Methods: This study followed a convergent parallel mixed-method design. To quantitatively measure integration, clinic teams completed the Maine Health Access Site Self-Assessment (SSA) at baseline and 24 months. To qualitatively understand integration, we conducted expert interviews with initiative stakeholders, and one implementation site visit per clinic during which all available BHICCI team members were interviewed, including the executive team, registered nurses, primary care providers, care managers, behavioral health specialists, and social workers. We also conducted follow-up visits at the BHICCI’s conclusion. Qualitative interviews were audio recorded, transcribed, were analyzed using constant comparative methods informed by grounded theory. Results were then organized using the Consolidated Framework for Implementation Research. Quantitative and qualitative results were compared to understand how qualitative findings explained quantitative results.
Results: Data were collected in 7 clinics (n =2 FQHC; n= 5 BHOs). FQHCs reported greatest improvement in the client centered subscale, with a baseline score of 4.6 (SD =0.64) and 7.8 (SD=0.89) at 24 months. BHOs reported greatest improvement in the organizational supports for integration subscale, with a baseline score of 4.8 (SD =1.07) and 7.9 (SD=1.1) at 24 months. We conducted interviews with n=75 stakeholders, including n=70 BHICCI team members (FQHC n=18; BHO n = 52), two health plan executives and three key advisors. Our Consolidated Framework for Implementation Research analysis illustrates contextual factors (such as insurance plan supports and support from practice coaches) and clinic-level challenges, (such as hiring providers and FQHC productivity requirements) that explain these scores.
Conclusions: All clinical settings received support from the health plan, but differences between BHOs and FQHCs affected program implementation. Study results can help identify organizational practices that advance or undermine the delivery of integrated care across multiple clinical settings.