Mind and body reunited: improving care at the behavioral and primary healthcare interface

Availability of Testing for Sexually Transmitted Infections and HIV in U.S. Outpatient Mental Healthcare Settings

People with mental illnesses experience higher incidence of sexually transmitted illnesses (STIs) and HIV, and estimates show fewer than 50% have received testing. The purpose of this study was to examine the prevalence of STI/HIV testing among United States outpatient mental healthcare service providers. Data from the National Mental Health Services Survey (NMHSS) was used to determine the rates of STI and HIV testing amongst 9,267 outpatient mental healthcare service providers in the U.S. Regression analyses were used to assess whether the likelihood a service provider offered STI or HIV testing was associated with service provider characteristics (facility type, services offered, accepted payments) and state-level incidence of STIs and HIV. We found 7.79% and 6.64% of outpatient mental healthcare service providers provided STI and HIV testing, respectively, with lowest rates in community mental health centers and partial hospitalization facilities. Providing dual-diagnosis for severe mental illness and substance use disorders was an independent predictor of STI testing (aOR = 2.17, [1.72-2.75] and HIV testing (aOR = 2.61, [2.07-3.30]. Higher state-level incidence of STIs and HIV were associated with higher rates of STI testing (β = 0.28, p = .047) and HIV testing (β = 0.48, p < .001). Preventing STIs and HIV among patients living with mental illness is a key priority of multiple national initiatives. Despite this, fewer than 10% of outpatient mental healthcare service providers responding to the NMHSS offered STI and HIV testing. Existing service co-delivery models may be one promising method for implementing STI/HIV testing within outpatient mental health settings.

Patient Service Utilization Among Individuals with Co-occurring Disorders: A Comparison of Two Models of Care Coordination

Healthcare systems have increasingly adopted integrated care models with demonstrated effectiveness. However, few studies examine integrated care for individuals with co-morbid mental illness and medical conditions. This quasi-experimental study compared service use for two integrated care models for patients with co-occurring conditions. We used hierarchical negative binomial and logistic regressions with random effects to test the relationship between integration and service use. Patients treated at co-located agencies had significantly higher odds of inpatient hospitalization compared to those in fully integrated settings. Additionally, some comorbidities had significantly different levels of service use. Patients at co-located agencies had more outpatient and emergency visits, but was not statistically significant. Our findings provide evidence that the model of care may impact service use for patients experiencing co-occurring conditions, however, variations in service use for specific co-morbid conditions highlight the need to examine the specific needs and characteristics of this population.

Integrated Behavioral Health and Intervention Models

Accumulating evidence documenting the high percentage of patients who first discuss mental health needs with their primary care physician has accelerated the integration of physical and mental health care to a national priority. Several models have been developed describing how health care settings can integrate physical and mental health care and how training programs might better prepare clinicians to work in integrated behavioral health care settings. This article explores models of integrated behavioral health, highlights contributions of social work and psychology, and describes the training and experiences of social workers and psychologists working in integrated behavioral health.

Leaning Into Whole Health: Sustaining System Transformation While Supporting Patients and Employees During COVID-19

BACKGROUND

The US Veterans Health Administration (VA) is transforming its healthcare system to create a Whole Health System (WHS) of care. Akin to such reorganization efforts as creating patient-centered medical homes and primary care behavioral health integration, the WHS goes beyond by transforming the entire system to one that takes a proactive approach to support patient and employee health and wellness. The SARS-CoV-2 pandemic disrupted the VA's healthcare system and added stress for staff and patients, creating an exogenous shock for this transformation towards a WHS.

OBJECTIVE

We examined the relationship between VA's WHS transformation and the pandemic to understand if transformation was sustained during crisis and contributed to VA's response.

METHODS

Qualitative interviews were conducted as part of a multi-year study of WHS transformation. A single multi-person interview was conducted with 61 WHS leaders at 18 VA Medical Centers, examining WH transformation and use during the pandemic. Data were analyzed using rapid directed content analysis.

RESULTS

While the pandemic initially slowed transformation efforts, sites intentionally embraced a WH approach to support patients and employees during this crisis. Efforts included conducting patient wellness calls, and, for patients and employees, promoting complementary and integrative health therapies, self-care, and WH concepts to combat stress and support wellbeing. A surge in virtual technology use facilitated innovative delivery of complementary and integrative therapies and promoted continued use of WH activities.

CONCLUSION

The pandemic called attention to the need for healthcare systems to address the wellbeing of both patients and providers to sustain high quality care delivery. At a time of crisis, VA sites sustained WH transformation efforts, recognizing WH as one strategy to support patients and employees. This response indicates cultural transformation is taking hold, with WH serving as a promising approach for promoting wellbeing among patients and employees alike.

Three Decades and Counting: HIV Service Provision in Outpatient Mental Health Settings

OBJECTIVE

People with serious mental illness in the United States have higher human immunodeficiency virus (HIV) infection rates than the general U.S. population. This study aimed to assess delivery of HIV services in New York State's outpatient mental health programs. Greater access would enhance efforts to improve HIV prevention and care outcomes.

METHODS

The authors surveyed directors of licensed outpatient mental health care programs statewide to investigate their HIV service delivery. Data were compared with surveys conducted in 1997 and 2004 in order to examine differences in services between geographic regions and time periods.

RESULTS

Outpatient mental health programs have improved in the volume and range of HIV services offered, but their provision of preexposure prophylaxis, condoms, HIV testing, and HIV antiretroviral treatment monitoring has lagged.

CONCLUSIONS

New York's initiative to end the HIV epidemic is not optimized to reach people with serious mental illness in settings designed for their care.

Experiences of Early Career Counseling Psychologists Working in Integrated Health Care

Psychologists are increasingly represented among interprofessional health care teams, yet little is known about counseling psychologists who fulfill these roles. We interviewed 13 early career counseling psychologists in different settings across the country about their roles and functions, the nature of their relationships with other health professionals, and counseling psychology identity and values. Results showed that counseling psychologists perform a variety of duties by adapting their counseling psychology training to medical settings, and that they find this work both challenging and rewarding. Participants incorporated traditional counseling psychology pillars of prevention, diversity, social justice, and strength-based interventions to make contributions to patient and community care in integrated health care settings. Implications for training and future research are discussed.

Improving Outcomes of Care for HRSA-Funded Health Center Patients Who Have Mental Health Conditions and Substance Use Disorders

The rising prevalence of mental health conditions and substance use disorders (MH/SUD) underscores the important role of health centers (HCs) in caring for low-income and uninsured MH/SUD patients. This study used the 2014 Health Center Patient Survey and 2014 Uniform Data System to determine the independent association between delivery of MH/SUD integration and related interventions to patients that reported a MH/SUD condition (n=2714) with the number of HC visits, emergency department (ED) visits, and hospitalizations last year. Results showed that health education was associated with fewer predicted ED visits (1.8 vs. 2.3) and lower likelihood of hospitalizations (16% vs. 24%) among MH patients. Medical enabling services was associated with lower rates of ED visits (0.3 vs.1.9) and hospitalizations (< 1% vs. 13%) among SUD patients. The results indicate the utility of integration and related intervention services in primary care settings to improve service use and reduce ED and hospitalization among MH/SUD patients.

Social Worker Integrated Care Competencies Scale (SWICCS): Assessing social worker clinical competencies for health care settings

Integrating physical and behavioral health services has the potential to reduce health disparities and service inequities among persons most at risk. However, clinical social workers in integrated health settings must possess relevant knowledge and skills to provide quality care to diverse populations. The Social Worker Integrated Care Competency Scale (SWICCS), developed to complement the Integrated and Culturally Relevant Care (ICRC) field education curriculum, measures students' self-perceptions of knowledge and skills associated with providing behavioral health care. Three student cohorts (n = 38) completed the SWICCS three times during an integrated care field practicum. Results indicated a statistically significant increase in student knowledge and skills at each time point, with a large effect size (r = -.87). The SWICCS demonstrated utility in measuring and tracking social work student acquisition of knowledge and skills required for practice in integrated care environments.

Models of care for populations with chronic conditions and mental/behavioral health comorbidity

Recent decades have seen increased interest in the integration of mental and physical healthcare. Healthcare reform in the US has provided an opportunity for integration of evidence-based mental health programmes. Three quarters of patients with behavioural health disorders are seen in medical settings, where behavioural problems are largely unaddressed. The human and economic toll of unaddressed mental and behavioural health needs is enormous and often hidden from view, since the behavioural or mental health implications of medical conditions like heart disease and diabetes have only recently begun to be appreciated. This paper has three goals: (1) to review models of integrated services delivery, providing a framework for making sense of strategies for integration; (2) to consider some evidence for clinical outcomes when care is integrated; and (3) to highlight some factors that enhance or impede integration in practice. The review concludes with comments on where the field is going.

Risk of Early Rehospitalization for Non-Behavioral Health Conditions Among Adult Medicaid Beneficiaries with Severe Mental Illness or Substance Use Disorders

The goal was to examine risk factors and expenditures for early rehospitalization (within 30 days of discharge) for non-behavioral health conditions among Medicaid-enrolled Floridians over 8 years. There were 1,689,797 hospitalization episodes with 19% (N = 314,742) resulting in early rehospitalization. Total gross charges for early rehospitalization were over 13 billion dollars. In Cox proportional hazards regression adjusted for demographic and health covariates, drug use disorder was associated with 50% increased risk of early rehospitalization. Having major depressive disorder increased risk by 17%; psychotic disorder, bipolar disorder, and alcohol use disorder increased risk of early rehospitalization slightly by 10, 6, and 6% respectively. The effect of dementia on risk was minimal at 2%. Risk of early rehospitalization decreased by 3.5% per year over the 8 years of the study. Attention to mental health problems, especially drug use disorder, may help further reduce rates of early readmission for non-behavioral health conditions.

The Role of Health Plans in Supporting Behavioral Health Integration

Health plan policies can influence delivery of integrated behavioral health and general medical care. This study provides national estimates for the prevalence of practices used by health plans that may support behavioral health integration. Results indicate that health plans employ financing and other policies likely to support integration. They also directly provide services that facilitate integration. Behavioral health contracting arrangements are associated with use of these policies. Delivery of integrated care requires systemic changes by both providers and payers thus health plans are key players in achieving this goal.

Psychiatry Residents' Perceptions and Reported Practices in Providing Primary Care

BACKGROUND

Patients with psychiatric disorders have higher rates of chronic medical conditions and decreased life expectancy. Integrating medical and psychiatric care is likely to improve health outcomes for these patients.

OBJECTIVE

This study examined what proportion of psychiatry residents viewed psychiatry as a primary care specialty, how important they felt it was to provide primary care to patients, and how this perception altered self-reported comfort and practice patterns in providing screening and treatment for select general medical conditions.

METHODS

An online survey was sent to current psychiatry residents of US residency programs.

RESULTS

A total of 268 residents from 40 programs completed the survey (25% response rate), with 55% (147 of 265) of respondents considering psychiatry to be a primary care specialty. Residents who held this opinion gave higher ratings for the importance of providing preventive counseling and reported counseling a higher percentage of patients on a variety of topics. They also reported screening more patients for several medical conditions. Residents who considered psychiatry to be primary care did not report greater comfort with treating these conditions, with the exception of dyslipidemia. The most commonly cited barrier to integrating primary care services was lack of time.

CONCLUSIONS

Residents' perceptions of psychiatry as a primary care field appears to be associated with a higher reported likelihood of counseling about, and screening for, medical conditions in their patients.

Behavioral Health Problems Presented to Integrated Pediatric Behavioral Health Clinics: Differences in Urban and Rural Patients

Behavioral health diagnoses and service use may differ based on rurality. The purpose of this study was to examine the patterns of mental disorder diagnoses of urban, rural, and remote pediatric populations. This retrospective study used electronic medical records from integrated behavioral health clinics in Nebraska from 2012 to 2013. Bivariate and multivariable models were used to examine the differences in diagnoses. Adolescents with attention deficit and related disorders were more likely to be male, younger, have public insurance and rural/remote residents. Adjustment disorders were associated with being female, older, and urban residents. Adolescents with anxiety disorder had a significant interaction between age and gender, with both genders being older, having private insurance, and urban residents. Adolescents with mood disorder were more likely to be female, older, and urban residents. Demographic and clinical differences among patients in urban and rural/remote settings have implications for care in rural settings.

Diabetes and Cardiovascular Care Among People with Severe Mental Illness: A Literature Review

Close to 19 million US adults have severe mental illnesses (SMI), and they die, on average, 25 years earlier than the general population, most often from cardiovascular disease (CVD). Many of the antipsychotic medications used to treat SMI contribute to CVD risk by increasing risk for obesity, type 2 diabetes, dyslipidemia, and hypertension. Based on compelling evidence, the American Diabetes Association and the American Psychiatric Association developed guidelines for metabolic screening and monitoring during use of these medications.In this manuscript, we have reviewed the evidence on diabetes and other CVD risk screening, prevalence, and management among populations with SMI. We also review differences in screening among subpopulations with SMI (e.g., racial/ethnic minorities, women, and children). We found that despite national guidelines for screening for diabetes and other cardiovascular risk factors, up to 70 % of people taking antipsychotics remain unscreened and untreated. Based on estimates that 20 % of the 19 million US adults with SMI have diabetes and 70 % of them are not screened; it is likely that over 2 million Americans with SMI have unidentified diabetes. Given that undiagnosed diabetes costs over $4,000 per person, this failure to identify diabetes among people with SMI represents a missed opportunity to prevent morbidity and translates to over $8 billion in annual preventable costs to our healthcare system.Given the high burden of disease and significant evidence of suboptimal medical care received by people with SMI, we propose several clinical and policy recommendations to improve diabetes and other CVD risk screening and care for this highly vulnerable population. These recommendations include reducing antipsychotic medication dose or switching antipsychotic medications, enhancing smoking cessation efforts, sharing electronic health records between physical and mental health care systems, and promoting integration of care.

Mini Review of Integrated Care and Implications for Advanced Practice Nurse Role

Literature related to primary care and behavioral health integration initiatives is becoming abundant. The United States’ 2010 Patient Protection and Affordable Care Act included provisions encouraging increased collaboration of care for individuals with behavioral and physical health service needs in the public sector. There is relatively little known of Advanced Practice Registered Nurses’ (APRNs) roles with integrating primary and behavioral healthcare. The goal of this review article is to: (a) define integration of physical and behavioral healthcare and potential models; (b) answer the question as to what are effective evidence based models/strategies for integrating behavioral health and primary care; (c) explore the future role and innovations of APRNs in the integration of physical and behavioral healthcare.

Integrated and Culturally Relevant Care: A Model to Prepare Social Workers for Primary Care Behavioral Health Practice

Policymakers and researchers emphasize needs for an integrated, effective, and efficient health care system to address well-documented disparities and inequities in care experienced by diverse populations. The Affordable Care Act, through its support of integrated health care, addresses social determinants of health with a goal of increasing access to care. Social work is poised to assume a central position in health care reform and integrated behavioral health, but must prepare practitioners to work alongside medical providers in health care settings. This article describes a social work field education model developed in partnership with community mental health and health care providers. The model, Integrated and Culturally Relevant Care, prepares social work students to provide behavioral health services in integrated primary care environments.

Prevalence and Impact of Mental and Physical Comorbidity in the Adult Singapore Population

Introduction: This study aims to assess the prevalence rates of mental disorders and chronic medical conditions in the Singapore resident population, and examine their association and respective impact on the quality of life. Materials and Methods: A household survey was carried out on a nationally representative sample of the adult (18 years and above) resident population. The main instrument used to establish the diagnosis of mental disorders is the World Mental Health Composite International Diagnostic Interview (WMH-CIDI). The mental disorders included in study were major depressive disorder, bipolar disorder, generalised anxiety disorder, obsessive compulsive disorder, alcohol abuse and alcohol dependence. Respondents were asked if they had any of the chronic medical conditions from a list of 15 conditions. Health-related quality of life was assessed with the EQ-5D. Results: Of the 6616 respondents, the lifetime prevalence of mental disorders was 12.0%, and that of chronic medical disorders were 42.6% and those with comorbid mental and medical disorders was 6.1%. The prevalence of any physical disorder in this population was high (42.6%). Among those with chronic physical disorders, 14.3% also had a mental disorder, and among those with mental disorders, more than half (50.6%) had a medical disorder. Most of the mental disorders were not treated. Males, Indians, older people, and those who were separated or divorced were more likely to have comorbidity. The health-related quality of life was significant worse in those with both mental and medical disorders compared to those with either mental or medical disorder. Conclusion: Our study re-emphasised the common occurrence of mental and medical disorders and the importance for an integrated care system with the capability to screen and treat both types of disorders. It also identified certain subpopulations which are more likely to have comorbidity for which a more targeted intervention could be planned. Key words: Chronic conditions, Ethnicity, Health-related quality of life, Marital status

Budget impact and sustainability of medical care management for persons with serious mental illnesses

OBJECTIVE

The authors assessed the 2-year outcomes, costs, and financial sustainability of a medical care management intervention for community mental health settings.

METHOD

A total of 407 psychiatric outpatients with serious mental illnesses were randomly assigned to usual care or to a medical care manager who provided care coordination and education. Two-year follow-up chart reviews and interviews assessed quality and outcomes of care, as well as costs from both the health system and managerial perspectives.

RESULTS

Sustained improvements were observed in the intervention group in quality of primary care preventive services, quality of cardiometabolic care, and mental health-related quality of life. From a health system perspective, by year 2, the mean per-patient total costs for the intervention group were $932 (95% CI=-1,973 to 102) less than for the usual care group, with a 92.3% probability that the program was associated with lower costs than usual care. From the community mental health center perspective, the program would break even (i.e., revenues would cover setup costs) if 58% or more of clients had Medicaid or another form of insurance. Given that only 40.5% of clients in this study had Medicaid, the program was not sustainable after grant funding ended.

CONCLUSIONS

The positive long-term outcomes and favorable cost profile provide evidence of the potential value of this model. However, the discrepancy between health system and managerial cost perspectives limited the program's financial sustainability. With anticipated insurance expansions under health reform, there is likely to be a stronger business case for safety net organizations considering implementing evidence-based interventions such as the one examined in this study.

Transforming assertive community treatment into an integrated care system: the role of nursing and primary care partnerships

Despite the high rate of co-occurring medical conditions experienced by individuals receiving assertive community treatment (ACT), this comprehensive service model continues to be considered primarily a mental health intervention. Without compromising fidelity to the model, ACT can serve as an ideal platform from which to provide both primary and behavioral health care to those with complex service needs. Using a case example, this article considers the transformation of the ACT mental health care model into an integrated health care delivery system through establishing nursing and primary care partnerships. Specifically, by expanding and explicitly redefining the role of the ACT nurse, well-developed care models, such as Guided Care, can provide additional guidelines and training to ACT nurses who are uniquely trained and oriented to serve as the leader and coordinator of health integration efforts.