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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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