Mentor Name: Jennifer Funderburk, PhD Research Psychologist Mentor Institution: Center for Integrated Healthcare, Syracuse VAMC

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1 Name: Jennifer Wray Degree: PhD Degree Completion Date: 2014 Institution: Center for Integrated Healthcare, Buffalo VACenter for Integrated Healthcare, Buffalo VA Current Position: Postdoc/Fellow If Student, Year in School: Are you enrolled in a degree/fellowship program? Yes If yes, where? Center for Integrated Healthcare, Buffalo VA If yes, what degree are you seeking? Postdoctoral Training If no, what is your primary place of work and position? Mentor Name: Jennifer Funderburk, PhD Research Psychologist Mentor Institution: Center for Integrated Healthcare, Syracuse VAMC Title of Project: Incorporating brief interventions for hazardous drinking and tobacco use into routine behavioral health appointments ; Investigators: Jennifer M. Wray, Jennifer S. Funderburk, & Laura O. Wray Description of Proposed Project: Tobacco use and hazardous drinking are among the top preventable causes of death in the United States (Mokdad, Marks, Stroup, & Gerberding, 2004), and quitting tobacco and reducing alcohol use to recommended limits can have substantial health benefits (Taylor, Hasselblad, Henley, Thun, & Sloan, 2002; Whitlock, Polen, Green, Orleans, & Klein, 2004). Brief interventions for tobacco use and hazardous drinking, even in very small doses, have been shown to be effective (Bertholet, Daeppen, Wietlisbach, Fleming, & Burnand, 2005; Fiore et al., 2008; Lai, Cahill, Qin, & Tang, 2010; Moyer & Preventive Services Task, 2013; Whitlock et al., 2004). While most patients do not pursue specialty services for these behaviors, most do visit their primary care provider on an annual basis (Strosahl, 1998). As such, primary care has long been identified as a promising setting for the delivery of interventions for tobacco use and hazardous drinking. Unfortunately, rates of implementing brief interventions for hazardous drinking and tobacco use are low (CDC, 1993; Ellerbeck, Ahluwalia, Jolicoeur, Gladden, & Mosier, 2001; Hamlett-Berry et al., 2009; Quinn et al., 2005; Schnoll, Rukstalis, Wileyto, & Shields, 2006). Primary care providers (PCPs) frequently cite barriers to addressing tobacco and alcohol use such as multiple competing demands, lack of training in interventions for these behaviors, and not having sufficient time to address these concerns during their appointments (AAMC, 2007; Vogt, Hall, & Marteau, 2005). Further, most PCPs report feeling â œnot very effectiveâ in addressing behavior change with patients (AAMC, 2007). PCPs have the option of referring patients who are hazardous drinkers or who use tobacco to

2 behavioral health providers (BHPs) in clinics where a BHP is a part of the patientâ s treatment team for intervention around these behaviors. However, BHPs report infrequent treatment of patients with tobacco use or hazardous alcohol use (Funderburk, Dobmeyer, Hunter, Walsh, & Maisto, 2013; Funderburk et al., 2011). Behavioral health providers (BHPs) embedded in the primary care setting (Hunter, Goodie, Oordt, & Dobmeyer, 2009; Post, Metzger, Dumas, & Lehmann, 2010) could fill a gap between PCPs and specialty services by implementing brief alcohol and tobacco interventions. BHPs have the potential to deliver effective brief interventions for tobacco use and hazardous drinking due to their background and expertise in behavior change strategies (Leffingwell & Babitzke, 2006; Williams & Ziedonis, 2006), however, research demonstrates that BHPs do not report delivering these types of intervetions in their clinical practice (Funderburk et al., 2011). Preliminary work with behavioral health providers working in outpatient mental health clinics and partial hospitalization programs has demonstrated that training in tobacco cessation treatments increases both implementaion of these services and quit attempts among patients (Williams et al., 2015), which suggests that training behavioral health providers in the primary care setting may increase utilization of interventions for tobacco use and hazardous drinking. In the medical home model, professionals from different disciplines collaborate on a shared treatment plan individualized for each patient (Rosenthal, 2008), and each provider on the team plays a unique and complementary role in patient care. Based on the literature reviewed above, the role of PCPs may be to identify patients who are appropriate for brief interventions for tobacco use and hazardous drinking and connect them with BHPs. Subsequently, BHPs could use their expertise in behavior change strategies to implement an appropriate intervention with the patient. Interventions to help these team members more effectively target tobacco use and alcohol misuse will likely increase rates of brief treatments for tobacco use and hazardous drinking in the primary care setting. An abundance of research has identified barriers to implementing brief alcohol intervention and tobacco cessation services among medical and behavioral health professionals (AAMC, 2007; Himelhoch, Riddle, & Goldman, 2014; Johnson, Jackson, Guillaume, Meier, & Goyder, 2011; Nilsen, 2010; Roche & Freeman, 2004; Williams et al., 2015). However, barriers have not yet been assessed among integrated behavioral health providers, who may experience unique challenges with delivering these interventions in the primary care setting. Further, while there is data to support the lack of referrals from PCPs to BHPs for hazardous drinking and tobacco use (Funderburk et al., 2013; Funderburk et al., 2011), no studies to date have examined the facilitators and barriers of PCPs referring these patients to BHPs. As such, the aims of the proposed project are as follows: Aim 1. Identify facilitators and barriers to implementing brief alcohol and brief tobacco interventions among integrated behavioral health providers. Aim 2. Identify facilitators and barriers to the referral of patients with hazardous drinking or tobacco use by primary care providers to behavioral health providers.

3 Setting: Methods overview. The methods of Aim 1 will be divided into two phases. In the first phase, BHPs will be recruited from primary care to participate in a qualitative interview to assess their perceptions regarding barriers and facilitators to implementing brief interventions for tobacco use and hazardous drinking. Data collected from Aim 1 will be used in combination with barriers and facilitators that have been identified in previous research; in this phase of the study a quantitative survey will be completed by BHPs. This will allow us to identify the most common barriers and facilitators to implementing these brief interventions encountered by BHPs. Aim 2 will be accomplished by conducting qualitative interviews with PCPs to assess barriers and facilitators surrounding connecting patients who screen positive for tobacco use or hazardous drinking with behavioral health providers on their team. Aim 1: During phase 1 of the study, BHPs will be recruited from primary care clinics located in the Syracuse VA Medical Center and the Buffalo VA Medical Center. BHPs will be interviewed at a location of their choice. Dr. Jennifer Wray has regular contact with BHPs in primary care at the Buffalo site given her part time role as an integrated BHP one day/week, and thus has access to at least 5 BHPs who could be targeted for this phase of the study. Dr. Laura Wray also has contact with BHPs at this site due to her past clinical work at this facility and her current research projects in integrated healthcare. Dr. Jennifer Funderburkâ s research team also has access to approximately 5 behavioral health providers at the Syracuse VAMC site given her previous research conducted in the primary care setting in this facility. BHPs from both the community and within the Veteranâ s Healthcare System will be recruited to participate in Aim 1, phase 2. We aim to target BHPs in different types of settings (e.g., VA, community primary care clinics) to enhance generalizability of the findings. Participants will be able to complete the survey online. An will be sent out to members of several PC-MH relevant listservs (e.g., CFHA PCBH SIG, APA Division 38 IPC, and VA Mental & Behavioral Health in PACT) with a link to the survey. Past work conducted in our research center using similar methods have been effective. Aim 2: Primary care providers will be recruited from the Buffalo and Syracuse VAMC hospitals. Although we believe that our results will be generalizable to providers outside of the VA, we will target VA providers given our access to this population in order to maximize feasibility of the project. PCPs will be able to choose the location of the interview to maximize convenience for the participants. As discussed above, due to the PIs clinical and research activities in the primary care clinics at the Buffalo and Syracuse VAMCs, we anticipate being able to recruit at least 8 PCPs to participate in Aim 2 of the study. Participants: Aim 1, phase 1. BHPs working in primary care clinics at the Syracuse VAMC and Buffalo VAMC will be targeted. Research staff will approach the BHPs working in these hospitals and ask if they would be willing to participate in an individual interview about their use of interventions for tobacco use and hazardous drinking for research purposes. A total of 5 integrated BHPs will be interviewed. In order to be eligible, BHPs must have worked in a primary care setting for at least six months and

4 must dedicate at least 10% effort to clinical activities. BHPs will be offered educational materials in exchange for their participation. Aim 1, phase 2. BHPs (e.g., psychologists, social workers, advanced practice nurses) who have worked in a primary care setting for at least six months and who allocate at least 10% effort to clinical activities will be invited to participate in an online survey of facilitators and barriers of implementing interventions for tobacco use and hazardous drinking. Participants will be recruited from a number of listservs relevant to primary care-mental health (e.g., CFHA PCBH SIG, APA Division 38 IPC, and VA Mental & Behavioral Health in PACT). Recruitment for this phase of the study will be broader in scope than the qualitative interviews; participants will be recruited from a range of PC-MH settings, including within the Veteranâ s Health Administration and in community settings. Based on previous research, we anticipate that approximately a third of BHPs who are contacted will enroll in the study. Based on the number of participants on the targeted listservs, we anticipate that between BHPs will complete the survey. BHPs will be offered educational materials in exchange for their participation. Aim 2. Primary care providers (e.g., physicians, nurse practitioners, physicians assistants) practicing in the Syracuse VAMC or Buffalo VAMC will be eligible to participate in this part of the project. Each of these clinics employs at least one BHP. A total of 8 primary care providers will be targeted. Potential participants will be approached by study staff and asked if they would be willing to be interviewed as part of a research study focused on their referral practices. PCPs will be offered educational materials in exchange for their participation. Procedures: Aim 1, phase 1. A number of facilitators and barriers to implementing brief interventions for hazardous drinking and tobacco use have previously been identified in the literature. However, no research has been conducted looking at barriers/facilitators in a sample of BHPs. As such, we propose to interview BHPs in phase 1 of this study, to ensure that the barriers/facilitators that are well established in the literature for other types of providers are also relevant for BHPs. Further, phase 1 will allow us to determine any barriers/facilitators that may have not previously been identified but that may be relevant for BHPs. Five BHPs will participate in an individual interview with study staff. BHPs will be told about the purpose of this phase of the study and consented. Data will be collected on background information, including number of years practicing in primary care, number of patients seen per week, and professional degree. Participants will be provided with information about the low rates of implementation of tobacco and alcohol use interventions in the PC setting. Next, they will be asked open ended questions designed to elicit barriers and facilitators to implementing brief alcohol interventions in their clinical practice. Then they will be asked to do the same for brief tobacco interventions. Finally, the BHPs will be asked to review a list of previously identified barriers and facilitators to implementing tobacco and alcohol interventions (see Aim 1, phase 2 for full list). The BHPs will be asked to comment on any barriers or facilitators they believe would be helpful to add to this list based on their own clinical

5 experience. Aim 1, phase 2. In phase 2, BHPs will be asked to fill out a survey that will ask about barriers and facilitators to delivering brief alcohol interventions and tobacco use interventions. These questions have been derived from the rich literature that has identified barriers cited by other types of medical and mental health professionals, and will be supplemented by additional barriers and facilitators that BHPs identify during phase 1 of the study. Participants will rate barriers (e.g., lack of training/guidance, poor knowledge of intervention, lack of time) on a scale from 1 (not a barrier) to 5 (significant barrier). Participants will rate facilitators (good relationship with patient, appropriate setting for the discussion, education on alcohol/tobacco treatment) on a scale from 1 (not a facilitator) to 5 (significant facilitator). The survey will also ask questions about the participantsâ background, including number of years practicing in primary care, number of patients seen per week, professional degree, and current use of tobacco and alcohol. BHPs will be assured that responses to the survey will be kept confidential. Aim 2. PCPs will participate in an individual interview with study staff. Participants will be told about the purpose of this phase of the study and consented. Data will be collected on background information, including number of years practicing in primary care, number of patients seen per week, and professional degree. Participants will be asked open ended questions to elicit their thoughts about barriers and facilitators to referring patients who screen positive for hazardous drinking and tobacco use to BHPs. Analysis/Evaluation Plans: Aim 1. A theory directed content analysis approach (Hsieh and Shannon 2005) will be used as this analysis will be performed with the intent to identify any additional barriers/facilitators common to integrated healthcare to help refine the questionnaire to be more specific for Aim 2. Raters will work together to identify the themes across field notes. Aim 2. We will calculate descriptive statistics for each question administered (frequencies for categorical variables, mean and standard deviation for all continuous variables), and we will use the frequency data to determine the most common barriers and facilitators to implementing interventions for tobacco use and hazardous drinking reported by behavioral health providers. Aim 3. A conventional content analysis approach will be used to identify themes and categories from the data using inductive coding (Hsieh & Shannon, 2005). Two raters will work together to establish definitions and exemplars for categories and codes to rate all of the notes from the interviews. Routine meetings will be used to discuss the coding and help refine it.cfha research fellowship funding October 2015 Submit IRB application November 2015 IRB revisions December 2015 IRB approval December 2015 Recruit participants for BHP interviews, formatting of BHP online survey January 2016 BHP interviews February 2016 BHP interview analysis/complete preparation of BHP online survey March 2016 BHP online survey April â June 2016 Recruit PCPs for interviews April 2016 Conduct PCP interviews May-June 2016 Data entry/cleaning June-July 2016 Analyze survey data, PCP interviews August-Sept 2016 Present results at CFHA conference October 2016

6 Timeline: CFHA research fellowship funding October 2015 Submit IRB application November 2015 IRB revisions December 2015 IRB approval December 2015 Recruit participants for BHP interviews, formatting of BHP online survey January 2016 BHP interviews February 2016 BHP interview analysis/complete preparation of BHP online survey March 2016 BHP online survey April â June 2016 Recruit PCPs for interviews April 2016 Conduct PCP interviews May-June 2016 Data entry/cleaning June-July 2016 Analyze survey data, PCP interviews August-Sept 2016 Present results at CFHA conference October 2016 How will you know you have achieved the project s goals? We will know that we have achieved our goals if we had 1) identified barriers and facilitators to implementing brief alcohol and tobacco interventions from the perspective of BHPs and 2) identified barriers and facilitators to referring patients (who use tobacco or who drink at hazardous rates) to BHPs from the perspective of PCPs. The project will be successful if, at the end, we are able to generate a list of the highestranking barriers and facilitators identified by BHPs and PCPs. How will you plan to use the information you gather in this project? The results of this project will be disseminated through a presentation at the 2016 CFHA conference, through the CFHA blog post, through a scientific manuscript that will be submitted to PC-MH relevant journal (e.g., Family, Systems, & Health), and by sharing the findings with research participants (PCPs and BHPs). In addition, data from this project will also be used to help inform next steps around increasing the overall rate of implementation of interventions for tobacco use and hazardous drinking in primary care. For example, we plan to intervene around the most commonly cited barriers to referring patients and delivering brief alcohol and tobacco interventions in future work. How does this project advance the field of collaborative care? The purpose of this work is to survey multiple members of the medical home to ultimately improve the delivery of interventions for tobacco use and hazardous drinking in the primary care setting. Findings from this research will help the care provided for patients who use tobacco and/or who drink at hazardous rates. Strategies for improving rates of referral from PCP to BHP and for implementing these interventions will likely be applicable to other mental health concerns that can be addressed in primary care. How does this project advance you professionally? Two of my goals for fellowship are to gain experience with research in the PC-MH setting and to conduct research on brief interventions for tobacco use and alcohol use. This project would advance me professionally by allowing me to gain more experience in the area of conducting research in PC-MH (e.g., approaching and recruiting PCPs and BHPs to participate in the study, using both qualitative and quantitative methods of data collection, collaborating with my co-investigators who have extensive experience

7 in PC-MH research). Furthermore, a study focused on identifying facilitators and barriers to implementing brief alcohol and tobacco interventions in the PC setting would allow me to establish a unique line of research in PC-MH integration, and data from this project could serve as important pilot data for subsequent grant applications in this area. Finally, working with Dr. Jennifer Funderburk and Dr. Laura Wray will allow me to gain expertise and knowledge in the area of conducting research in the PC-MH setting.