Chapter 13

The Primary Care/Behavioral Health Interface

Benjamin G. Druss, M.D., M.P.H.
Rollins School of Public Health, Emory University

Thomas Bornemann, Ed.D.
The Carter Center

Elvan Daniels, M.D.
National Center for Primary Care, Morehouse School of Medicine

Yvonne Fry-Johnson, M.D.
National Center for Primary Care, Morehouse School of Medicine

Ronald W. Manderscheid, Ph.D.
Center for Mental Health Services
Substance Abuse and Mental Health Services Administration

George Rust, M.D.
National Center for Primary Care, Morehouse School of Medicine

Harry Strothers, M.D.
Department of Psychiatry, Morehouse School of Medicine

Introduction

This chapter presents a broad overview of the primary care/mental health care interface in the United States. We begin with a brief discussion of four core elements that characterize primary care, consider the implications of each of these categories for efforts to improve the quality of care on the primary care/behavioral health care interface, and end with a discussion of multifaceted approaches that address multiple dimensions of care. In the spirit of the topic, we have sought to make this review as “integrative” as possible, considering populations with both mental and addictive disorders, and addressing both behavioral care in primary care settings and the primary care of persons with behavioral disorders.

What Is Primary Care?

Although the term primary care can be used to denote a group of medical specialties such as family practice, general internal medicine, and pediatrics, it is most appropriately defined in terms of its functions rather than training or specialties. The Institute of Medicine has defined primary care as “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health needs, developing a sustained partnership with patients, and practicing in the context of family and community” (Donaldson, Yordy, Loher, & Nasselow, 1996). The locus of this care can be an individual (physician or nonphysician), a team, or a clinic.

More specifically, primary care can be understood in terms of four core constructs, most fully articulated by Barbara Starfield (1998). First contact implies that the provider or providers are the point at which individuals seek entry into the health care system. At a population level, the concept of first contact care is closely related to the notion of access to care. Comprehensiveness reflects a scope of primary care “addressing a large majority of personal health needs.” It reflects both the notion that an individual should receive services of high quality, and that primary care providers can deliver the bulk of those services. Coordination denotes alignment of service delivery across providers, clinics, and organizations. Finally, longitudinality or continuity represents the degree to which the primary care provider is the principal source of care over time (Alpert and Charney, 1974).

These four constructs provide useful anchors for understanding, and seeking to improve, care on the interface between primary care and mental health care. What is the role of primary care as a point of first contact to behavioral services, and what is the role of behavioral settings in facilitating access to primary care? Given finite time and provider availability, how should we ensure that persons with behavioral conditions receive a comprehensive range of primary care and behavioral services? Particularly for persons with comorbid conditions, how well is care coordinated between medical and specialty settings, and who should be accountable for that coordination? Does that care reflect a continuous relationship with a primary care provider or team over time? This overview addresses each of these “Four C’s” sequentially, seeking to understand both behavioral health care in primary care settings and primary care for persons treated in specialty mental health settings. We seek to understand these constructs in the context of a fifth “C” alluded to in the Institute of Medicine (IOM) definition, the communities in which these services are delivered. Particularly in the public sector, interventions must be developed with a clear understanding of the values and cultures of the communities where they are to be used (Wells, Miranda, Bruce, Alegria, and Wallerstein, 2004).

Access to Care

Understanding the importance of access to care requires drawing a distinction between two notions of accessibility: “potential” and “realized” (Andersen and Aday, 1978). Whereas potential access embodies the structural ingredients needed for providing care (e.g., medical insurance, geographic proximity of care), realized access implies actual receipt of services. This distinction, in particular the gap between potential and realized access, provides a useful context for understanding both access to behavioral services in primary care and access to primary care for persons treated by specialist behavioral providers.

Primary Care and Access to Behavioral Services

The wide reach of primary care into the general population suggests its importance as a source of potential access to health services. Four-fifths of Americans report having a usual source of care (Pancholi, 2004), and three-fourths of Americans make one or more medical visits during any given year (Krauss, Machlin, and Kass, 2001). While this reach is not complete—primary care interventions will not reach many of the uninsured and other vulnerable populations—it is broader than any existing public health infrastructure in the United States (Starfield, 1996).

About 30 percent of the U.S. population meet Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for one or more behavioral disorder in any given year (Kessler et al., 1994; Robins and Regier, 1991); however, even among those with serious disorders, fewer than half receive any mental health care (Demyttenaere, Bruffaerts, Posada-Villa, Gasquet, Kovess, Lepine, et al., 2004; Wang, Demler, and Kessler, 2002). The high prevalence and low treatment rates of mental disorders make primary care settings an important source of potential access to treatment for mental and substance use disorders.

Data on service use suggest that primary care settings also represent a growing source of realized access to mental health care in the United States. In 1990, more mental health services were delivered by primary care providers than by specialty mental health providers (Robins and Regier, 1991). Since that time, primary care has played a growing role in the delivery of mental health care, particularly for depression and anxiety disorders. These shifts have in part been driven by the development of selective serotonin reuptake inhibitor (SSRI) antidepressants, whose side effect profiles and broad set of indications make them easy to prescribe (Olfson et al., 2003; Pincus et al., 1998).

Despite these rising treatment rates, there is still evidence of a substantial gap between potential and realized access to care for mental disorders in primary care. Primary care providers commonly fail to recognize or treat disorders such as alcohol abuse (Buchsbaum, Buchanan, Poses, Schnoll, & Lawton, 1992), depression (Hirschfeld et al., 1997), and anxiety disorders (Roy-Byrne et al., 2002) in their patients. A host of patient, provider, and system-level factors likely underlie these low rates of diagnosis and treatment. In contrast to individuals seeking care from the specialty system, patients in primary care are less comfortable in reporting behavioral symptoms or in accepting treatment (Van Voorhees et al., 2003). Primary care providers may lack knowledge about these conditions or may simply lack the time to adequately diagnose and treat them (Mechanic, McAlpine, & Rosenthal, 2001). Clinics rarely have organized procedures to screen and track care for behavioral disorders (Edlund, Unutzer, & Wells, 2004).

Access to Primary Medical Care for Persons with Behavioral Conditions

Particularly for persons with serious and persistent mental disorders, specialty behavioral settings may represent their main, and often their only, point of contact with the broader health system (Druss & Rosenheck, 2000). However, as with the case of mental disorders in primary care, this potential access commonly fails to be realized. While rates of medical morbidity in patients treated in the specialty behavioral sector disorders are high (Jeste, Gladsjo, Lindamer, & Lacro, 1996; Sokal et al., 2004; Stein, 1999), these conditions commonly go undiagnosed and untreated (Koran et al., 1989; Koryani, 1979; Marder et al., 2004).

As with behavioral disorders in primary care, these low rates likely represent a combination of patient, provider, and system-level factors. Patient factors include poor self-care, lack of motivation, and fearfulness about using medical services (Lin et al., 2004). Specialty mental health providers commonly lack expertise or comfort in diagnosing medical conditions (Golomb et al., 2000; Shore, 1996). Medical providers, in turn, often assume that these patients’ presenting complaints are psychologically rather than medically determined, leading them to be less aggressive in ordering procedures and diagnostic tests (Graber et al., 2000). Finally, most specialty mental health clinics in both the public sector (e.g., community mental health centers and substance abuse treatment programs) and private setting (managed behavioral health organizations) are financially and organizationally separated from medical care (Bartels, 2004; Koyanagi, 2004). This separation means that those organizations are typically accountable only for the treatment of behavioral conditions, rather than the full scope of issues affecting persons with those conditions.

Improving Access to Care

During the past 20 years, efforts by a broad range of stakeholders have reduced the gap between potential and realized access on the primary care/behavioral health interface. At the patient level, Federal agencies (National Institute of Mental Health, 2005) nonprofit advocacy groups (Glover, Birkel, Faenza, & Bernstein, 2003), and the pharmaceutical industry (Donohue, Berndt, Rosenthal, Epstein, & Frank, 2004) have all made efforts to reduce stigma and increase treatment rates for mental disorders. Studies have sought to make education and guidelines available to providers to improve recognition and treatment of behavioral disorders (Lin, Simon, Katzelnick, & Pearson, 2001; Thompson et al., 2000). System-level interventions, such as routine screening, have been shown to improve rates of accurate mental health and substance diagnoses (Gilbody, House, & Sheldon, 2001; Rollman et al., 2001). Facilitated referrals to primary care can improve rates of contact primary care services for persons with substance use disorders (Samet et al., 2003). However, these efforts have had more success in improving rates of service use than in improving quality and outcomes of care (Beich, Thorsen, & Rollnick, 2003; Gilbody, House, & Sheldon, 2001; Rollman et al., 2002).

These findings suggest that realized access to care is necessary but not sufficient to improve quality of care on the mental health behavioral interface. Meaningful quality improvement requires attention to the other core dimensions of primary care: comprehensiveness, coordination, and continuity.

Comprehensiveness

Primary Care and Comprehensiveness of Behavioral Services

Can comprehensive behavioral services be provided in primary care? A number of studies have shown that the quality of mental and substance use treatment in primary care settings typically is poor (McGlynn et al., 2003; Saitz, Mulvey, Plough, & Samet, 1997; Wells, Schoenbaum, Unutzer, Lagomasino, & Rubenstein, 1999). Mental health specialists often have interpreted these findings as evidence that primary care providers lack the knowledge or training to provide appropriate treatment for mental disorders (Hodges, Inch, & Silver, 2001; Munoz, Hollon, McGrath, Rehm, & VandenBos, 1994). However, as noted earlier, programs educating primary care providers have proved to have only a limited benefit in improving treatment of behavioral disorders in primary care, suggesting that other, more complex issues are involved.

Primary care providers by definition are responsible for managing a broad range of medical conditions and for preventive services in their patients. The number and complexity of these competing demands increased during the 1990s with the growth of managed care and increasing pressure on primary care providers to treat rather than refer common problems (Sox, 2003). The growth of treatment guidelines and of the medical knowledge base has further increased the pressures; it has been estimated that simply complying with the U.S. Preventive Services Taskforce recommendations would require 7.4 hours of each primary care provider’s time each day (Yarnall, Pollak, Ostbyte, Krause, & Michener, 2003). It is important for behavioral health advocates and researchers to remember that these conditions comprise only one of a host of conditions and tasks competing for primary care physicians’ attention and time (Klinkman, 1997; Rost et al., 2000).

Comprehensiveness of Primary Care in Persons with Behavioral Conditions

Even when persons with behavioral conditions have one or more primary care visits, there is evidence that comprehensiveness and quality of their primary medical care are substandard (Dixon et al., 2004; Druss, Rosenheck, Desai, & Perlin, 2002; Jones, Clarke, & Carney, 2004). The problem of competing demands may create similar challenges for delivering primary medical care for persons with behavioral disorders as it does in improving their mental health care. Behavioral providers feel stretched in managing their patients’ mental and addiction disorders; the thought of adding medical problems to their scope of responsibility may feel overwhelming.

Improving Comprehensiveness of Care

Given the limited time and resources available in primary care settings and in behavioral health settings, how is it possible to improve the care for each type of service without sacrificing care for the other? Information technology (IT) has been widely touted as a strategy to address these trade-offs more broadly in U.S. health care, particularly for its potential to improve quality and efficiency of care simultaneously (Berwick, 2002; Bodenheimer & Grumbach, 2003).

On the behavioral health/primary care interface, IT may include innovations such as patient registries, electronic medical records, or handheld patient records (Freedman, 2003). These systems hold an enormous potential to improve delivery of comprehensive services. However, for IT strategies to fulfill this potential, they must be embedded in a broader quality improvement strategy (Hersh, 2004). If the providers perceive these technologies as simply another “competing demand” on their limited time, they will not be willing to use them, and the technologies will have limited benefit in improving care (Warner, King, Blizart, McClenahan, & Tang, 2000).

Coordination

Coordination of care involves improving the alignment of service delivery across providers, clinics, and organizations. While effective coordination is important for all care delivered on the primary care/mental health interface, it is particularly critical for patients with comorbid conditions. Clinically, medical, addictive, and mental health disorders commonly co-occur; the presence of any one type of disorder is a risk factor for each of the others (Katon, 2003; Kessler, 2004).

Two major barriers exist to more effective coordination of care in patients with comorbid behavioral and medical conditions. First, because comorbid conditions typically are managed across multiple providers and systems of care, they require effective communication among the clinicians and settings. If primary care providers are unaware of patients’ behavioral conditions and treatment, or if specialty behavioral providers are unaware of patients’ medical needs, then care may be redundant, inefficient, or at worst, unsafe.

Second, multiplicity of providers and systems of care leads to a diffusion of responsibility. When a person is treated by more than one provider or system of care, which is responsible for ensuring that the care is delivered appropriately?

Primary Care and Coordination of Behavioral Services

The quality of behavioral services in primary care is worse for persons with comorbid medical conditions than it is for general medical populations (Katon et al., 2004). In cases in which primary care providers offer both forms of service, competing demands, described in the previous section, are the major concern. When service is provided by multiple providers in the same system of care, the issue of coordination across those providers becomes a concern.

The greatest challenges for coordination occur when the same patients are treated not only by different providers, but by providers who work in separate systems of care. Approximately 164 million Americans, or two-thirds of those with health insurance, are enrolled in a managed behavioral health program that is financially and organizationally “carved out” from medical care (Open Minds, 2002). While these organizations can provide expertise and economies of scale in managing mental disorders, they create enormous challenges for coordinating care with general medical services (Frank, Huskamp, & Pincus, 2003; Garnick et al., 2001).

Coordination of Primary Care for Patients with Behavioral Disorders

Patients with serious behavioral disorders are typically treated in the public mental health sector. With the exception of the Veterans Administration (VA) health system, the vast majority of this care is effectively “carved out” from public sector medical care and provided in freestanding community mental health centers and substance abuse treatment programs. These programs rarely have the capacity to provide medical care onsite and have few incentives to coordinate care with patients’ medical providers (Samet, Friedmann, & Saitz, 2001). This separation leads to lack of effective exchange of information between medical and mental heath providers and lack of accountability for care. The result is that even when patients in this system have a primary care provider, quality of primary care is often poor (Levinson, Druss, Dombrowski, & Rosenheck, 2003).

Improving Coordination

Efforts to improve coordination of care have involved both enhancing communication between medical and behavioral providers and better defining a locus of accountability for care. As with comprehensiveness of care, many efforts to improve communication have emphasized the importance of information technology, such as electronic medical records. However, sharing behavioral information outside the mental and substance systems raises concern about how best to balance effective communication and preservation of patient privacy (Appelbaum, 2002).
The issue of locus of accountability in comorbid conditions is addressed in the “four quadrant” model proposed by the Substance Abuse and Mental Health Services Administration (2002). This framework has been adapted to co-occurring medical and mental health conditions. Briefly, the framework proposes a continuum of care in which, when medical morbidity predominates, patients obtain care in the medical sector, and when mental health morbidity predominates, they are treated in the mental health sector (Mauer, 2004). While it is clearly worth striving for such a continuum of care, it is also important to acknowledge that organizational, geographic, and financing arrangements will likely always play as important a role as clinical considerations in influencing where patients receive their care.

Continuity

Whereas coordination involves organization across geographic and organizational boundaries, continuity involves organization over time. While continuity is important for all patients, it is particularly critical for the treatment of chronic conditions, which by definition persist over time. Both physicians and the systems they work in tend to be oriented toward the treatment of acute conditions, and fare more poorly in managing chronic illnesses.

Primary Care and Continuity
of Behavioral Services

The most common cause of poor quality behavioral treatment in primary care is inadequate followup after treatment initiation (Simon, Von Korff, Rutter, & Peterson, 2001; Stein et al., 2004). During the past 20 years, trends in health care insurance have raised particular challenges for delivering continuous care. The cost containment mechanisms associated with managed care, the predominant form of care delivery during the 1990s, reduced continuity of care (Safran, Tarlov, & Rogers, 1994), particularly for individuals with chronic illnesses (Druss, Schlesinger, Thomas, & Allen, 2000). Now, benefits designs are increasingly shifting toward models that rely on high deductibles and copayments to curb expenditures (Robinson, 2004). Work from the RAND Health Insurance Experiment found that mental health services are more sensitive to reduction due to cost sharing than are general health services (Manning, Wells, Duan, Newhouse, & Ware, 1986), reflecting the potential for these structures to reduce continuity of behavioral care. As these plans become more widespread, it will be important to monitor both their broad impact and their particular effects on the care of mental disorders on the primary care/behavioral health interface.

Continuity of Primary Care
for Patients with Behavioral Disorders

As is the case for behavioral disorders in primary care, continuity may be the single most challenging dimension of primary care to achieve for patients with mental and addictive disorders (Cohen et al., 2004; DiMatteo, Lepper, & Croghan, 2000). Continuity of primary care for persons treated in the public sector is typically hindered by poverty, underinsurance, social instability, and symptoms of the behavioral conditions themselves.

Improving Continuity

Because of challenges of providing continuous treatment in primary care, models that center accountability for ensuring that patients receive appropriate followup in a separate organization, commonly referred to as “disease management” programs, have enjoyed growing popularity. These programs, which are targeted at managing chronic conditions such as diabetes and depression, are promoted for their ability to increase efficiency, comprehensiveness, and efficiency of care without placing additional burdens on primary care providers.

However, shifting the locus of accountability for care away from primary care teams may involve analogous concerns to those seen in carve-out models, by reducing primary care providers’ knowledge of, and responsibility for, these conditions (Casalino, 2005). Similarly, efforts to improve continuity of primary care for persons with mental disorders must ensure both coordination of, and accountability for, care by guaranteeing that these persons receive care from specialty behavioral providers.

Putting It All Together: Multifaceted Interventions for Improving Care on the Behavioral/Primary Care Interface

While a number of approaches can be used to address each of the specific dimensions of primary care at the mental health care/primary care interface, these approaches have had a limited impact on improving quality of care. This recognition has led to the development and testing of multifaceted interventions that simultaneously address multiple dimensions.

Perhaps the best known approach to improving service delivery in primary care is the “chronic care model,” a multidimensional approach to the health care for individuals with chronic illnesses developed at Group Health Cooperative of Puget Sound. This model incorporates six elements for improving quality of chronic illness care: self-management support, clinical information systems, delivery system redesign, decision support, health care organization, and community resources (Bodenheimer, Wagner, & Grumbach, 2002).

In the mid-1990s, these models were adapted to the treatment of depression in primary care by Katon and colleagues (1995, 1996). These “collaborative care” models rely on a care manager who coordinates care between mental health experts and primary care staff, typically as part of a multidisciplinary team. This care manager facilitates access to care through patient screening and case identification, develops a comprehensive treatment plan with the patient, and afterwards works to ensure continuous followup with that plan.

A growing number of studies, including several large multi-site randomized trials (Bruce et al., 2004; Dietrich et al., 2004; Rost, Nutting, Smith, Elliott, & Dickinson, 2002; Unutzer et al., 2002; Wells et al., 2000), have demonstrated that these organized programs are highly effective for improving the treatment of depression in primary care (Badamgarav et al., 2004; Gilbody, Whitty, Grimshaw, & Thomas, 2003; Neumeyer-Gromen, Lampert, Stark, & Kallischnigg, 2004). These models have been shown to be as cost-effective as other common health interventions (Pirraglia, Rosen, Hermann, Olchanski, & Neumann, 2004). They have been successfully applied to the treatment of anxiety disorders (Roy-Byrne et al., 2001) and bipolar disorder (Simon et al., 2005), and hold promise for the treatment of addictive disorders (Watkins, Pincus, Tanielian, & Lloyd, 2003). They have also been successfully extended into Community Health Centers and public sector facilities as part of the Institute for Health Improvement/Health Resources and Services Administration “breakthrough” collaboratives (Wagner et al., 2001). At least one study has demonstrated that ethnic minorities may derive greater clinical benefit from these models than whites, suggesting the potential of these approaches to reduce disparities in treatment (Miranda et al., 2003).

Parallel approaches have been tested to improve the quality of primary medical care in persons with serious mental (Druss, Rohrbaugh, Levinson, & Rosenheck, 2001) and addictive (Willenbring & Olson, 1999; Weisner, Mertens, Parthasarathy, Moore, & Lu, 2001) disorders. These approaches appear to improve both the quality of health care and self-reported health status, with similar effect sizes as those of efforts to improve the treatment of mental disorders in primary care. In addiction disorders, these models are also associated with improved rates of abstinence.

The chronic care model has many appealing characteristics for improving care on the primary care/mental health interface. It targets multiple levels of care simultaneously; it includes both mental health and general health providers; and it focuses on improving broad functional outcomes rather than simply reducing symptoms. However, these very strengths create inherent challenges in the broader dissemination of these approaches.

Several characteristics of any innovation (within or outside of health care) have consistently been shown to predict their rate of diffusion: simplicity (versus complexity), compatibility with the existing organizational structure, and relative advantage (e.g., profitability) to the organization (Rogers, 1995). Collaborative care teams, which require hiring new staff and developing new infrastructure such as registries, are relatively complex to implement; it is striking to contrast the slow uptake of these models to the extremely rapid diffusion of SSRI antidepressants (National Center for Health Statistics, 2004). Second, health interventions spanning more than one department or organization are inevitably more difficult to institute than those that are fully housed in a single organizational entity (Bradley et al., 2004). Third, much of the relative advantage of these programs is experienced outside of the systems that are paying for them. Savings from these programs are likely to accrue in a diverse range of settings, including reduced emergency room use and improved workplace productivity, and in health improvements that do not translate into monetary gains.

Improving the uptake of these programs will require attention to these broad principles. It is important to ensure that these models can be introduced incrementally and tailored to fit local needs— “adapted” rather than simply “adopted” (Berwick, 2003). These approaches have largely been developed in staff model Health maintenance organizations (HMOs) and may need to look quite different to be sustainable in carve-out plans or rural settings. Efforts are needed to better align incentives so that primary care providers, mental health practitioners, and patients each share in their relative benefits (Pincus, 2003). Finally, particularly in the public sector, it is critical that such programs be developed and implemented as partnerships with local communities to ensure that they are compatible with those communities’ preferences and values (Wells et al., 2004).

Optimizing care on the primary care/behavioral interface requires striking several balances—between specialization and integration, between centralization and local innovation, and between structure and flexibility. These tensions are not unique to mental health care or even health care systems, but rather reflect deep properties of all organizations. The organizational literature reminds us that rather than seeking “one-size-fits-all” approaches to addressing these tensions, we should expect that the correct balance will vary greatly based on local geographic, workforce, and financing structures (Lawrence & Lorsch, 1969). We now have a strong evidence base demonstrating both the need and the potential to improve access, comprehensiveness, coordination, and continuity on the primary care/behavioral health interface. As we work to translate our “science” into “practice,” we must both recognize and embrace this local complexity and diversity.

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