Table 1
Six Dimensions of the Rainbow Model for Integrated Care (Valentijn et al., 2013).
| DIMENSION | DEFINITION |
|---|---|
| System integration (Macro level) | Rules, policies, and structures that promote delivery of holistic healthcare putting individuals’ needs at the center. |
| Organizational integration (Meso level) | Inter-organizational relationships (e.g., contracting, strategic alliances, knowledge networks) to deliver comprehensive services to a defined population. |
| Professional integration (Meso level) | Inter-professional partnerships (between or within organizations) based on shared roles, responsibilities and accountability to deliver a comprehensive continuum of care to a defined population. |
| Clinical integration (Micro level) | Coordination and delivery of person-focused care within a single setting and a single process across disciplines. |
| Functional integration (Across levels) | Key support functions and activities (e.g., financial, management and information systems) to coordinate and support accountability and decision-making between organizations and professionals. |
| Normative integration (Across levels) | Development and maintenance of common mission, vision, values and culture between professionals, groups, and organizations. |
Table 2
Participant Characteristics.
| VARIABLE | SURGEONS AND RESIDENTS (N = 48) | NON-PHYSICIAN HEALTHCARE PROFESSIONALS (N = 31) |
|---|---|---|
| Gender | ||
| Men | 92% (44) | 32% (10) |
| Women | 6% (3) | 68% (21) |
| Other | 2.1% (1) | 0% (0) |
| Age in years | ||
| 25–39 | 67% (32) | 65% (20) |
| 40–55 | 27% (13) | 32% (10) |
| 56–75 | 6.3% (3) | 3.2% (1) |
| Race | ||
| White | 73% (35) | 71% (22) |
| Black | 8% (4) | 10% (3) |
| Asian | 13% (6) | 0% (0) |
| Multiracial or other | 6% (3) | 19% (6) |
| Ethnicity | ||
| Hispanic or Latino | 2% (1) | 39% (12) |
| Non-Hispanic or Latino | 98% (47) | 61% (19) |
| Household income in USD | ||
| 20,001–50,000 | 0% (0) | 29% (9) |
| 50,001–100,000 | 44% (21) | 23% (7) |
| 100,001–200,000 | 17% (8) | 39% (12) |
| 200,001–300,000 | 4% (2) | 6% (2) |
| 300,001–400,000 | 0% (0) | 0% (0) |
| 400,001–500,000 | 4% (2) | 0% (0) |
| 500,001–750,000 | 25% (12) | 3% (1) |
| >750,000 | 6% (3) | 0% (0) |
| Self-reported mental health training | ||
| Yes | 50% (24) | 52% (16) |
| No | 50% (24) | 48% (15) |
Table 3
Semi-structured focus group script domains and questions.
| DOMAINS | QUESTIONS |
|---|---|
| Perceptions of the psychosocial needs of orthopedic patients | What comes to mind when you think of the terms “psychological, mental health, or behavioral concerns”? How often do you notice psychological, mental health, or behavioral problems in your patients? Do you formally assess or screen patients for psychological problems? What do you think about the role of these factors in the recovery trajectory of your patients? |
| Comfort addressing psychosocial factors in patients with orthopedic trauma | How do you address mental or behavioral health problems that you notice in your patients? Do you ever refer or initiate the connection of patients to mental or behavioral health services? What mental and behavioral health resources are you aware of that are potentially available to your patients? What would be an ideal scenario for addressing mental health factors for your patients? |
| Perspectives on integration of psychosocial care integration in orthopedic departments | How supportive are you of integrating psychosocial care within the orthopedic practice? What do you see as the most significant barriers to the integration of psychosocial care within orthopedic departments? |
| Individual exit interview (optional) | Is there anything that you would like to share that is relevant to the discussion from the focus group that you did not share in the focus group for any reason? How was your experience in the focus group today? |
Table 4
Orthopedic health care professionals’ positive and negative perceptions by integrated care dimension.
| DOMAIN | THEMES |
|---|---|
| Clinical integration (micro level): | Positive perceptions: Addressing psychosocial factors would increase patient satisfaction with care Integrated care would promote accessibility to mental health services for patients Negative perceptions: Uncertainty whether patients would accept psychosocial services in traditionally biomedical setting Uncertainty whether patients have interest in psychosocial services given stigma Offering psychosocial services at clinic would be time-consuming for patient Integrated care would demand time and resources from medical providers Offering psychosocial services might instigate or exacerbate patient anxiety |
| Professional integration (meso level): | Positive perceptions: Value would be generated for providers having service to offer patients in distress Psychosocial services may reduce burden on providers by minimizing post-op calls Interest in learning about psychosocial aspects of orthopedic traumas |
| Organizational integration (meso level): | Positive perceptions: Offering psychosocial services would fill a critical gap in patient care Psychosocial service integration could promote organizational efficiency (e.g., less follow-up visits, reduced provider burn-out) Negative perceptions: Changes made to clinic procedures need to be approved by hospital |
| System integration (macro level): | Positive perceptions: Psychosocial service integration could help reduce healthcare system burden (i.e., reduce healthcare costs, improve healthcare efficiency) |
| Functional integration (micro, meso, and macro levels): | Negativeperceptions: More providers would further fragment care and disrupt communication Lack of funding for psychosocial services/providers |
| Normative integration (micro, meso, and macro levels): | Positive perceptions: Existing collaborative culture to bolster multidisciplinary team cohesion Value placed in continued learning, research, and professional growth Shared mission across multidisciplinary providers (i.e., wanting patients to get back to their activities) Distress is common in orthopedic settings and that distress shapes patient recovery and experience of pain Addressing psychosocial factors is in line with valued patient-centered, holistic care Alignment of psychosocial services with medical treatment goals and recommendations (e.g., engage in physical therapy despite pain) Negative perceptions: Psychosocial factors are not relevant to orthopedic care and lack of interest in addressing them Misconceptions about mental health (e.g., belief it is patient’s choice to have a positive mindset or not) Mental health cannot be improved through intervention Discomfort discussing mental health among orthopedic medical providers |
Table 5
Orthopedic health care professionals’ recommendations by integrated care dimension.
| DOMAIN | THEMES |
|---|---|
| Clinical integration (micro level): | Assess psychosocial factors during patients’ earliest visits Dedicate sufficient time in clinic flow for psychosocial service delivery Protect patient privacy when receiving psychosocial services Ensure that integrated care does not cause significant delays to providers Make psychosocial services available to all patients regardless of risk to help normalize distress Tailor psychosocial services to patient needs (e.g., brief versus long-term) Tailor services to patient socio-economic status and health literacy needs (e.g., remote option, Zoom tutorial) Utilize frequent communication and reminders to support patient engagement (e.g., texts, emails, check-ins) |
| Professional integration (meso level): | Secure leadership and influential stakeholder support for integration to facilitate provider buy-in Equip medical providers with psychosocial knowledge to enhance inter-professional communication Equip psychosocial service providers with orthopedic knowledge to enhance inter-professional communication Focus on common provider treatment goals (e.g., patient wellbeing and recovery) to promote teamwork Ensure that roles and responsibilities of multidisciplinary healthcare teams are clear Have medical providers perform warm hand-offs to psychosocial service providers |
| Organizational integration (meso level): | Develop safety protocols for patients who require higher levels of psychiatric care |
| System integration (macro level): | Enhance inclusivity and accessibility of psychosocial services by addressing barriers to care engagement (e.g., housing, food security, transportation, internet, health insurance) |
| Functional integration (micro, meso, and macro levels): | Ensure ongoing communication among collaborating providers regarding patient outcomes and integration progress Have designated staff to help coordinate multidisciplinary services Use existing clinic information and record-keeping systems (e.g., OR boards, EMR) Streamline psychosocial screening and referral procedures (e.g., order in EMR) Use electronic resources for education and communication with providers Ensure that providers and/or interpretative services are available for patients who speak different languages Ensure that referrals to outpatient psychosocial services are accessible for patients Have office space designated for psychosocial services |
| Normative integration (micro, meso, and macro levels): | Educate orthopedic providers on the psychosocial aspects of pain and injury to support a shared vision Provide empirical evidence that integrated care can improve patient outcomes Ensure services are culturally sensitive, inclusive, and individualized to patient-specific needs Establish shared communication styles among team members (e.g., concise, data-driven) |