Integrating Behavioral Health and Primary Care (IBH-PC) to improve patient-centered outcomes in adults with multiple chronic medical and behavioral health conditions: study protocol for a pragmatic cluster-randomized control trial

Abigail M Crocker, Rodger Kessler, Constance van Eeghen, Levi N Bonnell, Ryan E Breshears, Peter Callas, Jessica Clifton, William Elder, Chet Fox, Sylvie Frisbie, Juvena Hitt, Jennifer Jewiss, Roger Kathol, Kelly Clark/Keefe, Jennifer O'Rourke-Lavoie, George S Leibowitz, C R Macchi, Mark McGovern, Brenda Mollis, Daniel J Mullin, Zsolt Nagykaldi, Lisa Watts Natkin, Wilson Pace, Richard G Pinckney, Douglas Pomeroy, Alexander Pond, Rachel Postupack, Paula Reynolds, Gail L Rose, Sarah Hudson Scholle, William J Sieber, Terry Stancin, Kurt C Stange, Kari A Stephens, Kathryn Teng, Elizabeth Needham Waddell, Benjamin Littenberg, Abigail M Crocker, Rodger Kessler, Constance van Eeghen, Levi N Bonnell, Ryan E Breshears, Peter Callas, Jessica Clifton, William Elder, Chet Fox, Sylvie Frisbie, Juvena Hitt, Jennifer Jewiss, Roger Kathol, Kelly Clark/Keefe, Jennifer O'Rourke-Lavoie, George S Leibowitz, C R Macchi, Mark McGovern, Brenda Mollis, Daniel J Mullin, Zsolt Nagykaldi, Lisa Watts Natkin, Wilson Pace, Richard G Pinckney, Douglas Pomeroy, Alexander Pond, Rachel Postupack, Paula Reynolds, Gail L Rose, Sarah Hudson Scholle, William J Sieber, Terry Stancin, Kurt C Stange, Kari A Stephens, Kathryn Teng, Elizabeth Needham Waddell, Benjamin Littenberg

Abstract

Background: Chronic diseases that drive morbidity, mortality, and health care costs are largely influenced by human behavior. Behavioral health conditions such as anxiety, depression, and substance use disorders can often be effectively managed. The majority of patients in need of behavioral health care are seen in primary care, which often has difficulty responding. Some primary care practices are providing integrated behavioral health care (IBH), where primary care and behavioral health providers work together, in one location, using a team-based approach. Research suggests there may be an association between IBH and improved patient outcomes. However, it is often difficult for practices to achieve high levels of integration. The Integrating Behavioral Health and Primary Care study responds to this need by testing the effectiveness of a comprehensive practice-level intervention designed to improve outcomes in patients with multiple chronic medical and behavioral health conditions by increasing the practice's degree of behavioral health integration.

Methods: Forty-five primary care practices, with existing onsite behavioral health care, will be recruited for this study. Forty-three practices will be randomized to the intervention or usual care arm, while 2 practices will be considered "Vanguard" (pilot) practices for developing the intervention. The intervention is a 24-month supported practice change process including an online curriculum, a practice redesign and implementation workbook, remote quality improvement coaching services, and an online learning community. Each practice's degree of behavioral health integration will be measured using the Practice Integration Profile. Approximately 75 patients with both chronic medical and behavioral health conditions from each practice will be asked to complete a series of surveys to measure patient-centered outcomes. Change in practice degree of behavioral health integration and patient-centered outcomes will be compared between the two groups. Practice-level case studies will be conducted to better understand the contextual factors influencing integration.

Discussion: As primary care practices are encouraged to provide IBH services, evidence-based interventions to increase practice integration will be needed. This study will demonstrate the effectiveness of one such intervention in a pragmatic, real-world setting.

Trial registration: ClinicalTrials.gov NCT02868983 . Registered on August 16, 2016.

Keywords: Behavioral health; Multiple chronic conditions; Pragmatic trials; Primary care; Randomized control trial.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Integrating Behavioral Health and Primary Care (IBH-PC) clinical sites
Fig. 2
Fig. 2
Study timeline
Fig. 3
Fig. 3
Patient participants identification schematic

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