Primary Care Clinicians Evaluate Integrated and Referral Models of Behavioral Health Care For Older Adults: Results From a Multisite Effectiveness Trial (PRISM-E)

INTRODUCTION

To address patient, physician, and health system barriers to adequate care of depression and other mental health conditions of late life, innovative models are being tested to enhance the recognition and management of mental health problems in primary care.^{1– 3} The Primary Care Research in Substance Abuse and Mental Health for the Elderly (PRISME) study was a multisite effectiveness trial designed to assess the use of a mental health and substance abuse (MH/SA) specialist co-located in the primary care practice to enhance treatment (the integrated care model) and the use of direct referral to specialty care (the enhanced referral model) for older adults with depression, anxiety, or alcohol use problems. We asked the clinicians to offer their perspectives on the specific interventions tested in PRISM-E. Given the heterogeneity of how primary care clinicians manage depression,⁴ it is important to be aware of systems of care that clinicians themselves think might work better. We believe primary care clinicians are important stakeholders in improving practice, and their opinions matter.

Our study differs from previous studies of attitudes of primary care clinicians regarding MH/SA treatment given to patients in primary care. First, most studies have focused on depression,^{5– 7} whereas we were able to examine several conditions that affect older adults in relation to primary health care. Second, we have focused on the mental health care of older adults, in contrast with other studies that have not considered the specific needs of older persons.^{5– 7} Most importantly, unlike studies that elicit opinions of primary care clinicians,^{5, 6, 8– 10} we specifically asked these clinicians about the effect of the integrated and enhanced referral models on the care of patients for whom the participating clinicians had clinical responsibility. No other study has asked clinicians about the preferences for new models of mental health care for older persons who were actually under their care.

METHODS

RESULTS

DISCUSSION

The primary care clinicians in our study expressed a strong preference for integrated care rather than enhanced referral care for older adults with psychiatric disturbances. Specifically, clinicians thought that older adults were more likely to experience greater convenience and less stigma if the mental health services were integrated with the primary care setting. When the primary care clinicians were more involved in counseling and management of medications in the integrated arm, communication regarding the MH/SA care was much more likely to be rated highly. Although the referral condition was enhanced with transportation and other services to engage older adults in treatment, the clinicians still preferred to have MH/SA care integrated into the primary health care setting.

Like all surveys, our results are based on the opinions of clinicians in practices that participated in a research project and might not be representative of all primary care practices. Our sample size was relatively small compared with other surveys.^{4, 9, 13} Although our response rate for the survey was high, clinicians who returned a survey instrument might have differed from others in important ways.

Despite limitations, our results about the preference of primary care clinicians for integrated rather than enhanced referral care deserve attention because our study of clinician attitudes differs in several important ways from other surveys carried out in primary care settings. First, we were able to focus our attention on 2 specific models of mental health service integration into primary care settings; namely, an integrated model that included a primary care-based mental health specialist and direct referral. Clinicians in our study were asked to comment on models of care they had actually experienced as a component of the PRISM-E study in contrast to hypothetical situations. Second, organizational-level data were available from parallel, standardized process evaluations carried out at each participating site so that we could relate practice characteristics from process evaluations to the survey responses from clinicians. Third, no survey to date has examined the perceptions of primary care clinicians regarding integrated mental health care for older persons under their care who had actually experienced one model of services organization or another.

Overall, responding clinicians preferred integrated care to enhanced referral care. Consistently, the added resources of integrated care were perceived as having enhanced aspects of primary health care, such as communication with the MH/SA specialist, convenience for patients, and less stigma for patients who require mental health care.

Women physicians and family physicians were more likely to prefer integrated care for improving some aspects of the care of older adults with mental disturbances. Previous studies have reported differences in the therapeutic stance of family physicians and internists in the treatment of depression. For example, Gallo and colleagues⁴ compared responses of family physicians and internists who had participated in an effectiveness trial of depression treatment in primary care settings.¹⁴ Family physicians were about twice as likely as internists to report that they would prescribe an antidepressant for a patient with moderate to severe depression, whereas the internists were about twice as likely to report they would refer the patient. Whether because of training or characteristics related to specialty choice, family physicians generally report feeling more comfortable than internists with the responsibility for depression management.^{4, 13, 15– 17} Primary care clinicians who actively provided counseling or pharmacologic management of depression were much more likely to rate communication about several aspects of MH/SA care highly. The association between active participation in care and improved communication suggests that the integrated model affords the clinician the ability to take a more active role in the management of MH/SA conditions.

Preference for integrated rather than enhanced referral care for the management of depression was strongly associated with the accessibility of the MH/SA specialist in the integrated arm but not with that in the enhanced referral arm. This finding suggests that clinicians preferred a care model affording them close access to an MH/SA specialist and possibly the opportunity to take a more active role in treatment.

If we are to deal with depression as a public health problem, we need to address the primary health care setting.^{18, 19} Numerous models for integrating mental health care into primary health care settings have been evaluated in randomized trials^{1– 3, 20, 21} or discussed in anecdotal reports.^{22– 24} For many aspects of care, clinicians in PRISM-E preferred mental health care to be integrated with primary health care for older patients with psychiatric disturbances. The integrated intervention was feasible in the community practices across the United States in diverse health care environments that participated in PRISM-E. Given the expansion of group practice, we think the intervention could be feasible in many practices beyond those that participated in PRISM-E.