Creating a 'reverse' integrated primary and mental healthcare clinic for those with serious mental illness

Client perspectives on primary care integration in a rural-serving behavioral health center

Purpose

Advancing behavioral health and primary care integration is a priority for helping clients overcome the complex health challenges impacting healthcare deserts like those in Arizona, United States of America (USA). This study aimed to explore the perspectives of people with a substance use disorder (SUD) on accessing integrated primary care (IPC) services in a rural-serving behavioral healthcare organization in Arizona.

Design/methodology/approach

Clients from a behavioral health facility in Arizona (n = 10) diagnosed with SUDs who also accessed IPC participated in a 45-min semi-structured interview.

Findings

The authors identified six overarching themes: (1) importance of IPC for clients being treated for SUDs, (2) client low level of awareness of IPC availability at the facility, (3) strategies to increase awareness of IPC availability at the behavioral health facility, (4) cultural practices providers should consider in care integration, (5) attitudes and perceptions about the experience of accessing IPC and (6) challenges to attending IPC appointments. The authors also identified subthemes for most of the main themes.

Originality/value

This is the first study in rural Arizona to identify valuable insights into the experiences of people with SUDs accessing IPC, providing a foundation for future research in the region on care integration.

Mental health is related to metabolic syndrome: The Hispanic community health study/ study of Latinos

OBJECTIVE

Metabolic syndrome (MetS) is associated with common mental health conditions. Using cross-sectional data from the observational Hispanic Community Health Study / Study of Latinos (HCHS/SOL), this study examined the relationship between MetS and depression and anxiety in addition to testing moderating effects of gender and Hispanic heritage subgroups.

METHODS

Participants included 13,496 Hispanic Americans aged 18-74 (59% women, mean age 46.59 ± 13.65) from seven heritage subgroups. Depression was measured using the Center for Epidemiologic Studies Depression 10-item scale, and anxiety was assessed using the State-Trait Anxiety Inventory 10-item scale. A 3-level categorical variable was developed to assess the combined influence of depression and anxiety. The dependent variable is dichotomous, delineating the presence or absence of MetS as defined by the National Cholesterol Education Program Third Adult Treatment Panel. Logistic regression and Hayes' PROCESS macro assessed these relationships and the moderating effects of gender-heritage subgroups.

RESULTS

Results suggest depression (p < .001) and anxiety (p < .001) were associated with an increased likelihood of MetS. Puerto Ricans had the highest, and South Americans had the lowest, levels of depression and anxiety. Gender moderated the relationship between mental health and MetS, with women having a significant increase in the probability of MetS with depression (p < .001), anxiety (p < .001), or both (p < .001).

CONCLUSION

Elevated symptoms of depression and anxiety are associated with the presence of MetS in US Hispanic subgroups. Gender-heritage differences are present among the study variables. Strategies to manage psychological well-being must be employed to optimize cardiometabolic health in US Hispanics.

Non-Pharmacological Integrated Interventions for Adults Targeting Type 2 Diabetes and Mental Health Comorbidity: A Mixed-Methods Systematic Review

Objective:

Adults living with Type 2 diabetes (T2D) and severe mental illness (SMI) disproportionally experience premature mortality and health inequality. Despite this, there is a limited evidence-base and evaluation of non-pharmacological integrated interventions that may contribute to improved patient experience and outcomes. To improve our understanding of how to optimise integrated care for this group, this review evaluates the effectiveness, acceptability, and feasibility of non-pharmacological integrated interventions for adults with SMI and T2D.

Methods:

Studies from nine electronic databases were searched. Of the 6750 papers retrieved, seven papers (five quantitative and two qualitative) met the inclusion/exclusion criteria. A convergent integrated approach was used to narratively synthesise data into four main themes: effectiveness, acceptability, feasibility, integrated care.

Results:

There is moderate evidence to suggest non-pharmacological integrated interventions may be effective in improving some diabetes-related and psychosocial outcomes. Person-centred integrated interventions that are delivered collaboratively by trained facilitators who exemplify principles of integrated care may be effective in reducing the health-treatment gap.

Conclusions:

Recommendations from this review can provide guidance to healthcare professionals, commissioners, and researchers to inform improvements to non-pharmacological integrated interventions that are evidence-based, theoretically driven, and informed by patient and healthcare professionals’ experiences of care.

An integrated approach to providing care for people who have been trafficked

People who have been trafficked often have complex medical and psychiatric needs. Integrated care is a treatment approach that may be used to improve the care of this population. The authors describe the integrated care model and how it may be applied to this population. They also describe some of the benefits and challenges of using an integrated care model with this population.

Assessing the Long-Term Effectiveness of a Behavioral Health Home for Adults With Bipolar and Psychotic Disorders

OBJECTIVE

This study aimed to examine the impact of a behavioral health home (BHH) to better understand its potential to improve health for individuals with serious mental illness.

METHODS

Propensity score-weighted interrupted time series analysis was used to estimate service utilization and chronic disease management through 3.5 years after BHH implementation and to compre BHH enrollees (N=413) with other patients with serious mental illness in the same health system (N=1,929).

RESULTS

Relative to control group members, BHH patients had an immediate increase in primary care visits (+0.18 visits/month), which remained higher throughout follow-up, and an immediate decrease in emergency department visits (-0.031 visits/month). Behavioral health outpatient visits, which were increasing for BHH participants before implementation, began decreasing postimplementation; this decrease (-0.016 visits/month) was significantly larger than for the control group. Inpatient and outpatient visits for general medical health were decreasing over time for both groups before implementation but decreased more slowly for BHH patients postimplementation. Although behavioral health inpatient visits decreased for both groups around the start of the BHH program and remained lower, this initial drop was larger for the non-BHH group. BHH participation was associated with decreases in hemoglobin A1c values but no shift in low-density lipoprotein cholesterol values.

CONCLUSIONS

The results reflect the challenges of improving health for patients with serious mental illness, even as access to primary care is increased. Further study is needed about which complex interventions inside and outside of the health care system can help offset the 20- to 30-year mortality gap faced by this population.

Patient and provider perception of appropriateness, acceptability, and feasibility of behavioral health home (BHH) core components based on program implementation in an urban, safety-net health system

Background

This manuscript evaluates patient and provider perspectives on the core components of a Behavioral Health Home (BHH) implemented in an urban, safety-net health system. The BHH integrated primary care and wellness services (e.g., on-site Nurse Practitioner and Care Manager, wellness groups and tools, population health management) into an existing outpatient clinic for people with serious mental illness (SMI).

Methods

As the qualitative component of a Hybrid Type I effectiveness-implementation study, semi-structured interviews were conducted with providers and patients 6 months after program implementation, and responses were analyzed using thematic analysis. Valence coding (i.e., positive vs. negative acceptability) was also used to rate interviewees' transcriptions with respect to their feedback of the appropriateness, acceptability, and feasibility/sustainability of 9 well-described and desirable Integrated Behavioral Health Core components (seven from prior literature and two additional components developed for this intervention). Themes from the thematic analysis were then mapped and organized by each of the 9 components and the degree to which these themes explain valence ratings by component.

Results

Responses about the team-based approach and universal screening for health conditions had the most positive valence across appropriateness, acceptability, and feasibility/sustainability by both providers and patients. Areas of especially high mismatch between perceived provider appropriateness and measures of acceptability and feasibility/sustainability included population health management and use of evidence-based clinical models to improve physical wellness where patient engagement in specific activities and tools varied. Social and peer support was highly valued by patients while incorporating patient voice was also found to be challenging.

Conclusions

Findings reveal component-specific challenges regarding the acceptability, feasibility, and sustainability of specific components. These findings may partly explain mixed results from BHH models studied thus far in the peer-reviewed literature and may help provide concrete data for providers to improve BHH program implementation in clinical settings.

Plain language abstract

Many people with serious mental illness also have medical problems, which are made worse by lack of access to primary care. The Behavioral Health Home (BHH) model seeks to address this by adding primary care access into existing interdisciplinary mental health clinics. As these models are implemented with increasing frequency nationwide and a growing body of research continues to assess their health impacts, it is crucial to examine patient and provider experiences of BHH implementation to understand how implementation factors may contribute to clinical effectiveness. This study examines provider and patient perspectives of acceptability, appropriateness, and feasibility/sustainability of BHH model components at 6-7 months after program implementation at an urban, safety-net health system. The team-based approach of the BHH was perceived to be highly acceptable and appropriate. Although providers found certain BHH components to be highly appropriate in theory (e.g., population-level health management), their acceptability of these approaches as implemented in practice was not as high, and their feedback provides suggestions for model improvements at this and other health systems. Similarly, social and peer support was found to be highly appropriate by both providers and patients, but in practice, at months 6-7, the BHH studied had not yet developed a process of engaging patients in ongoing program operations that was highly acceptable by providers and patients alike. We provide these data on each specific BHH model component, which will be useful to improving implementation in clinical settings of BHH programs that share some or all of these program components.

Integrating Behavioral Healthcare and Primary Care, Appropriate Balance on What Model is Driving Care, and, the Whole Spectrum of Individuals are Coming Through the Door…

With the integration of behavioral health services into primary care and other medical specialties, the community of providers and the public must address a number of questions, including: What models of care are there for these services? What kinds of providers supply these services? Are these providers trained behavioral health providers or extenders in some form? And, as these systems of care are constructed, who makes use of them? The purpose of this study is to address these questions as well as to consider some of the challenges of attending to the spectrum of needs that will arise as integrated healthcare services expand. Consideration of these questions may serve to clarify the impact that these models of healthcare will have in ways that may be readily apparent and, at the same time, in ways that may be subtler and less comprehensible. Addressing these questions is also intended to facilitate discussions within healthcare systems and among providers concerning which models of care best respond to specific populations. In turn, proactively answering these questions will, for the foreseeable future, shape not only behavioral healthcare, in perhaps small or large ways, but also healthcare in general.

Coordinating Mental and Physical Health Care in Rural Australia: An Integrated Model for Primary Care Settings

Introduction:

The ‘GP Clinic’ provides primary health care to people using community mental health services in a small town in Australia. This article examines the factors that have driven successful integration in this rural location.

Methods:

A multiple methods case study approach was used comprising service record data for a 24 month period and semi-structured interviews with sixteen staff members associated with the integrated rural service model.

Results:

Processes and structures for establishing integrated care evolved locally from nurturing supportive professional and organisational relationships. A booking system that maximised attendance and minimised the work of the general practice ensured that issues to do with remuneration and the capacity for the general practitioner to provide care to those with complex needs were addressed. Strong collaborative relationships led to the upskilling of local staff in physical and mental health conditions and treatments, and ensured significant barriers for people with mental illness accessing primary care in rural Australia were overcome.

Conclusions:

Integrated physical and mental health service models that focus on building local service provider relationships and are responsive to community needs and outcomes may be more beneficial in rural settings than top down approaches that focus on policies, formal structures, and governance.

Comorbidity of chronic somatic diseases in patients with psychotic disorders and their influence on 4-year outcomes of integrated care treatment (ACCESS II study)

BACKGROUND

People with psychotic disorders fulfilling criteria of a severe and persistent mental illness (SPMI) display a high risk of somatic comorbidity (SC).

METHODS

ACCESS II is a prospective, long-term study examining the effectiveness of Integrated Care for people with psychotic disorders fulfilling SPMI criteria. Chronic comorbid somatic disorders were systematically assessed according to ICD-10-GM criteria. Patients treated for ≥4years in ACCESS were categorized as early psychosis (treatment: ≤2years) or non-early psychosis (treatment: >2years) patients.

RESULTS

Of 187 patients treated in ACCESS for ≥4years (mean age=41.8years, males=44.4%), 145 (77.5%) had SC, (mean=2.1±2.1). Overall, 55 different diseases from 15 different ICD-10-GM disease areas were identified. Prevalence of ≥1 SC (p=0.09) and specific types of SC (p=0.08-1.00) did not differ between early and non-early psychosis patients, but non-early psychosis patients had a higher mean number of SC (2.3±2.2 vs. 1.3±1.3, p=0.002). SC patients had higher rates of comorbid mental disorders (93% vs. 81%, p=0.002), specifically posttraumatic stress disorder (23% vs. 7%, p=0.002), and suicide attempts (43% vs. 19%, p<0.001). At the 4-year endpoint, both patients with and without comorbidity displayed major improvements in psychopathology, severity of illness, functioning, quality of life and satisfaction with care.

CONCLUSIONS

SC is frequent in patients with severe psychotic disorders, even in the early psychosis phase. The magnitude of the problem underlines the need for regular screening, comprehensive assessment, preventive pharmacotherapy, and targeted SC management.

Mind the Gap: Developing an Integrated Behavioral Health Home to Address Health Disparities in Serious Mental Illness

OBJECTIVE

This study evaluated the impact of an integrated behavioral health home (BHH) pilot on adults with psychotic and bipolar disorders.

METHODS

Quasi-experimental methods were used to compare outcomes before (September 2014-August 2015) and after the intervention (September 2015-August 2016) among ambulatory BHH patients and a control group. Electronic health records were compared between 424 BHH patients (N=369, psychotic disorder; N=55, bipolar disorder) and 1,521 individuals from the same urban, safety-net health system who were not enrolled in the BHH. Groups were weighted by propensity score on the basis of sex, age, race-ethnicity, language, 2010 U.S. Census block group characteristics, Medicare and Medicaid enrollment, and diabetes diagnosis.

RESULTS

BHH patients had fewer total psychiatric hospitalizations and fewer total emergency visits compared with the control group, a difference that was predominantly driven by patients with at least one psychiatric hospitalization or ED visit. There were no differences in medical hospitalizations. Although BHH patients were more likely to receive HbA1c screening, there were no differences between the groups in lipid monitoring. Regarding secondary outcomes, there were no significant differences in changes in metabolic monitoring parameters among patients with diabetes.

CONCLUSIONS

Participation in a pilot ambulatory BHH program among patients with psychotic and bipolar disorders was associated with significant reductions in ED visits and psychiatric hospitalizations and increased HbA1c monitoring. This evaluation builds on prior research by specifying intervention details and the clinical target population, strengthening the evidence base for care integration to support further program dissemination.

Health Care Decisions among Mental Health Services Consumers in San Diego County: Implications for Integrated Care

People living with serious mental illness are at elevated risk for chronic diseases compared with those in the general population. Whether integrated care for this population would be most accessible in primary care or mental health settings is unclear. The cross-sectional study described in this article used descriptive analyses and multinomial logistic regression to assess factors associated with using physical health services from primary or mental health providers. Data were drawn from a large-scale assessment of client-reported use of primary care services in a large and ethnically diverse public mental health system. Most people (80.4 percent) reported accessing primary care services from one or more service settings. Having chronic conditions was associated with accessing physical health care from multiple service settings, whereas having poor self-rated emotional health decreased health services use from any setting. It was concluded that mental health services consumers access health care from various service settings. Social workers can play a critical role in enhancing care coordination across the mental health and primary care systems.