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; Jessica Clifton; Abigail M Crocker; Laura-Mae Baldwin; Levi N Bonnell; Ryan E Breshears; Peter Callas; Prama Chakravarti; Kelly Clark/Keefe; Deborah J Cohen; Frank V deGruy; Lauren Eidt-Pearson; William Elder; Chester Fox; Sylvie Frisbie; Katie Hekman; Juvena Hitt; Jennifer Jewiss; David C Kaelber; Kairn Stetler Kelley; Rodger Kessler; Jennifer B O'Rourke-Lavoie; George S Leibowitz; C R Macchi; Matthew P Martin; Mark McGovern; Brenda Mollis; Daniel Mullin; Zsolt Nagykaldi; Lisa W Natkin; Wilson Pace; Richard G Pinckney; Douglas Pomeroy; Paula Reynolds; Gail L Rose; Sarah Hudson Scholle; William J Sieber; Jeni Soucie; Terry Stancin; Kurt C Stange; Kari A Stephens; Kathryn Teng; Elizabeth Needham Waddell; Constance van Eeghen

doi:10.1370/afm.3027

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

Ann Fam Med. 2023 Nov-Dec;21(6):483-495. doi: 10.1370/afm.3027.

Authors

Benjamin Littenberg¹, Jessica Clifton^{2

3}, Abigail M Crocker², Laura-Mae Baldwin⁴, Levi N Bonnell², Ryan E Breshears⁵, Peter Callas², Prama Chakravarti⁶, Kelly Clark/Keefe², Deborah J Cohen⁷, Frank V deGruy⁸, Lauren Eidt-Pearson⁹, William Elder¹⁰, Chester Fox¹¹, Sylvie Frisbie², Katie Hekman¹², Juvena Hitt², Jennifer Jewiss², David C Kaelber^{13

14}, Kairn Stetler Kelley², Rodger Kessler⁸, Jennifer B O'Rourke-Lavoie², George S Leibowitz¹⁵, C R Macchi¹⁶, Matthew P Martin¹⁶, Mark McGovern¹⁷, Brenda Mollis⁴, Daniel Mullin⁹, Zsolt Nagykaldi¹⁸, Lisa W Natkin², Wilson Pace¹⁹, Richard G Pinckney², Douglas Pomeroy², Paula Reynolds², Gail L Rose², Sarah Hudson Scholle²⁰, William J Sieber¹², Jeni Soucie²⁰, Terry Stancin¹³, Kurt C Stange¹⁴, Kari A Stephens⁴, Kathryn Teng¹³, Elizabeth Needham Waddell⁷, Constance van Eeghen²

Affiliations

¹ University of Vermont, Burlington, Vermont (B.L., J.C., A.M.C., L.N.B., P.C., K.C/K., S.F., J.H., J.J., K.S.K., J.B.O-L., L.W.N., R.G.P., D.P., P.R., G.L.R., C.vE.); benjamin.littenberg@uvm.edu.
² University of Vermont, Burlington, Vermont (B.L., J.C., A.M.C., L.N.B., P.C., K.C/K., S.F., J.H., J.J., K.S.K., J.B.O-L., L.W.N., R.G.P., D.P., P.R., G.L.R., C.vE.).
³ Parhelia Wellness, Santa Rosa, California (J.C.).
⁴ University of Washington, Seattle, Washington (L-M.B., B.M., K.A.S.).
⁵ Wellstar Health System, Marietta, Georgia (R.E.B.).
⁶ Prama Psychology, PLLC, Richland, Washington (P.C.).
⁷ Oregon Health & Science University, Portland, Oregon (D.J.C., E.N.W.).
⁸ University of Colorado School of Medicine, Aurora, Colorado (F.V.D., R.K.).
⁹ UMass Chan Medical School, Worcester, Massachusetts (L.E-P., D.M.).
¹⁰ University of Houston, Houston, Texas (W.E.).
¹¹ University at Buffalo, Buffalo, New York (C.F.).
¹² University of California San Diego, San Diego, California (K.H., W.J.S.).
¹³ The MetroHealth System, Cleveland, Ohio (D.C.K., T.S., K.T.).
¹⁴ Case Western Reserve University, Cleveland, Ohio (D.C.K., K.C.S.).
¹⁵ Stony Brook University, Stony Brook, New York (G.S.L.).
¹⁶ Arizona State University, Tempe, Arizona (C.R.M., M.P.M.).
¹⁷ Stanford University School of Medicine, Stanford, California (M.M.).
¹⁸ University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma (Z.N.).
¹⁹ DARTNet Institute, Aurora, Colorado (W.P.).
²⁰ National Committee for Quality Assurance, Washington, DC (S.H.S., J.S.).

Abstract

Purpose: Patient outcomes can improve when primary care and behavioral health providers use a collaborative system of care, but integrating these services is difficult. We tested the effectiveness of a practice intervention for improving patient outcomes by enhancing integrated behavioral health (IBH) activities.

Methods: We conducted a pragmatic, cluster randomized controlled trial. The intervention combined practice redesign, quality improvement coaching, provider and staff education, and collaborative learning. At baseline and 2 years, staff at 42 primary care practices completed the Practice Integration Profile (PIP) as a measure of IBH. Adult patients with multiple chronic medical and behavioral conditions completed the Patient-Reported Outcomes Measurement Information System (PROMIS-29) survey. Primary outcomes were the change in 8 PROMIS-29 domain scores. Secondary outcomes included change in level of integration.

Results: Intervention assignment had no effect on change in outcomes reported by 2,426 patients who completed both baseline and 2-year surveys. Practices assigned to the intervention improved PIP workflow scores but not PIP total scores. Baseline PIP total score was significantly associated with patient-reported function, independent of intervention. Active practices that completed intervention workbooks (n = 13) improved patient-reported outcomes and practice integration (P ≤ .05) compared with other active practices (n = 7).

Conclusion: Intervention assignment had no effect on change in patient outcomes; however, we did observe improved patient outcomes among practices that entered the study with greater IBH. We also observed more improvement of integration and patient outcomes among active practices that completed the intervention compared to active practices that did not. Additional research is needed to understand how implementation efforts to enhance IBH can best reach patients.

Keywords: behavioral health integration; behavioral medicine; multiple chronic conditions; pragmatic clinical trial; primary care; randomized controlled trial.

Publication types

Randomized Controlled Trial

MeSH terms

Adult
Humans
Multiple Chronic Conditions*
Primary Health Care

Grants and funding

UM1 TR004528/TR/NCATS NIH HHS/United States