Daniel Mullin

Background: The American opioid use disorder (OUD) and overdose epidemic require physicians and advanced care providers to be prepared to care for patients with this life-threatening condition. Learning to identify, engage, and treat patients with OUD with medications is an essential skill for providers, as is developing requisite confidence and therapeutic attitudes regarding the care of patients with OUD (CP-OUD). To address the need for improved OUD treatment education, our team built and implemented a 12-module asynchronous course entitled, “Care of Patients with Opioid Use Disorder”, in 3 Doctor of Medicine (MD) programs and a Graduate School of Nursing (GSN) program. Methods: Students self-reported their attitudes and confidence regarding the CP-OUD before and after each module. Twelve questions assessed confidence, and 12 questions assessed attitude. Students’ change in confidence and attitudes before and after training was calculated. Results: Responses were collected between January 2021 and November 2024. The number of students completing each module ranged from 552 to 967 MD students and 81 to 149 GSN students. Students reported improved confidence after completing each of the 12 modules (<0.0001). Students reported improved attitudes after completing 10 of the 12 modules (<0.0001). Differences ranging from small to medium size were observed between MD and GSN student’s baseline confidence for 4 modules, and baseline attitudes for 6 modules. Conclusions: Asynchronous learning modules can be effectively implemented in medical and nursing education to improve confidence and attitudes regarding the CP-OUD. The use of asynchronous training modules allows for flexible deployment, as evidenced by their use in 3 MD programs and a GSN program. Future research should investigate whether improved confidence and attitudes during medical and nursing education result in more graduates caring for patients with OUD post-training.

Objective: To examine the psychometric characteristics of a survey about the experiences of people seeking mental health care and substance use services, the CAHPS Outpatient Mental Health (MH) survey.Study Settings and Design: Field tests were conducted in two Northeastern states—one among a state's Medicaid enrollees and the other in family medicine practices where psychologists and social workers were collocated with primary care providers. The survey asked about psychiatric medicines and counseling services received in the last 6 months.Data Sources and Analytic Sample: In each study, questionnaires were mailed to sampled patients with an option to complete a web survey. Study 1 included 5508 Medicaid enrollees 21 years and older from four health plans. Study 2 included 3328 patients 18 years and older who visited one of four family medicine practices. Samples included patients with mental health or substance use disorders or both.Principal Findings: Response rates were 9.98% (n = 470) and 13.00% (n = 416) for the Medicaid and family medicine surveys, respectively. About 20% of respondents reported difficulty getting appointments with mental health medicine prescribers. From 10% to 30% of respondents had difficulties finding a counselor, and 15% reported problems making appointments with counselors. Many respondents reported no mental health care in the last 6 months. Composite measures for communication with counselors had excellent internal consistency, but the measure for access to counseling services was modest (0.68 and 0.52 for the two studies). Inter‐unit reliability (IUR) was modest for the survey (IUR for all measures was lower than 0.60; highest for rating of counselors).Conclusions: Both studies had uniformly good distributions of responses to specific questions, although communication and respect questions about counselors were positively skewed. The survey performs better for respondents with any mental health condition and less well for those with only substance use disorders.

Purpose A pragmatic, cluster-randomized controlled trial of a comprehensive practice-level, multi-staged practice transformation intervention aimed to increase behavioral health integration in primary care practices and improve patient outcomes. We examined association between the completion of intervention stages and patient outcomes across a heterogenous national sample of primary care practices. Methods Forty-two primary care practices across the U.S. with co-located behavioral health and 2,426 patients with multiple chronic medical and behavioral health conditions completed surveys at baseline, midpoint and two year follow-up. Effects of the intervention on patient health and primary care integration outcomes were examined using multilevel mixed-effects models, while controlling for baseline outcome measurements. Results No differences were found associated with the number of intervention stages completed in patient health outcomes were found for depression, anxiety, fatigue, sleep disturbance, pain, pain interference, social function, patient satisfaction with care or medication adherence. The completion of each intervention stage was associated with increases in Practice Integration Profile (PIP) domain scores and were confirmed with modeling using multiple imputation for: Workflow 3.5 (95% CI: 0.9-6.1), Integration Methods 4.6 (95% CI: 1.5-7.6), Patient Identification 2.9 (95% CI: 0.9-5.0), and Total Integration 2.7 (95% CI: 0.7-4.7). Conclusion A practice-centric flexible practice transformation intervention improved integration of behavioral health in primary care across heterogenous primary care practices treating patients with multiple chronic conditions. Interventions that allow practices to flexibly improve care have potential to help complex patient populations. Future research is needed to determine how to best target patient health outcomes at a population level.

Comments on the original article by French, et al. (see record 2023-74550-001) regarding adapting psychotherapy in collaborative care for treating opioid use disorder and co-occurring psychiatric conditions in primary care. This article provided a potential treatment pathway for certain patients. However, it has left the question: What options are available for patients who decline to participate in this collaborative care approach? It is important to emphasize that we do not want to deny them access to treatment for their (opioid use disorder) OUD. Are there alternative interventions with a lower intensity that may still hold value for patients who opt out of this particular approach? In future research, the current authors would like to see expanded treatment pathways that match patients at all levels of engagement. By offering a more diverse range of options, we can better meet the needs of a broader spectrum of patients, ultimately improving treatment outcomes for individuals with OUD and psychiatric symptoms. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The Practice Integration Profile (PIP) is a reliable, valid, and broadly used measure of the integration of behavioral health (BH) into primary care. The PIP assesses operational and procedural elements that are grounded in the AHRQ Lexicon for Behavioral Health and Primary Care Integration. Prior analyses of PIP data and feedback from users suggested the measure was in need of revisions. This article describes the process used to improve readability, clarity, and pragmatic utility of the instrument. Two rounds of structured cognitive interviews were conducted with clinicians in primary care settings. After each round, interview transcripts were coded by an analytic team using an iterative and consensus-driven process. Themes were identified based on codes. Themes and recommendations for revisions were reviewed and modified by committee. Based on feedback and a prior factor analysis of the PIP, revisions were undertaken to: (a) eliminate redundant or overlapping items; (b) clarify the meaning of items; (c) standardize the response categories, and (d) place items in the most appropriate domains. The resulting measure has 28 items in five domains. PIP 2.0 will need further examination to confirm its continuing use as a foundational tool for evaluating integrated care. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Purpose: Although many primary care clinics screen for behavioral health (BH) conditions using validated tools, it is not clear whether adult BH screening leads to better patient outcomes. Our objective was to determine the evidence base by reviewing effectiveness research for multiple strategies of BH screening in adult primary care identified in the Practice Integration Profile. Method: We conducted five rapid reviews of effectiveness research supporting BH screening strategies cited in the Practice Integration Profile. Each rapid review was conducted using an adapted REAL (Rapid Evidence Assessment of the Literature) methodology and a standardized search tailored for each screening strategy to identify evidence related to BH screening in primary care. Results: The database search yielded 931 references. Following eligibility review and extraction, we evaluated data from 20 references examining five screening strategies. Results demonstrated limited support for all five strategies and high risk of bias within most studies. Outcomes associated with various BH screening strategies were rarely the focus of study. Conclusions: There is an absence of robust, well-structured evidence supporting many of the BH screening strategies advocated for in primary care. Stakeholders may wish to understand how to ensure value when developing a robust screening program that will improve patient health outcomes. Future research should advance the science of BH screen selection, timing, and implementation by answering new questions about screening strategies. Public Significance Statement Primary care clinicians play an important role in screening patients for unmet health needs, including behavioral health concerns. Given the broad array of potential conditions that can be identified in primary care, the ability to focus on screening strategies with the greatest potential to improve patient-centered outcomes is a meaningful advance in care. The results of our rapid reviews suggest that although screening strategies were found to be important components in some studies, additional research is needed to identify evidence-based screening strategies.

Context: Most patients in need of behavioral health (BH) care are seen in primary care, which often has difficulty responding. Some practices integrate behavioral health care (IBH), with medical and BH providers at the same location, working as a team. However, it is difficult to achieve high levels of integration. Objective: Test the effectiveness of a practice intervention designed to increase BH integration. Study Design: Pragmatic, cluster-randomized controlled trial. Setting: 43 primary care practices with on-site BH services in 13 states. Population: 2,460 adults with multiple chronic medical and behavioral conditions. Intervention: 24-month practice change process including an online curriculum, a practice redesign and implementation workbook, remote quality improvement coaching services, and an online learning community. Outcomes: Primary outcomes were changes in the 8 Patient-Reported Outcomes Measurement Information System (PROMIS-29) domain scores. Secondary outcomes were changes in medication adherence, self-reported healthcare utilization, time lost due to disability, cardiovascular capacity, patient centeredness, provider empathy, and several condition-specific measures. A sample of practice staff completed the Practice Integration Profile at each time point to estimate the degree of BH integration in that site. Practice-level case studies estimated the typical costs of implementing the intervention. Results: The intervention had no significant effect on any of the primary or secondary outcomes. Subgroup analyses showed no convincing patterns of effect in any populations. COVID-19 was apparently not a moderating influence of the effect of the intervention on outcomes. The intervention had a modest effect on the degree of practice integration, reaching statistical significance in the Workflow domain. The median cost of the intervention was $18,204 per practice. In post-hoc analysis, level of BH integration was associated with improved patient outcomes independent of the intervention, both at baseline and longitudinally. Conclusions: The specific intervention tested in this study was inexpensive, but had only a small impact on the degree of BH integration, and none on patient outcomes. However, practices that had more integration at baseline had better patient outcomes, independent of the intervention. Although this particular intervention was ineffective, IBH remains an attractive strategy for improving patient outcomes.

Background: Our rural health system sought to (1) increase the number of primary care clinicians waivered to prescribe buprenorphine for treatment of opioid use disorder (OUD) and (2) consequently increase the number of our patients receiving this treatment. Methods: We used the Project for Extension for Community Health Outcomes (ECHO) tele-education model as an implementation strategy. We examined the number of clinicians newly waivered, the number of patients treated with buprenorphine, the relationship between clinician engagement with ECHO training and rates of buprenorphine prescribing, and treatment retention at 180 days. Results: The number of clinicians with a waiver and number of patients treated increased during and after ECHO training. There was a moderate correlation between the number of ECHO sessions attended by a clinician and number of their buprenorphine prescriptions (r = 0.50, p = 0.01). The 180-day retention rate was 80.7%. Conclusions: Project ECHO was highly effective for increasing access to this evidence-based treatment. The high retention rate in this rural context indicates that most patients are increasing their likelihood of favorable outcomes.

Public Significance Statement The COVID-19 pandemic has threatened the welfare of the healthcare workforce. During emergencies such as this attending to the immediate safety needs of the workforce is critical. This paper describes one approach to supporting the physician workforce during a crisis. The COVID-19 pandemic presented unique biological, psychological, and social threats to health care providers. The failure of local macrosystems placed providers at elevated risk of psychological and physical harm. To reduce the immediate risk of trauma to our local physician workforce, our team initiated a program of proactive psychological first aid in which physicians were regularly contacted by behavioral health colleagues to assess safety conditions and physician's well-being. When threats to the physician's safety were identified, these concerns were escalated to leadership and addressed when possible. When threats to well-being were identified, behavioral health team members provided supportive listening, and, if indicated, provided referral information for appropriate treatment resources. This paper reviews the rationale for this program, addresses ethical concerns, and proposes future directions for responding to threats to safety during events such as the COVID-19 pandemic.