Practice interventions to enhance integrated behavioral health care may have minimal effect on patient outcomes

Researchers from around the United States collaborated on a clinical trial to test the effectiveness of a practice intervention for improving outcomes for patients with both physical and mental health problems by enhancing integrated behavioral health (IBH) activities. The research team recruited 42 primary care practice sites in 13 states, including internal medicine, family medicine, small and large groups, for-profit, academic, and safety-net clinics. Each site had a co-located behavioral health provider (a psychologist, social worker, or licensed counselor in the same building) working at least 0.5 FTE and a Practice Integration Profile (PIP) score (a measure of staff perception of IBH activities) below 75 out of 100. Electronic health records were used to identify eligible adult patients with multiple chronic medical and behavioral conditions at these practices, of whom 2,426 agreed to participate in the study.

Twenty practices randomly assigned to the active group were required to assemble an intervention team with a facilitator. They had access to an intervention toolkit with workbooks to guide quality improvement (QI) strategies within the practice and in care management; online education tailored to clinic roles; and remote coaching for the facilitator and intervention team. The 22 practices randomly assigned to the control group did not implement the intervention. At the start, midpoint, and two-year mark of the study, staff at all participating practices completed the PIP survey, while all patient participants (967 in the active group, 1,459 in the control group) completed the Patient-Reported Outcomes Measurement Information System (PROMIS-29) survey. The research team measured changes in the level of practice integration as indicated by the six domains of the PIP survey (Workflow, Clinical Services, Workspace, Integration of Providers, Patient Identification, and Patient Engagement) and changes in the eight PROMIS-29 domain scores (Physical Function, Anxiety, Depression, Fatigue, Sleep Disturbance, Social Functioning, Pain Intensity, and Pain Interference). 

Total PIP scores improved minimally for both active and control practices. Though there was no significant difference between their overall levels of improvement, the active group’s Workflow scores had a nearly 10-point increase, while the control group showed marginal improvement. Overall, the PROMIS-29 scores revealed no significant difference in the amount of change reported by patients at the active practices compared with patients at the control practices; patient outcomes also tended to be higher at practices that started with a higher level of IBH. However, patient outcomes showed greater improvement at the 13 active practices that followed the intervention workbook to completion.

What We Know: Mental health conditions such as depression and substance use disorder are often concurrent with a range of physical health concerns. For patients with both chronic physical and behavioral conditions, outcomes may improve with the use of integrative behavioral health (IBH) interventions, or the systematic collaboration between primary care and behavioral health providers on patient care. IBH interventions can range from simply working with a behavioral health provider in the same building to sharing patient records and scheduling. However, barriers such as the complexity of a health system can make it difficult to improve on existing IBH interventions or implement new ones.

What This Study Adds: The study intervention appeared to have no significant effect on patient-reported outcomes or practices’ overall PIP scores. However, the results showed a greater increase in PIP Workflow scores of practices in the intervention group than those in the control group. Researchers also found improved patient outcomes based on PROMIS-29 scores at active practices that completed the intervention and at practices that had a higher level of IBH per the PIP survey at the outset of the study. Further research is needed to determine how best to reach patients by enhancing IBH.

A Cluster Randomized Trial of Primary Care Practice Redesign to Integrate Behavioral Health for Those Who Need It Most: Patients With Multiple Chronic Conditions

Benjamin Littenberg, MD, et al, Division of General Internal Medicine Research, Department of Medicine, Robert Larner MD College of Medicine at the University of Vermont, Burlington, Vermont

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