Integrating behavioral health (BH) and primary care is an important strategy to improve health behaviors, mental health, and substance misuse, particularly at community health centers (CHCs) where disease burden is high and access to mental health services is low. Components of different integrated BH models are often combined in practice. It is unknown which components distinguish developing vs. established integrated BH programs. A survey was mailed to 128 CHCs in 10 Midwestern states in 2016. Generalized estimating equation models were used to assess associations between program characteristics and stage of integration implementation (pre-contemplation, contemplation, preparation, action, or maintenance). Content analysis of open-ended responses identified integration barriers. Response rate was 60% (N=77). Most CHCs had co-located BH and primary care services, warm hand-offs from primary care to BH clinicians, shared scheduling and EHR systems, and depression and substance use disorder screening. Thirty-two CHCs (42%) indicated they had completed integration and were focused on quality improvement (maintenance). Being in the maintenance stage was associated with having a psychologist on staff (OR=7.16, 95% CI 2.76–18.55), a system for tracking referrals (OR=3.42, 95% CI 1.03–11.36), a registry (OR=2.71, 95% CI 1.86–3.94), PCMH designation (OR=2.82, 95% CI 1.48–5.37), and a lower proportion of Black/African American patients (OR=0.82, 95% CI 0.75–0.89). The most common barriers to integration were difficulty recruiting and retaining BH clinicians and inadequate reimbursement. CHCs have implemented many foundational components of integrated BH. Future work should address barriers to integration and racial disparities in access to integrated BH.

Depression is a prevalent condition for which screening rates remain low and disparities in screening exist. This study examines the impacts of a medical assistant screening protocol on the rates of depression screening, overall and by sociodemographic groups, in a primary care setting. Between September 2016 and August 2018, a quasi-experimental study of adult primary care visits was conducted at an urban academic clinic to ascertain the change in the rates of completion of the Patient Health Questionnaire-2 after the implementation of a medical assistant protocol (intervention) versus that of physician-only screening (control arm). Analyses were conducted between April 2019 and April 2020 and used interrupted time-series models with generalized estimating equations. A total of 45,157 visits by 21,377 unique patients were included. Overall, screening increased from 18% (physician-only screening) to 57% (medical assistant protocol) (p<0.0001). Screening increased for all measured demographics. With physician screening, depression screening was less likely to occur at visits by women (than at visits by men; OR=0.91, 95% CI=0.85, 0.98) and at visits by Black/African American patients (than at visits by White; OR=0.91, 95% CI=0.84, 0.99). However, with the medical assistant protocol, depression screening was more likely to occur at visits by women (than at visits by men; OR=1.07, 95% CI=1.0002, 1.14) and at visits by Black/African American patients (than at visits by White; OR=1.11, 95% CI=1.02, 1.20). In addition, age-related disparities were mitigated for visits by patients aged 40-64 and ≥65 years (e.g., age ≥65 years: physician, OR=0.66, 95% CI=0.59, 0.73; medical assistant protocol, OR=0.78, 95% CI=0.71, 0.85), compared with visits by patients aged 18-39 years. Implementation of a medical assistant protocol in a primary care setting may significantly increase depression screening rates while mitigating or removing sociodemographic disparities.

Provider- and staff-perceived levels of integration were measured during implementation of a primary care behavioral health clinic; these data were used to tailor and evaluate quality improvement strategies. Providers and staff at an urban, academic, adult primary care clinic completed the 32-item Level of Integration Measure (LIM) at baseline and 7 months. The LIM assesses 6 domains of integrated care. Overall and domain scores were calibrated from 0 to 100, with ≥80 representing a highly integrated clinic. Response rate was 79% (N = 46/58) at baseline and 83% (N = 52/63) at follow-up. Overall, LIM score increased from 64.5 to 70.1, P = .001. The lowest scoring domains at baseline were targeted for quality improvement and increased significantly: integrated clinical practice, 60.0 versus 68.4, P < .001; systems integration, 57.0 versus 63.8, P = .001; and training, 56.7 versus 65.3, P = .001. Ongoing quality improvement, including organizational and financial strategies, is needed to achieve higher levels of integration.

Background: Depression and anxiety are common among people with HIV and are associated with inadequate viral suppression, disease progression, and increased mortality. However, depression and anxiety are underdiagnosed and undertreated in people with HIV owing to inadequate visit time and personnel availability. Conducting population-level depression and anxiety screening via the patient portal is a promising intervention that has not been studied in HIV care settings. Objective: We aimed to explore facilitators of and barriers to implementing population-level portal-based depression and anxiety screening for people with HIV. Methods: We conducted semistructured hour-long qualitative interviews based on the Consolidated Framework for Implementation Research with clinicians at an HIV clinic. Results: A total of 10 clinicians participated in interviews. In total, 10 facilitators and 7 barriers were identified across 5 Consolidated Framework for Implementation Research domains. Facilitators included advantages of systematic screening outside clinic visits; the expectation that assessment frequency could be tailored to patient needs; evidence from the literature and previous experience in other settings; respect for patient privacy; empowering patients and facilitating communication about mental health; compatibility with clinic culture, workflows, and systems; staff beliefs about the importance of mental health screening and benefits for HIV care; engaging all clinic staff and leveraging their strengths; and clear planning and communication with staff. Barriers included difficulty in ensuring prompt response to suicidal ideation; patient access, experience, and comfort using the portal; limited availability of mental health services; variations in how providers use the electronic health record and communicate with patients; limited capacity to address mental health concerns during HIV visits; staff knowledge and self-efficacy regarding the management of mental health conditions; and the impersonal approach to a sensitive topic. Conclusions: We proposed 13 strategies for implementing population-level portal-based screening for people with HIV. Before implementation, clinics can conduct local assessments of clinicians and clinic staff; engage clinicians and clinic staff with various roles and expertise to support the implementation; highlight advantages, relevance, and evidence for population-level portal-based mental health screening; make screening frequency adaptable based on patient history and symptoms; use user-centered design methods to refine results that are displayed and communicated in the electronic health record; make screening tools available for patients to use on demand in the portal; and create protocols for positive depression and anxiety screeners, including those indicating imminent risk. During implementation, clinics should communicate with clinicians and clinic staff and provide training on protocols; provide technical support and demonstrations for patients on how to use the portal; use multiple screening methods for broad reach; use patient-centered communication in portal messages; provide clinical decision support tools, training, and mentorship to help clinicians manage mental health concerns; and implement integrated behavioral health and increase mental health referral partnerships.

Background: In the United States, 1 in 11 people receive primary care from a federally qualified health center (FQHC). Text messaging interventions (TMIs) are accessible ways to deliver health information, engage patients, and improve health outcomes in the health center setting. Objective: We aimed to evaluate the impact of a TMI implemented with a group visit (GV) intervention among patients with type 2 diabetes mellitus (T2DM) at FQHCs on patient-reported outcomes and clinical outcomes based on patient TMI engagement. Methods: A TMI was implemented for 11 health centers participating in a cluster randomized study of diabetes GVs in Midwestern FQHCs targeting adults with T2DM. FQHC patients participated in 6 monthly GVs either in person or online and a concurrent 25-week TMI. Outcome measures included clinical markers such as glycated hemoglobin A_1c and patient-reported diabetes distress, diabetes self-care, diabetes self-efficacy, diabetes care knowledge, diabetes quality of life, diabetes social support, and TMI use and satisfaction. TMI response rate was calculated as responses to an SMS text message requesting a response divided by total messages requesting a response sent. Patients were grouped as high responders if their response rate was greater than or equal to the median response rate and low responders if their response rate was below the median. We conducted linear mixed models to compare high and low responders and within a group, adjusting for age, gender, GV attendance, and depression/anxiety at baseline. Results: In total, 101 of 124 GV patients (81.5%) enrolled in the TMI. The average age of the population in the TMI was 53 years. Of the 101 respondents, 61 (60%) were racial or ethnic minorities, while 42 of 82 respondents (51%) had a high school diploma/General Education Development or less, and 56 of 80 respondents (71%) reported an annual income less than US $30,000. In addition, 70 of 81 respondents (86%) owned a smartphone and 74 of 80 respondents (93%) had an unlimited texting plan. The median response rate was 41% and the mean response rate was 41.6%. Adjusted models showed significantly improved diabetes knowledge (P<.001), foot care (P<.001), and exercise (P=.002) in high responders (n=34) compared to low responders (n=23) at 6 months. No group difference was found in glycated hemoglobin A_1c. Within high responders, diabetes distress (P=.001), social support (P<.001), quality of life (P<.001), diabetes knowledge (P<.001), foot care (P<.001), and diet (P=.003) improved from baseline to 6 months. Low responders only improved in diabetes quality of life (P=.003) from baseline to 6 months. Conclusions: In a FQHC safety net population participating in a combined TMI and GV intervention, our study showed improved diabetes distress, social support, knowledge, self-care, self-efficacy, and quality of life among patients highly engaged in the SMS text messaging program.

Journal of Medical Internet Research - International Scientific Journal for Medical Research, Information and Communication on the Internet #Preprint #PeerReviewMe: Warning: This is a unreviewed preprint. Readers are warned that the document has not been peer-reviewed by expert/patient reviewers or an academic editor, may contain misleading claims, and is likely to undergo changes before final publication, if accepted, or may have been rejected/withdrawn. Readers with interest and expertise are encouraged to sign up as peer-reviewer, if the paper is within an open peer-review period. Please cite this preprint only for review purposes or for grant applications and CVs (if you are the author). Background: Chronic pain management in older adults can be challenging for primary care clinicians because of comorbidities, side effects, and complicated guideline recommendations. Clinical decision support systems (CDSS) can enhance guideline adherence in chronic pain management by collecting and organizing patient information and aiding clinician decision-making. This study examined clinicians’ views on challenges in managing chronic pain and their opinions on a CDSS that gathered patient preferences and provided clinicians with decision support for chronic pain management. Objective: The objective of this study was to explore primary care clinicians’ perspectives on the challenges of managing chronic pain in older adults and evaluate their opinions on a clinical decision support system (CDSS) designed to gather patient preferences and facilitate guideline-based, multimodal pain management. Methods: We conducted semi-structured interviews with 18 clinicians from two University of Chicago Medicine primary care clinics piloting the CDSS. The interview guide was informed by the Consolidated Framework for Implementation Research. Results: Participants included 89% physicians and 11% advanced practice nurses. Participants stressed the importance of a comprehensive, patient-centered approach to chronic pain management and favored multimodal and non-pharmacological treatments. Challenges included complex medical histories, competing priorities, insurance limitations, and opioid misuse concerns. Clinicians found the CDSS beneficial for promoting multimodal care discussions and enhancing visit efficiency. However, there were concerns regarding its complexity, workflow compatibility, and older patients' technology navigation difficulties. While tools, such as the pre-visit questionnaire and conversation tool, were valued, clinicians emphasized the need for adaptability and streamlined usability. Conclusions: The primary care clinicians in this study were aligned with clinical practice guidelines to provide patient-centered pain management using multimodal treatments. However, they had several concerns regarding how complex chronic pain management can be for older adult patients. They expressed interest in using the CDSS but were concerned about its complexity. I-COPE offers a promising approach to support guideline-based chronic pain and opioid management in primary care. By addressing usability and workflow compatibility, CDSS tools like I-COPE can better equip clinicians to provide comprehensive, patient-centered care, ultimately enhancing treatment outcomes for older adults with chronic pain.