Literature Collection

BACKGROUND: Integrating mental health services into primary care settings is complex and challenging. Although facilitation strategies have successfully supported implementation of primary care mental health integration and other complex innovations, we know little about the time required or its cost. OBJECTIVE: To examine the time and organizational cost of facilitating implementation of primary care mental health integration. DESIGN: Descriptive analysis. PARTICIPANTS: One expert external facilitator and two internal regional facilitators who helped healthcare system stakeholders, e.g., leaders, managers, clinicians, and non-clinical staff, implement primary care mental health integration at eight clinics. INTERVENTION: Implementation facilitation tailored to the needs and resources of the setting and its stakeholders. MAIN MEASURES: We documented facilitators' and stakeholders' time and types of activities using a structured spreadsheet collected from facilitators on a weekly basis. We obtained travel costs and salary information. We conducted descriptive analysis of time data and estimated organizational cost. KEY RESULTS: The external facilitator devoted 263 h (0.09 FTE), including travel, across all 8 clinics over 28 months. Internal facilitator time varied across networks (1792 h versus 1169 h), as well as clinics. Stakeholder participation time was similar across networks (1280.6 versus 1363.4 person hours) but the number of stakeholders varied (133 versus 199 stakeholders). The organizational cost of providing implementation facilitation also varied across networks ($263,490 versus $258,127). Stakeholder participation accounted for 35% of the cost of facilitation activities in one network and 47% of the cost in the other. CONCLUSIONS: Although facilitation can improve implementation of primary care mental health integration, it requires substantial organizational investments that may vary by site and implementation effort. Furthermore, the cost of using an external expert to transfer facilitation skills and build capacity for implementation efforts appears to be minimal.

BACKGROUND: Integrating mental health services into primary care settings is complex and challenging. Although facilitation strategies have successfully supported implementation of primary care mental health integration and other complex innovations, we know little about the time required or its cost. OBJECTIVE: To examine the time and organizational cost of facilitating implementation of primary care mental health integration. DESIGN: Descriptive analysis. PARTICIPANTS: One expert external facilitator and two internal regional facilitators who helped healthcare system stakeholders, e.g., leaders, managers, clinicians, and non-clinical staff, implement primary care mental health integration at eight clinics. INTERVENTION: Implementation facilitation tailored to the needs and resources of the setting and its stakeholders. MAIN MEASURES: We documented facilitators' and stakeholders' time and types of activities using a structured spreadsheet collected from facilitators on a weekly basis. We obtained travel costs and salary information. We conducted descriptive analysis of time data and estimated organizational cost. KEY RESULTS: The external facilitator devoted 263 h (0.09 FTE), including travel, across all 8 clinics over 28 months. Internal facilitator time varied across networks (1792 h versus 1169 h), as well as clinics. Stakeholder participation time was similar across networks (1280.6 versus 1363.4 person hours) but the number of stakeholders varied (133 versus 199 stakeholders). The organizational cost of providing implementation facilitation also varied across networks ($263,490 versus $258,127). Stakeholder participation accounted for 35% of the cost of facilitation activities in one network and 47% of the cost in the other. CONCLUSIONS: Although facilitation can improve implementation of primary care mental health integration, it requires substantial organizational investments that may vary by site and implementation effort. Furthermore, the cost of using an external expert to transfer facilitation skills and build capacity for implementation efforts appears to be minimal.

OBJECTIVE: Rapid patient referral to epilepsy centers may facilitate subsequent disease-modifying surgical and non-surgical treatments. Delays of 15-18 years have been reported from time of epilepsy diagnosis to surgical evaluation in some settings, though patterns for timely guideline-concordant referrals within integrated care models are not well known and could inform strategies for optimizing guideline-concordant access. METHODS: We performed a retrospective cohort study of 1088 patients undergoing epilepsy center evaluation from January 1, 2008 through June 30, 2023 in a Northern California integrated healthcare delivery system (IDS) with a Level 4 Epilepsy Center. Using electronic health record (EHR) data, we summarized time from diagnosis and other major care time points until first visit at the epilepsy center. A multivariate linear model was used to evaluate the relationship of select demographic, socioeconomic, and clinical characteristics with the time to first epilepsy center visit. RESULTS: The mean times to epilepsy center visit from first prescription of an anti-seizure medication (ASM), diagnosis of epilepsy or seizures, and first visit with a general neurologist, were 3.9 years (SD = 4.5), 3.2 years (SD = 3.2) and 2.7 years (SD = 3.2), respectively, for the full cohort of patients prescribed any number of ASMs. Comparable time frames were seen for patients prescribed two or more ASMs at the time of first visit. Significantly longer time to epilepsy center visit was seen in patients with multiple ASMs prescribed, a concordant diagnosis of developmental delay, and those age 40 and above. Longer times to epilepsy center visit were not seen among patients with psychiatric comorbidities, public health insurance coverage, and among patients in traditionally underserved groups. CONCLUSIONS: Patients evaluated at an epilepsy clinic within an IDS system did so within less than four years of diagnosis and initial treatment, with few disparities by demographics or comorbidities. Future studies can identify specific health system features that are key to shorter time frames to test transferable strategies to reduce time to epilepsy centers.

INTRODUCTION: Cigarette smoking rates among individuals with opioid use disorder (OUD) are notoriously high and may be improved by considering the timing of treatment integration for these two substances. The current study examined the feasibility of a method for assessing the timing of integrating smoking cessation pharmacotherapy within three different phases of outpatient treatment with medication for OUD (MOUD). METHODS: Seventy-four buprenorphine-maintained smokers were enrolled in a quasi-experimental study across three MOUD treatment phases: 0-90 (Phase 1), 91-365 (Phase 2), and > 365 days of MOUD treatment (Phase 3). During a 12-week varenicline-based intervention, the study assessed outcomes daily via text messages (cigarette smoking, varenicline adherence, side effects) or monthly at in-person visits (quit motivation and carbon monoxide levels). RESULTS: Thirty-five participants completed the study, with a lower retention rate in Phase 1 (37.5%) relative to Phases 2 (53.5%) or 3 (57.1%). A trend occurred for Phase 1 participants to report aversive side effects (e.g., abnormal dreams, gastrointestinal distress) on more study days. Among completers, adherence to text messaging and varenicline use was high and independent of MOUD treatment phase. Participants in all phases reported declines in cigarette smoking and increases in quit motivation over time; the study observed biochemically verified tobacco abstinence among only a few participants from Phases 2 or 3. CONCLUSIONS: This feasibility study demonstrates a method to evaluate the timing of treatment integration for cigarette smoking and MOUD. Method strengths include a study schedule that coincided with the MOUD clinic schedule and use of text messaging to encourage varenicline adherence and evaluate outcomes regularly.

Part 1: An introduction to medications for the treatment of opioid use disorder. The approach to OUD care -- Overview of medications for OUD -- Duration of treatment with OUD medication -- Treatment settings -- Challenges to expanding access to OUD medication -- Resources -- Notes -- Part 2: Addressing opioid use disorder in general medical settings. Scope of the Problem -- Screening -- Assessment -- Treatment planning or referral -- Resources -- Appendix -- Notes -- Part 3: Pharmacotherapy for opioid use disorder. Pharmacotherapy for opioid use disorder -- Overview of pharmacotherapy for opioid use disorder. Methadone -- Naltrexone -- Buprenorphine -- Medical management strategies for patients taking OUD medications in office-based settings -- Medical management of patients taking OUD medications in hospital settings -- PART 4: Partnering addiction treatment counselors with clients and healthcare professionals. Overview and context -- Quick guide to medications -- Counselor-prescriber communications -- Creation of a supportive counseling experience -- Other common counseling concerns -- Notes -- Part 5: Resources related to medications for opioid use disorder. General Resources -- Resources for counselors and peer providers -- Resources for clients and families -- Provider tools and sample forms -- Glossary of TIP terminology -- Notes