The warm handoff (WHO) has long been considered an essential and necessary element of integrated behavioral health (IBH). It is seen as critical to improving patient access and engagement with behavioral health care. While some studies have demonstrated that WHOs improve engagement with behavioral health care, other studies have revealed contradictory results. These mixed findings suggest that more nuanced examination may help elucidate other factors that increase the effectiveness of WHOs in improving access and patient engagement with behavioral health care. Our study seeks to expand on the existing literature by examining 1) whether WHOs increase patient engagement with behavioral health services, 2) what factors increase the likelihood of a WHO, 3) whether the content of the WHO (e.g., inclusion of brief intervention) or non-WHO factors (e.g., time on waitlist) impact engagement with behavioral health services. To address these questions, we extracted Electronic Health Record (EHR) data collected on IBH referrals and completed WHOs across 10 UC San Diego Health primary care clinics from 2018-2023. Specifically, we extracted a) patient demographic variables, b) patient health status data, c) referral information (e.g., referral date, date added to waitlist, date of first scheduled IBH visit), and d) warm handoff information (e.g., location and mode of consultation, consultation focus, and follow-up plan). We will present initial results, address limitations, including generalization of results, and discuss future directions.

Introduction:The purpose of this study was to determine whether heat waves are associated with increased frequency of clinic visits for ICD-9 codes of illnesses traditionally associated with heat waves. Methods:During 4 years of family medicine clinic data between 2012 and 2016, we identified six heat wave events in San Diego County. For each heat wave event, we selected a control period in the same season that was twice as long. Scheduling a visit on a heat wave day (versus a non-heat wave day) was the primary predictor, and receiving a primary ICD-9 disease code related to heat waves was the outcome. Analyses were adjusted for age, gender, race/ethnicity and marital status. Results:Of the 5448 visits across the heat wave and control periods, 6.4% of visits (n = 346) were for heat wave-related diagnoses. Scheduling a visit on heat wave day was not associated with receiving a heat wave-related ICD code as compared with the control period (adjusted odds ratio: 1.35; 95% confidence interval: 0.86-1.36; P = 0.51). Discussion:We show that in a relatively large and demographically diverse population, patients who schedule appointments during heat waves are not being more frequently seen for diagnoses typically associated with heat waves in the acute setting. Given that heat waves are increasing in frequency due to climate change, there is an opportunity to increase utilization of primary care clinics during heat waves.

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.