Effects of primary care clinician beliefs and perceived organizational facilitators on the delivery of preventive care to individuals with mental illnesses

Patient-level factors associated with receipt of preventive care in the safety net

Prevention is critical to optimizing health, yet most people do not receive all recommended preventive services. As the complexity of preventive recommendations increases, there is a need for new measurements to capture the degree to which a person is up to date, and identify individual-level barriers and facilitators to receiving needed preventive care. We used electronic health record data from a national network of community health centers (CHCs) in the United States (US) during 2014-2017 to measure patient-level up-to-date status with preventive ratios (measuring up-to-date person-time denoted as a percent) for 12 preventive services and an aggregate preventive index. We use negative binomial regression to identify factors associated with up-to-date preventive care. We assessed 267,767 patients across 165 primary care clinics. Mean preventive ratios ranged from 8.7% for Hepatitis C screening to 83.3% for blood pressure screening. The mean aggregate preventive index was 43%. Lack of health insurance, smoking, and homelessness were associated with lower preventive ratios for most cancer and cardiovascular screenings (p < 0.05). Having more ambulatory visits, better continuity of care, and enrollment in the patient portal were positively associated with the aggregate preventive index (p < 0.05) and higher preventive ratios for all services (p < 0.05) except chlamydia and HIV screening. Overall, receipt of preventive services was low. CHC patients experience many barriers to receiving needed preventive care, but certain healthcare behaviors - regular visits, usual provider continuity, and patient portal enrollment - were consistently associated with more up-to-date preventive care. These associations should inform future efforts to improve preventive care delivery.

Provider perceptions of pharmacists providing mental health medication support in patient-centered medical homes

OBJECTIVES

To identify primary care providers' (PCPs') comfort level, potential barriers to management of patients with mental health disorders, and attitudes around clinical pharmacist-provided mental health medication-related support.

METHODS

A 16-item cross-sectional survey was completed by PCPs in 14 patient-centered medical homes (PCMHs) at 1 academic medical center. Items assessed include PCPs' perceptions of the proportion of patients with a mental health condition, access to psychiatry services, confidence in mental health condition management, clinical pharmacist-provided mental health medication support, and demographics. Checklist, Likert-type-scale agreement statements, and an open-ended question to assess barriers to managing mental health medications were included. Descriptive statistics and qualitative content analysis were used.

RESULTS

Respondents (n = 85) included attending physicians (67.1%), resident physicians (24.7%), and advanced practice providers (8.2%). The average number of years in practice was 11 (SD 8.6). The majority perceived that 26% to 50% of their patients had a psychiatric illness (57.7%), referred < 10% of their patients (67.1%) to psychiatry services, and disagreed that access to psychiatric services was acceptably timely (87.0%). Participants felt confident diagnosing a patient with depression (97.6%) and starting antidepressants (94.1%) compared with antipsychotics (11.7%) or mood stabilizers (7.1%). Participants agreed that having the clinical pharmacist in clinic to provide support regarding psychiatric medications would increase their comfort level; increase in comfort level by provider type was not different (P = 0.20). Emerging barriers were lack of knowledge or training, low comfort in diagnosing severe psychiatric conditions, and access to psychiatry services.

CONCLUSION

Outside of the diagnosis and treatment of depression, PCPs indicate a lack of comfort in treating PCMH patients with mental health disorders. Pharmacists can play a key role by providing mental health medication management support to improve access and address PCMH patients' mental health needs.

Perspectives on Providing And Receiving Preventive Health Care From Primary Care Providers and Their Patients With Mental Illnesses

PURPOSE

Individuals with mental illnesses have higher morbidity rates and reduced life expectancy compared to the general population. Understanding how patients and providers perceive the need for prevention, as well as the barriers and beliefs that may contribute to insufficient care, are important for improving service delivery tailored to this population.

DESIGN

Cross-sectional; mixed methods.

SETTING

An integrated health system and a network of federally qualified health centers and safety net clinics.

PARTICIPANTS

Interviews (n = 30) and surveys (n = 249) with primary care providers. Interviews (n = 158) and surveys (n = 160) with patients diagnosed with schizophrenia, bipolar, anxiety, or major depressive disorders.

MEASURES

Semi-structured interviews and surveys.

ANALYSIS

Thematic analysis for qualitative data; frequencies for quantitative data.

RESULTS

More than half (n = 131, 53%) of clinicians believed patients with mental illnesses care less about preventive care than the general population, yet 88% (n = 139) of patients reported interest in improving health. Most providers (n = 216, 88%) lacked confidence that patients with mental illnesses would follow preventive recommendations; 82% (n = 129) of patients reported they would try to change lifestyles if their doctor recommended. Clinicians explained that their perception of patients' chaotic lives and lack of interest in preventive care contributed to their fatalistic attitudes on care delivery to this population. Clinicians and patients agreed on substantial need for additional support for behavior changes. Clinicians reported providing informational support by keeping messages simple; patients reported a desire for more detailed information on reasons to complete preventive care. Patients also detailed the need for assistive and tangible support to manage behavioral health changes.

CONCLUSIONS

Our results suggest a few clinical changes could help patients complete preventive care recommendations and improve health behaviors: improving clinician-patient collaboration on realistic goal setting, increasing visit time or utilizing behavioral health consultants that bridge primary and specialty mental health care, and increasing educational and tangible patient support services.