Journal of General Internal Medicine

, Volume 28, Issue 3, pp 353–362

Determinants of Readiness for Primary Care-Mental Health Integration (PC-MHI) in the VA Health Care System

  • Evelyn T. Chang
  • Danielle E. Rose
  • Elizabeth M. Yano
  • Kenneth B. Wells
  • Maureen E. Metzger
  • Edward P. Post
  • Martin L. Lee
  • Lisa V. Rubenstein
Original Research



Depression management can be challenging for primary care (PC) settings. While several evidence-based models exist for depression care, little is known about the relationships between PC practice characteristics, model characteristics, and the practice’s choices regarding model adoption.


We examined three Veterans Affairs (VA)-endorsed depression care models and tested the relationships between theoretically-anchored measures of organizational readiness and implementation of the models in VA PC clinics.


1) Qualitative assessment of the three VA-endorsed depression care models, 2) Cross-sectional survey of leaders from 225 VA medium-to-large PC practices, both in 2007.


We assessed PC readiness factors related to resource adequacy, motivation for change, staff attributes, and organizational climate. As outcomes, we measured implementation of one of the VA-endorsed models: collocation, Translating Initiatives in Depression into Effective Solutions (TIDES), and Behavioral Health Lab (BHL). We performed bivariate and, when possible, multivariate analyses of readiness factors for each model.


Collocation is a relatively simple arrangement with a mental health specialist physically located in PC. TIDES and BHL are more complex; they use standardized assessments and care management based on evidence-based collaborative care principles, but with different organizational requirements. By 2007, 107 (47.5 %) clinics had implemented collocation, 39 (17.3 %) TIDES, and 17 (7.6 %) BHL. Having established quality improvement processes (OR 2.30, [1.36, 3.87], p = 0.002) or a depression clinician champion (OR 2.36, [1.14, 4.88], p = 0.02) was associated with collocation. Being located in a VA regional network that endorsed TIDES (OR 8.42, [3.69, 19.26], p < 0.001) was associated with TIDES implementation. The presence of psychologists or psychiatrists on PC staff, greater financial sufficiency, or greater spatial sufficiency was associated with BHL implementation.


Both readiness factors and characteristics of depression care models influence model adoption. Greater model simplicity may make collocation attractive within local quality improvement efforts. Dissemination through regional networks may be effective for more complex models such as TIDES.


primary care mental health depression collaborative care implementation readiness 

Supplementary material

11606_2012_2217_MOESM1_ESM.pdf (62 kb)
ESM 1(PDF 62 kb)


  1. 1.
    Kessler R, Chiu W, Demler O, Walters E. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Arch Gen Psychiat. 2005;62(6):617–27.PubMedCrossRefGoogle Scholar
  2. 2.
    Singleton N, Bumpstead R, O’Brien M, Lee A, Meltzer H. Office of National Statistics: Psychiatric morbidity among adults living in private households, 2000. London: Her Majesty’s Stationery Office; 2001.Google Scholar
  3. 3.
    World Health Organization. Mental health: Depression. 2011; Accessed August 21, 2012.
  4. 4.
    Simon G, Von Korff M. Recognition and management of depression in primary care. Arch Fam Med. 1995;4:99–105.PubMedCrossRefGoogle Scholar
  5. 5.
    Young A, Klap R, Sherbourne C, Wells K. The quality of care for depressive and anxiety disorders in the United States. Arch Gen Psychiat. 2001;58(1):55–61.PubMedCrossRefGoogle Scholar
  6. 6.
    Wang P, Lane M, Olfson M, Pincus H, Wells K, Kessler R. Twelve-month use of mental health services in the United States. Arch Gen Psychiat. 2005;62:629–40.PubMedCrossRefGoogle Scholar
  7. 7.
    Alexopoulos G, Reynolds C, Bruce M, et al. Reducing suicidal ideation and depression in older primary care patients: 24-month outcomes of the PROSPECT study. Am J Psychiat. 2009;166:882–90.PubMedCrossRefGoogle Scholar
  8. 8.
    Reiss-Brennan B, Briot P, Savitz L, Cannnon W, Staheli R. Cost and quality impact of Intermountain’s Mental Health Integration Program. J Healthc Manag. 2010;55(2):97–114.PubMedGoogle Scholar
  9. 9.
    Unutzer J, Katon W, Callahan C, et al. Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA. 2002;288(22):2836–45.PubMedCrossRefGoogle Scholar
  10. 10.
    Katon W, Von Korff M, Lin E, et al. Stepped collaborative care for primary care patients with persistent symptoms of depression: a randomized trial. Arch Gen Psychiat. 1999;56(12):1109–15.PubMedCrossRefGoogle Scholar
  11. 11.
    Katon W, Von Korff M, Lin E, et al. Collaborative management to achieve treatment guidelines: impact on depression in primary care. JAMA. 1995;273:1026–31.PubMedCrossRefGoogle Scholar
  12. 12.
    Wells K, Sherbourne C, Schoenbaum M, et al. Five-year impact of quality improvement for depression. Arch Gen Psychiat. 2001;61:378–86.CrossRefGoogle Scholar
  13. 13.
    Gilbody S, Bower P, Fletcher J, Richards D, Sutton AJ. Collaborative care for depression. Arch Intern Med. 2006;166:2314–21.PubMedCrossRefGoogle Scholar
  14. 14.
    Bower P, Gilbody S, Richards D, Fletcher J, Sutton A. Collaborative care for depression in primary care. Br J Psychiat. 2006;189:484–93.CrossRefGoogle Scholar
  15. 15.
    Simon GE, Katon WJ, VonKorff M, et al. Cost-effectiveness of a collaborative care program for primary care patients with persistent depression. Am J Psychiat. 2001;158:1638–44.PubMedCrossRefGoogle Scholar
  16. 16.
    Unutzer J, Katon WJ, Fan M-Y, et al. Long-term cost effects of collaborative care for late-life depression. Am J Manag Care. 2008;14:95–100.PubMedGoogle Scholar
  17. 17.
    Liu C-F, Hedrick SC, Chaney EF, et al. Cost-effectiveness of collaborative care for depression in a primary care veteran population. Psychiat Serv. 2003;54(5):698–704.CrossRefGoogle Scholar
  18. 18.
    Lave J, Frank R, Schulberg H, Kamlet M. Cost-effectiveness of treatments for major depression in primary care practice. Arch Gen Psychiat. 1998;55:645–51.PubMedCrossRefGoogle Scholar
  19. 19.
    Schoenbaum M, Unutzer J, Sherbourne C, et al. Cost-effectiveness of practice-initiated quality improvement for depression: results of a randomized controlled trial. JAMA. 2001;286(11):1325–30.PubMedCrossRefGoogle Scholar
  20. 20.
    Nutting P, Rost K, Dickinson M, et al. Barriers to initiating depression treatment in primary care. J Gen Intern Med. 2002;17:103–11.PubMedCrossRefGoogle Scholar
  21. 21.
    Henke R, McGuire T, Zaslavsky A, Ford D, Meredity L, Arbelaez J. Clinician- and organization-level factors in the adoption of evidence-based care for depression in primary care. Health Care Manag Rev. 2008;33(4):289–99.CrossRefGoogle Scholar
  22. 22.
    Nutting P, Gallagher K, Riley K, et al. Care management for depression in primary care practice: findings from the RESPECT-depression trial. Ann Fam Med. 2008;6:30–7.PubMedCrossRefGoogle Scholar
  23. 23.
    Kilbourne A, Schulberg H, Post E, Rollman B, Belnap B, Pincus H. Translating evidence-based depression management services to community-based primary care practices. Milbank Q. 2004;82(4):631–59.PubMedCrossRefGoogle Scholar
  24. 24.
    Belnap BH, Kuebler J, Upshur C, et al. Challenges of implementing depression care management in the primary care setting. Adm Policy Ment Health. 2006;33(1):65–75.PubMedCrossRefGoogle Scholar
  25. 25.
    Scott WR. Innovation in medical care organizations: a synthetic review. Med Care Res Rev. 1990;47(165):165–92.CrossRefGoogle Scholar
  26. 26.
    Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O. Diffusion of innovations in Service Organizations: systematic review and recommendations. Milbank Q. 2004;82(2):581–629.PubMedCrossRefGoogle Scholar
  27. 27.
    Weiner B, Amick H, Lee SD. Review: conceptualization and measurement of organizational readiness for change: a review of the literature in health services research and other fields. Med Care Res Rev. 2008;65:379–436.PubMedCrossRefGoogle Scholar
  28. 28.
    Hamilton AB, Cohen AN, Young AS. Organizational readiness in specialty mental health care. J Gen Intern Med. 2009;25(Suppl 1):27–31.Google Scholar
  29. 29.
    Lehman W, Greener J, Simpson D. Assessing organizational readiness for change. J Subst Abus Treat. 2002;22:197–209.CrossRefGoogle Scholar
  30. 30.
    VHA Handbook 1160.01 Uniform Mental Health Services in VA Medical Centers and Clinics. Washington, DC: Department of Veterans Affairs: Office of Patient Care Services; 2008.Google Scholar
  31. 31.
    Rubenstein L, Meredith L, Parker L, et al. Impacts of evidence-based quality improvement on depression in primary care. J Gen Intern Med. 2006;21:1027–35.PubMedCrossRefGoogle Scholar
  32. 32.
    Rubenstein L, Chaney E, Ober S, et al. Using evidence-based quality improvement methods for translating depression collaborative care research into practice. Fam Syst Health. 2010;28:91–113.PubMedCrossRefGoogle Scholar
  33. 33.
    Zanjani F, Miller B, Turiano N, Ross J, Oslin D. Effectiveness of telephone-based referral care management, a brief intervention to improve psychiatric treatment engagement. Psychiatr Serv. 2008;59:776–81.PubMedCrossRefGoogle Scholar
  34. 34.
    Oslin D, Ross J, Sayers S, Murphy J, Kane V, Katz I. Screening, assessment, and management of depression in VA primary care clinics: The Behavioral Health Laboratory. J Gen Intern Med. 2006;21:46–50.PubMedCrossRefGoogle Scholar
  35. 35.
    Oslin D, Sayers S, Ross J, et al. Disease management for depression and at-risk drinking via telephone in an older population of veterans. Psychosom Med. 2003;65(6):931–7.PubMedCrossRefGoogle Scholar
  36. 36.
    Liu C-F, Rubenstein LV, Kirchner JE, et al. Organizational cost of quality improvement for Depression Care. Heal Serv Res. 2009;44(1):225–44.CrossRefGoogle Scholar
  37. 37.
    Rubenstein LV, Jackson-Triche M, Unutzer J, et al. Evidence-based care for depression in managed primary care practices. Heal Aff. 1999;18(5):89–105.CrossRefGoogle Scholar
  38. 38.
    Post EP, Kilbourne AM, Bremer RW, Solano FX, Jr, Pincus HA, Reynolds CF, III. Organizational factors and depression management in community-based primary care settings. Implement Sci. 2009;4:84.Google Scholar
  39. 39.
    Tew J, Klaus J, Oslin D. The behavioral health laboratory: building a stronger foundation for the Patient-centered medical home. Fam Syst Health. 2010;28(2):130–45.PubMedCrossRefGoogle Scholar
  40. 40.
    Thielke S, Vannoy S, Unutzer J. Integrating mental health and primary care. Prim Care Clin Office Pract. 2007;34:571–92.CrossRefGoogle Scholar
  41. 41.
    Bower P, Knowles S, Coventry PA, Rowland N. Counselling for mental health and psychosocial problems in primary care (Review). Cochrane Database of Syst Rev. 2011(9).Google Scholar
  42. 42.
    Krahn DD, Bartels SJ, Coakley E, et al. PRISM-E: comparison of integrated care and enhanced specialty referral models in depression outcomes. Psychiat Serv. 2006;57(7):946–53.CrossRefGoogle Scholar
  43. 43.
    Simpson D. A conceptual framework for transferring research to practice. J Subst Abus Treat. 2002;22:171–82.CrossRefGoogle Scholar
  44. 44.
    Rogers E. Diffusion of innovations. New York: The Free Press; 1995.Google Scholar
  45. 45.
    Yano E, Fleming B, Canelo, et al. National Survey Results for the Primary Care Director Module of the VHA Clinical Practice Organizational Survey. Sepulveda, CA: VA HSR&D Center for the Study of Healthcare Provider Behavior; 2008.Google Scholar
  46. 46.
    Chou A, Rose D, Farmer M, Canelo I, Rubenstein L, Yano E. Organizational Factors Affecting the Likelihood of CancerScreening among VA Patients. Paper presented at: 13th Annual Healthcare Organizational Research Association (HORA) ConferenceJune 2011; Seattle, WA.Google Scholar
  47. 47.
    Kline R. Principles and practice of structural equation modeling. New York: The Guilford Press; 2005.Google Scholar
  48. 48.
    Groves R, Fowler F Jr, Couper M, Lepkowski J, Singer E, Tourangeau R. Survey methodology. 2nd ed. Hoboken: Wiley; 2009.Google Scholar
  49. 49.
    Area Resource File (ARF). Rockville, MD: US Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions; 2008.Google Scholar
  50. 50.
    Department of Veterans Affairs. Office of Academic Affiliations. Accessed Aug 21, 2012.
  51. 51.
    Agresti A, Franklin C. Statistics: The art and science of learning from data. Upper Saddle River: Pearson Prentice Hall; 2009.Google Scholar
  52. 52.
    Wagner E, Austin B, Davis C, Hindmarsh M, Schafer J, Bonomi A. Improving chronic illness care: translating evidence into action. Heal Aff. 2001;20(6):64–78.CrossRefGoogle Scholar
  53. 53.
    Improving Chronic Illness Care. 1996-2012; The MacColl Center. The Improving Chronic Illness Care program is supported by The Robert Wood Johnson Foundation, with direction and technical assistance provided by Group Health’s MacColl Center for Health Care Innovation. Available at: Accessed Aug 21, 2012.
  54. 54.
    Pomerantz A, Shiner B, Watts B, et al. The White River Model of colocated collaborative care. Fam Syst Health. 2010;28(2):114–29.PubMedCrossRefGoogle Scholar
  55. 55.
    Pomerantz AS, Cole BH, Watts BV, Weeks WB. Improving efficiency and access to mental health care: combining integrated care and advanced clinical access. Gen Hosp Psychiat. 2008;30:546–51.CrossRefGoogle Scholar
  56. 56.
    Pomerantz A, Sayers S. Primary care-mental health integration in healthcare in the Department of Veterans Affairs. Fam Syst Health. 2010;28(2):78–82.PubMedCrossRefGoogle Scholar
  57. 57.
    Watts B, Shiner B, Pomerantz A, Stender P, Weeks W. Outcomes of a quality improvement project integrating mental health into primary care. Qual Saf Health Care. 2007;16:378–81.PubMedCrossRefGoogle Scholar
  58. 58.
    Parker V, Wubbenhorst W, Young G, Desai KR, Charns MP. Implementing quality improvement in hospitals: the role of leadership and culture. Am J Med Qual. 1999;14:64–9.PubMedCrossRefGoogle Scholar
  59. 59.
    Hemmelgarn A, Glisson C, James L. Organizational culture and climate: implications for services and interventions research. Clin Psychol Sci Pract. 2006;13(1):73–89.CrossRefGoogle Scholar
  60. 60.
    Shortell S, O’Brien J, Carman J, et al. Assessing the impact of continuous quality improvement/total quality management: concept vs implementation. Heal Serv Res. 1995;30(2):377–401.Google Scholar
  61. 61.
    Collaborative Care for Depression in the Primary Care Setting: a primer on VA’s Translating Initiatives for Depression into Effective Solutions (TIDES) Project. In: VA Health Services Research and Development Service, Office of Research and Development, Dept of Veterans Affairs, ed. Washington, DC 2008.Google Scholar

Copyright information

© Society of General Internal Medicine 2012

Authors and Affiliations

  • Evelyn T. Chang
    • 1
  • Danielle E. Rose
    • 2
  • Elizabeth M. Yano
    • 2
    • 3
  • Kenneth B. Wells
    • 3
    • 4
    • 5
  • Maureen E. Metzger
    • 6
  • Edward P. Post
    • 6
    • 7
  • Martin L. Lee
    • 2
    • 3
  • Lisa V. Rubenstein
    • 2
    • 5
  1. 1.VA Greater Los Angeles, General Internal MedicineLos AngelesUSA
  2. 2.VA HSR&D Center of Excellence for the Study of Healthcare Provider BehaviorSepulvedaUSA
  3. 3.UCLA School of Public HealthDepartment of Health ServicesLos AngelesUSA
  4. 4.UCLA Psychiatry and Biobehavioral SciencesLos AngelesUSA
  5. 5.RANDSanta MonicaUSA
  6. 6.VA Center for Clinical Management Research and Serious Mental Illness Treatment Resource and Evaluation CenterAnn ArborUSA
  7. 7.Department of Internal MedicineUniversity of Michigan School of MedicineAnn ArborUSA

Personalised recommendations