No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Integrated Primary and Mental Health Care Services: An Evolving Partnership Model
Abstract
Persons with serious psychiatric disabilities experience high rates of medical co-morbidities that, if properly treated, could improve overall well-being and the course of recovery.
This brief reports describes how two organizations-Thresholds Psychiatric Rehabilitation Centers and University of Illinois College of Nursing-partnered to offer integrated behavioral and physical health care responsive to the needs of the population and committed to consumer-centered, holistic and preventative care. Most recently, the partnership offers primary care in different community settings through different service models-tele-monitoring, home visits, group visits.
A combination of published literature, staff report, and quality assurance data informs this report.
The authors conclude that primary care outreach is a promising strategy in mental health settings and that the Chronic Care Model (CCM) provides a set of guidelines for designing and monitoring quality integrated care for a partnership model of integrated care.
... We found 18 studies that met our criteria, including two randomized controlled trials, one quasi-experimental trial, five qualitative studies and a range of observational studies with a mixed methods design (Table 1) 31,32]. Almost all studies covered collaborative models for common mental disorders in primary care; two publications explicitly focused on integrating primary care in the specialty setting for patients with severe mental disorders [17,21]. Although most studies combined several implementation strategies, we identified six predominant categories. ...
... According to the Cochrane Effective Practice and Organisation of Care Group (EPOC), organizational strategies are interventions that involve 'a change in who delivers health care, how care is organized or where it is delivered' (www.epoc.cochrane.org/ourscope). Davis [21] reports on the introduction of a new position, the clinical care coordinator, charged with the responsibility to collaborate with the primary care nurse in taking care of preventive, follow-up and educational tasks for mental health patients with medical comorbidities. In the study by Carson et al. [17], existing Assertive Community Treatment (ACT) platforms, providing community-based, comprehensive mental health services [37], were successfully used as vehicles for the delivery of integrated behavioral and primary healthcare within a community-based setting. ...
Extensive research exists that collaborative primary care-mental health models can improve care and outcomes for patients. These programs are currently being implemented throughout the United States and beyond. The purpose of this study is to review the literature and to generate an overview of strategies currently used to implement such models in daily practice.
Six overlapping strategies to implement collaborative primary care-mental health models were described in 18 selected studies. We identified interactive educational strategies, quality improvement change processes, technological support tools, stakeholder engagement in the design and execution of implementation plans, organizational changes in terms of expanding the task of nurses and financial strategies such as additional collaboration fees and pay for performance incentives.
Considering the overwhelming evidence about the effectiveness of primary care-mental health models, there is a lack of good studies focusing on their implementation strategies. In practice, these strategies are multifaceted and locally defined, as a result of intensive and required stakeholder engagement. Although many barriers still exist, the implementation of collaborative models could have a chance to succeed in the United States, where new service delivery and payment models, such as the Patient-Centered Medical Home, the Health Home and the Accountable Care Organization, are being promoted.
... The behavioral health home consisted of two primary care clinics operated by the University of Illinois at Chicago (UIC) College of Nursing that were colocated in an outpatient mental health program called Thresholds on the north and south sides of Chicago (39). Serving over 900 patients annually (40), each clinic was staffed by two or three advanced practice registered nurses authorized to provide primary care services without oversight of a medical doctor in the state of Illinois. ...
Meaningful reductions in racial and ethnic inequities in chronic diseases of aging remain unlikely without major advancements in the inclusion of minoritized populations in aging research. While sparse, studies investigating research participation disparities have predominantly focused on individual-level factors and behavioral change, overlooking the influence of study design, structural factors, and social determinants of health on participation. This is also reflected in conventional practices that consistently fail to address established participation barriers, such as study requirements that impose financial, transportation, linguistic, and/or logistical barriers that disproportionately burden participants belonging to minoritized populations. These shortcomings not only risk exacerbating distrust toward research and researchers, but also introduce significant selection biases, diminishing our ability to detect differential mechanisms of risk, resilience, and response to interventions across subpopulations. This forum article examines the intersecting factors that drive both health inequities in aging and disparate participation in aging research among minoritized populations. Using an intersectional, social justice, and emancipatory lens, we characterize the role of social determinants, historical contexts, and contemporaneous structures in shaping research accessibility and inclusion. We also introduce frameworks to accelerate transformative theoretical approaches to fostering equitable inclusion of minoritized populations in aging research.
... The behavioral health home consisted of two primary care clinics operated by the University of Illinois at Chicago (UIC) College of Nursing that were colocated in an outpatient mental health program called Thresholds on the north and south sides of Chicago (39). Serving over 900 patients annually (40), each clinic was staffed by two or three advanced practice registered nurses authorized to provide primary care services without oversight of a medical doctor in the state of Illinois. ...
Objective:
Longitudinal changes in health outcomes of patients with serious mental illness and co-occurring diabetes were examined after introduction of an intervention involving electronic disease management, care coordination, and personalized patient education.
Methods:
This observational cohort study included 179 patients with serious mental illness and diabetes mellitus type 2 at a behavioral health home in Chicago. The intervention employed a care coordinator who used a diabetes registry to integrate services; patients also received personalized diabetes self-management education. Outcomes included glucose, lipid, and blood pressure levels as assessed by glycosylated hemoglobin, low-density lipoprotein, triglycerides, and systolic/diastolic values from electronic medical records and completion of specialty visits confirmed with optometrists and podiatrists. Interrupted time-series segmented random-effects regression models tested for level changes in the eight study quarters following intervention implementation compared with eight preimplementation study quarters, controlling for clinic site and preimplementation secular trends.
Results:
Significant declines were found in levels of glucose, lipids, and blood pressure postimplementation. In addition, completed optometry referrals increased by 44% and completed podiatry referrals increased by 60%.
Conclusions:
Significant improvement in medical outcomes was found among patients of a behavioral health home who had comorbid diabetes and mental illness after introduction of a multicomponent care coordination intervention, regardless of which clinic they attended.
... 7,8 Many health care systems are working to increase clinical operating efficiencies by integrating care and providing care at multiple points of service. 9 The ATP model is consistent with established integrated care models ( Table 1) and overcomes organizational and administrative barriers that can impact nonvirtual, integrated care models. 10,11 ATP applied broadly can make the delivery of integrated care more accessible and less costly than other modalities, 12 particularly for patients with comorbid chronic diseases and mental illness. ...
Objective:
Asynchronous telepsychiatry (ATP) is an integrative model of behavioral health service delivery that is applicable in a variety of settings and populations, particularly consultation in primary care. This article outlines the development of a training model for ATP clinician skills.
Methods:
Clinical and procedural training for ATP clinicians (n = 5) was provided by master's-level, clinical mental health providers developed by three experienced telepsychiatrists (P.Y. D.H., and J.S) and supervised by a tele-psychiatrist (PY, GX, DL) through seminar, case supervision, and case discussions. A training manual and one-on-one sessions were employed for initial training. Unstructured expert discussion and feedback sessions were conducted in the training phase of the study in year 1 and annually thereafter over the remaining 4 years of the study. The notes gathered during those sessions were synthesized into themes to gain a summary of the study telepsychiatrist training recommendations for ATP interviewers.
Results:
Expert feedback and discussion revealed three overarching themes of recommended skill sets for ATP interviewers: (1) comprehensive skills in brief psychiatric interviewing, (2) adequate knowledge base of behavioral health conditions and therapeutic techniques, and (3) clinical documentation, integrated care/consultation practices, and e-competency skill sets. The model of training and skill requirements from expert feedback sessions included these three skill sets. Technology training recommendations were also identified and included: (1) awareness of privacy/confidentiality for electronic data gathering, storage, management, and sharing; (2) technology troubleshooting; and (3) video filming/retrieval.
Conclusions:
We describe and provide a suggested training model for the use of ATP integrated behavioral health. The training needs for ATP clinicians were assessed on a limited convenience sample of experts and clinicians, and more rigorous studies of training for ATP and other technology-focused, behavioral health services are needed. Clinical Trials number: NCT03538860.
... The clinic worked closely with a local social service organization to coordinate care. 28 This FQHC clinic received an award for their excellent diabetes outcomes in 2010 from a state-level agency and consistently surpassed diabetes goals for A 1C and cholesterol as set forth in Healthy People 2020 (D. Cesarone, MS, RN, personal communication, April 10, 2015). ...
People with serious mental illness (SMI) have a higher incidence of type 2 diabetes mellitus (T2DM) and shorter life span due to medical health problems. The chronic care model (CCM) has been used to improve care of patients with T2DM. One clinical organization that provided primary care to patients with SMI had excellent diabetes outcomes but did not have information on how they achieved those outcomes. Thus, we conducted a pilot study chart review for 30 patients with T2DM and SMI to determine how well the clinic’s system aligned with the overall CCM components and which components correlated with diabetes control. We also evaluated use of the CCM using the Assessment of Chronic Illness Care provider survey. Results showed that the clinic had an overall basic implementation level of the CCM, which allows opportunity for improvement. Two elements of the CCM were correlated with hemoglobin A1C and both were in an unexpected direction: self-management support in the variable of percentage of visits that included patient-specific goal-setting (rs = .52; P = .004) and delivery system design in the variable of number of nurse practitioner visits per study period (rs = .43; P = .02). These findings suggest that the clinic may have made more concentrated efforts to manage diabetes for patients who were not in good diabetes control. Providers noted the influence of SMI and social service organization support on these patients’ clinical outcomes. The findings will be reexamined after a fuller implementation of the CCM to further improve management in this population.
... Results indicated that 33% of the population lost weight and had improved blood glucose levels. An additional 33% of the population presented some improvement of blood glucose levels, and only one reflected a deterioration of the blood sugar levels (Davis, et al., 2011). ...
Workplace bullying is a topic that is ever-increasing in its popularity within management and organizational literature. Furthermore, the topic is also garnering a higher level of acceptance of managerial and organizational practitioners. In other words, it is no longer a phenomenon that can be ignored. The following research serves two purposes: 1) to provide a summary of what researchers have found to date and 2) provide postulations for how management and organizations should move forward to combat the effects or occurrence of bullying.
... 5 This broad scope of practice encompasses the diagnosis and management of serious mental illness (SMI), including pharmacotherapy and psychotherapy, monitoring co-existing medical conditions, and screening for emerging physical problems. 9 This skill set is foundational to integrated care models for complex populations 29 and undergirds best practices to underserved populations. 30,31 Drawing on preceptored field experiences, PMH-APNs are also valuable in wellness initiatives incorporating a holistic perspective in their health promotion efforts. ...
In the last ten years primary care providers have been encouraged to implement integrated models of care where individuals' medical and mental health needs are addressed holistically. Many integrated models use Psychiatric Mental Health (PMH) nurses as case managers and select exemplars use PMH Advanced Practice Nurses (APNs) as providers. However, the potential value of PMH nurses in integrated health care remains unrealized by health care planners and payers, limiting access to services for the populations most in need of comprehensive care approaches. This current situation is partially fueled by insufficient knowledge of the roles and skill sets of PMH nurses. In this paper, the PMH RN and APN skill sets are detailed, demonstrating how effective use of these nurses can further the aims of integrated care models. Finally, outlined are barriers and enabling factors to effective use of PMH RNs and APNs and attendant policy implications.
... Finally, a number of psychiatric rehabilitation agencies have embraced the Health Home model described above, and especially popular has been the Behavioral Health Home model which delivers primary care, prevention, and wellness activities in behavioral health care settings (Alexander & Druss, 2012). For example, Thresholds Psychiatric Rehabilitation Centers in Chicago operates a Behavioral Health Home consisting of two on-site primary care clinics in collaboration with the University of Illinois' College of Nursing, providing a full array of medical and preventative services along with care coordination (Davis et al., 2011). Arundel Lodge, a psychiatric rehabilitation program in Maryland, operates a Health Home in partnership with the Anne Arundel Medical Center that provides nurse care manager services on-site for medical and psychiatric assessment; development of a comprehensive plan of care including psychiatric rehabilitation services; and assignment to a care manager who tracks all medical and behavioral health appointments (Arundel Lodge, 2016). ...
The year 2010 saw passage of an historic piece of legislation in Public Law 111-148, entitled the Patient Protection and Affordable Care Act or ACA (2010). Since that time, the ACA has contributed to a number of improvements to the U.S. health care system including a large decrease in the number of uninsured individuals, substantially expanded access to health care services, and relief of the burden of uncompensated care provided by hospitals and other health care organizations (Jost, 2015). Various analyses of the law's impact on people with mental illnesses suggest that there have been both positive and negative outcomes from the first five years of ACA implementation. In this editorial, we reflect on these impacts as well as their current and future effects on the field of psychiatric rehabilitation. (PsycINFO Database Record
... PMH APNs have the educational background to build innovative transition processes and integrated care models for complex, often underserved populations (Hanrahan, Delaney, & Merwin, 2010). PMH APNs plan treatments that address social determinants of health and bring mental health expertise to communities (Davis et al., 2011). PMH APNs are skilled at shaping patient-focused outcomes and building patient engagement in services critical to reducing attrition. ...
Background:
The mental health service delivery transformation has created models of care that generate demand for a workforce with particular competencies.
Objective:
This article develops a psychiatric mental health (PMH) nursing workforce agenda in light of demand generated by new models of care and the capacity/capabilities of the PMH RN and advanced practice nurse (APN) workforce.
Design:
Examine the current capacity of the PMH nursing workforce and how health care reform and related service delivery models create demand for a particular set of behavioral health workforce competencies.
Results:
PMH RNs and APNs have an educational background that facilitates development of competencies in screening, care coordination, leveling care, and wellness education. PMH RNs are a large workforce but the size of the PMH APN group is inadequate to meet demand.
Conclusion:
The specialty must strategize on how to build requisite PMH RN and APN competencies for the evolving service landscape.
... Where are nurses in this trend? Certainly nurses are practicing in integrated care and creating both nurse-managed systems and models within large health care organizations (e.g., Davis et al., 2011;Nardi, 2011;Reiss-Brennan, Briot, Savitz, Cannon, & Staheli, 2010). But their work is not necessarily recognized in the larger policy/practice arena. ...
Currently the United States health care system is responding to the Patient Protection and Affordable Care Act (PPACA) and the vision it contains for health care transformation. Along with sweeping changes in service delivery and payment structures, health care reform has championed concepts such as patient-centered care, integrated care, and wellness. Although these are not new ideas, their adaptation, in both ideology and service design has been accelerated in the context for reform. Indeed they are reaching a tipping point; the point where ideas gain wide acceptance and become influential trends. Although psychiatric mental health (PMH) nurses have been active in wellness, patient-centered care, and integrated care, at the current time they seem to be situated peripheral to these national trends. Increased presence of PMH nurses will facilitate their contribution to the development of these concepts within service structures and interventions. To increase knowledge and appreciation of PMH nurses’ practice and unique perspective on these issues, leaders are needed who will connect and effectively communicate PMH nursing efforts to the broader health care arena. This article outlines the events that created a context for these three concepts (patient-centered care, wellness, and integrated care), and I suggest why they have reached a tipping point and discuss the need for greater PMH nursing presence in the American national dialog and the role of nursing leaders in facilitating these connections.
Background:
Further exploration of the practice roles of psychiatric mental health (PMH) advanced practice registered nurses (APRNs) is warranted.
Objective:
In March of 2016, the American Psychiatric Nurses Association (APNA) conducted a national survey to gather data on the demographics, practice roles, and activities of certified PMH APRNs.
Design:
The e-mail survey contained 46 questions consistent with minimum data set requirements of the Forum of State Nursing Workforce Centers.
Results:
The data indicate that PMH APRNs are a clinically active workforce; the majority deliver a wide variety of mental health services including diagnosis and management of both acute and chronic mental illness, prescribing, and providing psychotherapy.
Conclusion:
PMH APRNs are delivering care to clients dealing with a range of serious mental illnesses across the life span in a variety of roles. It will be critical to monitor the activities and outcomes of this expanding behavioral health care workforce.
Abstract Despite the fact that the United States dedicates so much of its resources to healthcare, the current healthcare delivery system still faces significant quality challenges. The lack of effective communication and coordination of care services across the continuum of care poses disadvantages for those requiring long-term management of their chronic conditions. This is why the new transformation in healthcare known as the patient-centered medical home (PCMH) can help restore confidence in our population that the healthcare services they receive is of the utmost quality and will effectively enhance their quality of life. Healthcare using the PCMH model is delivered with the patient at the center of the transformation and by reinvigorating primary care. The PCMH model strives to deliver effective quality care while attempting to reduce costs. In order to relieve some of our healthcare system distresses, organizations can modify their delivery of care to be patient centered. Enhanced coordination of services, better provider access, self-management, and a team-based approach to care represent some of the key principles of the PCMH model. Patients that can most benefit are those that require long-term management of their conditions such as chronic disease and behavioral health patient populations. The PCMH is a feasible option for delivery reform as pilot studies have documented successful outcomes. Controversy about the lack of a medical neighborhood has created concern about the overall sustainability of the medical home. The medical home can stand independently and continuously provide enhanced care services as a movement toward higher quality care while organizations and government policy assess what types of incentives to put into place for the full collaboration and coordination of care in the healthcare system.
Objectives:
The study's purpose was to examine the impact of somatic symptoms and perceived neighborhood environment on depression using a comparison among US-born and non-US-born free clinic patients.
Methods:
US-born English speakers (n = 99), non-US-born English speakers (n = 89), and non-US-born Spanish speakers (n = 158) 18 years old or older (N = 346) were surveyed at a free clinic that provides primary care to people without health insurance. Depression, somatic symptoms, and perceived neighborhood environment were measured using standardized instruments.
Results:
US-born English speakers reported higher levels of depression and a greater number of somatic symptoms than non-US-born Spanish speakers and non-US-born English speakers. Non-US born English speakers reported lower levels of depression and fewer somatic symptoms than Spanish speakers. Somatic symptoms and perceived neighborhood satisfaction were related to depression.
Conclusions:
Developing mental health services for patients in a free clinic setting is needed; however, because of limited financial and human resources, providing mental health services in a free clinic setting often is difficult. Community-based health promotion programs as supplements to efforts within clinical settings would be valuable in improving the mental health of free clinic patients. Future studies should implement collaborative pilot programs and evaluate health outcomes.
Individuals with serious mental illness are at an increased risk for developing co-morbid chronic physical illnesses, such as diabetes and cardiovascular disease. This article is a descriptive piece about an intervention to decrease physical health risks in this population through a partnership effort between a primary care clinic and mental health agency in rural Placer County, California. The project was conducted as a part of the CalMEND Pilot Collaborative to Integrate Primary Care and Mental Health Services, which took place in five California counties in 2010-2011. A description of the program elements, conceptual models, key measures, and the process of program implementation is provided. Benefits were observed in areas of quality assurance, intra- and inter-agency teamwork, and access to adequate primary care for this population.
This report provides a program description of a supported housing residence for individuals with co-occurring diabetes and serious mental illnesses and preliminary health outcome data.
Weight, blood glucose levels and satisfaction survey data were collected retrospectively on 13 individuals referred to the program.
Results indicate that individuals lost weight and fasting glucose readings fell into the ADA recommended range in the first six months of participation. Overall, consumers participating in the program were satisfied with the diabetes education and monitoring services provided.
While preliminary results suggest that consumers benefit, this study only begins to address how integrated behavioral health and diabetes-specific programming in residential settings meets the needs of persons with severe mental illnesses and diabetes. A more thorough understanding of the impact of these programs on consumers' health outcomes is needed to inform how to deliver diabetes management curricula and support consumers to improve their overall health.
Introduces the articles appearing in the present issue of Psychiatric Rehabilitation Journal. Selected articles in this Special Issue on Promoting Integrated Healthcare for People Living with Psychiatric Disabilities originated from an Integrated Health Care Conference, Critical Condition: Integrating Health Care to Increase Quality of Life and Life Expectancy, hosted by Thresholds Institute and Loyola University Chicago in 2009. This Integrated Health Care Conference program brought together scholars, policymakers, providers, consumers, and family members to present on innovative services that were successfully integrating primary care into public behavioral health care settings. Secondly, the conference provided a unique opportunity to report recent findings on a range of physical health co-morbidities experienced by individuals living with serious mental illnesses. (PsycINFO Database Record (c) 2013 APA, all rights reserved)
Poor quality of healthcare contributes to impaired health and excess mortality in individuals with severe mental disorders. The authors tested a population-based medical care management intervention designed to improve primary medical care in community mental health settings.
A total of 407 subjects with severe mental illness at an urban community mental health center were randomly assigned to either the medical care management intervention or usual care. For individuals in the intervention group, care managers provided communication and advocacy with medical providers, health education, and support in overcoming system-level fragmentation and barriers to primary medical care.
At a 12-month follow-up evaluation, the intervention group received an average of 58.7% of recommended preventive services compared with a rate of 21.8% in the usual care group. They also received a significantly higher proportion of evidence-based services for cardiometabolic conditions (34.9% versus 27.7%) and were more likely to have a primary care provider (71.2% versus 51.9%). The intervention group showed significant improvement on the SF-36 mental component summary (8.0% [versus a 1.1% decline in the usual care group]) and a nonsignificant improvement on the SF-36 physical component summary. Among subjects with available laboratory data, scores on the Framingham Cardiovascular Risk Index were significantly better in the intervention group (6.9%) than the usual care group (9.8%).
Medical care management was associated with significant improvements in the quality and outcomes of primary care. These findings suggest that care management is a promising approach for improving medical care for patients treated in community mental health settings.