Connections to Primary Medical Care after
Kim S. Griswold, MD, MPH, Timothy J. Servoss, MA, Kenneth E. Leonard, PhD,
Patricia A. Pastore, FNP, Susan J. Smith, MS, Christine Wagner, MSW,
Margaret Stephan, RN, and Mary Thrist
Background: Patients presenting with a psychiatric emergency face a unique set of challenges in con-
necting to primary care.
Objectives: We tested the hypothesis that, in contrast to usual care, case management will result in
higher rates of connection to primary care. We examined variables affecting primary care entry, includ-
ing insurance status, hospital admission, and concurrent linkages to mental health care.
Research Design/Methods: This article reports on a preliminary outcome of an ongoing randomized
controlled trial conducted with 101 patients presenting in an urban psychiatric setting. Patients were
randomized to a case management team or to usual care. The need for medical care was assessed by
documenting medical comorbidity.
Results: Average age of the sample was 37.5; 65% were male, and 78% had low income; 37% were
African American and 9% were Hispanic. Within 3 months of study enrollment, 57% of the intervention
group was successfully linked to primary care compared with 16% of the usual care group, a difference
that was statistically significant (P < .001). Associated positive predictors for linkage to primary care
included mental health care visits and success in obtaining health insurance. Inpatient hospital stay at
the time of psychiatric crisis was negatively associated with later attendance at primary care.
Conclusions: Case management intervention was effective in establishing linkage to primary care
within 3 months. Ongoing work will evaluate primary care retention and physical and mental health
outcomes. (J Am Board Fam Pract 2005;18:166–72.)
Patients with significant psychiatric disorders are
likely to have concomitant medical problems.1Per-
sons who need psychiatric care also need general
medical care, and those with severe mental disor-
ders suffer excess morbidity and mortality com-
pared with the general population.2
Integrated medical care for persons with psychi-
atric illness makes a positive difference in health
care quality and outcomes.3So far, efforts to inte-
grate mental and physical health care have focused
on patients appearing in a primary care setting.4,5
However, many patients with coexisting physical
and mental health problems fail to appear in pri-
mary health care systems, increasing the risk of
poorer health outcomes. Barriers to accessing pri-
mary care include inadequate skills or experience to
negotiate the health care system, poor support net-
works, and transportation difficulties.6Homeless
persons, approximately one third of whom may
have a chronic mental illness, are at a particular
disadvantage. Often, they are without insurance
and find it difficult to navigate the service system.7
This study addresses one such set of particularly
vulnerable and underserved patients—those pre-
senting to the emergency department in psychiatric
Case management approaches in the community
and collaborative efforts such as “stepped care”
have yielded improved outcomes for patients with
depression, suggesting that many patients with psy-
chiatric problems can be managed effectively
within primary care practices.8–10,11Moreover,
there is evidence that homeless persons can be
identified and linked to physical health care and
Submitted, revised, 31 January 2005.
From the Department of Family Medicine, Family Med-
icine Research Institute, The State University of New York
at Buffalo (KSG, TJS, PAP, SJS, CW, MS, MT), and the
Research Institute on Addictions, Buffalo (KEL). Address
correspondence to Kim Griswold, MD, MPH, Department
of Family Medicine, Family Medicine Research Institute,
The State University of New York, University at Buffalo,
462 Grider Street, Buffalo, NY 14215 (e-mail: griswol@
This study was supported by the Robert Wood Johnson
Foundation Generalist Physician’s Scholarship Program, the
Erie County Department of Mental Health, and the Depart-
ment of Family Medicine, State University of New York at
May–June 2005Vol. 18 No. 3http://www.jabfp.org
obtain appropriate treatment of mental illness and
However, getting connected to the doctor may
pose a problem for the patient emerging from psy-
chiatric crisis, and simply providing to patients the
name of a primary care provider or site does not
seem to result in effective linkage.13An opportune
time for connection to and engagement in a pri-
mary care setting may be after a psychiatric crisis.
This point may serve as an opportunity to initiate
linkages between medical and mental health ser-
vices, bridging the gap between mental health and
primary care and initiating care continuity in both
This study focuses on patients without a primary
care “home” emerging from psychiatric crisis, com-
paring facilitated linkage with primary medical care
with standard practice after a psychiatric emer-
gency visit. We test the hypothesis that, in contrast
to usual care, community-based care management
will result in higher rates of connection to primary
care. The study also examines variables that may
facilitate or deter primary care entry, including
insurance status, whether patients were admitted to
the hospital at the time of psychiatric crisis, and
linkages to community mental health care.
This article reports preliminary results on the rate
of linkage to primary care within 3 months as part
of an ongoing randomized control trial. So far, 101
patients have been enrolled and are being observed
for 1 year. Patients present at an urban Compre-
hensive Psychiatric Emergency Program (CPEP).
CPEP is accessible 24 hours a day, 7 days a week.
Eligibility criteria for the study require that persons
be older than 18 years and have a DSM-IV-R–
defined Axis I disorder.14Patients are eligible if
they either have no regular source of primary care
or have not seen a primary care provider within 6
months. “Primary care provider” is defined as a
clinician with whom the patient has an ongoing
relationship on a regular basis. Patients are ineligi-
ble if deemed unstable, actively suicidal or homi-
cidal, or unable to give informed consent. In the
case of patients being admitted for stabilization,
they are eligible for enrollment once stabilized and
ready for discharge. The prospective follow-up oc-
curs from the point of discharge. The study is
approved through our University’s Institutional
Services routinely offered through CPEP include
complete psychiatric assessment and management,
targeted therapeutic approaches, and linkages to
community mental health services. Referral to pri-
mary medical care is provided on patient request or
if a significant medical condition is identified in the
emergency ward. Uninsured patients are given on-
site assistance with health coverage. All patients
receive needed medications.
Care managers meet with intervention patients on
study enrollment, within the first week of facilita-
tion and routinely at primary care appointments.
They maintain regular contact through face-to-
face visits, and by phone. They also provide the
following case-based assistance in regular meetings:
● Information regarding sliding scale or “free” pri-
mary medical care sites.
● Facilitation of access to primary care, with shared
decision-making regarding primary care site lo-
cation, provider preference, and travel routes.
● Reinforce patient education and teaching that
occurs at primary care visits.
● Index cards for primary care providers with psy-
chiatric hospital discharge diagnosis, pharmaco-
therapy, and mental health treatment site referral.
● Follow-up, including home visits and mobile out-
reach when appropriate.
● Assistance through peer connections to commu-
nity mental health sites and social services.
The CPEP patient logs are screened on a daily
basis to determine patient eligibility. Those pa-
tients who meet the eligibility criteria are ap-
proached by a member of the research team and
invited to join the study. Those patients who agree
are given a series of baseline assessments and ran-
domized to either the intervention group or the
usual care group. The research team contacts both
intervention and control groups on a monthly ba-
sis, tracking primary care utilization, insurance sta-
tus, and mental health visits.
Outcome and Associated Variables
The primary outcome of interest for this article was
the relative connection rate to primary care for
each study group. “Connection” to primary care
http://www.jabfp.orgPrimary Medical Care after Psychiatric Crisis167
was defined as a completed visit within 3 months of
study entry. This definition was based on criteria
currently used for measuring quality of access to
care by behavioral organizations.15In pilot work
for this study, even those patients without medical
insurance completed a first visit within this time
Associated variables of interest included investi-
gating how other factors such as inpatient admis-
sion, insurance status, and linkage to mental health
services related to successful primary care linkage
within the specified time frame. Moreover, the rate
of linkage for those persons with chronic disease,
arguably those most in need of primary care, was of
Basic descriptive statistics were used to characterize
the participants in the usual care and intervention
groups with regard to demographics and psychiat-
ric and medical diagnosis. ?2tests were used to
ascertain the relationship between the categorical
variables of interest and the dichotomous outcome
variable (linkage to primary care within 3 months
of study enrollment). Odds ratios were calculated
where appropriate. Variables of interest were con-
dition (intervention versus usual care), insurance
status at baseline and at 3 months from enrollment,
linkage to mental health services before entering
CPEP and at 3 months after enrollment, psychiat-
ric diagnosis, medical diagnosis, and hospital status
at the time of enrollment (regardless of whether the
participant was admitted to the inpatient psychiat-
Thereafter, variables with a statistically signifi-
cant bivariate relationship with linkage to primary
care were entered into a logistic regression model.
Odds ratios from the final logistic regression anal-
ysis were examined to determine the association
between each of the variables in the model and the
outcome variable, controlling for the other predic-
The demographic and diagnostic characteristics of
participants in the intervention and usual care
groups are presented in Table 1. As a result of
randomization, the distributions of these variables
were very well balanced across the intervention and
usual care groups, suggesting that the 2 groups of
Table 1. Sample Characteristics
% (n ? 56)
% (n ? 45)
% (n ? 101)
Average age (SD)
Annual income ?$10,000
High school grad/GED
Substance use disorder
At least one comorbidity
* Dual diagnosis refers to having both a substance use disorder and any Axis I diagnosis.
†Chronic disease includes diabetes, hypertension, congestive heart failure, hyperlipidemia, stroke, arthritis, and asthma.
May–June 2005Vol. 18 No. 3http://www.jabfp.org
participants were largely equivalent across several
important dimensions. The average age of partici-
pants was relatively young (?37 years), and both
groups had a majority of male participants. Al-
though the gender presentation to the psychiatric
emergency ward was equal, more men presented
without a designated primary care physician. Mi-
nority participation in the study was high, account-
ing for approximately 50% of the sample. Nearly
70% of subjects were unemployed, and approxi-
mately 80% had incomes below $10,000 per year.
Most participants in both groups had either com-
pleted high school or had earned an equivalency
Within the sample as a whole, there was a wide
diversity of psychiatric diagnoses; however, there
were no significant group differences at baseline.
The most common diagnoses of study participants
fell under the umbrella of mood (primarily Major
Depression), psychotic (Schizophrenia and Schizo-
affective Disorder), and substance use disorders. A
substantial portion of participants (36%) was diag-
nosed with both a substance use disorder and an-
other Axis I disorder.
In addition to the aforementioned psychiatric
disabilities, nearly half of the study participants
suffered from one or more medical comorbidities—
despite their relatively young average age (37
years). Many of these medical comorbidities were
chronic conditions, including diabetes, hyperten-
sion, hyperlipidemia, arthritis, and asthma. The
presence of medical comorbidity to such an extent
provided further evidence of the necessity for and
potential benefit of prompt linkage to primary care
for study participants.
Linkage to Primary Care
A summary of the statistically significant results
from the subsequent bivariate relationships is dis-
played in Table 2.
There was a significant relationship between con-
dition (intervention versus usual care) and success-
ful linkage to primary care within 3 months of
enrollment in the study. Whereas 57% participants
in the intervention group were successfully linked,
only 16% of the usual care group completed a
primary care visit within the critical time period.
This relationship is statistically significant ?2(1) ?
18.21, P ? .001; odds ratio (OR) ? 7.24 (95% CI ?
2.76 to 18.99). It is arguable that it is most impor-
tant for those with a medical comorbidity to obtain
linkage to primary medical care. More than half
(54%) of these patients were linked to primary care
within 3 months.
At baseline, there was no difference in rates of
insurance coverage between groups. Approximately
48% of both the intervention and control groups
had some form of insurance coverage; the vast
majority who had insurance were publicly insured
(Medicaid). At the 3-month follow-up point, 78%
of the usual care and 86% of the intervention group
had managed to obtain insurance coverage. Al-
though there was no relationship between baseline
insurance status and linkage to primary care, there
was a relationship between insurance status at
3-month follow-up and linkage. In particular, 45%
of those who were insured at the 3-month time
Table 2. Relationships of Variables of Interest to Linkage to Primary Care
No. of Patients
Insurance with 3-month follow-up
Inpatient at hospital
Linked to mental health with 3-month follow-up
7 of 45
32 of 56
7.242.76 to 18.99
37 of 83
2 of 18
6.441.39 to 29.79 .008
15 of 55
24 of 46
0.340.15 to 0.79.01
31 of 64
8 of 36
3.291.30 to 8.30.01
OR, odds ratio; CI, confidence interval.
http://www.jabfp.orgPrimary Medical Care after Psychiatric Crisis169
point were linked to primary care compared with
only 11% of those without insurance [?2(1) ? 6.99,
P ? .008; OR ? 6.44 (95% CI ? 1.39 to 29.79)].
Approximately 55% of the sample required inpa-
tient hospitalization after the psychiatric crisis and
entry to CPEP. Those enrolled from the inpatient
ward comprised approximately equal portions of
both the intervention and usual care groups (58%
of usual care and 52% of intervention). Requiring
inpatient hospitalization at the time of psychiatric
crisis may serve as a proxy for the severity of the
crisis and may, in turn, relate to subsequent partic-
ipation in primary care. Of those persons who were
hospitalized at the time of psychiatric crisis, only
27% were linked to primary care, whereas 52% of
those with routine discharges from CPEP obtained
linkage. This relationship was statistically signifi-
cant [?2(1) ? 6.55, P ? .01; OR ? 0.34 (95% CI ?
0.15 to 0.79)].
Linkage to Mental Health Services
Approximately half of the participants in both the
intervention and usual care groups were linked to
mental health services before psychiatric crisis and
subsequent enrollment in the current study. Three
months after enrollment in the study, approxi-
mately 46% of the usual care group and 53% of the
intervention group reported linkage to mental
health services. Although there was not a significant
relationship between mental health linkage before
crisis and linkage to primary care, a significant
relationship did emerge for mental health linkage
at the 3-month time point [?2(1) ? 6.66, P ? .01;
OR ? 3.29 (95% CI ? 1.30 to 8.30)]. Forty-eight
percent of those linked to mental health services
were also linked to primary care, whereas only 22%
of those not linked to mental health services ob-
tained linkage to primary care.
There were no significant relationships between
psychiatric diagnosis or medical diagnosis and link-
age to primary care.
To create a more comprehensive preliminary
model for predicting linkage to primary care, all 4
of the variables listed in Table 2 were entered into
a logistic regression. The model yielded a Cox and
Snell R2of 0.35 and a Nagelkerke R2of 0.47.
Controlling for each of the other predictors in the
model, all 4 variables remained statistically signifi-
cant predictors of linkage to primary care.
Of most interest perhaps for the current study is
that participation in the intervention group was a
significant predictor of linkage to primary care even
when controlling for insurance status, linkage to
mental health, and inpatient status at the time of
psychiatric crisis. Adjusted odds ratios and other
relevant statistics from the logistic regression anal-
ysis are displayed in Table 3.
In this study of 101 persons, the primary outcome
of successful connection to primary medical care
after psychiatric crisis was significantly more likely
for patients who had community case managers,
relative to control subjects. In earlier studies, active
linkage after psychiatric crisis improved function16
and increased adherence to mental health care.17
Nurse case management of persons with serious
psychiatric disabilities is feasible and effective in
both community and primary care office settings.18
We found that care managers and case-based in-
terventions had a significant positive influence on
attendance at primary care. This may speak to a
“structured system” approach, as identified through
focus groups discussing the management of crisis in
Table 3. Results from Logistic Regression Predicting Linkage to Primary Care within 3 Months
Insurance status (2 months)
Linkage to mental health services (2 months)
3.78 to 41.09
1.01 to 52.06
1.78 to 20.41
0.07 to 0.64
OR, odds ratio.
May–June 2005Vol. 18 No. 3http://www.jabfp.org
We concentrated on 3 variables of interest that
may have had an association with our primary out-
come measure. In all 3 circumstances, intervention
and control groups had no significant differences at
Although initial insurance status was not associ-
ated with primary care linkage, obtaining insurance
within 3 months of psychiatric crisis seemed to
correlate with successful primary care attendance.
Persons reporting mental disorders are twice as
likely to report being denied medical insurance
because of a pre-existing condition, and even those
with insurance may delay medical care because of
inadequate coverage or access difficulties.20,21Al-
though we did not look specifically at insurance
type in this study, differences in health coverage
may affect primary and mental health care access.
There is a need for further investigation of how
health insurance patterns influence care attendance
Patients who accessed community mental health
care were more likely to attend primary care. An
earlier study22found that for patients discharged
after psychiatric emergency, use of care plans em-
phasizing liaisons with mental health and primary
care led to decreased emergency department visits.
Inpatient hospitalization had a negative effect on
initial linkage to primary medical care in this anal-
ysis. Although there was no significant relationship
between actual diagnosis and linkage, diagnostic
severity or other factors not identified in this study,
such as homelessness, may serve as barriers to pri-
mary care entry.
This study has several limitations. Although
linkage within 3 months was achieved through case
management, this time frame is obviously inade-
quate to assess adherence to care. At the comple-
tion of the study, data on changes over time and
downstream effects subsequent to primary care
linkage will be described. Furthermore, although
there is information on mental health visits, care
managers did not explicitly provide assistance with
integration of mental health and primary care. This
makes it difficult to assess in this study whether
features within the primary care setting influence
mental health care. Finally, the circumstances sur-
rounding inpatient admission need to be explored
and further evaluated with regard to primary care
Community case management did make a sig-
nificant difference in primary care entry for persons
without a primary care provider. Having a regular
doctor can make a positive difference on access to
primary care and lead to improvement in chronic
care conditions.23,24On-going work must elucidate
whether patients adhere to care, and whether a
mental health-primary care connection results in
improvement in health, functional status, and qual-
ity of life.
Linking patients from psychiatric crisis to a pri-
mary care home demonstrates one process of care
and coverage for a vulnerable population. Research
in this area may have long-term implications for
better care and public health policy by identifying
the features surrounding access to primary care that
may improve outcomes for patients with mental
We gratefully acknowledge the expert assistance of Angela
Henke in the preparation of the manuscript.
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