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Development and validation of a measure of primary care behavioral health integration.

Introduction: We developed the Practice Integration Profile (PIP) to measure the degree of behavioral health integration in clinical practices with a focus on primary care (PC). Its 30 items, completed by providers, managers, and staff, provide an overall score and 6 domain scores derived from the Lexicon of Collaborative Care. We describe its history and psychometric properties. Method: The PIP was tested in a convenience sample of practices. Linear regression compared scores across integration exemplars, PC with behavioral services, PC without behavioral services, and community mental health centers without PC. An additional sample rated 4 scenarios describing practices with varying degrees of integration. Results: One hundred sixty-nine surveys were returned. Mean domain scores ran from 49 to 65. The mean total score was 55 (median 58; range 0-100) with high internal consistency (Cronbach's alpha = .95). The lowest total scores were for PC without behavioral health (27), followed by community mental health centers (44), PC with behavioral health (60), and the exemplars (86; p < .001). Eleven respondents rerated their practices 37 to 194 days later. The mean change was + 1.5 (standard deviation = 11.1). Scenario scores were highly correlated with the degree of integration each scenario was designed to represent (Spearman's p = -0.71; P = 0.0005). Discussion: These data suggest that the PIP is useful, has face, content, and internal validity, and distinguishes among types of practices with known variations in integration. We discuss how the PIP may support practices and policymakers in their integration efforts and researchers assessing the degree to which integration affects patient health outcomes.

Keywords: integrated care, measurement, methods, primary care

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Behavioral Health (BH, defined here as mental health, substance abuse and health behavior services) is critically important to maintaining and improving health in Primary Care (PC) settings. Although some PC practices have long been able to integrate BH services, broad, effective dissemination continues to be challenging (Dickinson, 2015). Efforts toward the goal of delivering BH services to all who need them have been hampered by confusion over what services should be included and how they should be integrated into PC. Substantial progress on this front was made with the appearance of the Lexicon for Behavioral Health and Primary Care Integration (Peek & the National Integration Academy Council, 2013) that proposed a common language for describing multiple domains of integrated health care.

Although several checklists of collaboration and integration are available, there is no validated measure for describing or measuring the degree of BH integration in any particular PC setting. This limits the abilities of researchers, providers, managers, and policymakers to assess the value of Integrated Behavioral Health, make decisions about resource allocation, design and manage efforts to achieve and maintain it, and reward its achievement. This paper describes the development and validation of the Practice Integration Profile (PIP), a self-administered, Web-based survey that allows providers, staff, and managers to assess their own practices' progress toward an idealized goal of "fully integrated behavioral health services." Moreover, the PIP generates data to inform research about the effectiveness of varying degrees of integration.

As defined by the Agency for Health care Research and Quality (AHRQ) Integration Academy, integrated care is

A practice team of primary care and behavioral health clinicians working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population. This care may address mental health and substance abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, and ineffective patterns of health care utilization. (Peek & the National Integration Academy Council, 2013)

Integrated care, supported by a growing body of evidence, has become increasingly mainstream (Miller, 2015). Examples of behavioral health and primary care services in family medicine residency practices have existed for more than 30 years (Blount & Miller, 2009). The Department of Veterans Affairs and Department of Defense, with their unique population and financial structures, have been leaders in integration (Hunter, Goodie, Dobmeyer, & Dorrance, 2014). Innovative practice organizations focused on underserved populations, such as the South Central Foundation in Alaska and Cherokee Health Systems in Tennessee, have developed financially sustainable integrated care models in their communities (Cohen et al., 2015).

Multiple challenges hinder systematic, integrated care. No single set of metrics exists to guide program implementation or to evaluate the Triple Aim outcomes of improved patient experience, better outcomes, and lowered cost of care (Institute for Healthcare Improvement, 2015). If integration is to generate accelerated implementation, and if research focused on integrated Behavioral Health and identification best practices is to occur, a validated measure of what is being done in integrated practices is needed. Therefore, we sought to develop and validate a measure of the degree to which practices achieved an idealized state of integration.

Method

The Instrument

The approaches and parameters delineated in the AHRQ Lexicon (Peek & the National Integration Academy Council, 2013) served as the theoretical foundation of a new measure of integrated care, the Practice Integration Profile (PIP, formerly the Vermont Integration Profile (Kessler et al., 2015). The authors of the PIP began with a detailed review of the Lexicon's defining clauses, alternatives, and parameters and then developed questions organized into six domains of integrated care.

Pilot testing demonstrated that initial versions of some of the questions were ambiguous, and some of the domains overlapped enough to be combined. The current version of the PIP has 30 questions. Most of the questions have the stem "In our practice ... " followed by a practice characteristic (such as "... we use registry tracking for patients with identified BH issues"), an example ("Insomnia registry"), a definition ("Numerator = # of patients in BH registries; Denominator = # of patients with BH needs"), and five response options. The options include; Never (0%), Sometimes (1-33%), Often (34-66%), Frequently (67-99%), and Always (100%). Each of the possible responses is assigned a score near the midpoint of its stated range: 0, 25, 50, 75 and 100%. (Two of the questions have different response options. The full instrument appears in the Appendix).

The PIP is organized into six domains. Practice Workflow includes the policies and procedures that ensure the organizational structure to support consistent delivery of evidence-services to patients in need. Workspace Arrangement and Infrastructure addresses the physical proximity and use of shared medical records. Integration Methods (Shared Care) covers the type and degree of interactions among medical and behavioral providers. Case Identification specifies the practice's procedures for screening and identifying patients who need BH services. Patient Engagement captures the ability of the practice to initiate treatment, involve the patient in developing and delivering the care, and provide support to the patient through ongoing management and follow-up. The domains contain between two and nine questions each. They are scored as the average of their item scores. All scores can run from 0 (least degree of integration) to 100 (greatest degree of integration). The Total Integration Score is the unweighted numeric average of the six domains.

The PIP was presented to respondents by email invitation and administered via RED-Cap (Harris et al., 2009) a secure online survey system that automatically scores the responses and provides tabular and graphical feedback to the respondent comparing their scores to others. When administered in this fashion, there are no missing values. However, if the PIP is administered by a mechanism that allows skipped items or missing values (such as paper and pencil), the scoring algorithm calls for using the average of all the responses available for each domain as long as there at least two valid responses in that domain. The Total Integration Score is not calculated unless all six domains are available.

Scenario Studies

Prior to field testing, a sample of five raters used the measure to evaluate four practice scenarios describing hypothetical primary care practices with varying degrees of Behavioral Health Integration. The scenarios were each approximately one page long and described the physical arrangement of the practice, staff, the type of services offered and other information needed to assess the degree of BH integration. Raters were experienced primary care or behavioral health providers. Each rater ranked each scenario from most integrated (1) to least integrated (4) and completed a PIP for each one. We hypothesized that if the PIP reflected their gestalt judgments, the Total Integration Scores (and to a lesser degree, the domain scores) would correlate with their rankings. We tested this with a nonparametric correlation coefficient (Spearman's rho; Spearman, 1904).

Field Testing

The PIP was then tested in a convenience sample of primary care and BH practices recruited from email broadcasts to relevant listserves, national webinars, and national meetings. It was completed by physicians, BH clinicians, managers, and staff within the practices. Respondents were eligible if their practice provided Primary Care or Community Mental Health services with or without integrated BH and medical services.

In addition to the PIP. each respondent provided the name and location of their practice, their role (PC provider, BHC, manager, staff, or student), practice type, specialty, and number of providers. We asked respondents to base their responses on their personal knowledge of the practice and did not require that they measure any of the items with exactitude. We divided the practices into four levels of integration. Those with no behavioral or mental health clinicians were expected to have the lowest PIP scores, followed by Community Mental Health Centers (CMHC), and then PC practices. Based on reports by the Agency for Health care Research and Quality (Cohen et al., 2015), eight PC practices were identified as "exemplars" representing the most advanced examples of BH integration and were expected to have the highest PIP scores.

A small subset of respondents was asked to repeat the assessment weeks after their initial report.

Respondents received no compensation. The protocol was reviewed by the University of Vermont IRB and assessed as exempt from human subjects research regulations.

Analysis

We used Cronbach's alpha to assess the internal consistency of each domain scale and the Total Integration Score in the sample of 169 responses. (Bland & Altman, 1997; Cronbach, 1951). Analysis of variance (ANOVA) and linear regression were used to compare total and domain scores across four types of practice (PC without behavioral services, community mental health centers without PC, PC with some behavioral services, and exemplars) while controlling for other practice characteristics. We used Spearman's rho, a nonparametric method, to assess correlation (Spearman, 1904), and Cuzick's rank sum test to assess trends in scores across levels of integration (Cuzick. 1985). Graphical tools included Tukey Box Plots (Tukey, 1977) for distributions of continuous variables and paired-point scatter plots for bivariate associations.

Results

One hundred sixty-nine surveys were completed by staff at 152 practices in 35 states. The mean number of responses per practice was 1.1 (range 1 to 3). The respondents include: 61 BHCs, 34 PCPs, 67 managers and seven student BHCs. The practices serve inner city (15), urban (54), suburban (32), rural (46), and frontier (5) communities. Thirty-six are Community Health Centers and 23 are Community Mental Health Centers (CMHCs). Fifty-nine are Family Medicine, 18 Internal Medicine, two Pediatric, two Obstetric, and 12 multispecialty practices. The practices tend to be large with 135 reporting over 10 providers and only eight having fewer than six providers.

Of 169 collected surveys, 90% were completed in full. User reports suggest that completing the PIP is approximately a 10-ntin task. There were no significant differences between types of respondents- physicians, behavioral health clinicians, administrators, or other categories of rater.

The mean of the 169 Total Integration Scores was 55 (standard deviation 20) with median 58 and range from 0 to 100. The median domain scores were Workflow (54), Clinical Services (67), Workspace (75), Shared Care & Integration (50), Case Identification (50), and Patient Engagement (50; see Table 1). The distribution of scores used the full range of potential values (0-100) for each domain and tended to be symmetrical (see Figure 1). The exception is the Workspace domain which has only two items.

Internal Consistency

The scale reliability or internal consistency of each domain scale, expressed as Cronbach's alpha, ranged from 0.52 to 0.91. The internal consistency of the Total Integration Score was a = .95 (see Table 1).

Discrimination Among Levels of Integration

The average Total Integration Score was 27 for Non-Behavior Health Clinician (Non-BHC) practices, 44 for Community Mental Health Centers (CMHCs), 60 for Primary Care practices, and 86 for Exemplars (F = 20.2 by ANOVA; p < .0001). Similar differences were observed in the median values of the four types of practices (see Figure 2). For the individual domains, in nearly every case, the scores increased monotonically as predicted from Non-BHC to CMHC to PC to Exemplar (see Table 2). The only exception was in the Case Identification domain, where CMHCs had somewhat lower scores than the No Behaviorist practices. This difference was not significant (43 vs. 37; P = -45).

In linear regression, the PIP yielded significantly different Total Integration scores among all four practices types with p < .001 for all comparisons, demonstrating ability to discriminate across all levels of integration. Expanding the model to control for potential confounding by practice size, practice location and respondent type had little effect on the coefficients for each level of integration. A similar pattern of minimal change when controlling for potential confounders was observed in all the domains (see Table 3).

Intrarater Consistency Over Time (Test-Retest Reliability)

Among 11 subjects who repeated the survey 37 to 194 days later (median 48), the mean change in Total Integration Score was +1.5 of 100 (95% confidence interval = -5.0, +8.0) with a range from -19 to + 23, providing evidence of good test-retest reliability. There was no association between the time between assessments and the change in the total integration score. In linear regression, the coefficient on days was 0.07 (95% confidence interval = --0.10, +0.25; P = 0.38; see Figure 3). The individual domains had somewhat larger changes. See Table 4.

Within Practice Agreement

Fifteen practices had multiple respondents including two practices with three respondents (n = 32 respondents). The Total Integration scores among respondents from the same practices appears in Figure 4. The mean difference in Total Integration score among the 32 respondents was 7.1 with a range from 0 to 18. There was somewhat less agreement among respondents from the same practice in the other domains (see Table 4).

Discrimination Among Scenarios

Five PCPs or BHCs with integrated BH experience each completed the PIP for four written scenarios representing a range of practice settings. They were also asked to rank the four scenarios in terms of their overall degree of integration. The correlation between their rankings and their Total Integration Scores was significant (Spearman's p = -0.71; P = 0.0005). Correlations of their overall rankings with their domain scores were Workflow p = -0.58 (P = 0.007). Clinical Services p = -0.40 (P = 0.08), Workspace p = -0.89 (p < .0001), Shared Care Plans p = -0.67 (p = .002), Case Identification p = -0.47 (p = .04). Patient Engagement p = -0.24 (p = .33).

Discussion

Validity

A test or instrument is valid for a particular purpose if it measures the underlying phenomenon or construct that it purports to measure and supports the conclusions that are drawn from it (McDowell, 2006). Validity has many components, including reliability, content and construct validity, and the ability to discriminate among phenomena that are importantly different.

Reliability

We measured reliability three ways. First, the internal consistency of the instrument as measured by Cronbach's alpha is quite high (a = 0.95 for the Total Integration Score; see Table 4). Second, 11 respondents with repeat participation showed very little change in their responses (see Figure 3). Notably, there was no relationship between the amount of change and the time between the responses, which would have suggested that respondents simply remembered their previous answers. Finally, different respondents assessing the same practices showed a high level of agreement (see Table 4).

Content Validity

Content validity assesses whether the items chosen represent the underlying concepts or theoretical domain they are meant to reflect (Aday, 1996). In the case of the PIP, those domains are specified by the Lexicon for Behavioral Health and Primary Care Integration (Peek & the National Integration Academy Council, 2013). The PIP includes items representing all the Lexicon domains, albeit sometimes combined with another related domain.

Construct Validity

Construct validity measures how well an instrument reflects the underlying target construct (in this case "integration of behavioral health and primary care") to the exclusion of other characteristics. In the absence of a goldstandard reference test for integration, we rely on findings such as the PIP's ability to discriminate among practices with prima facie differences in integration in both real-world settings (see Table 2) and artificial scenarios. Construct validity is further supported by the observation that the PIP's ability to discriminate is not confounded by the practice location or size or the role of the respondent (see Table 3).

Strength, Weaknesses, Limitations and Future Directions

In the absence of a "gold standard" test for integration, it is impossible to determine the criterion validity (sensitivity and specificity) of the PIP. However, the use of the four levels of integration as a reference point increase our confidence that the PIP scores represent what observers of the field mean by "Integrated Behavioral Health."

Although the respondents were a convenience sample, they derive from a broad range of practices across many settings and in various stages of integration, suggesting that they may generalize well to other settings where the PIP is intended for use. Although the respondents included a broad range of raters from US practices, we have no information about PIP performance outside the US.

Because we requested repeat measures from only a small number of raters, conclusions about the within-rater reliability of the PIP are limited by small sample size.

The PIP is a measure of the structures and processes in place and does not record patient outcomes, financial performance, population health or other desired aspects of high quality care. Nonetheless, structure and process are two of the three essential aspects of quality (Donabedian, 1988) and must be measured to allow thoughtful and effective management.

Experience with the PIP is still relatively small. As more practices and researchers use it for quality management, identification of best practices, process redesign, assessment of interventions, and other health services analyses, we will learn more about its strengths and limitations. Additional opportunities remain to improve the items and apply the results of the PIP in other countries and languages. A version is being planned for use in China. The wording of items can be further improved to increase the measure's reliability. The creation of a companion measure that can be completed by patients has potential to enhance the PIP's validity.

Conclusion

Initial experience with the PIP suggests good feasibility and face validity, low response burden, high within-subject reliability, and good discrimination.

http://dx.doi.org/10.1037/fsh0000227

References

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Cohen, D. J., Balasubramanian, B. A., Davis, M., Hall, J., Gunn, R., Stange, K. C., ... Miller, B. F. (2015). Understanding care integration from the ground up: Five organizing constructs that shape integrated practices. Journal of the American Board of Family Medicine, 28 (Suppl. 1), S7S20. http://dx.doi.org/10.3122/jabfm.2015.S1 .150050

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Dickinson, W. P. (2015). Strategies to Support the integration of behavioral health and primary care: What have we learned thus far? Journal of the American Board of Family Medicine, 28, S102S106. http://dx.doi.org/10-3122/jabfm.2015.S1 .150112

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Appendix

The Practice Integration Profile (www.uvm.edu/~pip/pip.php)

Instructions: We suggest that it be rated both by the
medical director and a senior behavioral health clinician.
First, please check that you have reviewed the terms and
conditions. Then, read the statements in each of the eight
dimensions and select the response that best reflects your
organization. Most items ask for a rough approximation of
how often your practice meets a particular criterion and
with a numerator and denominator to guide your thinking. You
don't need to collect specific data--just provide your best
estimate. Where we refer to "patients," feel free to
consider family, caregivers, surrogates and other
stakeholders as appropriate. Some items are ordered such
that each level implies that all the previous criteria are
met. Please choose the highest level that applies based on
current practice activities.

In our
practice,                          Scoring
...         Examples               criteria

Practice workflow (PW)

WF1         ... we use         Patients in        Numerator =
              a standard         need of BH         # or
              protocol           services           patients
              for                are                receiving
              patients           identified,        protocol-
              who need or        assessed           based care
              can benefit        and receive
              from               care using
              integrated         a
              Behavioral         consistent
              Health             set of
              (BH).              processes

                                                  Denominator
                                                    = # of
                                                    patients in
                                                    need of BH

WF2         ... we use         Insomnia or        Numerator =
              registry           depression         # of
              tracking           registry           patients in
              for                                   BH
              patients                              registries
              with
              identified
              BH issues.

                                                  Denominator
                                                    = # of
                                                    patients
                                                    with BH
                                                    needs

WF3         ... we             We                 Numerator =
              provide            coordinate         # of
              coordination       appointments       patients
              of care for        with               receiving
              patients           outside            coordinated
              with               medical and        care
              identified         non-
              BH issues.         medical
                                 providers,
                                 or assist
                                 with social
                                 services
                                 contacts

                                                  Denominator
                                                    = # of
                                                    patients
                                                    with BH
                                                    needs

WF4         ... we             Exercise           Numerator =
              provide            programs,          # of
              referral           AA, housing        patients
              assistance         assistance,        receiving
              to connect         support            referral
              patients to        groups.            assistance
              community          etc.               to
              resources.                            community
                                                    resources

                                                  Denominator
                                                    = # of
                                                    patients
                                                    needing
                                                    referral to
                                                    community
                                                    resources

WF5         ... we             Psychiatry         Numerator =
              provide            for                # of
              referral           persistent         patients
              assistance         severe             receiving
              to connect         mental             referral
              patients to        illness            assistance
              specialty                             to
              mental                                specialty
              health                                mental
              resources.                            health
                                                    resources

                                                  Denominator
                                                    = # of
                                                    patients
                                                    needing
                                                    referral to
                                                    specialty
                                                    mental
                                                    health
                                                    resources

WF6         ... we use         Goals are          Numerator =
              a standard         documented         # of
              approach           in a               patients
              for                structured         with
              documenting        problem            documented
              patients'          list or            goals
              self-              other well-
              management         defined
              goals.             place

                                                  Denominator
                                                    = # of
                                                    patients
                                                    with BH
                                                    needs

Clinical services (CS)

CS1         ... we have        Scheduled          Numerator =
              clinicians         care               # hours
              available          (assessment,       non-crisis
              on site who        counseling,        BH services
              provide            referral,          are
              non-crisis         etc.) of           available
              focused BH         behavioral
              services.          issues

                                                  Denominator
                                                    = # of
                                                    hours the
                                                    clinic is
                                                    open

CS2         ... we have        Urgent care        Numerator =
              clinicians         of patients        # hours
              available          in                 crisis BH
              on site to         behavioral         services
              respond to         crisis             are
              patients in                           available
              behavioral
              crisis.

                                                  Denominator
                                                    = # of
                                                    hours the
                                                    clinic is
                                                    open

CS3         ... we have        Schizophrenia,     Numerator =
              BH                 problem            # hours BH
              clinicians         drinking,          services
              who can            etc.               for
              respond to                            seriously
              seriously                             mentally
              mentally                              ill and
              ill and                               substance-
              substance-                            dependent
              dependent                             patients
              patients.                             are
                                                    available

                                                  Denominator
                                                    = # of
                                                    hours the
                                                    clinic is
                                                    open

CS4         ... we             Assessment,        Numerator =
              offer              counseling,        # of
              behavioral         coaching for       patients
              interventions      BH needs of        offered BH
              for                diabetes,          interventions
              patients           cancer,            for
              with               heart              chronic/
              chronic/           disease,           complex
              complex            hypertension,      medical
              medical            etc.               illnesses
              illnesses.

                                                  Denominator
                                                    = # of
                                                    patients
                                                    needing
                                                    such
                                                    services

CS5         ... we                                Numerator =
              employ BH                             # of BH
              clinicians                            staff with
              with a                                training in
              background                            complex or
              and                                   specialized
              training in                           behavioral
              complex or                            health
              specialized                           therapies
              behavioral
              health
              therapies.

                                                  Denominator
                                                    = # of BH
                                                    staff

CS6         ... we             Screening          Numerator =
              offer              and brief          # of
              evidence-          intervention       patients
              based                                 offered
              substance                             evidence-
              abuse                                 based
              interventions.                        substance
                                                    abuse
                                                    interventions

                                                  Denominator
                                                    = # of
                                                    patients
                                                    needing
                                                    such
                                                    services

CS7         ... we             Moderate           Numerator =
              offer              depression         # of
              prescription       and anxiety        patients
              medications                           offered
              for routine                           prescription
              mental                                medications
              health and                            for routine
              substance                             mental
              abuse                                 health or
              diagnoses.                            substance
                                                    abuse
                                                    diagnoses

                                                  Denominator
                                                    = # of
                                                    patients
                                                    needing
                                                    such
                                                    services

CS8         ... we             Major              Numerator =
              offer              depression.        # of
              prescription       bi-polar.          patients
              medications        schizophrenia      offered
              for serious                           prescription
              complex co/                           medications
              occurring                             for serious
              mental                                mental
              health and/                           health or
              or                                    substance
              substance                             abuse
              abuse                                 diagnoses
              diagnoses

                                                  Denominator
                                                    = # of
                                                    patients
                                                    needing
                                                    such
                                                    services

CS9         ... we             Spiritual          Numerator =
              offer              advisors.          # of
              referral to        schools,           patients
              non-               criminal           offered
              clinical           justice            referrals
              services           (probation
              outside of         and parole,
              our                drug
              practice.          courts), or
                                 vocational
                                 rehabilitation

                                                  Denominator
                                                    = # of
                                                    patients
                                                    needing
                                                    such
                                                    services

Workspace (WS)

WS1         ... BH and         Shared             Ordered--Please
              Medical            building or        pick the
              Clinicians         unit               best
              work in:                              descriptor
                                                    of your
                                                    practice

WS2         ... patient        Medical and        Numerator =
              treatment/         BH                 # of
              care plans         clinicians         patients
              are                use the            with shared
              routinely          same               records
              documented         Electronic
              in a               Record
              medical
              record
              accessible
              to both BH
              and medical
              clinicians.

                                                  Denominator
                                                    = # of
                                                    patients
                                                    receiving
                                                    BH services

Integration and sharing methods (IN)

IN1         ... BH and         Active             Numerator =
              Medical            includes           # of
              Clinicians         "tasking"          patients
              regularly          or both            with
              and                clinicians         regular
              actively           signing            active
              exchange           shared             exchange of
              information        documentation.     information
              about              Does not
              patient            include
              care.              simply
                                 documenting
                                 in a place
                                 that is
                                 available
                                 to the
                                 other
                                 clinician

                                                  Denominator
                                                    = # of
                                                    patients
                                                    receiving
                                                    BH services

IN2         ... there          This               Educational
              are regular        includes           activities
              educational        but is not         should be
              activities         limited to         jointly
              including          sessions           provided to
              both BH and        focused on         medical and
              Medical            specific           behavioral
              Clinicians         conditions         clinicians.
                                 such as
                                 patients
                                 with
                                 chronic
                                 pain or
                                 depression.
                                 Includes
                                 case
                                 conferences,
                                 seminars,
                                 etc.

IN3         ... BH and         Face-to-           Numerator =
              Medical            face               # of
              Clinicians         contact to         patients
              regularly          discuss            discussed
              spend time         patient            in person
              together           care
              collaborating
              on patient
              care.

                                                  Denominator
                                                    = # of
                                                    patients
                                                    receiving
                                                    BH services

IN4         ...                Joint              Numerator =
              patients           visits with        # of
              with BH            patient,           patients
              needs have         caregivers,        with a
              shared care        medical and        shared care
              plans              BH                 plan
              developed          clinicians
              jointly by         for
              the                development
              patient, BH        of a
              and Medical        problem
              clinicians.        list and
                                 action
                                 plan;
                                 iterative
                                 development
                                 of the
                                 problem
                                 list and
                                 plan by
                                 individual
                                 clinicians
                                 meeting
                                 with the
                                 patient/
                                 caregivers.

                                                  Denominator
                                                    = # of
                                                    patients
                                                    receiving
                                                    BH services

Case identification (ID)

ID1         ... we             US                 Numerator = #
              screen             Preventative       screened
              eligible           Services
              adults for         Task Force
              BH                 guidelines
              conditions         for alcohol
              using a            use,
              standardized       depression,
              procedure.         etc.

                                                  Denominator
                                                    = # of
                                                    adults seen
                                                    in the
                                                    practice

ID2         ... we use         Billing,           Numerator =
              practice-          registration       # of
              level data         data, disease      patients
              to screen          registry, lab      screened
              for                results, etc.
              patients at
              risk for
              complex or
              special
              needs.

                                                  Denominator
                                                    = # of
                                                    patients in
                                                    the
                                                    practice

ID3         ... patients       Screening          Numerator = #
              are                for                screened
              screened at        depression
              least              in
              annually           diabetes,
              for                anxiety in
              behavioral         heart
              conditions         failure,
              related to         etc.
              a medical
              problem.

                                                  Denominator
                                                    = # of
                                                    patients
                                                    with target
                                                    medical
                                                    conditions

ID4         ... all            Poor diet,         Numerator = #
              patients           inadequate         screened
              are                exercise,
              screened at        sleep
              least              disorders,
              annually           etc.             Denominator
              for                                   = # of
              lifestyle                             patients
              or                                    seen in the
              behavioral                            practice
              risk
              factors

ID5         ... screening      Patients           Numerator =
              data are           with low           # of
              presented          physical           recommendations
              to                 activity           presented
              clinicians         are flagged        to
              with               for                clinician
              recommendations    physician
              for patient        to consider
              care.              referral to
                                 YMCA;
                                 patients
                                 with
                                 insomnia
                                 are flagged
                                 for
                                 referral to
                                 CBT.

                                                  Denominator
                                                    = #
                                                    positive
                                                    findings
                                                    (patients
                                                    with
                                                    multiple
                                                    positive
                                                    screens are
                                                    counted
                                                    multiple
                                                    times)

Patient engagement (PE)

PE1         ... we             Patients           Numerator = #
              successfully       who need           initiating
              engage             counseling         behavioral
              identified         actually           intervention
              patients in        start
              Behavioral         counseling
              Care

                                                  Denominator
                                                    = # of
                                                    patients
                                                    who are
                                                    identified
                                                    with a
                                                    specific
                                                    behavioral
                                                    need

PE2         ... we             Patients who       Numerator = #
              successfully       initiate           completing
              retain             counseling         behavioral
              patients in        complete           intervention
              Behavioral         counseling
              Care

                                                  Denominator
                                                    = # of
                                                    patients
                                                    who
                                                    initiate
                                                    behavioral
                                                    intervention

PE3         ... have           Post-              Numerator =
              specific           referral           # receiving
              systems to         "tickler"          action to
              identify           files with         engage or
              and                staff              retain
              intervene          follow-up
              on patients
              who did not
              initiate or
              complete
              care

                                                  Denominator
                                                    = # of
                                                    patients
                                                    who do not
                                                    initiate or
                                                    complete BH
                                                    care

PE4         ... we have        Automatically      Numerator =
              follow-up          scheduled          # of
              plans for          visits with        patients
              all                primary            with a
              patients           care               specific
              who                provider           follow-up
              complete BH                           plan
              interventions

                                                  Denominator
                                                    = # of
                                                    patients
                                                    who
                                                    complete a
                                                    BH
                                                    intervention

In our
practice,
...                                             Score

Practice workflow (PW)

WF1         Numerator =        Never              Sometimes
              # or
              patients
              receiving
              protocol-
              based care

            Denominator        0%                 1-33%
              = # of
              patients in
              need of BH

WF2         Numerator =        Never              Sometimes
              # of
              patients in
              BH
              registries

            Denominator        0%                 1-33%
              = # of
              patients
              with BH
              needs

WF3         Numerator =        Never              Sometimes
              # of
              patients
              receiving
              coordinated
              care

            Denominator        0%                 1-33%
              = # of
              patients
              with BH
              needs

WF4         Numerator =        Never              Sometimes
              # of
              patients
              receiving
              referral
              assistance
              to
              community
              resources

            Denominator        0%                 1-33%
              = # of
              patients
              needing
              referral to
              community
              resources

WF5         Numerator =        Never              Sometimes
              # of
              patients
              receiving
              referral
              assistance
              to
              specialty
              mental
              health
              resources

            Denominator        0%                 1-33%
              = # of
              patients
              needing
              referral to
              specialty
              mental
              health
              resources

WF6         Numerator =        Never              Sometimes
              # of
              patients
              with
              documented
              goals

            Denominator        0%                 1-33%
              = # of
              patients
              with BH
              needs

Clinical services (CS)

CS1         Numerator =        Never              Sometimes
              # hours
              non-crisis
              BH services
              are
              available

            Denominator        0%                 1-33%
              = # of
              hours the
              clinic is
              open

CS2         Numerator =        Never              Sometimes
              # hours
              crisis BH
              services
              are
              available

            Denominator        0%                 1-33%
              = # of
              hours the
              clinic is
              open

CS3         Numerator =        Never              Sometimes
              # hours BH
              services
              for
              seriously
              mentally
              ill and
              substance-
              dependent
              patients
              are
              available

            Denominator        0%                 1-33%
              = # of
              hours the
              clinic is
              open

CS4         Numerator =        Never              Sometimes
              # of
              patients
              offered BH
              interventions
              for
              chronic/
              complex
              medical
              illnesses

            Denominator        0%                 1-33%
              = # of
              patients
              needing
              such
              services

CS5         Numerator =        Never              Sometimes
              # of BH
              staff with
              training in
              complex or
              specialized
              behavioral
              health
              therapies

            Denominator        0%                 1-33%
              = # of BH
              staff


CS6         Numerator =        Never              Sometimes
              # of
              patients
              offered
              evidence-
              based
              substance
              abuse
              interventions

            Denominator        0%                 1-33%
              = # of
              patients
              needing
              such
              services

CS7         Numerator =        Never              Sometimes
              # of
              patients
              offered
              prescription
              medications
              for routine
              mental
              health or
              substance
              abuse
              diagnoses

            Denominator        0%                 1-33%
              = # of
              patients
              needing
              such
              services

CS8         Numerator =        Never              Sometimes
              # of
              patients
              offered
              prescription
              medications
              for serious
              mental
              health or
              substance
              abuse
              diagnoses

            Denominator        0%                 1-33%
              = # of
              patients
              needing
              such
              services

CS9         Numerator =        Never              Sometimes
              # of
              patients
              offered
              referrals

            Denominator        0%                 1-33%
              = # of
              patients
              needing
              such
              services

Workspace (WS)

WS1         Ordered--Please    Different          Different
              pick the           Buildings          Floors
              best
              descriptor
              of your
              practice

WS2         Numerator =        Never              Sometimes
              # of
              patients
              with shared
              records

            Denominator        0%                 1-33%
              = # of
              patients
              receiving
              BH services

Integration

IN1         Numerator =        Never              Sometimes
              # of
              patients
              with
              regular
              active
              exchange of
              information

            Denominator        0%                 1-33%
              = # of
              patients
              receiving
              BH services

IN2         Educational        No                 Educational
              activities         structured         activities
              should be          educational        are
              jointly            activities         provided
              provided to                           to BH
              medical and                           and
              behavioral                            medical
              clinicians.                           clinicians
                                                    separately

IN3         Numerator =        Never              Sometimes
              # of
              patients
              discussed
              in person

            Denominator        0%                 1-33%
              = # of
              patients
              receiving
              BH services

IN4         Numerator =        Never              Sometimes
              # of
              patients
              with a
              shared care
              plan

            Denominator        0%                 1-33%
              = # of
              patients
              receiving
              BH services

Case identification (ID)

ID1         Numerator = #      Never              Sometimes
              screened

            Denominator        0%                 1-33%
              = # of
              adults seen
              in the
              practice

ID2         Numerator =        Never              Sometimes
              # of
              patients
              screened

            Denominator        0%                 1-33%
              = # of
              patients in
              the
              practice

ID3         Numerator = #      Never              Sometimes
              screened

            Denominator        0%                 1-33%
              = # of
              patients
              with target
              medical
              conditions

ID4         Numerator = #      Never              Sometimes
              screened

            Denominator        0%                 1-33%
              = # of
              patients
              seen in the
              practice

ID5         Numerator =        Never              Sometimes
              # of
              recommendations
              presented
              to
              clinician

            Denominator        0%                 1-33%
              = #
              positive
              findings
              (patients
              with
              multiple
              positive
              screens are
              counted
              multiple
              times)

Patient engagement (PE)

PE1         Numerator = #      Never              Sometimes
              initiating
              behavioral
              intervention

            Denominator        0%                 1-33%
              = # of
              patients
              who are
              identified
              with a
              specific
              behavioral
              need

PE2         Numerator = #      Never              Sometimes
              completing
              behavioral
              intervention

            Denominator        0%                 1-33%
              = # of
              patients
              who
              initiate
              behavioral
              intervention

PE3         Numerator =        Never              Sometimes
              # receiving
              action to
              engage or
              retain

            Denominator        0%                 1-33%
              = # of
              patients
              who do not
              initiate or
              complete BH
              care

PE4         Numerator =        Never              Sometimes
              # of
              patients
              with a
              specific
              follow-up
              plan

            Denominator        0%                 1-33%
              = # of
              patients
              who
              complete a
              BH
              intervention

In our
practice,
...                                             Score

Practice workflow (PW)

WF1         Numerator =        Often              Frequently
              # or
              patients
              receiving
              protocol-
              based care

            Denominator        34-66%             67-99%
              = # of
              patients in
              need of BH

WF2         Numerator =        Often              Frequently
              # of
              patients in
              BH
              registries

            Denominator        34-66%             67-99%
              = # of
              patients
              with BH
              needs

WF3         Numerator =        Often              Frequently
              # of
              patients
              receiving
              coordinated
              care

            Denominator        34-66%             67-99%
              = # of
              patients
              with BH
              needs

WF4         Numerator =        Often              Frequently
              # of
              patients
              receiving
              referral
              assistance
              to
              community
              resources

            Denominator        34-66%             67-99%
              = # of
              patients
              needing
              referral to
              community
              resources

WF5         Numerator =        Often              Frequently
              # of
              patients
              receiving
              referral
              assistance
              to
              specialty
              mental
              health
              resources

            Denominator        34-66%             67-99%
              = # of
              patients
              needing
              referral to
              specialty
              mental
              health
              resources

WF6         Numerator =        Often              Frequently
              # of
              patients
              with
              documented
              goals

            Denominator        34-66%             67-99%
              = # of
              patients
              with BH
              needs

Clinical services (CS)

CS1         Numerator =        Often              Frequently
              # hours
              non-crisis
              BH services
              are
              available

            Denominator        34-66%             67-99%
              = # of
              hours the
              clinic is
              open

CS2         Numerator =        Often              Frequently
              # hours
              crisis BH
              services
              are
              available

            Denominator        34-66%             67-99%
              = # of
              hours the
              clinic is
              open

CS3         Numerator =        Often              Frequently
              # hours BH
              services
              for
              seriously
              mentally
              ill and
              substance-
              dependent
              patients
              are
              available

            Denominator        34-66%             67-99%
              = # of
              hours the
              clinic is
              open

CS4         Numerator =        Often              Frequently
              # of
              patients
              offered BH
              interventions
              for
              chronic/
              complex
              medical
              illnesses

            Denominator        34-66%             67-99%
              = # of
              patients
              needing
              such
              services

CS5         Numerator =        Often              Frequently
              # of BH
              staff with
              training in
              complex or
              specialized
              behavioral
              health
              therapies

            Denominator        34-66%             67-99%
              = # of BH
              staff

CS6         Numerator =        Often              Frequently
              # of
              patients
              offered
              evidence-
              based
              substance
              abuse
              interventions

            Denominator        34-66%             67-99%
              = # of
              patients
              needing
              such
              services

CS7         Numerator =        Often              Frequently
              # of
              patients
              offered
              prescription
              medications
              for routine
              mental
              health or
              substance
              abuse
              diagnoses

            Denominator        34-66%             67-99%
              = # of
              patients
              needing
              such
              services

CS8         Numerator =        Often              Frequently
              # of
              patients
              offered
              prescription
              medications
              for serious
              mental
              health or
              substance
              abuse
              diagnoses

            Denominator        34-66%             67-99%
              = # of
              patients
              needing
              such
              services

CS9         Numerator =        Often              Frequently
              # of
              patients
              offered
              referrals

            Denominator        34-66%             67-99%
              = # of
              patients
              needing
              such
              services

Workspace (WS)

WS1         Ordered--Please    Different          Separate
              pick the           Office             parts of
              best               Suites             the same
              descriptor                            suite
              of your
              practice

WS2         Numerator =        Often              Frequently
              # of
              patients
              with shared
              records

            Denominator        34-66%             67-99%
              = # of
              patients
              receiving
              BH services

Integration and sharing methods (IN)

IN1         Numerator =        Often              Frequently
              # of
              patients
              with
              regular
              active
              exchange of
              information

            Denominator        34-66%             67-99%
              = # of
              patients
              receiving
              BH services

IN2         Educational        Some               Frequent
              activities         activities         activities
              should be          with both          with both
              jointly            medical            medical
              provided to        and BH             and BH
              medical and        clinicians         clinicians
              behavioral
              clinicians.

IN3         Numerator =        Often              Frequently
              # of
              patients
              discussed
              in person

            Denominator        34-66%             67-99%
              = # of
              patients
              receiving
              BH services

IN4         Numerator =        Often              Frequently
              # of
              patients
              with a
              shared care
              plan

            Denominator        34-66%             67-99%
              = # of
              patients
              receiving
              BH services

Case identification (ID)

ID1         Numerator = #      Often              Frequently
              screened

            Denominator        34-66%             67-99%
              = # of
              adults seen
              in the
              practice

ID2         Numerator =        Often              Frequently
              # of
              patients
              screened

            Denominator        34-66%             67-99%
              = # of
              patients in
              the
              practice

ID3         Numerator = #      Often              Frequently
              screened

            Denominator        34-66%             67-99%
              = # of
              patients
              with target
              medical
              conditions

ID4         Numerator = #      Often              Frequently
              screened

            Denominator        34-66%             67-99%
              = # of
              patients
              seen in the
              practice

ID5         Numerator =        Often              Frequently
              # of
              recommendations
              presented
              to
              clinician

            Denominator        34-66%             67-99%
              = #
              positive
              findings
              (patients
              with
              multiple
              positive
              screens are
              counted
              multiple
              times)

Patient engagement (PE)

PE1         Numerator = #      Often              Frequently
              initiating
              behavioral
              intervention

           Denominator        34-66%             67-99%
              = # of
              patients
              who are
              identified
              with a
              specific
              behavioral
              need

PE2         Numerator = #      Often              Frequently
              completing
              behavioral
              intervention

            Denominator        34-66%             67-99%
              = # of
              patients
              who
              initiate
              behavioral
              intervention

PE3         Numerator =        Often              Frequently
              # receiving
              action to
              engage or
              retain

            Denominator        34-66%             67-99%
              = # of
              patients
              who do not
              initiate or
              complete BH
              care

PE4         Numerator =        Often              Frequently
              # of
              patients

              with a
              specific
              follow-up
              plan

            Denominator        34-66%             67-99%
              = # of
              patients
              who
              complete a
              BH
              intervention

In our
practice,
...                            Score

Practice workflow (PW)

WF1         Numerator =        Always
              # or
              patients
              receiving
              protocol-
              based care

            Denominator        100%
              = # of
              patients in
              need of BH

WF2         Numerator =        Always
              # of
              patients in
              BH
              registries

            Denominator        100%
              = # of
              patients
              with BH
              needs

WF3         Numerator =        Always
              # of
              patients
              receiving
              coordinated
              care

            Denominator        100%
              = # of
              patients
              with BH
              needs

WF4         Numerator =        Always
              # of
              patients
              receiving
              referral
              assistance
              to
              community
              resources

            Denominator        100%
              = # of
              patients
              needing
              referral to
              community
              resources

WF5         Numerator =        Always
              # of
              patients
              receiving
              referral
              assistance
              to
              specialty
              mental
              health
              resources

            Denominator        100%
              = # of
              patients
              needing
              referral to
              specialty
              mental
              health
              resources

WF6         Numerator =        Always
              # of
              patients
              with
              documented
              goals

            Denominator        100%
              = # of
              patients
              with BH
              needs

Clinical services (CS)

CS1         Numerator =        Always
              # hours
              non-crisis
              BH services
              are
              available

            Denominator        100%
              = # of
              hours the
              clinic is
              open

CS2         Numerator =        Always
              # hours
              crisis BH
              services
              are
              available

            Denominator        100%
              = # of
              hours the
              clinic is
              open

CS3         Numerator =        Always
              # hours BH
              services
              for
              seriously
              mentally
              ill and
              substance-
              dependent
              patients
              are
              available

            Denominator        100%
              = # of
              hours the
              clinic is
              open

CS4         Numerator =        Always
              # of
              patients
              offered BH
              interventions
              for
              chronic/
              complex
              medical
              illnesses

            Denominator        100%
              = # of
              patients
              needing
              such
              services

CS5         Numerator =        Always
              # of BH
              staff with
              training in
              complex or
              specialized
              behavioral
              health
              therapies

            Denominator        100%
              = # of BH
              staff

CS6         Numerator =        Always
              # of
              patients
              offered
              evidence-
              based
              substance
              abuse
              interventions

            Denominator        100%
              = # of
              patients
              needing
              such
              services

CS7         Numerator =        Always
              # of
              patients
              offered
              prescription
              medications
              for routine
              mental
              health or
              substance
              abuse
              diagnoses

            Denominator        100%
              = # of
              patients
              needing
              such
              services

CS8         Numerator =        Always
              # of
              patients
              offered
              prescription
              medications
              for serious
              mental
              health or
              substance
              abuse
              diagnoses

            Denominator        100%
              = # of
              patients
              needing
              such
              services

CS9         Numerator =        Always
              # of
              patients
              offered
              referrals

            Denominator        100%
              = # of
              patients
              needing
              such
              services

Workspace (WS)

WS1         Ordered--Please    Fully
              pick the           shared
              best               space
              descriptor
              of your
              practice

WS2         Numerator =        Always
              # of
              patients
              with shared
              records

            Denominator        100%
              = # of
              patients
              receiving
              BH services

Integration and sharing methods (IN)

IN1         Numerator =        Always
              # of
              patients
              with
              regular
              active
              exchange of
              information

            Denominator        100%
              = # of
              patients
              receiving
              BH services

IN2         Educational        Regularly
              activities         scheduled
              should be          activities
              jointly            with full
              provided to        participation
              medical and        by both
              behavioral         medical and
              clinicians.        BH clinicians

IN3         Numerator =        Always
              # of
              patients
              discussed
              in person

            Denominator        100%
              = # of
              patients
              receiving
              BH services

IN4         Numerator =        Always
              # of
              patients
              with a
              shared care
              plan

            Denominator        100%
              = # of
              patients
              receiving
              BH services

Case identification (ID)

ID1         Numerator = #      Always
              screened

            Denominator        100%
              = # of
              adults seen
              in the
              practice

ID2         Numerator =        Always
              # of
              patients
              screened

            Denominator        100%
              = # of
              patients in
              the
              practice

ID3         Numerator = #      Always
              screened

            Denominator        100%
              = # of
              patients
              with target
              medical
              conditions

ID4         Numerator = #      Always
              screened

            Denominator        100%
              = # of
              patients
              seen in the
              practice

ID5         Numerator =        Always
              # of
              recommendations
              presented
              to
              clinician

            Denominator        100%
              = #
              positive
              findings
              (patients
              with
              multiple
              positive
              screens are
              counted
              multiple
              times)

Patient engagement (PE)

PE1         Numerator = #      Always
              initiating
              behavioral
              intervention

            Denominator        100%
              = # of
              patients
              who are
              identified
              with a
              specific
              behavioral
              need

PE2         Numerator = #      Always
              completing
              behavioral
              intervention

            Denominator        100%
              = # of
              patients
              who
              initiate
              behavioral
              intervention

PE3         Numerator =        Always
              # receiving
              action to
              engage or
              retain

            Denominator        100%
              = # of
              patients
              who do not
              initiate or
              complete BH
              care

PE4         Numerator =        Always
              # of
              patients
              with a
              specific
              follow-up
              plan

            Denominator        100%
              = # of
              patients
              who
              complete a
              BH
              intervention


Received April 18, 2016

Revision received July 21, 2016

Accepted July 25, 2016

Rodger S. Kessler, PhD, ABPP

University of Vermont College of Medicine

Juvena R. Hitt, BS

University of Vermont College of Medicine

Daniel Mullin, PsyD, MPH

University of Massachusetts Medical School

Andrea Auxier, PhD

New Directions Behavioral Health, Kansas City, Missouri

C. R. Macchi, PhD

Arizona State University

Constance van Eeghen, DrPH and Benjamin Littenberg, MD

University of Vermont College of Medicine

This article was published Online First October 13, 2016.

Rodger S. Kessler, PhD. ABPP, Department of Family Medicine, University of Vermont College of Medicine; Andrea Auxier, PhD, New Directions Behavioral Health, Kansas City. Missouri; Juvena R. Hitt, BS. Department of Family Medicine, University of Vermont College of Medicine; C. R. Macchi, PhD, Integrated Behavioral Healthcare, Arizona State University; Daniel Mullin, PsyD, MPH, Department of Family Medicine and Community Health. University of Massachusetts Medical School; Constance van Eeghen, DrPH and Benjamin Littenberg, MD, Department of Family Medicine, University of Vermont College of Medicine.

Rodger S. Kessler, Andrea Auxier. Juvena R. Hitt, C. R. Macchi, Daniel Mullin, Constance van Eeghen, and Benjamin Littenberg participated in the study design and coordination and helped to draft the manuscript. Additionally, B.L. performed the statistical analysis. All authors read and approved the final manuscript.

Correspondence concerning this article should be addressed to Rodger S. Kessler, PhD. ABPP. Department of Family Medicine, University of Vermont College of Medicine, 89 Beaumont Avenue, Given Courtyard South S456, Burlington, VT 05405. E-mail: rodger.kessler@uvm.edu

Table 1
Practice Integration Profile Domain Scores

Domain            k    Mean   SD   Minimum   25th percentile   Median

Workflow          6     53    21      0            38            54
Services          9     62    24      0            44            67
Workspace         2     65    33      0            38            75
Shared care       4     49    27      0            25            50
Identification    5     51    26      0            25            50
Engagement        4     49    22      0            31            50
Total             30    55    21      0            40            58

Domain            75th percentile   Maximum   [alpha]

Workflow                67            100       .82
Services                81            100       .91
Workspace               100           100       .52
Shared care             69            100       .87
Identification          70            100       .88
Engagement              63            100       .80
Total                   71            100       .95

Note, k = number of items; SD = standard deviation; [alpha]
= Cronbach's [alpha].

Table 2
Average Domain Scores by Level of Integration

                         Average domain scores

Level            Respondents   Practices   Workflow

Non-BHC              20           20          31
CMHC                 25           22          54
Primary care         114          102         55
Exemplar             10            8          80
All practices        169          152         53

                        Average domain scores

Level            Services   Workspace   Shared care

Non-BHC             23         21           18
CMHC                56         38           32
Primary care        67         77           56
Exemplar            94         98           86
All practices       62         65           49

                           Average domain scores

Level            Identification   Engagement   Total

Non-BHC                43             27        27
CMHC                   37             49        44
Primary care           53             51        60
Exemplar               83             73        86
All practices          51             49        55

Note. Non-BHC = Practice with no Behavioral Health
Clinicians. CMHC = Community Mental Health Center. Within
each domain, the trend across levels is statistically
significant (p < .001) by the Cuzick nonparametric test of
trend (Cuzick, 1985).

Table 3
Effect of Potential Confounders on the Domain Scores by
Level of Integration

Domain                               Workflow

Model                         A               B

Level of integration
  Non-BHC                        --              --
  CMHC                  22 ([dagger])   22 ([dagger])
  Primary care          24 ([dagger])   22 ([dagger])
  Exemplar              48 ([dagger])   45 ([dagger])
location
  Urban                                  8 *

Respondent role
  Behaviorist                           --
  Manager                                2
  Physician                             -2

Practice size
  10+ employees          2
Constant                31 ([dagger])   27 ([dagger])

Domain                               Services

Model                         A               B

Level of integration
  Non-BHC               --              --
  CMHC                  33 ([dagger])   35 ([dagger])
  Primary care          44 ([dagger])   40 ([dagger])
  Exemplar              71 ([dagger])   62 ([dagger])
location
  Urban                                  9 ([double
                                          dagger])
Respondent role
  Behaviorist                           --
  Manager                               -9 *
  Physician                             -3

Practice size
  10+ employees         -3
Constant                23 ([dagger])   29 ([dagger])

Domain                               Workspace

Model                         A               B

Level of integration
  Non-BHC               --              --
  CMHC                  17 *            15 *
  Primary care          56 ([dagger])   51 ([dagger])
  Exemplar              77 ([dagger])   67 ([dagger])
location
  Urban                                  5

Respondent role
  Behaviorist                           --
  Manager                               -6
  Physician                             -14 ([double
                                          dagger])
Practice size
  10+ employees         13 *
Constant                21 ([dagger])   15

Domain                               Shared care

Model                         A               B

Level of integration
  Non-BHC               --              --
  CMHC                  14 *            15 *
  Primary care          38 ([dagger])   37 ([dagger])
  Exemplar              68 ([dagger])   64 ([dagger])
location
  Urban                                 6

Respondent role
  Behaviorist                           --
  Manager                               0
  Physician                             -2

Practice size
  10+ employees         6
Constant                18 ([dagger])   11

Domain                               Identification

Model                         A               B

Level of integration
  Non-BHC               --              --
  CMHC                  -6              -6
  Primary care          10              11
  Exemplar              40 ([dagger])   42 ([dagger])
location
  Urban                                 1

Respondent role
  Behaviorist                           --
  Manager                               3
  Physician                             1

Practice size
  10+ employees         -3
Constant                43 ([dagger])   43 ([dagger])

Domain                               Engagement

Model                         A               B

Level of integration
  Non-BHC               --              --
  CMHC                  21 ([dagger])   21 ([dagger])
  Primary care          24 ([dagger])   23 ([dagger])
  Exemplar              46 ([dagger])   45 ([dagger])
location
  Urban                                 2

Respondent role
  Behaviorist                           --
  Manager                               -1
  Physician                             1

Practice size
  10+ employees         -5
Constant                27 ([dagger])   31 ([dagger])

Domain                               Total

Model                         A               B

Level of integration
  Non-BHC               --              --
  CMHC                  17 ([dagger])   17 ([dagger])
  Primary care          33 ([dagger])   30 ([dagger])
  Exemplar              58 ([dagger])   54 ([dagger])
location
  Urban                                 5

Respondent role
  Behaviorist                           --
  Manager                               -2
  Physician                             -3

Practice size
  10+ employees         2
Constant                27 ([dagger])   26 ([dagger])

Note. In each domain. Model A is a linear regression of the
domain score as a function of the level of integration
alone.
Model B also includes three potential confounders. Non-BHC =
Practice with no Behavioral Health Clinicians; CMHC =
Community Mental Health Center. Urban location includes
inner city practices. Behaviorist includes student interns.

([dagger]) p <.001. ([double dagger]) p < .01. * p < .05.

Table 4 Reliability by Domain

                          Intrarater consistency
                                over time
                            (N = 11 subjects)

                      Mean             95% limits
Domain               change    SD     of agreement

Workflow              +2.7    16.7    -31,     +36
Services              +2.3    16.3    -30,     +35
Workspace             -5.7    15.2    -36,     +25
Shared care           -5.1    16.0    -37,     +27
Identification       +10.9    18.1    -25,     +47
Engagement            +4.0    12.6    -21,     +29
Total integration     +1.5    11.1    -21,     +24

                       Interrater agreement
                         within practice
                       (N = 32 respondents
                        from 15 practices)

                     Mean
Domain               diff    Min   Max    SD

Workflow             12.8     0    38     8.6
Services             11.2     0    36     7.2
Workspace            14.5     0    50     9.5
Shared care          11.7     0    25     7.3
Identification       17.0     0    50    11.3
Engagement           13.3     0    31     8.8
Total integration     7.1     0    18     4.7

Note. SD = standard deviation; Diff = difference;
Min = minimum difference; Max = maximum difference.
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Article Details
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Author:Kessler, Rodger S.; Hitt, Juvena R.; Mullin, Daniel; Auxier, Andrea; Macchi, C.R.; van Eeghen, Const
Publication:Families, Systems & Health
Article Type:Report
Date:Dec 1, 2016
Words:7759
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