Our nation faces a behavioral health crisis as mental health and substance use disorders are on the rise, while access to care for these conditions has become increasingly limited.32 Behavioral health is an overarching term which includes "mental health and substance abuse conditions, life stressors and crises, stress-related physical symptoms, and health behaviors."33 As primary care is the first point of entry into the healthcare system for many people, primary care clinicians are often in a good position to diagnose and treat these common conditions.34 Evidence suggests that providing comprehensive behavioral health care within the primary care setting leads to improved care and reduced costs.35 AHRQ defines behavioral health and primary care integration (also referred to as “behavioral health integration”, “integrated care” and “collaborative care”)33 as:
The care that results from 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."33
In addition to funding contracts and research grants focused on behavioral health and behavioral health integration, AHRQ hosts the Academy for Integrating Behavioral Health and Primary Care, and has developed several resources in this topic area. This section of the report includes a summary of AHRQ’s primary care grants, initiatives, and resources with a main focus on behavioral health and behavioral health integration.
Grants with a focus on health equity are indicated with this icon.
Grants
There were 9 AHRQ primary care grants actively funded during FYs 2021 and 2022 that focused mainly on behavioral health or behavioral health integration. This included four R01s (Research Projects), two R18s (Research Demonstration and Dissemination Projects), one R03 (Small Research Grant), one R21 (Exploratory/ Developmental Grant), and one K08 (Mentored Clinical Scientist Development Award). An additional nine grants included some focus on behavioral health content and are described in other sections of this report, including in Practice and Quality Improvement (6) and Person-Centered Care (3).
Below are tables, organized by subtopic, which include short summaries of the 9 studies focused mainly on behavioral health or behavioral health integration. The 3 subtopics include use of digital healthcare tools in behavioral health, substance use disorders, and behavioral health integration.
Behavioral Health Integration
Three studies focus on behavioral health integration.
| Behavioral Health Integration in Community Health Centers and Hospital Emergency Department Utilization (R03) |
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PI: Kathleen Carey Organization: Boston University Medical Campus; School of Public Health Uses the existing variation in the level of behavioral health services provided in community health centers to examine if greater integration of behavioral health services in primary care settings leads to reductions in emergency department visits for behavioral health issues. |
| Implementation and Evaluation of an Evidence-Based Physical Activity Screening and Promotion Program in Six Primary Care Clinics (K08) |
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PI: Sarah Elizabeth Linke Organization: University of California, San Diego; School of Medicine; Family Medicine Looks at the barriers and facilitators of incorporating screening and counseling for insufficient physical activity into routine primary care visits with a referral to primary care behavioral health. This study builds on evidence that counseling to increase physical activity is more effective when delivered by behavioral health providers. |
| Impact of a Novel Community-Based Biobehavioral Chronic Pain Team Training Program (4PCP) on Practitioner and Patient Outcomes (R01) |
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PI: Thomas C. Chelimsky Organization: Virginia Commonwealth University; School of Medicine; Neurology Looks at using a “biopsychosocial” approach to treating chronic pain rather than a “biopharmacologic” approach. This “biopsychosocial” approach treats chronic pain syndrome as a brain disorder, which has been reinforced though negative cognitive, emotional, and behavioral habits. In a previous pilot study, the researchers demonstrated that primary care practitioners were eager to implement this new approach, and those who did so had increased confidence with chronic pain management, reduced visit times, and improved patient pain. The primary care practices in this study will receive training from a paired psychologist and a physical therapist to build a clinical team. The study will examine if patient improvements can be sustained for 2 years and if increased practitioner confidence leads to a tapering of prescribed opioids. |
Use of Digital Healthcare Tools in Behavioral Health
Three studies look at the use of digital healthcare tools in behavioral health, as described in the following table.
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PI: Carmela Alcantara Organization: Columbia University New York Morningside; Schools of Social Welfare/Work; Other Health Professions Examines the effectiveness of an electronic health intervention to provide culturally adapted cognitive behavioral therapy to treat insomnia among Spanish-speaking Hispanic primary care patients with chronic insomnia. |
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PI: Nathalie Moise Organization: Columbia University Health Sciences; School of Medicine; Internal Medicine Examines if care manager technical assistance, provider education, and an automated shared decision-making process—with an interactive shared decision-making tool—improves clinician and patient participation in collaborative care to treat depression in primary care. Collaborative care in this study relies on care managers to provide antidepressant adherence counseling and/or psychotherapy. |
| Implementation of Digital Mental Health Tools in Ambulatory Care Coordination (R01) |
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PI: Emily Gardiner Lattie Organization: Northwestern University at Chicago; Domestic Higher Education Adapts a digital mental health platform and service model to improve access to, and coordination of, mental health services in ambulatory care. |
Substance Use Disorders
Three studies in this topic area focused on substance use disorders. In addition to the grants described in the table below, there were six grants focused on managing unhealthy alcohol use that are part of an EvidenceNOW initiative and are described in the Practice and Quality Improvement section, along with the other EvidenceNOW grants.
Two of the studies about substance use disorders described below focus on opioid use disorder. In addition to these, there are another eight AHRQ primary care grants funded during the 2021 and 2022 period that look at opioids—many of which focused on chronic pain and medication safety. The full list of the 10 opioid related grants is included in Appendix C: Opioids.
| Group Well Child Care Intervention for Infants of Mothers in Treatment for Opioid Use Disorder (R18) |
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PIs: Neera Goyal; Vanessa L. Short Organization: Alfred I. Du Pont Hospital for Children; Independent Hospital Looks at the use of comprehensive group well child visits for mothers with opiate use disorder and their children. The group visits examined in this study allow for increased time with the pediatrician, peer-to-peer learning, and an enhanced focus on behavior change and self-care. Learn more about this study in a recent NCEPCR webinar: Qualitative Methods Used in AHRQ Funded Primary Care Research. |
ECHO-F Model to Expand Medication Assisted Treatment in Rural Primary Care (R18) |
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PI: Julie G. Salvador Organization: University of New Mexico Health Sciences Center; School of Medicine; Psychiatry Uses the Extensions for Community Healthcare Outcomes (ECHO©) model, with additional supports as needed, to train primary care providers in rural New Mexico to provide medication to treat opioid use disorders. |
| Real-time Assessment of Dialogue in Motivational Interviewing Training (ReadMI) (R21) |
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PI: Paul J Hershberger Organization: Wright State University; Schools of Medicine, Family Medicine Develops and tests Real-time Assessment of Dialogue in Motivational Interviewing (ReadMI), a tool to help train primary care clinicians to effectively use motivational interviewing for drug and alcohol misuse intervention. Motivational interviewing (MI) is a strategy clinicians can use to help patients identify and change unhealthy behaviors. ReadMI uses natural language processing to provide low-cost analysis of MI discussions and give immediate feedback to clinicians. |
Initiatives and Resources
AHRQ developed several resources and materials related to behavioral health and substance use disorders in primary care that were ongoing or new in 2021 and 2022. These resources and materials are described below with links to additional information or to the specific material.
The Academy for Integrating Behavioral Health and Primary Care, which was created in 2010, is a national resource and coordinating center focused on the integration of behavioral health and primary care.36 The Academy’s website serves as a centralized portal for information and materials on behavioral health integration—including a focus on using evidence-based practices to manage unhealthy alcohol use and opioid use disorder.37 The portal includes several materials developed in 2021 and 2022, as described below.
- Materials developed by the EvidenceNOW: Managing Unhealthy Alcohol Use initiative
- Unhealthy Alcohol Use Tools & Resources is an online compendium of tools and resources for clinicians and clinical teams, health system leaders, and patients to support the implementation of evidence-based approaches to manage unhealthy alcohol use.
- The Overview of Medications Used in the Treatment of Alcohol Use Disorder and Frequently Asked Questions includes information about medications approved by the Food and Drug Administration (FDA) for treatment of alcohol use disorder to assist primary care clinicians.
- Implementing Screening and Treatment of Unhealthy Alcohol Use During COVID-19 is a blog post from AHRQ’s Senior Staff Fellow Sebastian Tong, MD MPH on the increased need for screening and treatment for unhealthy alcohol use in primary care during the COVID-19 pandemic.
- Materials developed by the AHRQ Older Adult Opioid Initiative
- Identifying and Testing Strategies for Management of Opioid Use and Misuse in Older Adults in Primary Care Practices: Opioid and Pain Management Tools and Resources. This set of tools and resources can be used for the management of opioids in older adults in primary care practices and includes descriptions, empirical evidence, applicability to older adults and/or primary care practices, and links to resources.
- Management of Opioid Use and Misuse in Older Adults: High-Leverage Changes for Improvement is an infographic providing an overview of change strategies to improve the management of chronic pain and opioid use and misuse among older adults in primary care.
Many other products are currently available on the Academy website, and new resources are developed and shared regularly.
Six Building Blocks: A Team-based Approach to Improving Opioid Management in Primary Care—How-To-Implement Toolkit
This implementation guidance provides a roadmap for healthcare organizations to improve care treatment for patients using
long-term opioid therapy to treat chronic pain.38 After reviewing How-To-Implement Toolkit: Overview to determine which approach fits best, organizations can select the Fast-Track or Full Program Approach. Each approach includes implementation guides, a self-assessment tool, and additional resources.
