Integrating Behavioral Health and Primary Care Services for People with Serious Mental Illness: A Qualitative Systems Analysis of Integration in New York

Abstract

People with co-occurring behavioral and physical conditions receive poorer care through traditional health care services. One solution has been to integrate behavioral and physical care services. This study assesses efforts to integrate behavioral health and primary care services in New York. Semi-structured interviews were conducted with 52 professionals in either group or individual settings. We aimed to identify factors which facilitate or hinder integration for people with serious mental illness and how these factors inter-relate. Content analysis identified structural, process, organizational (“internal”) and contextual (“external”) themes that were relevant to integration of care. Network analysis delineated the interactions between these. We show that effective integration does not advance along a single continuum from minimally to fully integrated care but along several, parallel pathways reliant upon consequential factors that aid or hinder one another.

Appendix A

Semi-structured Interview

PREAMBLE TO BE READ BY RESEARCHER: My name is Dr. X and I’m from the New York State Psychiatric Institute (NYSPI). I am here today to learn about your day-to-day clinic operations so that we can understand how integrated services are implemented. I am particularly interested in how you integrate care for your population with severe mental illness; by that I mean people with debilitating mental illnesses or people with diagnoses like schizophrenia or bipolar affective disorder.

You have all individually been asked to participate because you either help deliver or administer the integrated care project. Any information that you share with me today will be used for research purposes only, and the NYSPI will not disclose your identity like your name or any other identifying information outside of the project. This interview will not be made available to the OMH or to anyone within your organization. Your participation in this discussion is entirely voluntary and you may skip any questions that you prefer not to answer. I’ll be happy to answer any of your questions now or at the end of the interview. I expect the interview to take about 60 min and if we don’t finish today or there is more you would like to tell me we can continue it at a later time.

Are you happy to proceed?

Is there anything you’d like to ask me?

Ok can we begin by…

Factors Specific to Participant

• 1. GRP: Can you tell me a little bit about your organization?

  Article 28 or 31 or both? FQHC?

  Affiliated with a hospital site or standalone?

  Structure of organization?

  Mechanisms of integration they’re using e.g. DSRIP, PBHCI, Health Homes, OMH-CQI

  How long have they been integrating for

• 2. IND: Let’s start by having you describe what you do here.

  Provide a comfortable, non-threatening way into the interview; begin to establish a relationship; locate the person within the organization from his or her own perspective; gain a sense of his or her role in the larger process of providing care

Organizational Factors

• 3. ALL: Can you walk me through the process of identifying a person who has both a behavioral and physical health problem who is seen here?

  How are people with co-morbid physical and mental illnesses identified? Is there a formal process or is it ad-hoc; is everyone screened or those considered to be “high-risk”, how is that process determined? How is baseline assessed (assessment tools?)

• 4. And then what kinds of services are those people offered?

  Elicit descriptions of clinic processes for physical health care. Give the interviewer the opportunity to explore a broad range of factors that the interviewee considers relevant to physical health care in their setting, not necessarily mandated through either the PBHCI or OMH-CEI programs.

Prompts

How effective do you think this process for identifying/assessing/treating people is?

What influences the kinds of services people with both physical and mental health problems get? How was that decision made?

Integration Factors

• 5. ALL: What have you found as an organization has helped you integrate care?

  Explore integration efforts, both formal and informal. How does the process of integration work within the organization:

• - are there regular team meetings with physical health providers?

• - care coordination,

• - what role does the leadership play? Is integration part of the vision and mission? If so how is this message disseminated through the organization?

• - How is the EHR used? Is it searchable? Is it shared throughout network? Is there feedback to different teams or individual clinicians?

• 6. ALL: What has needed to be ironed out along the way?

  Elicits difficulties but with the presumption that the organization has been proactive in finding solutions for these

  Co-location versus affiliation; Data burden; Work intensity; Maintaining relationships; Achieving buy-in

• 7. ALL: Have there been any difficulties which have been more difficult to resolve? (Reimbursement, regulation, insurance)

• 8. ALL: Where do you think the physical health needs of people with serious mental illness should be met? If they ask for clarification: in primary care, in mental health settings, somewhere else or it doesn’t matter? Why? If different to where they’re providing it: would there be any problems with doing it like that?

Implementation Factors

• 9. ALL: There has been a move to integrate care in healthcare policy for a while now. Would you say, in your experience, that you have noticed an impact in how you deliver care from the different ways that the state or government have been trying to achieve integration?

  If ask for clarification mention: PBHCI, DSRIP, different ways to bring funding together (TO FRONTLINE STAFF: have you heard of these things?)

• 10. GRP: What changes could be made to the system to allow you to implement integration better?

  If they ask for clarification: I’m thinking about the difficulties you’ve spoken about. If you were running the system, would you make any changes?

Sustainability

• 11. ALL: What do you think has happened or needs to happen to maintain the changes you have implemented?

  Workforce training; task shifting; using other PCPs e.g. not just physicians; use of peer-support specialists; emphasizing shared decision-making; how have care managers been used (care manager buy-in is essential)

• 12. GRP: Has the organization thought about how the improvements you have made could be maintained beyond the life of [insert mechanism here e.g. PBHCI, DSRIP, etc]

  Are they looking for different opportunities? When did they start looking? What is the impact on regularly having to find new opportunities? What would they do differently?

  Have they used any tools or algorithms to sustain care e.g. the CIHS sustainability tool (did they think it was useful)? Have they been able to identify the total costs of providing integrated care (do they plan to, if not)?

• 13. Is there anything else you would like to share about the process of integrating physical health and mental health services?