Literature Collection

The authors describe a real-world application of virtually integrated primary and behavioral health care implemented within an accountable care organization (ACO) system. Cost-of-care data from before and after a 6-month intervention were analyzed for 121 Medicaid and Child Health Plan Plus ACO members. The intervention was associated with a significant shift in the distribution of health care costs, from inpatient and emergency care to outpatient and preventive care. The program demonstrates a flexible and replicable approach to integration that can help expand effective primary care.

INTRODUCTION: The RAINBOW randomized clinical trial validated the efficacy of an integrated collaborative care intervention for obesity and depression in primary care, although the effect was modest. To inform intervention optimization, this study investigated within-treatment variability in participant engagement and progress. METHODS: Data were collected in 2014-2017 and analyzed post hoc in 2018. Cluster analysis evaluated patterns of change in weekly self-monitored weight from week 6 up to week 52 and depression scores on the Patient Health Questionnaire-9 (PHQ-9) from up to 15 individual sessions during the 12-month intervention. Chi-square tests and ANOVA compared weight loss and depression outcomes objectively measured by blinded assessors to validate differences among categories of treatment engagement and progress defined based on cluster analysis results. RESULTS: Among 204 intervention participants (50.9 [SD, 12.2] years, 71% female, 72% non-Hispanic White, BMI 36.7 [6.9], PHQ-9 14.1 [3.2]), 31% (n = 63) had poor engagement, on average completing self-monitored weight in <3 of 46 weeks and <5 of 15 sessions. Among them, 50 (79%) discontinued the intervention by session 6 (week 8). Engaged participants (n = 141; 69%) self-monitored weight for 11-22 weeks, attended almost all 15 sessions, but showed variable treatment progress based on patterns of change in self-monitored weight and PHQ-9 scores over 12 months. Three patterns of weight change (%) represented minimal weight loss (n = 50, linear β1 = -0.06, quadratic β2 = 0.001), moderate weight loss (n = 61, β1 = -0.28, β2 = 0.002), and substantial weight loss (n = 12, β1 = -0.53, β2 = 0.005). Three patterns of change in PHQ-9 scores represented moderate depression without treatment progress (n = 40, intercept β0 = 11.05, β1 = -0.11, β2 = 0.002), moderate depression with treatment progress (n = 20, β0 = 12.90, β1 = -0.42, β2 = 0.006), and milder depression with treatment progress (n = 81, β0 = 7.41, β1 = -0.23, β2 = 0.003). The patterns diverged within 6-8 weeks and persisted throughout the intervention. Objectively measured weight loss and depression outcomes were significantly worse among participants with poor engagement or poor progress on either weight or PHQ-9 than those showing progress on both. CONCLUSIONS: Participants demonstrating poor engagement or poor progress could be identified early during the intervention and were more likely to fail treatment at the end of the intervention. This insight could inform individualized and timely optimization to enhance treatment efficacy. TRIAL REGISTRATION: ClinicalTrials.gov# NCT02246413.

BACKGROUND: This study has two aims: first, to identify variables associated with interprofessional collaboration (IPC) among a total of 315 Quebec mental health (MH) professionals working in MH primary care teams (PCTs, N = 101) or in specialized service teams (SSTs, N = 214); and second, to compare IPC associated variables in MH-PCTs vs MH-SSTs. METHODS: A large number of variables acknowledged as strongly related to IPC in the literature were tested. Multivariate regression models were performed on MH-PCTs and MH-SSTs respectively. RESULTS: Results showed that knowledge integration, team climate and multifocal identification were independently and positively associated with IPC in both MH-PCTs and MH-SSTs. By contrast, knowledge sharing was positively associated with IPC in MH-PCTs only, and organizational support positively associated with IPC in MH-SSTs. Finally, one variable (age) was significantly and negatively associated with IPC in SSTs. CONCLUSIONS: Improving IPC and making MH teams more successful require the development and implementation of differentiated professional skills in MH-PCTs and MH-SSTs by care managers depending upon the level of care required (primary or specialized). Training is also needed for the promotion of interdisciplinary values and improvement of interprofessional knowledge regarding IPC.