Please select the eligibility criteria that correspond to the clinical trial below.
Title: Integrating Behavioral Health and Primary Care for Comorbid Behavioral and Medical Problems
Brief Summary: Behavioral problems are part of many of the chronic diseases that cause the majority of illness, disability and death. Tobacco, diet, physical inactivity, alcohol, drug abuse, failure to take treatment, sleep problems, anxiety, depression, and stress are major issues, especially when chronic medical problems such as heart disease, lung disease, diabetes, or kidney disease are also present. These behavioral problems can often be helped, but the current health care system doesn't do a good job of getting the right care to these patients.

Behavioral health includes mental health care, substance abuse care, health behavior change, and attention to family and other psychological and social factors. Many people with behavioral health needs present to primary care and may be referred to mental health or substance abuse specialists, but this method is often unacceptable to patients. Two newer ways have been proposed for helping these patients. In co-location, a behavioral health clinician (such as a Psychologist or Social Worker) is located in or near the primary practice to increase the chance that the patient will make it to treatment. In Integrated Behavioral Health (IBH), a Behavioral Health Clinician is specially trained to work closely with the medical provider as a full member of the primary treatment team.

The research question is: Does increased integration of evidence-supported behavioral health and primary care services, compared to simple co-location of providers, improve outcomes? The key decision affected by the research is at the practice level: whether and how to use behavioral health services.

The investigators plan to do a randomized, parallel group clustered study of 3,000 subjects in 40 practices with co-located behavioral health services. Practices randomized to the active intervention will convert to IBH using a practice improvement method that has helped in other settings. The investigators will measure the health status of patients in each practice before and after they start using IBH. The investigators will compare the change in those outcomes to health status changes of patients in practices who have not yet started using IBH.

The investigators plan to study adults who have both medical and behavioral problems, and get their care in Family Medicine clinics, General Internal Medicine practices, and Community Health Centers.


Options:
A: Inclusion Criteria:

* Age \>40 years
* Chart-document severe or very severe COPD (FEV1\<50% predicted) or COPD-related ED/hospitalization ≥ 1 visit within the past 12 months
* Prescribed any daily medication for COPD, English or Spanish speaking, Smoking history ≥ 10 pack-years

Exclusion Criteria:

* Diagnosis in the clinical record of dementia, because the study focuses on patients with capacity to independently perform self-management tasks.
B: Inclusion Criteria:

* People who live in either Ringkoebing-Skjern or Ikast-Brande municipalities and have a GP in the municipality and have been in hospital during the last 5 years with a lung related diagnosis or has redeemed a prescription for medication for lung related problems twice during the last year or has had at least two spirometries done during the last year.

Exclusion Criteria:

* People who do not fit the above inclusion criteria
C: Inclusion Criteria:

1. Patients: aged 65 years and older with diagnosis of COPD registered as J-44 (ICD-10).
2. Centres: Primary Health Care Centers (PHCC) with at least 46 COPD patients listed.

Exclusion Criteria:

None
D: Inclusion Criteria:

* Over 18 years of age
* At least one target chronic medical condition:
* arthritis
* asthma
* chronic obstructive lung disease
* diabetes
* heart failure
* or hypertension.
* Evidence of a behavioral problem or need:
* Diagnosis of:
* anxiety
* chronic pain including headache
* depression
* fibromyalgia
* insomnia
* irritable bowel syndrome
* problem drinking
* substance use disorder
* OR persistent use of certain medications used for behavioral concerns:
* antidepressants
* anxiolytics
* opioids
* antineuropathy agents
* OR persistent failure to attain physiologic control of a medical problem:
* blood pressure\>165 while on 3 or more medications
* A1C \> 9% for 6 months)
* OR the presence of three or more of the target chronic medical conditions.

Exclusion Criteria:

* Not seeking care at a participating practice
* Inability to consent due to cognitive and/or developmental impairment/delays
* Living in the same household as a previously enrolled study participant

Answer: D