UVM-led research team to study benefits of integrating behavioral health care with medical care

A University of Vermont-led research team has received approval for $18.5 million in funding to study whether patients with both medical and behavioral problems do better when their primary care physicians work in combination with behavioral health professionals including psychologists and social workers.

Benjamin Littenberg, M.D., professor of medicine, gathered a team of colleagues at UVM and across the country for a five-year research project, titled "Integrating Behavioral Health and Primary Care." The Patient-Centered Outcomes Research Institute (PCORI) selected Littenberg's project as one of four out of 124 original applications to receive funding. Based in Washington D.C., the organization seeks to answer questions that patients and their clinicians face daily and find approaches to health care that work best for the end user.

Patients with chronic illnesses, such as diabetes, heart disease or asthma that are exacerbated by behavioral difficulties -- anxiety, depression, alcohol or drug abuse, poor diet, smoking, sleep disruptions or lack of exercise -- particularly need to address those personal problems, but often struggle to do so. Their doctors might refer them for cognitive behavioral therapy or motivational interviewing to help them change their habits.

Those personal challenges "heavily influence how their medical problems turn out," Littenberg says. "Also, their medical problems influence the severity of their behavioral problems."

But the inconvenience and cost of going to another doctor, making another appointment and dealing with another billing office -- on top of managing their physical problems -- often prevents them from starting or continuing that behavioral treatment, says Littenberg, an expert in examining the patient experience to improve the health care system.

In some cases, behavioral therapists are located within a primary care practice -- called "co-location" -- but, according to Littenberg, that arrangement doesn't eliminate all of the barriers.

"When it works, it works great, but it doesn't work well often enough," he says.

The PCORI grant will allow Littenberg's team to look more closely at the benefits of fully integrating behavioral health care with medical care. The clinicians would collaborate -- possibly sharing notes, using the same nurses and support staff -- and even coordinate their appointment and billing offices.

"The question here is really about how to design the systems for better care," says Littenberg.

The researchers propose to include 30 practices nationwide and as many as 60 patients at each, for a total of 1,800 cases. The group will compare the integrated practices to those using the co-located model.

Littenberg's UVM colleagues Rodger Kessler, Ph.D., associate professor of family medicine, and Constance van Eeghen, Dr.P.H., assistant professor of medicine, will help lead the project as co-principal investigator and project director respectively.

The project team also includes three patients who will serve as funded co-investigators -- not just as consultants or advisors -- and who have dealt with their own or a family member's chronic illness and behavioral health problems. The patients, who all live in Vermont, will sit alongside medical and academic professionals in guiding the study's progress.

"At every turn, we want to be able to get their input," Littenberg explains. "We need them to keep us focused on what's important to the patients all along. To do that, they need to be at the table as we're making decisions."

The inclusion of patients on the investigation team isn't unusual for studies funded by PCORI, because of its patient-oriented mission, says Christine Stencel, the institute's associate director of media relations. "But this is essentially a new thing for health research" in general, she says. "This study is among those that are really leading the way and demonstrating how the patients can be partners and not just subjects."

To measure the integrated systems, Littenberg's team will rely on the patients themselves: how they're doing; how successfully they get treatment for their problems; how much those problems, their daily lives and their health improve.

If the study can help remove some hurdles for these hard-to-treat patients, it could provide insights into ways to increase efficiency, cut costs and improve patient outcomes across the entire health care system, Littenberg suggests.

"If it was easy," he says with a smile, "we would have done it years ago."