Paper Session 8: Integrated Primary Care

Introduction: Integrated Behavioral Health (IBH) clinics in primary care offer cost-effective options for receiving mental health (MH) support for Black patients. By tracking specific aspects of social determinants of health (SDOH), more commonly assessed in primary care, IBH programs can provide helpful insights to both MH and primary care providers. Methods: This retrospective study examined the impact of IBH care delivery on MH and select SDOH variables in a Black adult patient population. MH outcomes were assessed using the PHQ9 and GAD7, with a positive score being greater than 5. Results: There were N = 119 Black patients included in analysis. The sample was 83% female and the average age at first visit was 41. There was a significant reduction in both GAD7 (change = -1.8, p < .001) and PHQ9 (change = -2.3, p < .001) scores for patients receiving IBH services. There were no significant differences between those who had a SDOH screen and having an initial elevated GAD7/PHQ9 score. Conclusion: More culturally inclusive research on the impact of IBH implementation where Black patients receive their primary care is needed to maximize treatment possibilities among this group.

Author - Keri F. Kirk, PhD,
Georgetown University School of Medicine

Co-Author - Aniket Kini, MBBS, MPH,
Medstar Georgetown University Hospital

Co-Author - Serenity Budd, MS,
Medstar Health Research Institute

Co-Author - Clara Parsons,
Medstar Georgetown University Hospital

Co-Author - George Daniel,
Howard University

Co-Author - Ashley Splain,
University of Maryland, Baltimore County

Co-Author - Kezia Alexander, MPH,
Medstar Health Research Institute

Co-Author - Jenna Warren,
Howard University

Co-Author - Christine Laccay, MHA,
Medstar Health Research Institute

Background: Depressive symptoms frequently co-occur with diabetes and, when unaddressed, can worsen diabetes control and increase the risk of diabetes-related morbidity. Integrated care (IC) approaches incorporate behavioral health interventions to address depressive symptoms and diabetes, but there is no current meta-analysis examining their effects or studies that examine the moderating effects of IC models.

Purpose: Our study summarizes the effects of IC approaches for addressing co-occurring depression and diabetes while examining moderating effects (e.g. type of behavioral intervention; IC approach, training of interventionist, number of behavioral interventions).

Data Sources and Study Selection: A systematic search was conducted utilizing PubMed, PsycINFO, CINAHL, and ProQuest. Two reviewers triaged titles, abstracts, and full-text articles to identify relevant articles. Inclusion criteria consisted of participants having diabetes and depressive symptoms, the study using a Randomized Controlled Trial design, the study examining an IC approach and behavioral intervention, and the study providing sufficient data to calculate an effect size for HbA1c and/or depressive symptoms.

Data Extraction: Two reviewers extracted demographic information, depression screening scores, diabetes outcomes (HbA1c), and relevant intervention details. Reviewers assessed the risk of bias during data extraction with the Cochrane Risk of Bias 2 Tool.

Data Synthesis: Out of 517 abstracts, 75 full-text reports were reviewed, of which, 31 studies with 8,843 participants were analyzed. Of 28 studies reporting HbA1c, IC approaches were associated with a significant between-group difference regarding the percent decrease of HbA1c (d = -0.36, 95% CI: -0.52 to -0.21). Studies including a combination of behavioral interventions (e.g. behavioral activation with cognitive behavioral therapy) had greater reductions in HbA1c. Of 23 studies reporting depressive symptoms, the pooled effect of IC approaches was to lower depressive scores by 0.72 points (95% CI: -1.15 to -0.28). We identified no significant moderating effects on depressive symptoms.

Conclusion: IC approaches are associated with improved glycemic control and lower depressive symptoms compared to treatment as usual. IC approaches had similar treatment effects regardless of the IC approach or behavioral intervention used suggesting potential flexibility when selecting IC approaches and behavioral interventions.

Presenter - Zach Cooper, LCSW, LCSW,
University of Georgia

Co-Author - Jay O'Shields, PhD,
University of Alabama at Birmingham

Co-Author - Mohammed K Ali, MD, MBA,
Emory University

Co-Author - Lydia Chwastiak, MD,
The University of Washington

Co-Author - Leslie Johnson, PhD, PhD,
Emory University

Background: Warm handoffs have shown to improve engagement in care for integrated mental health services; however, in a clinic population with high degrees of socioeconomic disadvantage and multiple comorbid chronic conditions to be addressed, clinic appointments can be lengthy and often patients cannot stay for an additional appointment. The current work set out to understand if a brief introduction—a non-billable encounter where a psychology team member meets with the patient to describe services and schedule future appointment—improved attendance and engagement in care for patients who were unable to stay for a full warm handoff appointment in a primary care clinic.

Methods: Participants included 171 patients who were referred to an integrated psychology team within an academic internal medicine clinic at an urban hospital. Data was tracked from December 2023 until February 2024 following an educational didactic on the importance of warm handoffs. Team members were asked to notify the integrated psychology team when placing a referral to complete a warm handoff or brief introduction. Referrals, brief introductions, and attendance rates were pulled from the electronic medical record.

Results: 38.6% of patients referred to the integrated psychology team completed a brief introduction. 80.3% of patients who completed a brief introduction then went on to complete a visit with the integrated psychology team whereas 57.1% of those who were referred for an appointment without a brief introduction completed an appointment at the later date. There is a significant relationship between the brief introduction and attendance at a future appointment, such that completing a brief introduction significantly impacts the completion of an appointment with the integrated psychology team at a later date (McNemar’s test X2 =28.99, p < .01).

Discussion: Briefly meeting with psychology team member improves attendance at future visits with the integrated psychology team in a primary care clinic. Prior work from our team highlights barriers to utilizing warm handoffs and that a brief didactic on the benefits of warm handoffs increases use (DePascale et al., 2024). This work supports the emphasis on the warm handoff being a critical component of the primary care behavioral health model and extends the work to show that a brief non-billable encounter can improve engagement in needed psychological services in an integrated care setting with a diverse patient population.

Author - Eve DePascale,
Henry Ford Health

Author - McKenzie Berezin,
Henry Ford Health

Author - Michael Evitts, PhD,
Henry Ford Health

Author - Emily Thomas, PharmD,
Henry Ford Health

Author - Anupama Nair, MD,
Henry Ford Health

Author - David Willens, MD MPH,
Henry Ford Health

Author - Erin Tobin, PhD, PhD,
Henry Ford Health