To evaluate changes in access to and utilization of behavioral health (BH) services after the integration of psychologists into primary care clinics compared with clinics without integrated psychologists.

We integrated 4 of 12 primary care clinics within our academic health system. We used the median wait time for BH services as a proxy for changes in access and defined BH utilization as the percentage of primary care visits that resulted in contact with a BH clinician within 180 days. We compared changes in access and utilization from the year before integration (September 2015 to September 2016) with the 2 years after integration (October 2016 to October 2018) within integrated clinics and between integrated and nonintegrated clinics. We used difference-in-difference analysis to test the association of study outcomes with the presence of integrated psychologists.

Access and utilization were similar across all practices before integration. After integration, BH utilization increased by 143% in integrated clinics compared with 12% in nonintegrated clinics. The utilization of BH services outside of the medical home (ie, specialty BH service) decreased for integrated clinics only. In clinics with integrated psychologists, 93% of initial BH visits happened on the same day as a need was identified. The median wait time for the 7% in integrated clinics who were not seen on the same day was 11.4 days (interquartile range = 5.3-17.7) compared with 48.3 days (interquartile range = 20.4-93.6) for nonintegrated clinics.

A team-based integration model increased BH utilization and access.

There are meaningful gaps in equitable access to Primary Health Care (PHC), especially for vulnerable populations after widespread reforms in Western countries. The Innovative Models Promoting Access-to-Care Transformation (IMPACT) research program is a Canadian-Australian collaboration that aims to improve access to PHC for vulnerable populations. Relationships were developed with stakeholders in six regions across Canada and Australia where access-related needs could be identified. The most promising interventions would be implemented and tested to address the needs identified. This realist review was conducted to understand how community coalition and outreach (e.g., mobile or pop-up) services improve access for underserved vulnerable residents.

To inform the development and delivery of an innovative intervention to increase access to PHC for vulnerable populations.

A realist review was conducted in collaboration with the Local Innovative Partnership (LIP) research team and the IMPACT research members who conducted the review. We performed an initial comprehensive systematic search using MEDLINE, EMBASE, PsycINFO, and the Cochrane Library up to October 19, 2015, and updated it on August 8, 2020. Studies were included if they focused on interventions to improve access to PHC using community coalition, outreach services or mobile delivery methods. We included Randomized Controlled Trials (RCTs), and systematic reviews. Studies were screened by two independent reviewers and the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework was used for data extraction and framework analysis to obtain themes. The LIP research team was also allowed to suggest additional papers not included at screening.

We included 43 records, comprising 31 RCTs, 11 systematic reviews, and 1 case control study that was added by the LIP research team. We identified three main themes of PHC interventions to promote access for vulnerable residents, including: 1) tailoring of materials and services decreases barriers to primary health care, 2) services offered where vulnerable populations gather increases the "reach" of the interventions, 3) partnerships and collaborations lead to positive health outcomes. In addition, implementation designs and reporting elements should be considered.

Realist reviews can help guide the development of locally adapted primary health care interventions.

The gap between rates of children's mental health problems and their participation in services highlights the need to address concerns related to engagement in mental health services more effectively. To identify, understand, and resolve engagement concerns appropriately requires effective measurement. In this study, we employed a multidimensional conceptual framework of engagement to examine the measurement of engagement in intervention studies focused on improving children's and/or families' engagement in services.

We coded 52 randomized controlled trials (RCTs) of interventions designed to enhance treatment engagement published between 1974 and 2019 to examine what engagement constructs have been measured, how these constructs have been measured, who has provided information about engagement, and when and why engagement measures have been administered.

Attendance was measured in 94.2% of studies, and 59.6% of studies measured only attendance. Furthermore, most studies (61.5%) measured only one engagement dimension. One hundred twelve unique indicators of treatment engagement were used (61.6% measuring attendance). Infrequent measurement of youth (19.2% of studies) or caregiver (26.9%) perspectives was apparent. About half (54.7%) of measures were completed on one occasion, with 53.7% of measures completed after treatment was concluded.

Results highlight how the field's measurement of engagement has focused narrowly on attendance and on interventions that improve attendance. We consider promising new directions for capturing the multidimensional, dynamic, and subjective aspects of engagement, and for leveraging measurement in research and practice settings to feasibly and effectively identify, monitor, and address engagement challenges.

The objective of this Clinical Update is to review the principles, structures, processes, and outcomes of community systems of care as they pertain to the delivery of behavioral health care to children and adolescents METHOD: A search of the literature on this topic from 2002 was initially conducted in 2016 and repeated in 2019 and 2021, yielding 1,604 English-language citations. These citations were supplemented by references suggested by topic experts and identified through Web searches, increasing the yield to 1,684 total citations, of which 1,184 were unduplicated. After sequential review by Update authors at title/abstract and then full-text levels, the citations were winnowed to 156 based on relevance to the topic.

The systems of care approach, arising in the 1980s, expanded child and adolescent behavioral health care from the core services of psychotherapy, medication management, inpatient psychiatric services, and residential treatment to include home- and community-based treatment and support services; promotion, prevention, and early intervention programs; and specialized services for very young children and youth and young adults of transition age. These services and supports are delivered by a large multidisciplinary workforce and are governed by key principles, including a biopsychosocial case conceptualization; family-driven, youth-guided, strengths-based, and trauma-informed care. Services in the least restrictive setting; continuity of care across transitions; a public health framework for service delivery; promotion of wellness and resilience; and elimination of health disparities. Challenges to systems of care implementation include funding availability, workforce shortages, deficiencies in cross-systems collaboration, and variability in insurance coverage. Although controlled studies have failed to provide convincing evidence of favorable outcomes from the whole systems of care approach, uncontrolled research has demonstrated increased access to care, positive clinical and functional outcomes, improved family functioning, and reductions in costs, particularly when research is focused on specific behavioral health problems, specific interventions such as Wraparound care, or highly specified groups of youth.

Health professionals who are educated in the systems of care approach can improve access to and quality of behavioral health care for children and adolescents with behavioral health needs.

Attention deficit hyperactivity disorder (ADHD) is a common and impairing behavioral health disorder, impacting over 5% of children worldwide. There are multiple evidence-based pharmacological and psychosocial treatments for ADHD, and greater service utilization is associated with improved acute and long-term outcomes. However, long-term outcomes are suboptimal as multimodal treatments are often not accessed and most care ends prematurely. This narrative review discusses barriers to engagement for children and adolescents with ADHD and their families as well as interventions to overcome these barriers. Families face a variety of structural and attitudinal barriers, ranging from cost and access to stigma and low self-efficacy to successfully implement change. There are multiple interventions that may enhance engagement with ADHD care including psychoeducation, integration of behavioral services in general medical settings, telehealth as well as specific adaptations to existing ADHD treatments, such as the use of motivational interviewing or shared decision making. Integration of behavioral health into general medical settings and telehealth have been found in controlled studies to increase access by reducing both structural and attitudinal barriers. Adding motivational interviewing, shared decision making and other engagement interventions to evidence-based ADHD treatments has been found to reduce attitudinal barriers that translates into improved participation and satisfaction while enhancing outcomes. However, little is known about how to promote extended engagement with ADHD services even though a chronic care model for ADHD is recommended.