The Comprehensive Care Program (CCP provides both primary care and hospital care for Medicare recipients who have had at least one hospitalization in the prior year. The CCP program is the intervention arm of a large randomized controlled trial funded at different points in time by Center for Medicare and Medicaid Innovation, the Robert Wood Johnson Foundation, and the Patient-centered Outcomes Research Institute. Patients in CCP have higher medical and social complexity than the general population and therefore also high healthcare utilization and costs for Medicare as well as higher risk for poor health outcomes. They also have higher Behavioral Health (BH) needs than the general population and such needs significantly interact with their physical health and ability to access medical care and adhere to treatment plans. Yet, only half or fewer of Medicare recipients actually receive behavioral health care, due in part to healthcare system barriers and shortage of BH providers who accept Medicare.

To address these problems, the CCP program has started a program of Behavioral Health Integration, following the models of other Primary Care Behavioral Health Integration (PCBHI), which has over 2 decades of evidence of improving BH access and outcomes for patients. This model helps to reduce several barriers for patients by detecting behavioral health needs in both the outpatient and inpatient settings, connecting patients with BH resources, providing brief BH interventions, and tracking and managing BH care to ensure patients ultimately receive the care they need.

Multiple projects will aim to evaluate various aspects of the CCP BHI program, including the process of detecting and documenting BH problems among our patients, referring them to our BH care management team, providing initial BH care within our team, connecting them with BH resources, and the impact of these processes on health outcomes and healthcare utilization.

Depending on the specific project focus, the methods will include organizing and analyzing existing data from CCP's extensive research surveys, chart review, and interviews with CCP team members and with patients.

Research analysts for the CCP study use Stata, and it would be smoothest if Stata was used for a student project as well. Other statistical programs like R can be used, as long as data can be combined with Stata. Stata can be provided by the research team. Basic training and methods specific to the project can be provided.

Daily multi-disciplinary CCP team meetings, monthly CCP team meetings. National conferences including Society for General Internal Medicine, Society of Hospital Medicine, and a number of other conferences are candidates for submitting an abstract for poster or oral presentation. A written manuscript will be a goal as well.