Abstract
The historical fragmentation of physical and mental health services has impeded efforts to improve quality and outcomes of care for persons with mental disorders. However, there is little information on effective strategies that might reduce fragmentation and improve integrated services within non-academic, community-based healthcare settings. Twenty-three practices from across the U.S. participated in a learning community meeting designed to identify barriers to integrated care and strategies for reducing such barriers. Barriers were initially identified based on a quantitative survey of organizational factors. Focus groups were used to elaborate on barriers to integrated care and to identify strategies for reducing barriers that are feasible in community-based settings. Participants identified key barriers, including administrative (e.g., lack of common medical records for mental health and general medical conditions), financial (e.g., lack of reimbursement codes to bill for mental health and general medical care in the same setting), and clinical (e.g., lack of an integrated care protocol). Top strategies recommended by participants included templates (i.e., for memoranda of understanding) to allow providers to work across practice settings, increased medical record security to enable a common medical record between mental health and general medical care, working with state Medicaid agencies to establish integrated care reimbursement codes, and guidance in establishing workflows between different providers (i.e., avoid duplication of tasks). Strategies to overcome barriers to integrated care may require cooperation across different organizational levels, including administrators, providers, and health care payers in order for integrated care to be established and sustained over time.
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Badamgarav, E., Weingarten, S. R., Henning, J. M., Knight, K., Hasselblad, V., Gano, A., Jr., et al. (2003). Effectiveness of disease management programs in depression: A systematic review. American Journal of Psychiatry, 160, 2080–2090.
Creswell, J. W., & Plano Clark, V. L. (2007). Designing and conducting mixed methods research. Thousand Oaks: Sage Publication.
Druss, B. G., Bradford, W. D., Rosenheck, R. A., Radford, M. J., & Krumholz, H. M. (2001a). Quality of medical care and excess mortality in older patients with mental disorders. Archives of General Psychiatry, 58, 565–572. doi:10.1001/archpsyc.58.6.565.
Druss, B. G., Rohrbaugh, R. M., et al. (2001b). Integrated medical care for patients with serious psychiatric illness: A randomized trial. Archives of General Psychiatry, 58, 861–868. doi:10.1001/archpsyc.58.9.861.
Dufour, R. (2004). What is a “Professional Learning Community”? Schools as Learning Communities., 61(8), 6–11.
Frank, R. G., Huskamp, H., & Pincus, H. A. (2003). Aligning incentives in the treatment of depression in primary care with evidence-based practice. Psychiatric Services, 54, 682–687. doi:10.1176/appi.ps.54.5.682.
Fullan, M. (1993). Change forces: Probing the depths of educational reform. New York: Falmer Press.
Grazier, K. I., Hegedus, A. M., Carli, T., Neal, D., & Reynolds, K. (2003). Integration of behavioral and physical health care for a Medicaid population through a public-public partnership. Psychiatric Services, 54(11), 1508–1512. doi:10.1176/appi.ps.54.11.1508.
Guba, E. G. (1978). Toward a methodology of naturalistic inquiry in educational evaluation. Monograph 8. Los Angeles: UCLA Center for the Study of Evaluation.
Guba, E. G. (1981). Criteria for assessing the trustworthiness of naturalistic inquiries. Educational Communication and Technology Journal., 29(2), 75–91.
Harris, E. C., & Barraclough, B. (1998). Excess mortality of mental disorder. British Journal of Psychiatry, 173, 11–53.
Horvitz-Lennon, M., Kilbourne, A. M., & Pincus, H. A. (2006). From Silos to Bridges: Meeting the general health care needs of adults with severe mental illnesses. Health Affairs, 25(3), 659–669. doi:10.1377/hlthaff.25.3.659.
Institute of Medicine. (2005). Improving quality of health care for mental and substance use conditions. Washington, DC: National Academy Press.
Kilbourne, A. M., Cornelius, J. R., Han, X., Haas, G. L., Salloum, I., Conigliaro, J., et al. (2005). General medical conditions in older patients with serious mental illness. American Journal of Geriatric Psychiatry., 13, 250–254. doi:10.1176/appi.ajgp. 13.3.250.
Kilbourne, A. M., McCarthy, J. F., Post, E. P., Welsh, D., Pincus, H. A., Bauer, M. S., et al. (2006a). Access to and satisfaction with care comparing patients with and without serious mental illness. International Journal of Psychiatry in Medicine, 36, 383–399. doi:10.2190/04XR-3107-4004-4670.
Kilbourne, A. M., McCarthy, J., Welsh, D., & Blow, F. (2006b). Recognition of co-occurring medical conditions among patients with serious mental illness. Journal of Nervous and Mental Disorders., 194, 598–602. doi:10.1097/01.nmd.0000230637.21821.ec.
Kilbourne, A. M., Post, E. P., Bauer, M. S., Zeber, J. E., Copeland, L. A., Good, C. B., Pincus, H. A. (2007). Therapeutic drug and cardiovascular disease risk monitoring in patients with bipolar disorder. Journal of Affective Disorders, 102(1–3), 145–151.
Kilbourne, A. M., Schulberg, H. C., Post, E. P., Rollman, B. L., Belnap, B. H., & Pincus, H. A. (2004). Translating evidence-based depression management services to community-based primary care practices. Milbank Quarterly, 82(4), 631–659. doi:10.1111/j.0887-378X.2004.00326.x.
Klein-Kracht, P. A. (1993). The principal in a community of learning. Journal of School Leadership, 3(4), 391–399.
Mauer, B. (2004). Behavioral health/primary care integration: Environmental assessment tool state level policy and financing. Rockville, MD: National Council for Community Behavioral Healthcare.
Mauer, B. (2005). In: J. Parks, D. Pollack, & S. Bartels (Eds.), Integrating behavioral health and primary care services: Opportunities and challenges for state mental health authorities. Eleventh in a Series of Technical Reports. Alexandria, VA.
McKenzie, L. (1994). Cross-functional teams in health care organizations. Health Care Supervision., 12, 1–10.
McLaughlin, M., & Talbert, J. E. (1993). Teachers’ work: Individuals, colleagues, and contexts. New York: Teachers College Press.
Murray, C. J., & Lopez, A. D. (1996). Evidence-based health policy—lessons from the Global Burden of Disease Study. Science, 274, 740–743. doi:10.1126/science.274.5288.740.
Peck, M. C., & Scheffler, R. M. (2002). An analysis of the definitions of mental illness used in state parity laws. Psychiatric Services, 53(9), 1089–1095. doi:10.1176/appi.ps.53.9.1089.
Pincus, H. A. (2003). The future of behavioral health and primary care: Drowning in the mainstream or left on the bank? Psychosomatics., 44(1), 1–11. doi:10.1176/appi.psy.44.1.1.
Reynolds, K. M., Chesney, B. K., & Capobianco, J. (2006). A collaborative model for integrated mental and physical health care for the individual who is seriously and persistently mentally ill: The Wastenaw Community Health Organization. Families, Systems & Health, 24(1), 19–27.
Rosenholtz, S. (1989). The social organization of schools. New York: Longman.
Shortell, S. (2000). Remaking health care in America: The evolution of organized delivery systems (2nd ed.). San Francisco: Jossey-Bass.
Sokal, J., Messias, E., Dickerson, F. B., Kreyenbuhl, J., Brown, C. H., Goldberg, R. W., et al. (2004). Comorbidity of medical illnesses among adults with serious mental illness who are receiving community psychiatric services. Journal of Nervous and Mental Diseases., 192(6), 421–427. doi:10.1097/01.nmd.0000130135.78017.96.
Stewart, W. F., Ricci, J. A., Chee, E., Hahn, S. R., & Morganstein, D. (2003). Cost of lost productive work time among US workers with depression. JAMA, 289, 3135–3144. doi:10.1001/jama.289.23.3135.
Strauss, A. & Corbin, J. (1998). Basics of qualitative research: Techniques and procedures for developing grounded theory. Thousand Oaks: Sage Publications.
Substance Abuse and Mental Health Services Administration (SAMHSA). (2002). Report to congress on the prevention and treatment of co-occurring substance abuse disorders and mental disorders. November, 2002. http://www.samhsa.gov/reports/congress2002/index.html.
U.S. Department of Health and Human Services, New Freedom Commission on Mental Health. (2003). Achieving The Promise: Transforming Mental Health Care in America, Pub. no. SMA-03-3832 (Rockville, MD: DHHS). Available at: www.mentalhealthcommission.gov/reports/reports.htm.
Wagner, E. H., Austin, B. T., & Von Korff, M. (1996). Organizing care for patients with chronic illness. Milbank Quarterly, 74(4), 511–544. doi:10.2307/3350391.
Wang, P. S., Lane, M., et al. (2005). Twelve-month use of mental health services in the United States. Archives of General Psychiatry, 62, 629–640. doi:10.1001/archpsyc.62.6.629.
Wells, K., Schoenbaum, M., Unutzer, J., Lagomasino, I., & Rubenstein, L. (1999). Quality of care for primary care patients with depression in managed care. Archives of Family Medicine, 8, 529–536. doi:10.1001/archfami.8.6.529.
Yano, E. M., Simon, B., Canelo, I., Parker, L., & Rubenstein L. (2000). VHA survey of primary care practices. Technical Monograph #00-MC12.
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This project was supported by the National Council for Community Behavioral Healthcare, the Institute for Behavioral Healthcare Improvement, the University of Michigan Health Systems and Depression Center, the National Institute of Mental Health (MH74509), and the Department of Veterans Affairs, Veterans Health Administration.
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Kilbourne, A.M., Irmiter, C., Capobianco, J. et al. Improving Integrated General Medical and Mental Health Services in Community-based Practices. Adm Policy Ment Health 35, 337–345 (2008). https://doi.org/10.1007/s10488-008-0177-8
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DOI: https://doi.org/10.1007/s10488-008-0177-8