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Integrate This: Evidence-Based Practice in Integrated Primary Care

Posted By Elizabeth Horevitz, Thursday, December 22, 2011

This October, I attended my very first CFHA conference. As many others have already described, I experienced that sense of "professional Zen” that comes from being surrounded by like-minded practitioners, researchers and students coming together because of a shared belief in and commitment to integrated/collaborative health care. We spent the weekend discussing the best ways to break down the old silos of health and mental health services, and integrate mind and body in whole-person, patient-centered health care. One of the clear take-away messages was that in order to effectively "accelerate the adoption of collaborative care” (the theme of the conference) research will increasingly play a centralized role in CFHA.

This resonated with me. As a doctoral student at UC Berkeley, the importance of evidence-based practice (EBP) has been drilled into me for the past four years. Evidence-based health care refers to "use of best current knowledge in decision making about groups and populations” (Gray, 2001). EBP requires critical thinking about claims of knowledge, and a willingness to reject false claims of knowledge or truth.

In contrast to evidence-based practice is authority-based practice, which relies on claims based on authority, tradition, popularity or consensus, rather than subjecting claims to "critical tests of their accuracy” (Gambrill, 1999, p. 346).

Now comes the hard part.

What if one of the key cornerstones of collaborative health care "best practices” might actually be authority-based?

The culprit? The Warm-Handoff.

For those of you not immersed in the world of collaborative care/integrated primary care, the warm handoff refers to a referral practice wherein the medical provider introduces the patient to the behavioral health consultant in real-time. Although there is no specific one way to do a warm handoff, it is generally agreed upon that behavioral health consultant can, at the time of the referral, offer a brief intervention if the patient is in acute distress, or at the very least engage in a "meet and greet” to assuage any patient concerns about behavioral health treatment. If you Google it (go ahead), you willl find thousands of hits describing the central role it plays in collaborative care, links lamenting the inability to bill for this "cutting-edge” same-day service to clients, and videos demonstrating how to properly make a warm handoff referral in primary care.

As a behavioral health consultant in a Federally Qualified Health Center, I can tell you I love the warm handoff referral. It makes intuitive sense: a personal introduction to the behavioral health consultant by the medical provider is thought to help increase engagement, reduce stigma, and enhances continuity of care. It is a standard part of collaborative care practice, and, I can tell you from experience that nothing will lull you into believing in the power of collaborative care like a well-executed warm handoff.

But the warm hand-off has never been rigorously tested. We have no proof of its effectiveness in enhancing follow-up to behavioral health treatment.
While there is mounting evidence for the benefit of specific stepped-care interventions for depression, anxiety and management of other co-morbid conditions in primary care (see for example: the IMPACT trials and the CALM studies referenced at the end of this entry), very little research has been done on what actually gets patients to the door of behavioral health treatment in integrated settings.

As a researcher interested in health and mental health disparities, particularly among Latinos, I decided to conduct my dissertation research on predictors of follow-up to depression treatment within an integrated primary care clinic (where I also work as a behavioral health consultant). After all, what good are all of these evidenced-based interventions if no one shows up for treatment?
I can tell you from my preliminary analysis that the warm hand-off may not be all it is cracked up to be.

My findings suggest that at best receiving a warm handoff (as opposed to a "cold handoff” wherein no personal introduction is made) is ineffective (it is not a significant predictor of follow-up for depressed Latinos). At worst (for English-speaking Latinos), receiving a warm handoff has the exact opposite effect from what it is intended to do: English-speaking Latinos with depression who receive a warm handoff are significantly less likely to attend a first visit with the behavioral health consultant as compared to those who receive a cold handoff.

As a behavioral health consultant, these results are pretty hard for me to believe (I've been in the room! I've seen it work with my own eyes!). The colleagues with whom I've shared this information have also been stunned. The next questions people usually ask me are:

  1. How big was your sample? (431)
  2. Did you account for [insert various patient demographics, comorbidities and provider characteristics here]? (Yes, and I am happy to share them with you. All of my methods and analyses will be available for scrutiny in an upcoming published article (in preparation)
  3. WHY? (I don't know, but I am currently conducting in-depth interviews to find out).

Certainly, preliminary results from one study at one clinic are not enough to warrant a referendum on the warm handoff. This information should, however, raise questions about what we are doing and how we are doing it.

Undoubtedly every integrated clinic has its own take on the warm handoff (how and when it is done), but most integrated clinics practice some form of it. Some may have better outcomes than others, and some populations/cultures may respond better than others. All of this underscores the need for better understanding…a need to break open the "black box” of how we engage patients into care. While the integration of behavioral health services into primary care undoubtedly improves access to behavioral health services, the extent to which the warm handoff helps engage people (in this case, Latinos) into care beyond the mere existence of co-located services merits further study. There are many possible reasons for my findings (maybe meeting the behavioral health consultant is so effective that folks don't feel they need a follow-up visit?), but we don't yet know enough to say.

I'm left wondering, though, what do we do with this information?


Gambrill, E. (1999). Evidence-based practice: An alternative to authority-based practice. Families in society, 80, 341–350.

Gambrill, E. (2005). Evidence-based practice and policy in California: Choices ahead. Power point presentation. Leadership Symposium on Evidence-based practice in the human services, Sacramento, California

Gray, J. A. M. (2001). Evidence-based healthcare. Elsevier Health Sciences.
Manoleas, P. (2008). Integrated primary care and behavioral health services for Latinos: A blueprint and research agenda. Social work in health care, 47(4), 438–454.

Roy-Byrne, P., Craske, M. G., Sullivan, G., Rose, R. D., Edlund, M. J., Lang, A. J., Bystritsky, A., et al. (2010). Delivery of Evidence-Based Treatment for Multiple Anxiety Disorders in Primary Care. JAMA: The Journal of the American Medical Association, 303(19), 1921 -1928.

For a listing of evidence for IMPACT depression trials, check out:

Elizabeth Horevitz, MSW, is a doctoral candidate at the University of California, Berkeley. She is interested in the integration of behavioral health services in primary care settings with a particular emphasis on research and dissemination of evidence-based interventions for Latinos and other underserved populations. Concurrently, she is interested in the preparation and training of social workers for practice in integrated behavioral health/collaborative care settings. Her dissertation examines follow-up to depression treatment among Latinos at Community Health Clinic Olé in Napa, CA, where she also works as a behavioral health consultant. When she is not researching or working, she enjoys hiking and biking in the Bay Area and, until she can adopt one of her own, spending time with other people's dogs.

The view expressed in the blogs and comments should be understood as the personal opinions of the author and do not necessarily reflect the opinions and views of the Collaborative Family Healthcare Association (CFHA). No information on this blog will be understood as official. CFHA offers this blog site for individuals to express their personal and professional opinions regarding their own independent activities and interests.

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Comments on this post...

Randall Reitz says...
Posted Tuesday, December 27, 2011
Lizzie, WOW, a provocative and daring post. I look forward to reading your research. Where will it be published?

As you state, your findings do fly against the traditions of collaborative care, but it is vital that our practices be informed by empirical findings. Interestingly, data presented in the youtube link you sent along contradict your findings, but I'm doubtful of the 80% follow-through they report on warm referrals. My own data from Marillac Clinic also document an improved show rate for warm referrals, but it was an only an improvement from 35% to 50%.

In your post you refer to a "warm referral". I think your data indicate the importance of moving beyond a "warm referral" and actually facilitating a "warm hand-off" for same-day services. Integrated systems would do better to facilitate provider availability so that the initial contact will be for an intervention rather than for a meet and greet. In that way, if the patient chooses not to follow through on a referral for therapy, they at least benefit from one service.

Keep the provocations coming!
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Peter Y. Fifield says...
Posted Tuesday, December 27, 2011

Lizzie, I love mixing of the pot! I am curious to read your research as well and wonder how it relates to other populations. Thanks for putting this out there for us all to ponder.

As Randall stated, this bring up an important question regarding allotment and availability of a provider. We have played around with this idea and created a "wave schedule" that provides time to have the first meeting actually be a session. The problem is that due to our limited availability of BHS providers and the unavailability of H&B code billing, it only allows for a longer (+/- 15 minutes) session about 50% of the time; the rest or typically meet and greet in nature. We intend to keep working on this provider scheduling for we think it is vital to have first visits be a session to possibly eliminate the need for some second sessions.

I have no data to back this up but anecdotally, I have witnessed here at Families First (an FQHC in NH) that our no show rates for persons I have not met (aka cold referral) are similar to our external referrals to other specialty mental health compared to a much lower no show rate with ones I have met via a warm referral. In addition, as Randall pointed out, there seems to be a significant reduction of follow up with the persons that have actually had a "session" via a warm handoff. The later group is typically made up of persons looking to deal w/ a more acute issue such as a single behavior change compared to a more complex situation. It would be interesting to see in your research if the follow up rate relates to the type of intervention [warm handoff vs. warm referral].

Thanks again.
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Elizabeth Horevitz says...
Posted Sunday, January 1, 2012
Thank you for the comments. I agree with both of you that there is likely a difference between a simple "meet and greet" versus an actual intervention or initial visit in terms of follow-up rates. My study couldn't account for these different "types" of WHOs, though I am examining this to some extent in the interviews.

Our clinic has just switched to an "open" schedule, meaning that all warm-handoffs will be converted into initial visits (as opposed to what we did before, which was about 50/50 interventions vs meet-and-greets). This is a big change for us and I am looking forward to reviewing the before/after data on show-rates.

I think a clear next step would be an intervention study to establish causality in terms of a same-day BH intervention... I will certainly keep you all updated on my findings from the interviews, which I believe will illuminate much of the decision-making around follow-up.

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Anu Kotay says...
Posted Wednesday, March 28, 2012
I am glad to see your work on this topic! At Montefiore, we have explored this topic at 2 sites (n=110) and we also found that having a face to face contact with a member of the mental health team had no impact on follow up to treatment. Our findings did not reveal a negative impact of this interaction. We are currently in the midst of follow-up exploratory qualitative research to better understand in what ways this collaborative interventionis helpful and/or could be more helpful. We have done interviews with MD providers, Psychology providers, and are working on IRB for patient interviews. I am glad to see the science of collaboration is moving along with the rise in clinical practice. This critical work will provide support for the disclipine as it moves forward!
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