Purpose: To identify how organizations prepare clinicians to work together to integrate behavioral health and primary care.Methods: Observational cross-case comparison study of 19 U.S. practices, 11 participating in Advancing Care Together, and 8 from the Integration Workforce Study. Practices varied in size, ownership, geographic location, and experience delivering integrated care. Multidisciplinary teams collected data (field notes from direct practice observations, semistructured interviews, and online diaries as reported by practice leaders) and then analyzed the data using a grounded theory approach.Results Behavioral health and primary care integration refers to primary care clinicians (PCCs) and behavioral health clinicians (BHCs) and staff working together with patients to address patients' primary care and behavioral health needs.1 As integrated care becomes a more widely adopted clinical apThis article was externally peer reviewed.

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Purpose: This paper sought to describe how clinicians from different backgrounds interact to deliver integrated behavioral and primary health care, and the contextual factors that shape such interactions.Methods: This was a comparative case study in which a multidisciplinary team used an immersioncrystallization approach to analyze data from observations of practice operations, interviews with practice members, and implementation diaries. The observed practices were drawn from 2 studies: Advancing Care Together, a demonstration project of 11 practices located in Colorado; and the Integration Workforce Study, consisting of 8 practices located across the United States.Results: Primary care and behavioral health clinicians used 3 interpersonal strategies to work together in integrated settings: consulting, coordinating, and collaborating (3Cs). Consulting occurred when clinicians sought advice, validated care plans, or corroborated perceptions of a patient's needs with another professional. Coordinating involved 2 professionals working in a parallel or in a backand-forth fashion to achieve a common patient care goal, while delivering care separately. Collaborating involved 2 or more professionals interacting in real time to discuss a patient's presenting symptoms, describe their views on treatment, and jointly develop a care plan. Collaborative behavior emerged when a patient's care or situation was complex or novel. We identified contextual factors shaping use of the 3Cs, including: time to plan patient care, staffing, employing brief therapeutic approaches, proximity of clinical team members, and electronic health record documenting behavior. Compelling research evidence, health care reform initiatives, and clinician and patient needs are driving the integration of primary care and behavioral health services. Emotional, behavioral, and physical comorbidities are common and compound the risk for undesirable patient health outcomes. Conclusion1-11 Regardless of implementation site, integration requires professionals of different backgrounds interacting to provide care, yet little research has focused on understanding the ways clinicians work This article was externally peer reviewed.

Objective This study examined a cohort of Medicaid patients with new prescriptions for atypical antipsychotic medication to determine the prevalence of sub-therapeutic atypical antipsychotic medication use and to identify patient and prescribing provider characteristics associated with its occurrence. Method This observational cohort study examined Medicaid administrative claims data for patients age 20–64 with a new prescription for an atypical antipsychotic medication (clozapine, olanzapine, quetiapine, risperidone, ziprasidone) between 1/2004 and 12/2004. Patient characteristics, prescribing provider characteristics, length of therapy, and dosing were examined. A logistic regression assessed the probability of sub-therapeutic dosing. Results Among 830 individuals starting an atypical antipsychotic, only 15% had a documented diagnosis of schizophrenia, sub-therapeutic dosing was common (up to 86% of patients taking quetiapine), and 40% of the sample continued less than 30 days with the indexed prescription. A logistic model indicated that a general practitioner as prescribing provider, length of therapy less than 30 days, and prescription of quetiapine were significantly associated with a sub-therapeutic dose. Conclusions These results suggest there is extensive use of expensive atypical anti-psychotic medications for off-label purposes such as sedation or for other practice patterns that should be explored further. Approaches that minimize off-label atypical antipsychotic use could be of considerable value to Medicaid programs. In addition, theses findings support the need for the introduction or increased use of utilization monitoring, and the implementation of medication practice guidelines as appropriate decision support for prescribing providers.

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People with serious mental illnesses are increasingly becoming more active participants in their treatment and recovery. At times, their participation may be limited by incomplete, unclear, or insufficient information. The authors used a grounded theory approach to look at the unmet informational needs described by consumers. Participants in this study called for materials appropriate to their level of understanding, assistance with interpreting and comprehending information when necessary, and information on policies that affect the treatment they receive. Ultimately, an informed consumer is one empowered to make decisions about the course of his or her recovery and participate meaningfully in the patient–provider relationship.

Objective: The patient-centered medical home (PCMH) is emerging as a key strategy to improve health outcomes, reduce total costs, and strengthen primary care, but a myriad of operational measures of the PCMH have emerged. In 2009, the state of Oregon convened a public, legislatively mandated committee charged with developing PCMH measures. We report on the process of, outcomes of, and lessons learned by this committee.Methods: The Oregon PCMH advisory committee was appointed by the director of the Oregon Department of Human Services and held 7 public meetings between October 2009 and February 2010. The committee engaged a diverse group of Oregon stakeholders, including a variety of practicing primary care physicians.Results: The committee developed a PCMH measurement framework, including 6 core attributes, 15 standards, and 27 individual measures. Key successes of the committee's work were to describe PCMH core attributes and functions in patient-centered language and to achieve consensus among a diverse group of stakeholders.Conclusions: Oregon's PCMH advisory committee engaged local stakeholders in a process that resulted in a shared PCMH measurement framework and addressed stakeholders' concerns. The state of Oregon now has implemented a PCMH program using the framework developed by the PCMH advisory committee. The Oregon experience demonstrates that a brief public process can be successful in producing meaningful consensus on PCMH roles and functions and advancing PCMH policy. The patient-centered medical home (PCMH) is a promising strategy to achieve the triple aim of improved health outcomes, better patient experiences, and reduced per-capita costs by strengthening primary care.1-4 Professional organizations representing US primary care physicians have developed 7 principles that outline the core elements of the PCMH: a personal physician, physiciandirected medical practice, whole-person orientation, coordination and integration of care, attention to quality and safety, enhanced access to care, and payment that appropriately recognizes the value of the PCMH. 5 Coalitions of insurers, employers, professional organizations, and others have endorsed these principles, leading to broad agreement about general concepts underlying the PCMH. 6 As the PCMH moves from concept to reality, many entities have developed detailed operational PCMH definitions and measurement strategies based on the needs of their particular stakeholders. [7][8][9][10][11] This diversity of operational definitions has led to a range of projects all bearing the same generic name "medical home." 2,4,12 This article was externally peer reviewed. The most widely used tools to measure attributes of a medical home are the PCMH recognition programs developed by the National Committee for Quality Assurance (NCQA). 3,8 The 2008 version of the NCQA criteria has been criticized for a variety of reasons: the administrative burden and expense required to achieve recognition, a failure to emphasize practice characteristics associated with short-term...

This study examined the outcomes of patients in a low-intensity, short-duration involuntary outpatient commitment program. After release from inpatient commitment, one group (N = 150) entered an involuntary outpatient commitment program that lasted up to six months; a comparison group (N = 140) was released into the community without further involuntary care. After the analysis adjusted for confounding variables, patients who were in the involuntary outpatient commitment program had greater use of follow-up outpatient and residential services and psychotropic medications than patients in the comparison group. No differences were found between the groups in follow-up acute psychiatric hospitalization or arrests. Low-intensity, short-duration involuntary outpatient commitment appears to have a limited, but important, impact.