, 71 (75.53%) identified as White, and 90 (95.74%) were of non-Hispanic ethnicity. Fifty-five patients (58.51%) were retained in treatment by 3 months (90 days) after baseline. Opioid use was reduced by 32.84% at 3 months, compared with baseline, and was negatively associated with treatment duration (F = 12.69; P = .001). In addition, compared with the nearest brick-and-mortar treatment location, TM-MTU treatment was a mean of 6.52 miles (range, 0.10-58.70 miles) (10.43 km; range, 0.16-93.92 km) and a mean of 10 minutes (range, 1-49 minutes) closer for patients. CONCLUSIONS AND RELEVANCE: These data demonstrate the feasibility of combining TM with mobile treatment, with outcomes (retention and opioid use) similar to those obtained from office-based TM MOUD programs. By implementing a traveling virtual platform, this clinical paradigm not only helps fill the void of rural MOUD practitioners but also facilitates access to underserved populations who are less likely to reach traditional medical settings, with critical relevance in the context of the COVID-19 pandemic.