ACT Findings

Advancing Care Together by Integrating Primary Care and Behavioral Health
September 2015

Health Elevations
A quarterly journal on health policy in Colorado
Spring 2015

From Reform to the Norm?

2015 is the year when integrated care and payment overhaul begin in earnest.


Symposium Unplugged: Colorado’s Journey to Integrated Care

Event Highlights:

  • Overview of ACT, followed by a panel discussion with clinicians and patients from four ACT innovation sites that have begun to close the division between physical and behavioral health care delivery in their communities
  • Remarks from Dr. Deborah Cohen, Associate Professor of the Oregon Health & Science University Department of Family Medicine, who will share preliminary ACT results and highlight lessons learned to inform the future of integrated care in Colorado
  • Keynote address by Dr. William Beardslee, Director of the Baer Prevention Initiatives at Boston Children’s Hospital and Garner-Monks Professor of Child Psychiatry at Harvard Medical School, including a discussion of the importance of clinician-facilitated and family-based preventive intervention, particularly for children and families at risk

Event Resources:
Recorded Video

Meeting Materials

ACT Early Results


Background: More than 20 years ago the Institute of Medicine advocated for integration of physical and behavioral health care. Today, practices are integrating care in response to recent policy initiatives. However, few studies describe how integration is accomplished in real-world practices without the financial or research support available for most randomized controlled trials.

Methods: To study how practices integrate care, we are conducting a cross-case comparative, mixed-methods study of 11 practices participating in Advancing Care Together (ACT). Using a grounded theory approach, we analyzed multiple sources of data (e.g., documents, practice surveys, field notes from observation visits, semistructured interviews, online diaries) collected from each ACT innovator.

Results: Integration requires making changes in organization and interpersonal relationships. During early integration efforts, challenges related to workflow and access, leadership and culture change, and tracking and using data to evaluate patient- and practice-level improvement emerged for ACT innovators. We describe the strategies innovators are developing to address these challenges.

Conclusion: Integrating care is a fundamental and difficult change for practices and health care professionals. Research identifying common challenges that manifest in early efforts can help others attempting integration and inform state, local, and federal policies aimed at achieving wide-spread implementation.

Davis M, Balasubramanian BA, Waller E, Miller BF, Green LA, Cohen DJ. Integrating Behavioral and Physical Health Care in the Real World: Early Lessons from Advancing Care Together. The Journal of the American Board of Family Medicine. September 1, 2013 2013;26(5):588-602.

ACT Learning Evaluation


Background: In healthcare change interventions, on-the-ground learning about the implementation process is
often lost because of a primary focus on outcome improvements. This paper describes the Learning Evaluation, a
methodological approach that blends quality improvement and implementation research methods to study healthcare

Methods: Learning Evaluation is an approach to multi-organization assessment. Qualitative and quantitative data are
collected to conduct real-time assessment of implementation processes while also assessing changes in context,
facilitating quality improvement using run charts and audit and feedback, and generating transportable lessons. Five
principles are the foundation of this approach: (1) gather data to describe changes made by healthcare organizations and
how changes are implemented; (2) collect process and outcome data relevant to healthcare organizations and to the
research team; (3) assess multi-level contextual factors that affect implementation, process, outcome, and transportability;
(4) assist healthcare organizations in using data for continuous quality improvement; and (5) operationalize common
measurement strategies to generate transportable results.

Results: Learning Evaluation principles are applied across organizations by the following: (1) establishing a detailed
understanding of the baseline implementation plan; (2) identifying target populations and tracking relevant process
measures; (3) collecting and analyzing real-time quantitative and qualitative data on important contextual factors; (4)
synthesizing data and emerging findings and sharing with stakeholders on an ongoing basis; and (5) harmonizing and
fostering learning from process and outcome data. Application to a multi-site program focused on primary care and
behavioral health integration shows the feasibility and utility of Learning Evaluation for generating real-time insights into
evolving implementation processes.

Conclusions: Learning Evaluation generates systematic and rigorous cross-organizational findings about implementing
healthcare innovations while also enhancing organizational capacity and accelerating translation of findings by facilitating
continuous learning within individual sites. Researchers evaluating change initiatives and healthcare organizations
implementing improvement initiatives may benefit from a Learning Evaluation approach.

Balasubramanian BA, Cohen DJ, Davis MM, Gunn R, Dickinson LM, Miller WL, Crabtree BF, Stange KC. Learning Evaluation: blending quality improvement and implementation research methods to study healthcare innovations. Implement Sci. 2015 Mar 10;10(1):31

Integrated Behavioral Health and Primary Care Special Issue – COMING SOON

Findings from the ACT evaluation will be a published by the Journal of the American Board of Family Medicine as a special issue on behavioral health and primary care integration containing 8 original research papers and 4 editorials. It is slated for publication September, 2015. The special issues draws on the results of ACT and the Integrated Workforce Study funded by Agency for Healthcare Research and Quality, the Maine Health Access Foundation, and the CalMHSA Foundation.