559283
research-article2014
JPCXXX10.1177/2150131914559283Journal of Primary Care & Community HealthMaragakis et al
Case Studies
Using Quality Improvement to Increase Access to Behavioral Health Care in Federally Qualified Health Centers
Journal of Primary Care & Community Health 2015, Vol. 6(3) 182–186 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/2150131914559283 jpc.sagepub.com
Alexandros Maragakis1, Cassandra Snipes2, Joseph Mazzucotelli3, and Charles Duarte3
Abstract Objectives: Integrated care programs, in which behavioral health is integrated in primary care settings, have been widely implemented as solution to rising health care expenditures. A number of recommendations for implementation of integrated care have been published in the past decade; however, data regarding how to produce the most effective system are lacking. This may be because of the fact that existing integrated care programs do not institute quality improvement initiatives that could generate this needed data. Methods: A quality improvement program was instituted at an integrated Federally Qualified Health Center. As a result, productivity and no-show rates were analyzed for two psychology externs providing integrated care services. A process map was created to identify systematic methods to improve outcomes. Results: There were statistically significant increases to productivity increased and decreases no-show rates through systematic changes. Conclusion: This case study provides evidence that quality improvement systems in integrated care can result in systemic changes that improve access to care. Keywords access to care, community health centers, program evaluation, quality improvement, efficiency
Introduction Development of clinical care pathways to reduce health care costs has become an international agenda. Specifically, pathways associated with the integration of behavioral health services in primary care settings have received particular attention.1 This model, known as integrated care (IC), was generated in part as a response to the fact that 50% to 70% of individuals seen in a primary care setting suffer from a clinically relevant behavioral health problem.2 By integrating behavioral health consultants (BHCs) in the primary care setting, patients are able to see both their primary care provider (PCP) and receive behavioral health intervention in the same location and at times, during the same visit. Perhaps more important, BHCs and PCPs can develop a collaborative treatment plan to address complex symptom presentations. This integration can increase quality of care and reduce stigma traditionally associated with behavioral health care. Furthermore, IC also has been shown to reduce overall medical costs by leveraging PCPs’ time and reducing the use of specialty and emergency care.3 Although there has been a proliferation of guidelines regarding implementation of IC,4-6 data indicating the best way to achieve optimum integration are lacking.1 The use of quality improvement (QI) initiatives by IC systems can aid
in generating these sorely needed evidence-based answers.7 QI is a philosophy and set of tools that systematically identify measurable and meaningful outcomes in an attempt to understand the processes that influences them.8 Through this systematic evaluation, learning trials are performed in an attempt to continuously improve outcomes. These learning trials also help enhance the QI system of measurement because of the fact that they may generate hypotheses regarding possible systematic change. An important BHCs metric in an IC program is their productivity.7 Analysis of productivity and no-show rates, 2 factors that are interrelated, may help identify possible gaps in the IC program (eg, low productivity and low no-show rates may indicate that referrals from PCPs are not occurring effectively). This case study presents the use of a QI system to increase the productivity and reduce the patient
1
University of Maryland School of Medicine, Baltimore, MD, USA University of Nevada, Reno, NV, USA 3 Community Health Alliance, Reno, NV, USA 2
Corresponding Author: Alexandros Maragakis, University of Maryland School of Medicine, 701 W. Pratt Street, Third Floor, Baltimore, MD 21230, USA. Email: [email protected]
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183
Maragakis et al 1.9 1.7 1.5
Change in Extern schedule
1.3 Pa ents Per Hour 1.1 0.9 0.7
Extern #1 Extern #2
0.5 0.3
Figure 1. Total productivity.
metrics for PCPs at CHA. However, since the BHC externs are not eligible to bill insurance companies, administration did not initially analyze productivity and no-show rates reports. Therefore, it was uncertain how optimally BHCs time was being used. When the topic of BHC productivity was initially addressed, both administrative and medical staff reported high satisfaction with the productivity and accessibility. However, both externs reported that they were under the optimal productivity goal of two patients per hour. This concern spurred the analysis of productivity and no-show data for both BHCs and implementation of QI initiatives.
Data Source
no-show rate of behavioral health care providers, in order improve patient access to behavioral health services.
Setting Community Health Alliance: Federally Qualified Health Centers in Northern Nevada Community Health Alliance (CHA) was founded in 2012 to address the need of low-income families with inadequate access to health care, via a merger of 2 existing Northern Nevada health care systems: Health Access Washoe County (HAWC) and Saint Mary’s Mission Outreach. Since the merger, CHA has provided primary medical, behavioral, and dental care for both adult and pediatric populations at 4 distinct locations. In 2013, X served a total of approximately 26 300 patients. Of these patients, the majority identified as either Hispanic/Latino (49%) or Caucasian (41%). The overwhelming majority of patients that receive services at X live at or below 100% of the federal poverty line. Integrated Care at Community Health Alliance. In August 2012, X began integration efforts by collaborating with the University of Nevada, Reno. This partnership resulted in the hiring of a 20 hours per week psychological extern (a doctoral student in Clinical Psychology at the University of Nevada), who was trained specifically in IC. During the initial months, clinical pathways and IC practices were created (eg, behavioral health screening of all patients) to support the extern’s role. This BHC role included brief psychological assessment, intervention (ie, 20-30 minute appointments), and patient consultation with PCPs. A second 20 hour per week psychological extern was hired to provide care at 2 additional X health centers in August 2013, which resulted in IC services at 3 of the 4 health centers operated by CHA. Productivity and No-Show Rates Analyses at Community Health Alliance. Productivity and no-show rates are important
Behavioral health consultant productivity and no-show reports, assessed by the electronic health record, were generated for the period from August 2013 to May 2014. Potential areas for improvements were identified and changes to the IC system were implemented. Data were continually analyzed to determine if the intervention had met the objectives of increased productivity and decreased patient no-shows.
Results In October 2013, concerns regarding productivity and patient no-shows were raised and a retrospective analysis was conducted between the months of August 2013 and October 2013 (Figures 1 and 2; Tables 1 and 2). The 2 BHC externs, across the 3 locations, had provided 248 individual services (extern 1 = 155). During that time, they both averaged a productivity rate of 0.85 patients per hour. Patient no-show rates during that time period for extern 1averaged at 30% and for extern 2 averaged at 19%. These data remained consistent for the months of November and December. In December 2013, a QI approach was taken to address the underutilization of the BHC externs. After deliberation regarding the process of care map (see Figure 3), it was decided by the IC team that the appointment blocks for patients would be scheduled for 20 minutes, instead of 30 minutes, starting in February 2014. By reducing appointment times by 10 minutes, it was hypothesized that patients would be provided with more options to schedule an appointment, given that the extern’s hours were limited. This change would also reduce the impact of no-shows on reaching the productivity of 2 patients per hour by allowing for maximum of 3 patients, instead of 2, to be seen. Finally, it was hypothesized that this change would allow for more appointment times to be available for “warm” hand-offs to occur, for patients to receive behavior health services immediately. Immediately after this scheduling change took place, productivity was affected for both BHC externs. The
Downloaded from jpc.sagepub.com at UNIV OF WINNIPEG on October 13, 2015
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Journal of Primary Care & Community Health 6(3)
35% 30% 25% 20% 15%
Extern #1
Reminder calls started for Extern 1
10%
Extern #2
5% 0%
Figure 2. Total no-show rates. Table 1. Psychology Extern Behavioral Health Consultant (BHC) Productivity August 2013 to May 2014.
Patients seen by BHC 1 Patients per hour BHC 1 Patients seen by BHC 2 Patients per hour BHC 2 Total patients served by BHCs
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
46 0.80 N/A N/A 46
55 0.85 48 0.82 103
54 0.90 45 0.87 99
56 0.80 59 0.95 115
56 0.90 47 0.81 103
53 1.08 68 0.92 121
90 1.25 51 1.21 141
102 1.50 72 1.26 174
98 1.56 67 1.18 165
99 1.80 56 1.24 155
Table 2. Psychology Extern Behavioral Health Consultant No-Show Rates August 2013 to May 2014.a
BHC 1 BHC 2
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
31 Not applicable
30 18
29 20
30 19
31 20
32 21
26 20
22 19
27 17
27 21
a
Values are given as percentage.
2 BHC externs, across the 3 locations, had provided 635 individual services (extern 1 = 389). In comparison with baseline (0.85 patients per hour), extern 1 averaged a productivity rate of 1.52 patients per hour—t(7) = 6.62, P < .001)—with the last point of 1.8 patients per hour. Extern 2 average productivity rate was 1.22 patients per hour—t(6) = 9.87, P < .001. To further improve services, QI was also used to address, the discrepancy of no-show rates between the 2 externs was also addressed. It was hypothesized that the reminder calls that patients who were scheduled with BHC extern 2 were receiving made a significant impact on no-show rates. To address this, starting in February 2014, reminder calls were made for all patients at CHA who were receiving behavioral health services. This resulted in an end result of a 5% average decrease in no-show rates for extern #1—t(7) = 5.78, P < .001.
Discussion Through the use of QI, CHA was able to improve the efficiency and access of its BHC externs. Analyzing productivity data for the BHC externs led to specific systematic change in care processes that were followed by statistically significant increases in total patients per hour and reduction in no-show rates. By engaging in this quality improvement process, 1 BHC extern yielded almost an 80% increase in productivity. Also, by placing reminder calls for extern 1, there was average 5% drop in the total of no-show rates. Through the use of QI, other potential factors that may influence productivity and no-show rates are currently being addressed at CHA. For example, it is hypothesized that new medical providers may not effectively use or understand the referral process to BHCs and the importance of the “warm” hand-off. This in turn may impact productivity and no-show
Downloaded from jpc.sagepub.com at UNIV OF WINNIPEG on October 13, 2015
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Maragakis et al
Patient is roomed for appointment
Behavioral health screening
Provider reviews screening
Behavioral health issue detected
No
Continue with appointment without making behavioral health referral
Yes Behavioral health provider onsite Yes “Warm” hand-off to behavioral health provider
Behavioral health appointment
No
Continue with appointment and make behavioral health referral
Thirty minute appointment scheduled with extern during check out
Patient receives reminder call 24 hours before appointment (extern 2 only)
Behavioral health appointment
Figure 3. Process map of behavioral health referral and appointment scheduling.
rates. As a result, CHA has begun an initiative to provide refresher training to all staff and providers in IC practice. This case study provides preliminary evidence of the utility of QI in IC. Through the use of data gathered from the electronic health record, areas that were not initially a concern with administration and staff were identified. By collecting these data and using items, like the process map,
areas that may have been influencing outcomes were identified and changed on a systematic level. These changes were followed with statistically significant improved outcomes across multiple providers in various settings. This provides some support that QI programs are an integral and important aspect of successful implementation of integrated care.
Downloaded from jpc.sagepub.com at UNIV OF WINNIPEG on October 13, 2015
186
Journal of Primary Care & Community Health 6(3)
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
Improvement in Behavioral Health. New York, NY: Springer. In press. 8. Bobbitt BL, Cate RA, Beardsley SD, Azocar F, McCulloch J. Quality improvement and outcomes in the future of professional psychology: opportunities and challenges. Prof Psychol Res Pract. 2012;43:551-559.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Author Biographies
References
Alexandros Maragakis, MA, is a predoctoral intern at the University of Maryland School of Medicine. His research and clinical work involves integrated primary and behavioral providers, and using quality improvement to enhance access to care.
1. Robinson PJ, Strosahl K. Behavioral health consultation and primary care: lessons learned. J Clin Psychol Med Settings. 2009;16:58-71. 2. VandenBos GR, DeLeon P. The use of psychotherapy to improve physical health. Psychotherapy. 1988;125:335-343. 3. Cummings NA, O’Donohue WT, Cummings JL. The financial dimension of integrated behavioral/primary care. J Clin Psychol Med Settings. 2009;16:31-39. 4. Blount FA, Miller BF. Addressing the workforce crisis in integrated primary care. J Clin Psychol Med Settings. 2009;16:113-119. 5. O’Donohue W, Cummings N, Cucciarre M, Cummings J, Runyan C. Integrated Behavioral Healthcare: A Guide for Effective Action. New York, NY: Prometheus; 2006. 6. Rozensky RH. Health care reform: preparing the psychology workforce. J Clin Psychol Med Settings. 2012;19:5-11. 7. Maragakis A, O’Donohue W. Quality improvement in integrated care. In: O’Donohue W, Maragakis A, eds. Quality
Cassandra Snipes, MA, is a doctoral candidate in Clinical Psychology at the University of Nevada, Reno. She also practices as Behavioral Health Consultant in an integrated care setting at Community Health Alliance, Reno, Nevada. Joseph Mazzucotelli, MA, MBA, is a graduate from the University of Nevada and the University of Phoenix. For the last 19 years, he has worked in health care administration, including serving as a CEO/administrator for Behavioral Health Hospitals. He is currently the chief operating officer for Community Health Alliance. Charles Duarte, MBA, is a graduate of the University of Hawaii and currently is the chief executive officer for Community Health Alliance, a non-profit Federally Qualified Health Center in Reno, Nevada. He previously ran community health centers and administered Medicaid programs in Hawaii and Nevada.
Downloaded from jpc.sagepub.com at UNIV OF WINNIPEG on October 13, 2015
research-article2014
JPCXXX10.1177/2150131914559283Journal of Primary Care & Community HealthMaragakis et al
Case Studies
Using Quality Improvement to Increase Access to Behavioral Health Care in Federally Qualified Health Centers
Journal of Primary Care & Community Health 2015, Vol. 6(3) 182–186 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/2150131914559283 jpc.sagepub.com
Alexandros Maragakis1, Cassandra Snipes2, Joseph Mazzucotelli3, and Charles Duarte3
Abstract Objectives: Integrated care programs, in which behavioral health is integrated in primary care settings, have been widely implemented as solution to rising health care expenditures. A number of recommendations for implementation of integrated care have been published in the past decade; however, data regarding how to produce the most effective system are lacking. This may be because of the fact that existing integrated care programs do not institute quality improvement initiatives that could generate this needed data. Methods: A quality improvement program was instituted at an integrated Federally Qualified Health Center. As a result, productivity and no-show rates were analyzed for two psychology externs providing integrated care services. A process map was created to identify systematic methods to improve outcomes. Results: There were statistically significant increases to productivity increased and decreases no-show rates through systematic changes. Conclusion: This case study provides evidence that quality improvement systems in integrated care can result in systemic changes that improve access to care. Keywords access to care, community health centers, program evaluation, quality improvement, efficiency
Introduction Development of clinical care pathways to reduce health care costs has become an international agenda. Specifically, pathways associated with the integration of behavioral health services in primary care settings have received particular attention.1 This model, known as integrated care (IC), was generated in part as a response to the fact that 50% to 70% of individuals seen in a primary care setting suffer from a clinically relevant behavioral health problem.2 By integrating behavioral health consultants (BHCs) in the primary care setting, patients are able to see both their primary care provider (PCP) and receive behavioral health intervention in the same location and at times, during the same visit. Perhaps more important, BHCs and PCPs can develop a collaborative treatment plan to address complex symptom presentations. This integration can increase quality of care and reduce stigma traditionally associated with behavioral health care. Furthermore, IC also has been shown to reduce overall medical costs by leveraging PCPs’ time and reducing the use of specialty and emergency care.3 Although there has been a proliferation of guidelines regarding implementation of IC,4-6 data indicating the best way to achieve optimum integration are lacking.1 The use of quality improvement (QI) initiatives by IC systems can aid
in generating these sorely needed evidence-based answers.7 QI is a philosophy and set of tools that systematically identify measurable and meaningful outcomes in an attempt to understand the processes that influences them.8 Through this systematic evaluation, learning trials are performed in an attempt to continuously improve outcomes. These learning trials also help enhance the QI system of measurement because of the fact that they may generate hypotheses regarding possible systematic change. An important BHCs metric in an IC program is their productivity.7 Analysis of productivity and no-show rates, 2 factors that are interrelated, may help identify possible gaps in the IC program (eg, low productivity and low no-show rates may indicate that referrals from PCPs are not occurring effectively). This case study presents the use of a QI system to increase the productivity and reduce the patient
1
University of Maryland School of Medicine, Baltimore, MD, USA University of Nevada, Reno, NV, USA 3 Community Health Alliance, Reno, NV, USA 2
Corresponding Author: Alexandros Maragakis, University of Maryland School of Medicine, 701 W. Pratt Street, Third Floor, Baltimore, MD 21230, USA. Email: [email protected]
Downloaded from jpc.sagepub.com at UNIV OF WINNIPEG on October 13, 2015
183
Maragakis et al 1.9 1.7 1.5
Change in Extern schedule
1.3 Pa ents Per Hour 1.1 0.9 0.7
Extern #1 Extern #2
0.5 0.3
Figure 1. Total productivity.
metrics for PCPs at CHA. However, since the BHC externs are not eligible to bill insurance companies, administration did not initially analyze productivity and no-show rates reports. Therefore, it was uncertain how optimally BHCs time was being used. When the topic of BHC productivity was initially addressed, both administrative and medical staff reported high satisfaction with the productivity and accessibility. However, both externs reported that they were under the optimal productivity goal of two patients per hour. This concern spurred the analysis of productivity and no-show data for both BHCs and implementation of QI initiatives.
Data Source
no-show rate of behavioral health care providers, in order improve patient access to behavioral health services.
Setting Community Health Alliance: Federally Qualified Health Centers in Northern Nevada Community Health Alliance (CHA) was founded in 2012 to address the need of low-income families with inadequate access to health care, via a merger of 2 existing Northern Nevada health care systems: Health Access Washoe County (HAWC) and Saint Mary’s Mission Outreach. Since the merger, CHA has provided primary medical, behavioral, and dental care for both adult and pediatric populations at 4 distinct locations. In 2013, X served a total of approximately 26 300 patients. Of these patients, the majority identified as either Hispanic/Latino (49%) or Caucasian (41%). The overwhelming majority of patients that receive services at X live at or below 100% of the federal poverty line. Integrated Care at Community Health Alliance. In August 2012, X began integration efforts by collaborating with the University of Nevada, Reno. This partnership resulted in the hiring of a 20 hours per week psychological extern (a doctoral student in Clinical Psychology at the University of Nevada), who was trained specifically in IC. During the initial months, clinical pathways and IC practices were created (eg, behavioral health screening of all patients) to support the extern’s role. This BHC role included brief psychological assessment, intervention (ie, 20-30 minute appointments), and patient consultation with PCPs. A second 20 hour per week psychological extern was hired to provide care at 2 additional X health centers in August 2013, which resulted in IC services at 3 of the 4 health centers operated by CHA. Productivity and No-Show Rates Analyses at Community Health Alliance. Productivity and no-show rates are important
Behavioral health consultant productivity and no-show reports, assessed by the electronic health record, were generated for the period from August 2013 to May 2014. Potential areas for improvements were identified and changes to the IC system were implemented. Data were continually analyzed to determine if the intervention had met the objectives of increased productivity and decreased patient no-shows.
Results In October 2013, concerns regarding productivity and patient no-shows were raised and a retrospective analysis was conducted between the months of August 2013 and October 2013 (Figures 1 and 2; Tables 1 and 2). The 2 BHC externs, across the 3 locations, had provided 248 individual services (extern 1 = 155). During that time, they both averaged a productivity rate of 0.85 patients per hour. Patient no-show rates during that time period for extern 1averaged at 30% and for extern 2 averaged at 19%. These data remained consistent for the months of November and December. In December 2013, a QI approach was taken to address the underutilization of the BHC externs. After deliberation regarding the process of care map (see Figure 3), it was decided by the IC team that the appointment blocks for patients would be scheduled for 20 minutes, instead of 30 minutes, starting in February 2014. By reducing appointment times by 10 minutes, it was hypothesized that patients would be provided with more options to schedule an appointment, given that the extern’s hours were limited. This change would also reduce the impact of no-shows on reaching the productivity of 2 patients per hour by allowing for maximum of 3 patients, instead of 2, to be seen. Finally, it was hypothesized that this change would allow for more appointment times to be available for “warm” hand-offs to occur, for patients to receive behavior health services immediately. Immediately after this scheduling change took place, productivity was affected for both BHC externs. The
Downloaded from jpc.sagepub.com at UNIV OF WINNIPEG on October 13, 2015
184
Journal of Primary Care & Community Health 6(3)
35% 30% 25% 20% 15%
Extern #1
Reminder calls started for Extern 1
10%
Extern #2
5% 0%
Figure 2. Total no-show rates. Table 1. Psychology Extern Behavioral Health Consultant (BHC) Productivity August 2013 to May 2014.
Patients seen by BHC 1 Patients per hour BHC 1 Patients seen by BHC 2 Patients per hour BHC 2 Total patients served by BHCs
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
46 0.80 N/A N/A 46
55 0.85 48 0.82 103
54 0.90 45 0.87 99
56 0.80 59 0.95 115
56 0.90 47 0.81 103
53 1.08 68 0.92 121
90 1.25 51 1.21 141
102 1.50 72 1.26 174
98 1.56 67 1.18 165
99 1.80 56 1.24 155
Table 2. Psychology Extern Behavioral Health Consultant No-Show Rates August 2013 to May 2014.a
BHC 1 BHC 2
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
31 Not applicable
30 18
29 20
30 19
31 20
32 21
26 20
22 19
27 17
27 21
a
Values are given as percentage.
2 BHC externs, across the 3 locations, had provided 635 individual services (extern 1 = 389). In comparison with baseline (0.85 patients per hour), extern 1 averaged a productivity rate of 1.52 patients per hour—t(7) = 6.62, P < .001)—with the last point of 1.8 patients per hour. Extern 2 average productivity rate was 1.22 patients per hour—t(6) = 9.87, P < .001. To further improve services, QI was also used to address, the discrepancy of no-show rates between the 2 externs was also addressed. It was hypothesized that the reminder calls that patients who were scheduled with BHC extern 2 were receiving made a significant impact on no-show rates. To address this, starting in February 2014, reminder calls were made for all patients at CHA who were receiving behavioral health services. This resulted in an end result of a 5% average decrease in no-show rates for extern #1—t(7) = 5.78, P < .001.
Discussion Through the use of QI, CHA was able to improve the efficiency and access of its BHC externs. Analyzing productivity data for the BHC externs led to specific systematic change in care processes that were followed by statistically significant increases in total patients per hour and reduction in no-show rates. By engaging in this quality improvement process, 1 BHC extern yielded almost an 80% increase in productivity. Also, by placing reminder calls for extern 1, there was average 5% drop in the total of no-show rates. Through the use of QI, other potential factors that may influence productivity and no-show rates are currently being addressed at CHA. For example, it is hypothesized that new medical providers may not effectively use or understand the referral process to BHCs and the importance of the “warm” hand-off. This in turn may impact productivity and no-show
Downloaded from jpc.sagepub.com at UNIV OF WINNIPEG on October 13, 2015
185
Maragakis et al
Patient is roomed for appointment
Behavioral health screening
Provider reviews screening
Behavioral health issue detected
No
Continue with appointment without making behavioral health referral
Yes Behavioral health provider onsite Yes “Warm” hand-off to behavioral health provider
Behavioral health appointment
No
Continue with appointment and make behavioral health referral
Thirty minute appointment scheduled with extern during check out
Patient receives reminder call 24 hours before appointment (extern 2 only)
Behavioral health appointment
Figure 3. Process map of behavioral health referral and appointment scheduling.
rates. As a result, CHA has begun an initiative to provide refresher training to all staff and providers in IC practice. This case study provides preliminary evidence of the utility of QI in IC. Through the use of data gathered from the electronic health record, areas that were not initially a concern with administration and staff were identified. By collecting these data and using items, like the process map,
areas that may have been influencing outcomes were identified and changed on a systematic level. These changes were followed with statistically significant improved outcomes across multiple providers in various settings. This provides some support that QI programs are an integral and important aspect of successful implementation of integrated care.
Downloaded from jpc.sagepub.com at UNIV OF WINNIPEG on October 13, 2015
186
Journal of Primary Care & Community Health 6(3)
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
Improvement in Behavioral Health. New York, NY: Springer. In press. 8. Bobbitt BL, Cate RA, Beardsley SD, Azocar F, McCulloch J. Quality improvement and outcomes in the future of professional psychology: opportunities and challenges. Prof Psychol Res Pract. 2012;43:551-559.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Author Biographies
References
Alexandros Maragakis, MA, is a predoctoral intern at the University of Maryland School of Medicine. His research and clinical work involves integrated primary and behavioral providers, and using quality improvement to enhance access to care.
1. Robinson PJ, Strosahl K. Behavioral health consultation and primary care: lessons learned. J Clin Psychol Med Settings. 2009;16:58-71. 2. VandenBos GR, DeLeon P. The use of psychotherapy to improve physical health. Psychotherapy. 1988;125:335-343. 3. Cummings NA, O’Donohue WT, Cummings JL. The financial dimension of integrated behavioral/primary care. J Clin Psychol Med Settings. 2009;16:31-39. 4. Blount FA, Miller BF. Addressing the workforce crisis in integrated primary care. J Clin Psychol Med Settings. 2009;16:113-119. 5. O’Donohue W, Cummings N, Cucciarre M, Cummings J, Runyan C. Integrated Behavioral Healthcare: A Guide for Effective Action. New York, NY: Prometheus; 2006. 6. Rozensky RH. Health care reform: preparing the psychology workforce. J Clin Psychol Med Settings. 2012;19:5-11. 7. Maragakis A, O’Donohue W. Quality improvement in integrated care. In: O’Donohue W, Maragakis A, eds. Quality
Cassandra Snipes, MA, is a doctoral candidate in Clinical Psychology at the University of Nevada, Reno. She also practices as Behavioral Health Consultant in an integrated care setting at Community Health Alliance, Reno, Nevada. Joseph Mazzucotelli, MA, MBA, is a graduate from the University of Nevada and the University of Phoenix. For the last 19 years, he has worked in health care administration, including serving as a CEO/administrator for Behavioral Health Hospitals. He is currently the chief operating officer for Community Health Alliance. Charles Duarte, MBA, is a graduate of the University of Hawaii and currently is the chief executive officer for Community Health Alliance, a non-profit Federally Qualified Health Center in Reno, Nevada. He previously ran community health centers and administered Medicaid programs in Hawaii and Nevada.
Downloaded from jpc.sagepub.com at UNIV OF WINNIPEG on October 13, 2015
