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Response to Gallo et al.: Rural applications
IMPLEMENTING INTEGRATED BEHAVIORAL HEALTH CARE IN PRIMARY CARE
Integrated mental health: Translatability and sustainability vary by system
Response to article: Primary Care Clinicians Evaluate Integrated and Referral Models of Behavioral Health Care For Older Adults: Results From a Multisite Effectiveness Trial (PRISM-E)
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Rene J. McGovern, Kirksville, MO, USA Geriatric Psychologist, Associate Professor, A.T. Still University and CWRU, Jeffrey Vittengl, Ph.D.
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As a project director for a federally funded program that has been working to integrate mental health care for the elderly in primary care in rural Missouri, Gallo et al.’s evaluation of primary care clinicians’ attitudes toward integrated vs enhanced referral care models was helpful in identifying key motivators for encouraging physician participation: 1. Better communication between primary care clinicians and mental health specialists, 2. Less stigma for patients and 3. Better coordination of mental and physical care. The PRISM-E study, which is the largest randomized study of behavioral health care among the elderly conducted to date, established a standardized study protocol across sites, yet allowed variation across local delivery systems in an attempt to achieve generalizability to real- world clinical setting.(1) In reviewing the methodology for the PRISM-E Study to apply outcomes to our region, however, it was noted that only one site in the study was rural. Also, participating clinics in the PRISM-E study may have been more supportive, or at least tolerant, of integrated care than physicians in general, particularly in rural areas. We have found true integration a challenge to accomplish in our region, due to practical concerns, such as lack of space and other resources, and due to issues perhaps more unique to rural areas, such as economic competition for a limited patient base and perceived threats to practice autonomy. We have also found that primary care providers in our region report less confidence in the mental health providers that are available,(2) perhaps due to the familiarity encountered in small towns. It would seem, however, that despite the barriers to integration in rural or urban settings, Gallo, et al. makes a strong case for favorable attitudes by physicians and outlines the key variables that need to be established for effective care delivery for the elderly. He establishes the physicians’ desire to communicate with mental health providers and protect their patient from stigma, while acknowledging the importance of treating the body, mind and spirit. We applaud the fine work done by the PRISM-E team and look forward to the results of the clinical outcome studies that will further refine the best practice model. References: 1. Levkoff, SE, Chen, H., Coakley, E., Herr, EC, Oslin, DW, Katz, I, Bartels, SJ, Maxwell, J., Olsen, E., Miles, KM, Constantino, G., & Ware, JH (2004). Design and sample characterisitcs of the PRIMS-E multisite randomized trial to improve behavioral health care for the elderly. J of Aging Health, Feb; 16(1):3-27. 2. Smith, LD, Peck, PL, & McGovern, RJ (2003). A comparison of medical students, medical school faculty, primary care physicians, and the general population on attitudes toward psychological help seeking. Psychological Reports, 91, 1268-1272. Competing interests: None declared |
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Lawrence Fisher, San Francisco, CA 94143 Professor, Department of Family & Community Medicine, University of California, San Francisco
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Gallo, et al. has demonstrated that not only is integrated behavioral health care beneficial clinically, but that primary care physicians generally prefer this model of care. Despite the demonstrated efficacy, however, there has been only modest adoption of this collaborative model nationwide. An important question concerns the willingness of the players to resolve a considerable number of complex and practical problems that arise when such programs are implemented in community practice. Three groups of problems are important. The first centers on practice culture and addresses whether behavioral health care is viewed as an integral part of primary care that is reflected in the practice’s mission statement, or it is viewed as an ‘add-on’ advanced by one or two champions. This issue reflects the view of the practice as a whole and, as such, it is tied to how long these services will be sustained by the practice over time. We have a spotted record when it comes to the uptake of behavioral health care efficacy trials in real world practice. A second set of problems concerns practice logistics. Issues of confidentiality are paramount. Are there shadow charts for confidential notes and who has access to them? Are office staff educated and respectful about issues of scheduling and confidentiality, especially since it is often the case that family members and other members of the patient’s community receive care at the practice? How much information is communicated between the behavioral health practitioner and the primary care physician, and how are releases of information forms handled? A third set of problems involves practice finances. What position does the behavioral health practitioner hold in the practice: employee, partner, self—supporting outsider? Who manages and pays for billing of behavioral health care services? Most practices serve patients insured by different third party payers. These include carve-outs, PPOs, and other managed care insurers, each with different rates of reimbursement, different procedures and different forms. Is billing assumed by the practice, as it would be for all other clinical services? Importantly, can behavioral health care generate sufficient reimbursement to support overhead and the salary of a behavioral health specialist? Can behavioral health care be self-supporting and not viewed as a ‘cost-center’ in the practice budget, especially given the relatively low reimbursement rate? All of these are real-world issues that reflect how behavioral health care is considered by the practice – as an ‘add-on’ or as part of ‘what we do’ in the care of the whole person. Competing interests: None declared |
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James E Aikens, Ann Arbor, MI, USA Assistant Professor of Family Medicine and Psychiatry, University of Michigan Medical School
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Gallo et al.’s well-conducted survey validates and extends the findings of prior naturalistic work (e.g., Valenstein et al.1) namely, that primary care providers (PCPs) prefer onsite mental health care. It thus makes intuitive sense that this preference is most pronounced among family physicians, and among respondents who tend to provide mental health care themselves and who find specialty care inaccessible. However, the likely overlap between these three provider variables begs the question of which factor is primary. For example, family physicians are more likely to provide mental health care than other providers are.2 They are also more likely to practice rurally, which probably complicates referrals. Providers who cannot refer will naturally provide more mental health care themselves, and so on. Second, I wonder whether preferences have different determinants at different stages of specialty treatment. If preferences were assessed early in the trial, then they may be driven by ease of referral. If assessed late in the trial, then overall clinical outcomes probably rule the day. Repeated measurements may be needed to disentangle these two issues. Finally, translatability and sustainability are major issues. Access (related to PCP preference) usually varies by payor; a given onsite specialist may or may not be paneled by a given patient’s insurer. While the older patient sample is study strength, it may have restricted variation in mental health coverage, giving co-located services an advantage. For example, I practice psychology within two family practice clinic sites. I’m amazed at the immense clerical time spent negotiating the "carve-out du jour," arranging for pre- certification, determining out-of-network co-pays, etc. In lieu of mental health parity or some other access-enhancing mechanism, access to onsite services can sometimes raise daunting administrative issues. James E. Aikens, Ph.D. Departments of Family Medicine and Psychiatry University of Michigan Medical School Ann Arbor, MI, USA References: 1. Valenstein M, Klinkman M, Becker S, et al. Concurrent treatment of patients with depression in the community: provider practices, attitudes, and barriers to collaboration, J Fam Pract, 1999;48:180-7. 2. Gallo JJ, Meredith L, Gonzales J, et al. Do family physicians and internists differ in knowledge, beliefs, and self-reported approaches for depression? Int J Psych Medicine. 2002;32:1–20 Competing interests: None declared |
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Macaran A. Baird, Minneapolis, MN USA family physician, family therapist; University of Minnesota family medicine department head
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This small but well designed study represents one more signal that the time has come for integrating mental health services directly into primary care practices. This paper, focused on the care of older patients, is notable by its features not commonly a part of studies on the effectiveness of integrated care vs. enhanced referral care. First, it found that family physicians are more likely than internists to perceive the benefit of integrated (on site) mental health and substance abuse care. This should be predictable since family medicine education has always included mental health clinicians (behavioral scientists) as part of the training and practice paradigm. Unfortunately, family medicine and internal medicine graduates rarely find on site mental health team members in their community practices. It is noteworthy that this study identified a sufficient number of community practices that provide integrated care to make a comparison to an enhanced referral model. Secondly, the integrated care experience links support to a more active treatment role for primary care physicians in managing their patients with depression and substance abuse disorders. There are many theoretical reasons to support team based and integrated care, but this study demonstrates that integrated care is well received by clinicians in practice and yields a more satisfying practice experience. Perhaps a future study could test a larger population of clinicians and evaluate resource utilization patterns associated with integrated (on site) mental health and primary care vs. a primary care model with an enhanced referral to mental health/substance abuse specialists. Eventually, we may come to the realization that people arrive in primary care offices with their mental health dilemmas as interwoven issues not always rationally separated from their medical problems. Appropriate evaluation and treatment should reflect the same natural integration. This study is one more paving stone on the path to integrated care. Competing interests: None declared |
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