Section III.
Mental Health Care
in Primary Care Settings

Chapter 12

Introduction to Mental Health Care in Primary Care Settings

Brenda Reiss-Brennan, M.S.N.
Intermountain Health Care

What Is It?

Mental health integration (MHI) is a comprehensive approach to promoting the health of individuals, families, and communities based on communication and coordination of evidence-based primary care and mental health services. The World Health Organization defines health as a complete state of physical and mental well-being (World Health Organization, 2002). The Surgeon General defines mental health as a state of successful performance of mental and physical function resulting in productive activities and fulfilling relationships with others and the ability to adapt to and cope with adversity (U.S. Department of Health and Human Services, 1999). MHI is mental health care that is integrated into everyday primary care practice. The integration of mental health into primary care simply means to treat mental health like any other health condition. This integration is one example of quality health care delivery redesign that is team based and outcomes oriented and follows a standardized quality process that facilitates communication and coordination, based on consumer and family preferences and sound economics.

Why Do We Care?

Today, the responsibility for providing mental health care falls increasingly to primary care providers. Both consumer preference and economic disincentives are driving the need for reform of our fragmented system. In the past decade, there has been a significant increase in the proportion of people with serious mental illness and substance abuse disorders who report receiving care from primary care providers and hospital emergency rooms (Kessler et al., 2005; Reiger et al., 1993).

Depression and mental disorders are increasingly associated with high disability, projected to rank second only to cardiovascular illness as the leading cause of disability worldwide by 2020 (Murray & Lopez, 1996). Despite the availability of evidence-based treatment for mental disorders, many patients and families do not receive effective treatment (Eisenberg, 1992; Kessler et al., 2005; Wang, Demler, & Kessler, 2002; Whooley & Simon, 2000; Young et al., 2001). Ethnic minorities, older patients, and less educated patients are more likely to be subject to treatment disparities and to receive lower quality care than are other depressed patients (Melfi et al., 2000; Miranda, 2004; U.S. Department of Health and Human Services, 1999; Young et al., 2001).

Although primary care provides the majority of mental health care, lack of time and documented economic benefit make it difficult for health care delivery systems to proactively implement effective treatment strategies for these growing disabilities. Current care delivery models are inadequate and inefficient, leading to provider and consumer exhaustion, as well as significant gaps in care and poor outcomes.

Where Is It Going?

The Institute of Medicine has outlined in its Quality Chasm series of reports a new conceptual framework for defining and operationalizing quality health care reform in our country (Quality of Health Care Committee, 2001). Although not coordinated on a national level, multiple research and practice efforts across the country and abroad are actively testing and redesigning care to realign quality, performance, and economic value. Many of the most effective models of care redesign combine several quality principles into “collaborative care” models in an effort to improve the process and clinical outcomes of care for chronic illness (Katon et al., 1999; Simon et al., 2000; Wagner, Austin, & Von Korff., 1996). Reorganized systems of collaborative care can improve health outcomes and lower overall costs, and enhance consumer and provider satisfaction. Ongoing evaluation of these efforts to measure the value of the impact of integrated models on satisfaction, clinical outcomes, and cost will require engaging diverse stakeholders who are influential in developing the business case for quality in their unique communities.

As a nonprofit organization with no commercial investors, Intermountain Health Care (IHC) combines the financial, administrative, and delivery aspects of health care into one integrated network committed to providing clinical excellence, quality, and innovation. In 1999, a key group of IHC leaders became increasingly concerned that primary care medical resources were not being used efficiently to treat patients with depression and other mental health conditions. These leaders were influential in establishing the MHI quality improvement program to address the practice burden of managing these conditions and to build a business case for integration. Consumers, providers, hospital and physician administrators, community partners, and research staff worked together to enable this integration. Early results demonstrated that collaborative primary and mental health care led to improved functional status in patients and improved satisfaction and confidence among physicians in managing mental health problems as part of routine care at a neutral cost (Quality of Health Care Committee, 2004). This is only one of many examples of integrated systems success in promoting clinical quality as the driver of sound economics.

What Are the Barriers?

A significant barrier to integration efforts is the lack of a well-coordinated national effort to improve the quality of mental health and substance abuse services in primary health care or to improve the quality of primary health care services available in specialty mental health care services. Lack of oversight and national leadership prevent the implementation of available research and practice findings into real-world health delivery systems by enabling stigma, perverse economics, and technological barriers to persist.

Although stigma continues to be a leading barrier to mental health care, economic disincentives in our health care market have reinforced the low relative value of “quality of life” outcomes. The historical and prevailing disconnect between primary medical care and behavioral health impedes reimbursement for mental health care. Mental health benefits are also subject to monetary restrictions that are not imposed for other medical conditions. Many of the key elements of the proven collaborative care models are not currently reimbursable through public and private insurers. Quality care provision without accompanying reimbursement is impractical and promotes economic waste.

Shared communication in an integrated system is key to providing safe, person-centered, efficient, effective, timely, and equitable health care. Current language and interface barriers (e.g., technical vocabulary, Web pages in English only, and lack of access to the Internet), limit smooth information transfer. These barriers also present ongoing challenges in confidentiality and privacy interpretations of regulations pertaining to the Health Insurance Portability and Accountability Act (HIPAA).

What Do We Need to Do About It?

Identify Champion Leaders. The delivery of sustainable health care quality requires strong leadership. National leadership is needed to legislate policies that will support health care redesign. These policies would drive health care organizations toward continuous quality improvement and building national standards to measure, improve, and reward quality.

Establish Community Coalitions. Community coalitions of consumers, providers, and payers are needed to negotiate disparate and competing interests and lead the implementation of these common national quality standards.

Provide Consumer Access to Health Information. Consumers need access to information on service quality and community outcomes. Access would promote consumer demand and consumer choice, which should be supported by equitable health care policy mandating mental health parity with general medical benefits (Goldman, 2002). This would be a step forward in actualizing “personalized” consumer-centered medicine. Consumers and families who have an active role in choosing their care and designing their treatment goals are more likely to achieve optimal health outcomes that match their cultural preferences.

Enact Measurement Standards. To improve the quality of care will require continual monitoring and sound measurement. National organizations, such as National Committee for Quality Assurance (NCQA), that develop standard quality guidelines need to balance scientific inquiry with cost and practicality of administering them in real-world health systems. Reimbursement can then be based on achievement of selected process and outcome measures, rather than solely on consumption of health care resources (Leatherman et al., 2003).

National standards for data collection and storage are essential to this measurement process. A vigorous but flexible clinical information system is needed to provide care coordination; generate proactive care reminders; maintain clinical registries; and create transparent communication between consumers and their family, their primary care providers, and mental health resources.

Build Flexible Information Systems. Technological decision support at the point of care will increase providers’ use of clinical practice guidelines as a baseline in their treatment decisions and, hence, improve outcomes (Hunkler et al., 2000; Simon et al., 2000; Wells et al., 2000). Once effective information systems are in place, communities can report their quality outcomes and compare them with those of other communities throughout the Nation.

The most effective and sustainable health care delivery systems will be able to match health care resources to level of disease severity, thereby providing the communities they serve with the means to plan and allocate resources in a rational way. Measuring and reporting satisfaction and clinical and cost outcomes that are meaningful to all stakeholders will build consensus and foster continued support of mental health integration. The quality reform leaders of our time would say that health care in our communities is all about using resources responsibly and building and maintaining quality relationships with all our stakeholders.

References

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Goldman, H. H. (2002). Perspectives: Parity—prelude to a fifth cycle of reform. Journal of Mental Health Policy Economics, 5(3), 109–113.

Hunkler, E., Meresman, J., et al. (2000). Effectiveness of nurse telehealth and peer support in augmenting SSRI treatment of depression in primary care. Archives of Family Medicine, 9, 100–105.

Katon, W., Von Korff, M., et al. (1999). Collaborative care models for the treatment of depression. American Journal of Managed Care, 5, 794–800.

Kessler, R., Demler, O., et al. (2005). Prevalence and treatment of mental disorders, 1990 to 2003. New England Journal of Medicine, 352(24), 2515–2523.

Leatherman, Berwick, et al. (2003). The business case for quality: Case studies and an analysis. Health Affairs, 22(2), 17–30.

Melfi, C. A., Croghan, T. W., et al. (2000). Racial variation in antidepressant treatment in a Medicaid population. Journal of Clinical Psychiatry, 61, 16–21.

Miranda, J. (2004). Disparities in care for depression among primary care patients. Journal of General Internal Medicine, 19(2), 120–126.

Murray, C., & Lopez, A. (1996). The global burden of disease. A comprehensive assessment of mortality and disability for diseases, injuries and risk factors in 1990 and projected to 2020. Cambridge, MA: Harvard School of Public Health.

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Wang, P. S., Demler, O., & Kessler, R. C. (2002). Adequacy of treatment for serious mental illness in the United States. American Journal of Public Health, 92, 92–98.

Wells, K., Sherbourne, C., Schoenbaum, M., et al. (2000). Impact of disseminating quality improvement programs for depression in managed primary care: A randomized control trail. JAMA, 283(24), 212–220.

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