Title and Citation

Summary

Format

ABCs of Wellness: Facts and Tips for Whole Health

Clients are the principal audience for this fact sheet, but it provides an introduction to the core physical health factors--blood sugar, blood pressure, body mass index, and cholesterol levels, diet and exercise--that contribute to the health of the "whole person," and so should be of value to members of a behavioral health support team.

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(450 KB)

Accelerating Disparity-Reducing Advances

While the focus of this review of patient navigation programs and toolkits is the area of cancer treatment, findings will have relevance to other treatment fields. The programs reviewed in this report had in their mission to reduce disparities in outcomes among under-served populations; many delivered impressive results using health navigation.

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(210 KB)

After an Attempt: A Guide for Medical Providers in the Emergency Department taking Care of Suicide Attempt Survivors

A booklet for emergency department medical providers taking care of suicide attempt survivors.

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(970 KB)

Arkansas Health Workforce Strategic Plan: A Roadmap to Change

This report provides recommendations to expand the capacity and effectiveness of Arkansas's health workforce using technology, care coordination, and system navigation. Addresses workforce education, training, recruitment, retention, distribution, coordination, incentives, and structure.

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(3.2 MB)

Behavioral Approaches to Chronic Disease in Adolescence: A Guide to Integrative Care

This resource offers clinicians an evidence-based guide to helping their young clients manage their chronic conditions and treating the psychosocial effects-from school problems and stigma to noncompliance and depression-that frequently follow diagnosis. Expert contributors present up-to-date information on epidemiology, symptoms, comorbid psychosocial problems, and treatment options for a variety of common illnesses, arranged to foster effective interventions for adolescents and efficient collaboration with other care providers in the team.

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Behavioral Health as Primary Care: Beyond Efficacy to Effectiveness

Integrated care, defined as the better coordination of behavioral health services with medical services, holds much promise in addressing the above problems. One of the key advantages to this healthcare delivery system is that it can reduce demand for healthcare by providing patients with the healthcare they actually need. There is significant clinical research all pointing to one fact: many patients (perhaps even the majority) receiving traditional primary care or specialty care medicine also need behavioral care.

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Behavioral Health Integration: Blending Behaviorists into the Patient Centered Medical Home

This conference slide presentation stresses the imperative for integrating behavioral specialists into the PCMH model, distinguishing between true integration and mere co-location of services. The author describes the model presently in operation at Cherokee Health Systems in Knoxville, Tennessee.

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(900 KB)

Behavioral Health/Primary Care Integration and the Person-Centered Healthcare Home

The report unambiguously calls for the integration of behavior specialists into the PCMH, with particular attention to the IMPACT model, which emphasizes real-time collaborative care by a physician and a behavior specialist to deliver effective behavioral healthcare. The paper also identifies current systemic barriers (financing, regulation, privacy policies, and so on) that must be addressed to optimize the opportunity to realize meaningful patient and clinician outcomes. Copyrighted.

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Behavioral Integrative Care: Treatments That Work in the Primary Care Setting

Integrated care is one of the most important developments in the delivery of health care. In this practical volume, contributors address specific health problems that can be aided with integrated care to the benefit of the patient. Clinical psychologist and psychiatric social workers looking to expand their practice will find this volume of interest.

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Bellin's Total Health Model Improves Workforce Health and Reduces Costs

The Institute for Healthcare Improvement's Triple Aim Initiative has developed a report series to catalog Triple Aim model program progress. This overview describes Bellin Health in Wisconsin, which works with employers using an innovative framework it calls the Total Health Model.

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(340 KB)

Building Medical Homes: Lessons from Eight State with Emerging Programs

Eight states profiled in this report are at different stages in the development and implementation of PCMH programs and have relied on different strategies to encourage adoption of the model. Their experiences demonstrate that states can play a critical role in helping practices improve performance and can productively address systemic barriers such as those that can lead to conflict among payers.

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(550 KB)

Building the Person-Centered Healthcare Home of the Future

This training presentation was part of a SAMHSA-funded Mental Health Transformation State Incentive project. The training seeks to build a knowledge base within state government regarding the integration of mental health and substance use services in primary care and the integration of primary care into specialty mental health and substance use settings. Desired outcomes of the training are for state agency programs, policies and financing options be shaped by a consistent vision of how integrated services are delivered, and how program, policy and financing decisions align to this vision.

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(1 MB)

Business Case for Bidirectional Integrated Care: Mental Health and Substance Use Services in Primary Care Settings and Primary Care Services in Specialty Mental Health and Substance Use Settings

Integration Policy Initiative participants recommended development of a business case for integration (with an emphasis on the SafetyNet system) while acknowledging the role of specialty services. This business case paper is intended for use by audiences who share the desire to simultaneously accomplish the three critical healthcare objectives of the Institute for Healthcare Improvement's Triple Aim, including decision- and policy-makers in the medical and behavioral health communities, health plan administrators, government, and advocacy groups.

Related reports of interest: The IPI Volume I: Report, issued in late 2009, and two volumes of additional materials, Volume II: Working Papers and Volume III: Examples for Dissemination, are available at the California Institute for Mental Health website

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(1 MB)

Care Coordination Model: Better Care at Lower Cost for People with Multiple Health and Social Needs

This white paper outlines methods and opportunities to better coordinate care with people with multiple health and social needs, and reviews ways that organizations have allocated resources to better meet the range of needs in this population. There is special emphasis on the experience of care coordination with populations of people experiencing homelessness.

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(510 KB)

Case Studies in Innovation: The Puget Sound Health Alliance

An overview of the community stakeholders and the 2003 state-of-the-healthcare-state in the King County, WA, is followed by an outline of the practice innovations that the Puget Sound Health Alliance implemented, which, the authors find, hold the potential to strengthen the health care system and provide hope that first-rate health care can be viable and sustainable.

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(140 KB)

Certified Peer Specialist Roles and Activities: Results From a National Survey

A synthesis of the results of an online survey of 291 certified peer specialists from 28 states. Factors addressed include variability in context in which CPSs work and the types of issues they typically provided support around, along with those they do not. Concluding remarks touch on the challenges faced by CPSs, among them a lack of acknowledgment of the value of experiential knowledge versus traditional credentialing; the field is moving, somewhat controversially, towards nationally standardized training.

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(70 KB)

Challenges and Opportunities in a Changing Health Care Environment

This slide presentation explores the challenges in meeting the behavioral health needs of the nation and reviews some of the opportunities that health reform will bring to enhance access and services. The presentation considers provider readiness, workforce challenges, and emergency preparedness.

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(3 MB)

Change, Challenge, & Opportunity-Substance Abuse and Addiction in a Changing Health Care Environment

This slide presentation presents an overview of substance abuse in the U.S. and discusses a prevention framework that prioritizes underage drinking and prescription drug abuse. Discussion also reviews changes in healthcare resulting from health reform and discusses provider readiness and the workforce.

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(6.5 MB)

Changes Involved in Patient-Centered Medical Home Transformation

The patient-centered medical home model has been proposed by the major primary care professional societies as a way to achieve more effective, less costly care. Commonwealth Fund-supported researchers reviewed the professional literature and convened a panel of experts to identify characteristics of fully transformed medical homes and the necessary changes to infrastructure, organization, and care delivery that practices and clinicians must make to get there. (Only the abstract is in the public domain.)

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Changing Roles: How Health Navigators Support Whole Health

This webinar reviews the role of health navigator and its relationship among the existing roles in a primary care practice. The "ABC Wellness Initiative," which the National Council designed to highlight important physical health baselines (blood sugar, blood pressure, body mass index, and cholesterol levels) and other resources are also discussed. These are tools that the behavioral health navigator is encouraged to use as in their work with clients to improve health status.

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(2.3 MB)

Clinical Community Health Workers: Linchpin of the Medical Home

The emerging clinical community health worker model integrates community health workers as integral members of primary care teams inside a medical home. This evaluation documents the case management services provided by two clinical CHW programs at La Clínica del Cariño in Hood River, Oregon, and how they affected the care team's ability to deliver efficient, effective primary care. Clinical CHWs have the potential to make a significant impact on clinical efficiency and effectiveness as ambulatory primary care clinics strive to transform into high-quality, patient-centered medical homes and become linchpins in accountable care organizations. (Abstract only is in the public domain.)

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Community Health Workers and Integrated Primary Health Care Teams in the 21st Century

CHWs provide structured linkages between the community, the patient, and the health care system. Effective CHWs are strongly embedded in the communities that they serve. Moreover, they have clear supervision and defined roles and they are well trained, with a defined system of advancing their education and roles within the health care system. (Only the abstract is in the public domain.)

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Community Health Workers Can Be a Public Health Force for Change in the United States: Three Actions for a New Paradigm

This discussion focuses on how to strengthen the roles of CHWs to enable them to become collaborative leaders in dramatically changing health care from "sickness care" systems to systems that provide comprehensive care for individuals and families and supports community and tribal wellness. The authors identify approaches that can make optimal contributions, integrate CHWs into "community health teams" as part of "medical homes," and improve evaluation frameworks to better measure community wellness and systems change. (Only the abstract is in the public domain.)

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Consensus Operational Definition of Patient-Centered Medical Home (PCMH) Also known as Health Care Home

To develop an operational definition of "PCMH" useful for implementers, payers, policy makers and others, researchers from the University of Minnesota and the Institute for Clinical Systems Improvement engaged a core and a secondary group of sector stakeholders who collaboratively developed a consensus definition of PCMH that encompasses both essential functionalities and reasonable variations, as delimited by specific parameters. The report's methodology is explained in detail. (Protected by copyright.)

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Coordinating Care for Adults With Complex Care Needs in the Patient-Centered Medical Home-Challenges and Solutions

This paper explores the current landscape of PCMH services for patients with complex needs, details five programs that have addressed the challenges of caring for these patients, and offers programmatic and policy changes that can help smaller practices better deliver services to all patients. PCMHs offer a promising model for providing comprehensive, coordinated care. Smaller practices, however, face particular challenges in coordinating care for these patients.

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(2.1 MB)

Cost and Quality Impact of Intermountain's Mental Health Integration Program

This review of Intermountain Healthcare in Utah focuses quality and safety as the practice network adopts principles of integrated care including patient and family involvement in care decisions, care coordination and community stewardship. Intermountain Healthcare has implemented a standardized clinical and operational team process that incorporates mental health as a complementary component of wellness and healing.

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(3.2 MB)

Creation of the Pillars of Peer Support Services: Transforming Mental Health Systems of Care Transforming Mental Health Systems of Care

The Pillars of Peer Support Services Summit convened in November 2009, to examine the multiple levels of state support necessary for a strong peer support workforce. Summit participants developed and agreed upon a set of Pillars of Peer Support Services. Twenty five "pillars" of peer support services propose a framework for states interested in developing or expanding peer support programs. (Online only.)

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Developing a Mental Health Peer Specialist Workforce in Massachusetts

This position paper describes the deficiencies in the behavioral health system that more recent national legislation is meant to address: insufficient patient involvement and few and inadequate formal patient support systems. In specific, the CHPR argues for the development of a mental health peer specialist workforce to meet the needs of the more patient-centered behavioral health system that calls for transformation envision.

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(60 KB)

Developing and Running a Primary Care Practice Facilitation Program: A How-to Guide

This how-to guide was developed by the AHRQ to support organizations interested in starting a practice facilitation program for primary care transformation in light of the growing consensus that the U.S. primary care system must be redesigned in fundamental ways to improve health and patient experience and lower costs.

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(3 MB)

Developing the Medical Home in Primary Care: Using a Patient Navigator to Coordinate Care

Overlook Hospital Foundation funded a pilot project to demonstrate how patient navigators can help improve care coordination for patients of primary care practices. This is a report of the types of services the navigator provided, the barriers and facilitators to patient navigation in primary care practices, and understanding patients', physicians' and the navigator's perspectives and experiences with this service. (Online only.)

Web Access

Development of Peer Specialist Roles: A Literature Scoping Exercise

The Scottish Recovery Network commissioned the Scottish Development Centre for Mental Health to undertake a sector review to assist in the development of peer specialist roles in Scotland. This paper reports on a literature review of existing models of accredited training and peer specialist roles and on telephone interviews with peer specialist/peer support projects in Scotland and the United States.

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(165 KB)

Early Detection and Treatment of Substance Abuse Within Integrated Primary Care (Healthcare Utilization and Cost Series, V. 7)

Substance abuse is a major public health concern, affecting millions of people in the United States. Given its far-reaching impact on the welfare of society, healthcare professionals should make substance abuse a priority. Most patients with substance abuse problems present in primary care settings, oftentimes with other complaints. When professionals, working in primary or integrated care settings, know what to look for and there is adequate infrastructural support with respect to triage, implementing substance programs with an eye on early detection and intervention can dramatically improve health outcomes and create significant financial benefits.

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Engaged Leadership: Transforming Safety Net Clinics into PCMHs (Implementation Guide)

SNMHI developed this implementation guide to help leaders drive and sustain PCMH transformation in their organizations. The guide uses the Institute for Healthcare Improvement's (IHI) Seven Leadership Leverage Points for Organization-Level Improvement in Health Care framework to explain the areas in which leaders can most effectively use their time and energies to drive and sustain transformation.

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(2.1 MB)

Enhancing the Capacity of Community Health Centers to Achieve High Performance: Findings from the 2009 Commonwealth Fund National Survey of Federally Qualified Health Centers

This 2009 survey assessed ability of FQHCs to deliver high-quality healthcare across a range of services and criteria. Difficulty with access to off-site specialty care was a common theme, and adoption of HIT was found to lead to improved patient care. Recommendations for strengthening the model are included.

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(1.8 MB)

Ensuring Equity: A Post-Reform Framework to Achieve High Performance Health Care for Vulnerable Populations

This report examines the problems facing vulnerable populations and offers a framework for moving forward. It features three overarching strategies to close the health care divide: ensuring that health coverage provides adequate access and financial protection; strengthening the care delivery systems serving vulnerable populations; and coordinating care delivery with other community resources, including public health services.

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(3.5 MB)

Establishing a Professional Profile of Community Health Workers: Results from a National Study of Roles, Activities and Training

This paper presents results from the 2010 National Community Health Worker Advocacy Survey (NCHWAS) and in sum demonstrates that CHWs apply core competencies in a synergistic manner to assure that their clients get the services they need. In research and practice, the field would benefit from being considered a health profession rather than an intervention. (Only the abstract is in the public domain.)

Web Access

Evidence about the Role of the Patient Centered Medical Home and Accountable Care Organizations in Improving Quality and Safety

This slide presentation begins with an overview of the PCMH model and accountable care system, discusses how both can improve quality and safety, and provides examples of specific practices that are implementing change towards those aims.

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(600 KB)

Evolving Models of Behavioral Integration in Primary Care

A primer on integrated care that includes both a description of the various models along the continuum and a useful planning guide for those seeking to successfully implement an integrated care model in their jurisdiction.

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(650 KB)

From Striving to Thriving: Systems Thinking, Strategy, and the Performance of Safety Net Hospitals

Leading researchers explored the organizational characteristics of higher-performing Safety-net institutions. Strategic management, more so than structural characteristics, plays a critical role in thriving safety-net hospitals. Those that prosper have an understanding of the full spectrum of patient needs, seek partners to complement their operations, and limit services to those in which their organizations perform well. (Only the abstract is in the public domain.)

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Geisinger Health System: Achieving the Potential of System Integration Through Innovation, Leadership, Measurement, and Incentives

Pennsylvania's Geisinger Health System is a physician-led, non-profit integrated delivery system serving approximately 2.6 million. Geisinger's objectives are to simultaneously improve quality, satisfaction, and efficiency only by redesigning and reengineering the delivery of care. This philosophy is epitomized by ProvenCare, a portfolio of products for which care processes have been redesigned to reliably administer a coordinated bundle of evidence-based best practices. Use of the ProvenCare model has improved clinical outcomes while decreasing resource utilization.

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(1.4 MB)

Genesys HealthWorks Integrates Primary Care with Health Navigator to Improve Health, Reduce Costs

The Institute for Healthcare Improvement's Triple Aim Initiative has developed a report series to catalog Triple Aim model program progress. This overview describes Genesys HealthWorks in Michigan, which has focused on integrating care in primary care practices by adding health navigators to the care team.

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(440 KB)

Getting Started with Maryland's Patient Centered Medical Home Program

The objective of the Maryland Health Care Commission PCMH pilot program is to evaluate whether the PCMH model provides higher quality, more efficient care, and higher satisfaction for patients, nurse practitioners, and primary care physicians. The Pilot was designed to reward medical homes for the additional services, while creating a viable economic model for health care purchasers and maintaining administrative simplicity given multiple payers, diverse physician practices, and our desire to avoid risk selection against sicker patients.

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(700 KB)

Growing Your Own: Community Health Workers and Jobs to Careers

Quantitative and qualitative case study data demonstrate that investing in CHWs can achieve measurable worker and programmatic outcomes. To achieve these outcomes, targeted changes were made to the structure, culture, and work processes of employing organizations. These findings have implications for other health care employers interested in developing their CHW workforce. (Only the abstract is in the public domain.)

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Guiding Transformation: How Medical Practices can Become Patient-Centered Medical Homes

This report provide an assessment of the changes that most medical practices would need to make to become PCMHs. The broad changes include: engaged leadership; a quality improvement strategy; empanelment to ensure the continuity of the patient-provider relationship; continuous and team-based healing relationships; evidence-based care; increased patient involvement in their own care; enhanced access; and care coordination.

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(330 KB)

Health Navigators Support Self-Management With Primary Care Patients, Leading to Improved Behaviors and Lower Utilization

Using a combination of health coaching, case manager, and care coordinator skills, health navigators help insured and uninsured patients cared for by PCMHs adopt healthier behaviors and better manage chronic diseases. This review of Genesys HealthWorks' health navigator model found that navigators improved lifestyle-related and self-management behaviors, leading to better health outcomes and significant reductions in emergency department and inpatient utilization.

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(160 KB)

HealthPartners Uses "BestCare" Practices to Improve Care and Outcomes, Reduce Costs

The Institute for Healthcare Improvement's Triple Aim Initiative has developed a report series to catalog Triple Aim model program progress. This overview describes HealthPartners Medical Group in Minnesota, which developed BestCare, a program that has institutionalized four key care principles: consistency, customization, convenience, and coordination.

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(350 KB)

Impact of Medical Cost Offset on Practice and Research: Making It Work for You (Healthcare Utilization and Cost Series, V. 5)

The United States is facing a healthcare crisis. Costs are escalating and yet few seem satisfied with the current state of healthcare delivery. What can be done to contain costs? If restricting the supply of medical services is not an acceptable answer, then what is? Can demand be legitimately reduced? If so, how? How can we have more quality in our healthcare system? This volume, the result of a national conference sponsored by The Nicholas and Dorothy Cummings Foundation and the University of Nevada, Reno, examines these and attempts to provide empirically-supported answers.

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Inclusion of Peer Support: Catalyst to Recovery, Trauma Informed and Community-Integrated-Based Services

The focus of this presentation is on the demonstrated benefits of including peer support for people in recovery in the toolkit of resources. Peer-delivered services improve participants' experience of recovery, reduce substance use, and offer other beneficial outcomes for individuals and systems.

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(400 KB)

Integrated Behavioral Healthcare: A Guide To Effective Intervention

Integrated behavioural health care is a health-care service delivery system in which behavioural health care is co-ordinated with primary medical care. Integrated care recognises that many patients present to medical professionals with behavioural problems. In this comprehensive, step-by-step guide, a team of national experts in integrated behavioural health care discusses the economic, clinical, administrative, and procedural issues involved in designing, implementing, and maintaining a successful integrated care delivery system.

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Integrated Behavioral Healthcare: Prospects, Issues, and Opportunities (Practical Resources for the Mental Health Professional)

Healthcare is practiced in a different financial and delivery system than it was two decades ago. Currently managed care defines what is treated, how, by whom and for what reimbursement. Mental health professionals have been greatly impacted by these changes. The present volume explores these issues, prospects and opportunities from the vantage of mental health /medical professionals and managed care executives who are in the very process of implementing changes to the existing system of managed care.

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Integrated Health Promotion: A Practice Guide for Service Providers

The objective of this State of Victoria guide is to assist agencies and organizations to strengthen the development and delivery of quality integrated health promotion programs. This strengthened approach will lead to a greater focus on planned and integrated health promotion that will improve the health of local communities and build the evidence base for the effectiveness of integrated health promotion. The resource includes toolkits, checklists, and case studies.

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(100 KB)

Integrating a Behavioral Health Specialist Into Your Practice

This peer-reviewed article identifies and discusses the positive outcomes of integrating behavioral health specialists in primary care practices, addressing such factors as increased efficiency; increased patient and physician satisfaction; improved health outcomes; and improved mental health outcomes. (Only the abstract is in the public domain.)

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Integrating Behavioral Health and Primary Care Services: Opportunities and Challenges for State Mental Health Authorities

The National Association of State Mental Health Program Directors (NASMHPD) Medical Directors Council commissioned this overlay analysis of The Four Quadrant Clinical Integration Model and The Care Model approaches to integrated healthcare to establish baseline data on states' implementation of and to elicit recommendations in the areas of: Community Health Centers and their role in providing behavioral health services; needs of the people served by state mental health authorities; and evidence for integrating behavioral health services into primary care.

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(510 KB)

Integrating Mental Health Treatment into the Patient Centered Medical Home

A discussion of the PCMH model for improving quality and efficiency of primary in the context of mental health services integration, including a review of PCMH and current strategies used to deliver mental health treatment in primary care. The authors outline programmatic and policy changes that can facilitate integration of high-quality mental health treatment within a PCMH.

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(200 KB)

Integrating Primary Care & Mental Health-Substance Use

The objective of this review was to describe the integration of collaborative medication therapy management (CMTM) into a safety net PCMH. Researchers studied a FQCH for homeless individuals over a 21-month period. Reviewers found that integrated CMTM was a valuable patient-centered strategy for addressing medication-related problems among homeless individuals. (Abstract only in public domain.

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Introduction to Integrated Physical and Mental Health Care

This APNA webpage offers a basic but well-developed overview of integrated care, especially behavioral specialists in primary care settings. Information is offered in the context of health care reform and mental health parity laws that have led to today's sector-wide adaptive changes towards greater integration and collaboration between disciplines.

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Maximizing Team-Based Care in the Patient-Centered Medical Home

Implementing care teams is a critical element of transforming a practice into a patient-centered medical home. This guide presents a curriculum and provides training materials (PowerPoint presentations, handouts, skill assessments, exams, etc.) that practices can use to enhance the skills of Medical Assistants and Clinical Assistants.

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(2 MB)

Mental Healthcare: Framework for Emergency Department Services

This practice guide provides direction for delivery of emergency mental health care in Australia's state of Victoria's public hospital emergency departments. The framework assists health services to: plan appropriate emergency department care for people who present with mental health needs; promote service coordination and collaboration between specialist mental health services and emergency departments; and promote best-practice management and care coordination. Protected by copyright but offered as a download by the Government of Victoria.

Web Access

Model Patient Navigation Program

This brief article on the patient navigator model highlights the disparity in medical care for disease, cancer in specific, between that available to members of the dominant culture and members of underserved populations. The author, a past president of the American Cancer Society, provides historical context for the evolution of the navigator concept and emphasizes the significant improvement in outcomes for patients who are provided access to a health navigator.

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(70 KB)

Next Level Transformation-Care Coordination and Care Managers

A review of the shortcomings of traditional (specialized) medical practices in is followed by a description of the care coordination inherent in the PCMH model. Wagner emphasizes the need to build in accountability, patient supports, and care coordination.

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(270 KB)

Outcomes of Community Health Worker Interventions

This literature review examines the evidence on characteristics of community health workers (CHWs) and CHW interventions. Sources included studies published in English from 1980 through 2008 available at MEDLINE®, Cochrane Collaboration resources, and the Cumulative Index to Nursing and Allied Health Literature. Reviewers found that CHWs can serve as a means of improving outcomes for underserved populations for some health conditions, yet also found the effectiveness of CHWs requires further research.

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(5 MB)

Patient-Centered Innovation in Health Care Organizations: A Conceptual Framework and Case Study Application

Patient-centered innovation is spreading at the federal and state levels. The authors propose a framework for understanding the process of initiating patient-centered innovations. The study identifies elements that will lead to implementation success: effective leadership, motivation to change; organizational mission, strategy, and capacity, continuous feedback and organizational learning. (Only the abstract is in the public domain.)

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Peer Delivered Services and Programs Within Managed Care

This webinar provides a review of the role consumers and their families are playing in transforming Managed Care Organization staff and processes. The presentation outlines the types of services that peers deliver, reviews findings from recent field applications of peer-delivered services, and discusses mechanics related to contracting and financing this new model.

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(2 MB)

Peer Navigation Demonstration Program

This slide presentation provides an overview of the evolution of the role of the health navigator from the medical field (i.e., for cancer patients) and moves to a review of the benefits of navigators in the context of behavioral health. A behavioral health navigator model program was found to deliver positive outcomes in areas such as: increased performance of healthy behaviors; increase utilization of primary care; increased adherence to primary care treatment and medication regimes; and others.

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(70 KB)

Peer Support Specialists, Core Competencies

Glossary listing of peer specialist competency areas

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(90 KB)

Physician "Costs" in Providing Behavioral Health in Primary Care

Previous research has shown that behavioral health concerns lengthen primary care visits. This study is the first to quantify those effects on pediatrician reimbursement. Integrating behavioral health services allows physicians to refer patients with behavioral issues to in-house specialists. These, in turn, can address the behavioral health issue and are licensed to receive mental health reimbursement. (Only the abstract is in the public domain.)

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Pillars of Peer Support: Transforming Mental Health Systems of Care Through Peer Support Services

A summary of the results and findings of the Pillars of Peer Support Services Summit convened at the Carter Center in November 2009; a review of the literature related to the evolving policy for mental health services and peer support services; a review of existing state level data of peer support services collected as part of the Summit.

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(700 KB)

Preparing the Workforce for a Reformed Health Care System: Toward a Research Agenda

Rutgers Center for State Health Policy and the John J. Heldrich Center for Workforce Development convened a meeting of senior experts in the health care policy and workforce arenas to identify key research questions regarding the impact of health care reform on the health care workforce. A principal objective of the session was development of a health care workforce research agenda. The group identified areas where additional research will assist key decision-makers: regulations, education policy, corporate training policy, and labor policy.

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(900 KB)

Primary and Behavioral Healthcare Integration: Guiding Principles for Workforce Development

This concise fact sheet identifies barriers to workforce integration; sets out CIHS' goals and the principles that will inform its workforce development planning efforts; and includes Recommended Strategies for Training and Education, Recruitment and Retention, Leadership, Persons in Recovery, Community, Infrastructure Development, and Research and Evaluation.

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(1 MB)

Primary Care and Healthcare Reform

This AAFP annual scientific assembly presentation provides a review of the main issues facing primary care physicians, practices and networks: payment issues, health delivery systems reforms, coverage changes, cost containment provisions, and workforce development.

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(500 KB)

Primary Care Toolkit: Practical Resources for the Integrated Behavioral Care Provider

The integration of behavioral health into the medical setting brings effective, coordinated treatment and increased satisfaction for both practitioner and patient. In reality, however, the results can be far from perfect-and far from integrated. The Primary Care Toolkit introduces mental health professionals to the best possibilities for the collaboration while preparing them for the crucial differences between primary care and traditional mental health settings, to make the transition as worthwhile and non-traumatic as possible.

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Principles for Patient and Family Centered Care: The Medical Home from the Consumer Perspective

The National Partnership for Women and Families has prepared a 9-point set of principles to guide health care providers and patients in the development and implementation of the PCMH model of care.

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(400 KB)

Promoting Recovery-Oriented Mental Health Services through a Peer Specialist Employer Learning Community

Many service providers are unsure of how to include peer specialists in their organizations and may be skeptical of their value. This case study describes an employer learning community model for providers and consumers to explore, through a team approach, the value of having consumers in peer specialist roles and the importance of recovery-oriented practice.

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Psychological Approaches to Chronic Disease Management: A Report of the Fifth Reno Conference on the Integration of Behavioral Health in Primary Care (Healthcare Utilization and Cost Series)

Health care has undergone a significant shift during the past century from targeting primarily acute diseases such as small pox, influenza, and tuberculosis, to managing more costly chronic conditions that include diabetes, asthma, Alzheimer's disease, arthritis, and somatization. Although western medicine has evolved to effectively curb the incidence of acute conditions, it has not had similar success with chronic diseases. The astronomical costs associated with the current management of chronic diseases have resulted in a health care crisis that underscores the imperative for effective treatment and management protocols.

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QuadMed's Onsite Clinics Reduce Corporate Costs, Enhance Care

The Institute for Healthcare Improvement's Triple Aim Initiative has developed a report series to catalog Triple Aim model program progress. This overview describes QuadMed, which is based in Wisconsin, but whose innovative approach is to co-locate practices with businesses in four states in addition to Wisconsin.

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(360 KB)

Recommended Core Measures for Evaluating the Patient-Centered Medical Home: Cost, Utilization, and Clinical Quality

Initiatives across the country are testing the promise of the medical home model. To properly evaluate and compare results that will aid in the implementation of these and other initiatives, researchers need a standard set of core measures. This brief describes the process and recommendations of more than 75 researchers who came together to identify a core set of standardized measures to evaluate the patient-centered medical home. The focus is on two domains of medical home outcomes: cost/utilization and clinical quality.

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(1 MB)

Recovery Support Services: Behavioral Health Peer Navigator

This brief developed by SAMHSA sets out baseline definitions and standards for peer specialists (named here "Behavioral Health Peer Navigators") that cover the following parameters: target population, expected outcomes, service definition, service requirements, and staffing requirements.

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(350 KB)

Report from the Field: Recommendations for Developing and Sustaining Community Health Workers

This report provides recommendations for the development and sustenance of community health workers. The recommendations are a result of the San Antonio Community Health Worker Summit held January 2010. Recommendations include defining the workforce, training standards, evaluating financial benefit, strategizing Medicaid reimbursement, and creating support networks. (Protected by copyright but accessible for download at Project Muse.)

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Role Development of Community Health Workers: An Examination of Selection and Training Processes in the Intervention Literature

Consistent reporting of CHW selection and training will allow consumers of intervention research to better interpret study findings. A standard approach to reporting selection and training processes will also more effectively guide the design and implementation of future CHW programs. All community-based researchers must find a balance between describing the research process and reporting more traditional scientific content. The current conceptual model provides a guide for standard reporting in the CHW literature. (Only the abstract is in the public domain.)

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Sentara Healthcare: Making Patient Safety an Enduring Organizational Value

Sentara Healthcare, an integrated health care delivery system serving parts of Virginia and North Carolina, has developed a systematic program to foster a culture of safety throughout its member hospitals, with the aim of reducing the potential for patient harm. During the past five years, Sentara has intensified and expanded the program. The initiative has helped to reduce the measured rate of serious safety events at Sentara hospitals by 80 percent over seven years.

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(700 KB)

Service User and Carer Involvement in the National Mental Health Development Unit

This report highlights the findings of an evaluation of service user and carer (peer specialist and health navigator) involvement within Britain's National Mental Health Development Unit and its predecessor, and the National Institute for Mental Health in England. The report concludes that effective peer specialist and navigator involvement is needed at a national level across all Government departments. The aim is to ensure that the advice of peer specialists and navigators is taken on board when developing and implementing decisions, particularly in relation to decisions about policy and practice within the field of mental health.

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(500 KB)

Skills Required for Mental Health Providers Integrated into Primary Care

MaineHealth has developed a synopsis of core competencies for mental health providers in primary care that describes the skill sets needed and makes recommendations to providers about how to establish mental health services in primary care setting.

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(40 K)

Strategies to Put Patients at the Center of Primary Care

AHRQ encourages medical practice decision makers to promote greater patient engagement in their own care, quality improvement in the practice, and in the development and implementation of policy and research. Putting the patient at the center of the PCMH is one key to ensuring that this health care delivery model meet patients' needs and achieves its potential for improving health.

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(108 KB)

Transformation of Health and Health Care Delivery: A Conversation with Barbara Spurrier, Administrative Director of the Mayo Clinic Center for Innovation

The AHRQ Innovations Exchange Team interviewed Barbara Spurrier to explore lessons learned from experience of the Mayo Clinic's Center for Innovation. The Center was launched in 2008 with a goal to deliver health care in ways that are accessible, affordable, and sustainable.

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Transforming Community Health Centers into Patient-Centered Medical Homes: The Role of Payment Reform

This report examines how changes in the way federally qualified health centers (FQHCs) are financed could support the transformation of these critical safety-net providers into high performing patient-centered medical homes. Through surveys and interviews, the authors explore the current landscape of health center involvement in medical home initiatives, adoption of medical home standards, and receipt of payment incentives. Based on their findings, the authors make preliminary recommendations to encourage health centers to serve as patient- and community-centered medical homes.

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(430 KB)

Transforming the Delivery of Care in the Post-Health Reform Era: What Role Will Community Health Workers Play?

The Patient Protection and Affordable Care Act (PPACA) affords opportunities to sustain the role of community health workers (CHWs). Strategies encouraged by PPACA are prevention and care coordination, functions that have been performed by CHWs for decades, particularly among underserved populations. The two key delivery models promoted in the PPACA are accountable care organizations and health homes. Payment structures encouraged by PPACA to support these delivery models offer the vehicles to sustain the role of these valued workers. (Only the abstract is in the public domain.)

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Triple AIM Journey: Improving Population Health and Patients' Experience of Care, While Reducing Costs

Case studies of three organizations participating in the Institute for Healthcare Improvement's Triple Aim initiative shed light on how they are partnering with provid¬ers and organizing care to improve the health of a population and patients' experience of care while lowering-or at least reducing the rate of increase in-the per capita cost of care.

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(600 KB)

Understanding the Behavioral Healthcare Crisis: The Promise of Integrated Care and Diagnostic Reform

The book offers a review what reforms are needed in healthcare and provides specific recommendations. Some of the serious concerns about the healthcare system that Cummings, O'Donohue, and their contributors address include access problems, safety problems, costs problems, the uninsured, and problems with efficacy.

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Unique Model of the Community Health Worker: The MGH Chelsea Community Health Improvement Team

The role of the CHW is gaining much deserved attention. However, a system needs to be built for any CHW program to be successful and sustainable. This article describes a unique approach to community health work at the Massachusetts General Hospital Chelsea HealthCare Center, where a well-integrated CHW model provides support for patients, providers, the community at large, and the internal CHW staff. (Only the abstract is in the public domain.)

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Value of an Integrated Healthcare System: How MaineHealth Serves Its Communities, Members and Employees

MaineHealth is a non-profit integrated health system providing a range of care from prevention and health maintenance through tertiary services, rehabilitation, chronic care and long-term care. The health system serves three-quarters of the state's population. MaineHealth received funding from the Informed Medical Decisions Foundation to serve as a model program demonstration site for excellence in clinical care, patient safety, education and research.

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(2.3 MB)

Wellness Coaching: A New Role for Peers

People with serious mental illnesses are at greater risk of living with untreated chronic medical conditions that severely impact their quality of life and result in premature mortality. Wellness coaching by peers in recovery has potential to address health and wellness issues facing persons living with mental illnesses who are at high risk of comorbid medical conditions. (Only the abstract is in the public domain.)

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