Skip to main content

Behavioral Health Integration and Outcomes that Matter to Patients: a Longitudinal Mixed-Methods Observational Study

Abstract

Research on behavioral health integration (BHI) often explores outcomes for quality and cost, but less is known about impacts of integration work on key patient experience outcomes. A mixed-methods longitudinal study of BHI was conducted in 12 primary care clinics in Oregon to assess how adoption of key integration practices including integrated staffing models, integrated care trainings for providers, and integrated data sharing impacted a set of patient experience outcomes selected and prioritized by an advisory panel of active patients. Results showed that adopting key aspects of integration was not associated with improved patient experience outcomes over time. Patient interviews highlighted several potential reasons why, including an overemphasis by health systems on the structural aspects of integration versus the experiential components and potential concerns among patients about stigma and discrimination in the primary care settings where integration is focused.

This is a preview of subscription content, access via your institution.

References

  1. 1.

    Insel T. The Global Cost of Mental Illness. Rockville, MD: National Institute of Mental Health, 2011.

    Google Scholar 

  2. 2.

    World Health Organization. Global Status Report on Noncommunicable Diseases 2010: Description of the Global Burden of NCDs, Their Risk Factors and Determinants. 2011.

  3. 3.

    Substance Abuse and Mental Health Services Administration. Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings. Rockville, MD: Substance Abuse and Mental Health Services Administration;2013.

    Google Scholar 

  4. 4.

    Chapman DP, Perry BD, Strine TW. The Vital Link Between Chronic Disease And Depressive Disorders. Preventing Chronic Disease. 2005;2(1).

  5. 5.

    Evans DL, Charney DS, Lewis L, et al. Mood Disorders in the Medically Ill: Scientific Review And Recommendations. Biological Psychiatry. 2005;58(3):175–189.

    PubMed  Google Scholar 

  6. 6.

    Hackett ML, Anderson CS. Predictors of Depression After Stroke: A Systematic Review of Observational Studies. Stroke. 2005;36(10):2296–2301.

    PubMed  Google Scholar 

  7. 7.

    Goldberg D. The Detection and Treatment of Depression in the Physically Ill. World Psychiatry. 2010;9(1):16–20.

    PubMed  PubMed Central  Google Scholar 

  8. 8.

    Benton T, Staab J, Evans DL. Medical Co-Morbidity in Depressive Disorders. Annals of Clinical Psychiatry. 2007;19(4):289–303.

    PubMed  Google Scholar 

  9. 9.

    Bodurka-Bevers D, Basen-Engquist K, Carmack CL, et al. Depression, Anxiety, and Quality of Life in Patients with Epithelial Ovarian Cancer. Gynecologic Oncology. 2000;78(3 Pt 1):302–308.

    CAS  PubMed  Google Scholar 

  10. 10.

    Creed F. Psychological Disorders in Rheumatoid Arthritis: A Growing Consensus? Annals of the Rheumatic Diseases. 1990;49(10):808–812.

    CAS  PubMed  PubMed Central  Google Scholar 

  11. 11.

    Strine TW, Mokdad AH, Balluz LS et al. Impact of Depression and Anxiety on Quality of Life, Health Behaviors, and Asthma Control Among Adults in the United States With Asthma, 2006. Journal of Asthma. 2008;45(2):123–133.

    PubMed  Google Scholar 

  12. 12.

    McCusker J, Cole M, Ciampi A et al. Major Depression in Older Medical Inpatients Predicts Poor Physical and Mental Health Status over 12 Months. General Hospital Psychiatry. 2007;29(4):340–348.

    PubMed  Google Scholar 

  13. 13.

    Patten SB, Williams JV, Lavorato DH et al. Major Depression as a Risk Factor for Chronic Disease Incidence: Longitudinal Analyses in a General Population Cohort. General Hospital Psychiatry. 2008;30(5):407–413.

    PubMed  Google Scholar 

  14. 14.

    Jonas BS, Mussolino ME. Symptoms of Depression as a Prospective Risk Factor for Stroke. Psychosomatic Medicine. 2000;62(4):463–471.

    CAS  PubMed  Google Scholar 

  15. 15.

    Jonas BS, Franks P, Ingram DD. Are Symptoms of Anxiety and Depression Risk Factors for Hypertension? Longitudinal Evidence from the National Health And Nutrition Examination Survey I Epidemiologic Follow-Up Study. Archrives of Family Medicine. 1997;6(1):43–49.

    CAS  Google Scholar 

  16. 16.

    Simon GE, Ludman EJ, Linde JA, et al. Association between Obesity and Depression in Middle-Aged Women. General Hospital Psychiatry. 2008;30(1):32–39.

    PubMed  PubMed Central  Google Scholar 

  17. 17.

    Wagner EH, Austin BT, Von Korff M. Organizing Care for Patients with Chronic Illness. The Milbank Quarterly. 1996;74(4):511–544.

    CAS  PubMed  Google Scholar 

  18. 18.

    Rosenthal TC. The Medical Home: Growing Evidence to Support a New Approach to Primary Care. Journal of the American Board of Family Medicine. 2008;21(5):427–440.

    PubMed  Google Scholar 

  19. 19.

    Chapa T. Mental Health Services in Primary Care Settings for Racial and Ethnic Minority Populations. U.S. Department of Health and Human Services Office of Minority Health. 2004.

  20. 20.

    Kathol RG, Rollman BL. Value-Based Financially Sustainable Behavioral Health Components in Patient-Centered Medical Homes. The Annals of Family Medicine. 2014;12(2):172–175.

    PubMed  Google Scholar 

  21. 21.

    Croghan TW, Brown JD. Integrating Mental Health Treatment into the Patient Centered Medical Home. Agency for Healthcare Research and Quality Rockville, MD; 2010.

    Google Scholar 

  22. 22.

    Crowley RA, Kirschner N. The Integration of Care for Mental Health, Substance Abuse, and Other Behavioral Health Conditions into Primary Care: Executive Summary of an American College of Physicians Position PaperIntegration of Behavioral Health into Primary Care. Annals Of Internal Medicine. 2015;163(4):298–299.

    PubMed  Google Scholar 

  23. 23.

    Reiter JT, Dobmeyer AC, Hunter CL. The Primary Care Behavioral Health (PCBH) Model: An Overview and Operational Definition. Journal Of Clinical Psychology In Medical Settings. 2018;25(2):109–126.

    PubMed  Google Scholar 

  24. 24.

    Whitlock EP, Orleans CT, Pender N et al. Evaluating Primary Care Behavioral Counseling Interventions: An Evidence-Based Approach. American Journal Of Preventive Medicine. 2002;22(4):267–284.

    PubMed  Google Scholar 

  25. 25.

    Mullins CD, Abdulhalim AM, Lavallee DC. Continuous Patient Engagement in Comparative Effectiveness Research. Journal of the American Medical Association. 2012;307(15):1587–1588.

    CAS  PubMed  Google Scholar 

  26. 26.

    Craven MA, Bland R. Better Practices in Collaborative Mental Health Care: An Analysis of the Evidence Base. Canadian Journal of Psychiatry. 2006;51(6):1S.

    Google Scholar 

  27. 27.

    Blount A. Integrated Primary Care: Organizing the Evidence. Families, Systems, & Health. 2003;21:121–134.

    Google Scholar 

  28. 28.

    Butler M, Kane R, McAlpine D, et al. Integration of Mental Health/Substance Abuse and Primary Care No. 173 (Prepared By The Minnesota Evidence-Based Practice Center Under Contract No. 290–02-0009.) AHRQ Publication No. 09-E003. Rockville, MD: Agency for Healthcare Research and Quality. 2008.

  29. 29.

    Davis D, Corrin-Pendry S, Savill M. A Follow-Up Study of the Long-Term Effects of Counselling in a Primary Care Counselling Psychology Service. Counselling and Psychotherapy Research. 2008;8(2):80–84.

    Google Scholar 

  30. 30.

    Katon WJ, Roy-Byrne P, Russo J et al. Cost-Effectiveness and Cost Offset of a Collaborative Care Intervention for Primary Care Patients with Panic Disorder. Archives of General Psychiatry. 2002;59(12):1098–1104.

    PubMed  Google Scholar 

  31. 31.

    Ray-Sannerud BN, Dolan DC, Morrow CE, et al. Longitudinal Outcomes after Brief Behavioral Health Intervention in an Integrated Primary Care Clinic. Families, Systems, & Health. 2012;30(1):60–71.

    Google Scholar 

  32. 32.

    Roy-Byrne PP, Katon W, Cowley DS et al. A Randomized Effectiveness Trial of Collaborative Care for Patients with Panic Disorder in Primary Care. Archives of General Psychiatry. 2001;58(9):869–876.

    CAS  PubMed  Google Scholar 

  33. 33.

    Asarnow JR, Jaycox LH, Duan N, et al. Effectiveness of a Quality Improvement Intervention for Adolescent Depression in Primary Care Clinics: A Randomized Controlled Trial. Journal of the American Medical Association. 2005;293(3):311–319.

    CAS  PubMed  Google Scholar 

  34. 34.

    Balasubramanian BA, Cohen DJ, Jetelina KK, et al. Outcomes of Integrated Behavioral Health with Primary Care. The Journal of the American Board of Family Medicine. 2017;30(2):130–139.

    PubMed  Google Scholar 

  35. 35.

    van Steenbergen-Weijenburg KM, van der Feltz-Cornelis CM, Horn EK, et al. Cost-Effectiveness of Collaborative Care for the Treatment of Major Depressive Disorder in Primary Care: A Systematic Review. 2010;10(1):19.

  36. 36.

    Freeman DS, Manson L, Howard J et al. Financing the Primary Care Behavioral Health Model. Journal of Psychology in Medical Settings. 2018;25(2):197–209.

    Google Scholar 

  37. 37.

    Auxier A, Farley T, Seifert K. Establishing an Integrated Care Practice in a Community Health Center. Professional Psychology: Research and Practice. 2011;42(5):391.

    Google Scholar 

  38. 38.

    Blount A, Schoenbaum M, Kathol R, et al. The Economics of Behavioral Health Services in Medical Settings: A Summary of the Evidence. Professional Psychology: Research and Practice. 2007;38(3):290.

    Google Scholar 

  39. 39.

    Gordon AJ, Montlack ML, Freyder P et al. The Allegheny Initiative for Mental Health Integration for the Homeless: Integrating Heterogeneous Health Services for Homeless Persons. American Journal of Public Health. 2007;97(3):401–405.

    PubMed  PubMed Central  Google Scholar 

  40. 40.

    Monson SP, Sheldon JC, Ivey LC et al. Working Toward Financial Sustainability of Integrated Behavioral Health Services in a Public Health Care System. Families, Systems, & Health. 2012;30(2):181–186.

    Google Scholar 

  41. 41.

    Oliveira JM, Austin AA, Miyamoto RE et al. The Rural Hawai'i Behavioral Health Program: Increasing Access to Primary Care Behavioral Health for Native Hawaiians in Rural Settings. Professional Psychology: Research and Practice. 2006;37(2):174.

    Google Scholar 

  42. 42.

    Ward-Zimmerman B, Cannata E. Partnering with Pediatric Primary Care: Lessons Learned Through Collaborative Colocation. Professional Psychology: Research and Practice. 2012;43(6):596.

    Google Scholar 

  43. 43.

    Weisner C, Mertens J, Parthasarathy S et al. Integrating Primary Medical Care with Addiction Treatment: A Randomized Controlled Trial. Journal of the American Medical Association. 2001;286(14):1715–1723.

    CAS  PubMed  Google Scholar 

  44. 44.

    Reiss-Brennan B, Brunisholz KD, Dredge C, et al. Association of Integrated Team-Based Care with Health Care Quality, Utilization, and Cost. Journal of the American Medical Association. 2016;316(8):826–834.

    PubMed  Google Scholar 

  45. 45.

    Wright B, Broffman L, Rinaldi JB. Tracking Transformation: Assessing The Spread Of Coordinated Care In Oregon. Center for Outcomes Research and Education (CORE);2015.

  46. 46.

    Baxter P, Jack S. Qualitative Case Study Methodology: Study Design and Implementation for Novice Researchers. The Qualitative Report. 2008;13(4):544–559.

    Google Scholar 

  47. 47.

    Guest G, MacQueen KM, Namey EE. Applied Thematic Analysis. SAGE Publications, Inc; 2012.

  48. 48.

    Holden K, McGregor B, Thandi P, et al. Toward Culturally Centered Integrative Care for Addressing Mental Health Disparities among Ethnic Minorities. Psychological Services. 2014;11(4):357.

    PubMed  PubMed Central  Google Scholar 

  49. 49.

    Royal Kenton N, Broffman L, Jones K, et al. Patient Experiences in Behavioral Health Integrated Primary Care Settings: The Role of Stigma in Shaping Patient Outcomes over Time. Psychology, Health, & Medicine. 2019:1182–1197.

Download references

Funding

This study was funded by the Patient-Centered Outcomes Research Institute (PCORI), Grant #IHS-1310-08388.

Author information

Affiliations

Authors

Contributions

All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Corresponding author

Correspondence to Natalie Royal Kenton MS, MPH.

Ethics declarations

Conflict of Interest

The authors declare that they have no conflicts of interest.

Disclaimer

The views expressed here do not necessarily reflect the views of the Institute.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Appendix

Appendix

Table 5 Brief narrative description of study clinics
Table 6 Associations between domain-specific integration scores and patient experience outcomes over time

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Wright, B., Broffman, L., McMenamin, K.A. et al. Behavioral Health Integration and Outcomes that Matter to Patients: a Longitudinal Mixed-Methods Observational Study. J Behav Health Serv Res 47, 509–525 (2020). https://doi.org/10.1007/s11414-020-09691-8

Download citation