Survey 1: Opinion leaders
Ten opinion leaders from medical clinics and two from psychological training clinics took the survey (N=12). We used grounded theory to code the open-ended prompts to identify unique barriers and facilitators to integration. We used two coders per entry to reduce bias. Six barriers (i.e., limited office space, limited public transit, limited parking, difficulty obtaining approval from multiple administrative structures including complicated processes and procedures for approval, and possible push back from similar professions), and four facilitators (i.e., comprehensive psychological services was recently pitched by hospital administration, similar professions may welcome the support of psychology, and obvious desire for in house presurgical evaluations) to integration were noted.
Five areas of patient need were elicited, including serving low SES groups [only a few pro bono/low fare clinics], those without cars, health disparities groups in the city, marginal groups at risk of HIV [including undocumented workers]), people living with HIV/AIDS).
Areas of student training needs including integrated health, behavioral health, consultation, interprofessional teams, and team care planning. On a scale of 1-10, importance of integration was 9.8 (SD = 0.1).
Survey 2: Clinic ORIC
Clinicians and directors (N = 15) completed surveys assessing organizational readiness for implementing change (ORIC), which included questions about knowledge about interdisciplinary teams, the current status of integration in their clinics, their perceived importance, need and desire for integration, and qualitative responses on barriers and facilitators to change in these clinics. Respondents were also asked about burnout. Respondents represented several Rutgers University clinics, including a graduate training clinic in psychology, an affiliate community primary care center, a hospital sleep clinic and pediatric primary care clinic, and a large cancer institute including but not limited to endocrine surgery, surgical oncology, and breast oncology and gynecological oncology. Respondents’ roles included clinic director and psychologist, Nurse Navigator, Advanced Practice Nurse, social worker, nurse clinicians, and physicians. The ORIC scale total score ranges from 12 – 60, with higher scores indicating greater organizational readiness for implementing change. Results from the sample demonstrated a wide range of perceived readiness for change across clinics (M = 26.12, SD = 10.49). There was also a positive correlation between level of satisfaction with being able to help people and degree of integration within the clinic [r(13) = 0.576 p = 0.50].
Respondents were asked to rank, on a scale of 0 – 100, how important they perceived integration of mental health services into medical settings (M = 81.2, SD = 29.78). They were also asked to rank their perception of patient need for mental health integration into medical settings (M = 77.2, SD = 27.98), as well as respondents’ personal desire for integration of other disciplines into their clinic (M = 84.7, SD = 28.81). The range of results are shown in Figures 1-3 (see Figure 1, Figure 2, Figure 3).
Respondents were also asked to share barriers and facilitators to integrating mental health services into their clinics. The most prevalent barrier reported by respondents was financial, with nine of the 15 respondents indicating budget concerns. Additionally, five respondents noted administration and clinicians in positions of power as potential barriers to integration. Few respondents indicated any facilitators to integration, however some listed desire for better patient outcomes, for new clinicians with new ideas, and a demonstrated need for mental health services as facilitators to integration. When asked about whether psychologists-in-training would be appropriate to work in their clinics, 10 of the 15 respondents said that their clinics would be conducive to an integrated training psychologist.
Survey 3: Hospital administration
Two hospital administration leaders (N=2)at CINJ and one at RWJ completed a survey about the desire for integration, barriers and facilitators to integration, and the metrics they would like to see prior to investing in more integration. The desire for further integration of mental health was high, with respondents reporting an average of 8.6 out of 10 desirability for integration. Administrators cited cost, especially in the context of COVID-19 budget crises, as the primary barrier to integration. Desired outcomes demonstrated from preliminary pilot work within their institution was patient quality of life increases, complications decreases, and institutional cost savings.
Survey 4: D&I scientists
Twenty-seven behavioral scientists completed this survey about methods for integration of behavioral health into an entire healthcare system (N=27). A number of theoretical models guiding implementation were noted. Twelve respondents (48%) reported using primary care behavioral health (PCBH) or integrative/collaborative care theoretical models to guide the process of implementation. Other models mentioned include determinant frameworks, AIMS model, biopsychosocial, population-based care, and feminist and multicultural models.
Respondents reported prioritizing integration in primary care/family medicine settings (32%) as well prioritizing clinics with demonstrated interest and readiness (36%) or where patient need was identified (16%). Respondents further highlighted the importance of established relationships (12%) with clinical and administrative leadership and support and buy-in from these professionals (48%) as facilitators to behavioral health integration efforts. Additionally, barriers to successful integration were identified, including billing and reimbursement issues (40%), cost and physical resource concerns (40%), and lack of understanding of behavioral health role and efficacy (44%).
Priority integration list
In order to create a blueprint for where to begin the rollout of behavioral health integration in a healthcare system, these researchers propose a grid measuring patient needs, organizational readiness for change, and student training needs, derived from surveys of clinic providers, stakeholders, opinion leaders and available public health data. Ethically, patient health and wellbeing should be prioritized, followed by clinic organizational readiness for change. As there are inadequate policies for reimbursement for behavioral health integration in the United States, as there is evidence that those who receive training in behavioral health integration tend to practice it more often than those who do not, and as students tend to provide low- or no-cost services, we also incorporated alignment with student training needs. The proposed sustainable intervention includes supervising advanced psychology doctoral students providing services within these clinics. We used self-reported patient needs, as well as public health data about any underserved groups (+10 if mentioned in survey), for the 0-100 patient needs metric. We scaled up ORIC scores to a 0-100 scale to begin integration with the easiest clinics for integration and move on, with lessons learned to the more challenging clinics to integrate, and to conduct additional stakeholder interviews at the bottom 10% ORIC surveys in order to understand the barriers to integration and whether integration is desired or needed. We used psychology stakeholder surveys and interviews to develop a student training needs 0-100 scale. Total score is the average of these scores by clinic, then clinics were organized by the highest to lowest scores in excel (see Table 2). Two raters double-coded for these values, with an inter-rater reliability of 0.90. Conflicts were resolved via discussion with the study team.