Associations of intervention completion in a pragmatic trial on integrated behavioral health (IBH) and patient outcomes

Context Primary care must address the complex needs of patients with multiple chronic conditions, given 40% of patients seen in primary care have behavioral health needs. Integrated Behavioral Health (IBH) is associated with improved access and engagement in mental health services and mental and physical health patient outcomes.

Objective Increase behavioral health integration in primary care practices and improve patient reported outcomes through a practice-centric intervention targeting patients with multiple chronic conditions.

Study Design and Analysis A pragmatic, cluster-randomized controlled trial of a comprehensive practice-level, multi-staged practice transformation intervention. We assessed the association between the number of intervention stages completed and outcomes using 3-level mixed models with repeated (midpoint and 2-year follow-up) measurements (level 1) nested in staff/providers (level 2) nested in primary care practices (level 3).

Setting/Dataset Forty-two primary care practices across the U.S. with co-located behavioral health providers and IBH levels <=75 based on the Practice Integration Profile (PIP). Practice and patient surveys were collected at baseline, midpoint, and 2-year follow-up.

Population Studied Primary care practice providers and staff (N=237) and patients (N=2,945) >=18 years old with at least two or more chronic medical and/or behavioral health conditions completed surveys.

Intervention The IBH Primary Care (IBH-PC) Toolkit intervention included four components: 1) workbooks; 2) online education; 3) online learning community; and 4) remote coaching.

Outcome Measures Outcomes included patient reported outcomes measured by the PROMIS-29 (function), PHQ-9 (depression), and GAD-7 (anxiety) and practice outcomes included the PIP (practice level of IBH).

Results No differences were found associated with the number of intervention stages completed for patient reported outcomes; however, associations in practice increases in PIP domain scores were found 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).

Conclusions The IBH-PC Toolkit intervention improved levels of IBH 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.