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Service Delivery Innovation Profile

Placing Mental Health Specialists in Primary Care Settings Enhances Patient Engagement, Produces Favorable Results Relative to Evidence-Based Care


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Snapshot

Summary

An integrated care program places mental and behavioral health specialists in more than 50 primary care locations to treat patients ages 65 years and older with depression or anxiety and those who engage in risky alcohol use. The model uses comprehensive assessments and promotes coordinated care planning and treatment based on chronic disease management principles and established treatment guidelines. The integrated approach was compared with an enhanced (i.e., better than usual care) specialty care referral model, and a study showed that the integrated model resulted in higher levels of patient engagement in treatment, comparable clinical results (except for symptom control in severely depressed patients), and lower overall costs.

Evidence Rating (What is this?)

Strong: The evidence consists of a large randomized controlled trial of more than 2,000 patients comparing the integrated primary care model with an enhanced referral care model considered to be superior to usual care.
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Developing Organizations

Harvard University; Substance Abuse and Mental Health Services Administration (U.S.); University of Pennsylvania; Veteran’s Administration
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Use By Other Organizations

  • Blue Cross Blue Shield of South Carolina under the name Companion Benefits is using the training manuals, software, and decision support from this program.

Date First Implemented

1998
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Patient Population

Age > Aged adult (80 + years); Vulnerable Populations > Mentally ill; Military/dependents/veterans; Age > Senior adult (65-79 years)end pp

Problem Addressed

Older Americans experience high rates of depression and anxiety disorders, as well as alcohol and drug use. They often seek and receive treatment in primary care settings, but the many demands of primary care present substantial challenges to effective detection and treatment.
  • Many elders affected: Between 5 and 10 percent of older primary care patients experience major depression or dysthymia, and at least 5 to 16 percent experience subsyndromal symptoms of depression.1 Estimates suggest that the 1-year prevalence of alcohol use disorder is nearly 3 percent for elderly men and 0.5 percent for elderly women.2
  • Primary care frequently sought, but often ineffective: Older adults are more likely to seek and receive mental health and substance abuse services from primary care providers than from specialists. Compared with younger adults, older primary care patients are at increased risk of inadequate treatment and are less likely to be referred to specialty mental health clinics. Standard approaches to support primary care practice in treating depression (e.g., physician education, routine depression screening, and dissemination of treatment guidelines) have had a minimal effect on outcomes.1

What They Did

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Description of the Innovative Activity

This integrated care model co-locates mental and behavioral health specialists in primary care offices to treat patients ages 65 years and older. The model uses comprehensive assessments and promotes coordinated care planning and treatment based on chronic disease management principles and established guidelines. The main components of the intervention are as follows:
  • Clinic setting and eligible patients: The model is used in 50 clinics located in urban, suburban, and rural areas, including those affiliated with hospitals and the Veterans Affairs (VA) system as well as stand-alone community-based clinics. To avoid potential stigma (a major barrier to care for older adults), no signs are placed in the clinic about the availability of mental health services. Because of the presence of the VA sites, most participants in the initial study were male, with an average age of 74 years. Just more than one-half (55 percent) were ethnic minorities. On average, participants suffered from five chronic conditions, including nearly two-thirds (63 percent) who had major depression and roughly 1 in 10 (9 percent) who engaged in risky drinking behaviors.
  • Screening: VA medical centers recommend annual alcohol misuse and depression screenings; the VA's electronic medical record prompts primary care providers to conduct or arrange for such screenings. For this implementation of the program, all patients were screened for these conditions. A three-item Alcohol Use Disorders Test-Consumption screen can be an efficient method for identifying heavy and abusive drinking patterns.
  • Mental and behavioral health specialists: The specialists are either social workers, psychologists, psychiatric nurses, psychiatrists, or master's level counselors. They are trained and supervised by psychiatrists. Mental and behavioral health specialists can manage approximately 75 to 100 cases at any given time. A psychiatrist provides staffing supervision, requiring approximately 1 to 2 hours per week per specialist; psychiatrist duties include reviewing cases, ensuring that nurses/social workers are making appropriate recommendations, providing a level of comfort and consultation to primary care physicians by lending authority to nurse recommendations, and occasionally seeing patients who are particularly complex.
  • Assessment: The mental and behavioral health specialists assess patients for anxiety, depression, and risky alcohol use using screening tools designed to reduce staff burden, an important consideration in a busy primary care setting. The assessment typically takes place 2 to 4 weeks after a primary care visit. Care management planning uses structured assessments such as the PHQ9 and follows guideline concordant algorithms. Because the mental and behavioral health specialists are co-located in the primary care office, the assessment visit is quite convenient for elderly patients, thus increasing the likelihood of the appointment being scheduled and kept.
  • Care planning: The mental and behavioral health specialist communicates with the primary care doctors about the assessment and takes on shared responsibility for patients. The specialist's notes become a formal part of the primary care medical record, thus improving documentation, communication, and coordination across the provider team.
  • Guideline-based treatment: Mental and behavioral health treatment is in accordance with VA or Agency for Healthcare Research and Quality (AHRQ) guidelines. Each site reviewed VA or AHRQ clinical practice guidelines for depression. For depression, these guidelines call for individual therapy, group therapy, or pharmacological therapy as deemed appropriate by the specialist. For risky alcohol use, the guidelines recommend three 20- to 30-minute face-to-face educational counseling sessions. Patients who exhibit risky drinking behavior and also have another mental health/substance abuse disorder are treated for both disorders simultaneously.

Context of the Innovation

Fifty primary care and referral mental health specialty clinics participated at 11 study sites across the country, including 3 community health centers, 6 VA medical centers, and 2 hospital networks. The participating primary care practices generally had 10 to 15 full-time providers and were located in urban, suburban, and rural areas.
The evaluation was sponsored by several federal agencies with the goal of comparing two models for delivering mental health and substance abuse services to older adults. The study explored whether the needs of older adults were better served by integrating mental health services into primary care settings or by referring patients and giving them added support to visit mental health specialty practices. The study was specifically designed so that the strategies used to integrate care and to strengthen the referral care approach could be easily duplicated in real world medical practice.

Did It Work?

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Results

A randomized controlled trial of more than 2,000 patients at 11 study sites compared the integrated care model with an enhanced specialty care referral model3 that is considered better than "usual care" for most patients. The results show that the integrated care model achieved higher levels of patient engagement and delivered comparable clinical results (except for symptom control in severely depressed patients), and may lower costs.1,2
  • Higher levels of patient engagement: Patients were more likely to see a mental and behavioral health specialist if the service was integrated into the primary care setting, with 71 percent making the first visit to the specialist and 54 percent having at least one additional visit, compared with 49 and 30 percent, respectively, in the referral care model.
  • Generally comparable treatment success: Both approaches succeeded in significantly improving patients' depressive symptoms (gains of two to five points on the Mental Component Score of the Medical Outcomes Study SF-36). There were no significant differences in remission rates and mental functioning, although severely depressed patients showed greater improvements in symptom relief in the referral model. In addition, patients in both arms of the study demonstrated a significant decline in at-risk drinking (from approximately 18 drinks per week to 12 drinks per week 6 months later).
  • Similar levels of patient satisfaction: Older adults expressed similarly high levels of satisfaction with the care in both models.
  • Possible lower overall costs in non-VA sites: Ongoing preliminary research suggests that over a 6-month period, patients in the integrated care model who received care at non-VA sites may have had lower total health care expenditures than did participants in the specialty referral model due to lower emergency department and inpatient usage and expenditures.

Evidence Rating (What is this?)

Strong: The evidence consists of a large randomized controlled trial of more than 2,000 patients comparing the integrated primary care model with an enhanced referral care model considered to be superior to usual care.

How They Did It

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Planning and Development Process

Key components in the planning and development process included the following:
  • Approval: Most primary care physicians at the participating sites were receptive to integrated mental and behavioral health services as they recognized the convenience and benefits for patients.
  • Selection of guidelines: Evidence-based guidelines for alcohol misuse and depression screening and assessment were reviewed and selected for implementation in the program.
  • Staff training: Mental and behavioral health specialists underwent a 3-day training program conducted on site. Ongoing updates are provided via a monthly clinical telephone conference in which various topics are reviewed.
  • Development of patient education materials: The program identified an evidence-based brief intervention model to be used for alcohol abuse treatment. No patient education materials were developed specifically for depression; each site developed their own.

Resources Used and Skills Needed

  • Staffing: The mental and behavioral health specialists are licensed mental health providers, primarily social workers, psychologists, psychiatric nurses, and master's-level counselors working under the supervision of psychiatrists.
  • Costs: Depression care management is not billable to Medicare or Medicaid; however, some private insurers have started to reimburse for depression case management. Brief interventions for alcoholism are billable through Medicare/Medicaid. Data on program costs is not available.
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Funding Sources

Centers for Medicare and Medicaid Services; Health Resources and Services Administration; Substance Abuse and Mental Health Services Administration (U.S.); Veterans Health Administration
Within the VA system, all facilities are required to have an integrated care management system for all veterans regardless of age. Insurance companies are taking a greater interest in the model, and some have begun to reimburse screening and care management services.end fs

Tools and Other Resources

Ross JT, TenHave T, Eakin AC, et al. A randomized controlled trial of a close monitoring program for minor depression and distress. J Gen Intern Med. 2008;23(9):1379-85. [PubMed]

Zanjani F, Miller B, Turiano N, et al. Effectiveness of telephone-based referral care management, a brief intervention to improve psychiatric treatment engagement. Psychiatr Serv. 2008;59(7):776-81. [PubMed]

Adoption Considerations

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Getting Started with This Innovation

  • Make changes to patient flow that increase convenience. Arranging care so that older adults need only travel across the hall or less than a mile away for mental health care helps ensure that they get that care.
  • Make changes to practice signage that reduce stigma. Stigma is a major barrier to older adults seeking mental health treatment. Eliminating "mental health" signage around medical buildings and practices helps reduce that barrier.

Sustaining This Innovation

  • Provide initial and ongoing training and supervision to the mental and behavioral health specialists, led by a psychiatrist.
  • Use brief education with older, at-risk drinkers; existing protocols for this type of education can help reduce the quantity and frequency of drinking.
  • Use one program to cover multiple conditions; there is no need for three separate programs for depression, anxiety, and at-risk drinking.

Use By Other Organizations

  • Blue Cross Blue Shield of South Carolina under the name Companion Benefits is using the training manuals, software, and decision support from this program.

Additional Considerations

  • Integrating primary and mental health care by locating specialists in the primary care office helps get older adults engaged in treatment. The program appears to be sustainable in practices of 10 or more primary care physicians; smaller practices may not have sufficient volume to support it unless they can collaborate with other groups' practices.

More Information

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Contact the Innovator

David W. Oslin, MD
VA Associate Chief of Staff for Behavioral Health
Director, VISN 4 MIRECC
Professor
Perelman School of Medicine
University of Pennsylvania
Room 228B
University and Woodland Ave.
Philadelphia, PA 19104
(215) 823-5894
E-mail: oslin@upenn.edu

Dean D. Krahn, MD
Madison VA Medical Center
2500 Overlook Terrace
Madison, WI 53705
(608) 256-1901
E-mail: dean.krahn@va.gov

Innovator Disclosures

Dr. Oslin and Dr. Krahn have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Krahn DD, Bartels SJ, Coakley E, et al. PRISM-E: comparison of integrated care and enhanced specialty referral models in depression outcomes. Psychiatr Serv. 2006;57(7):946-53. [PubMed]

Oslin DW, Grantham S, Coakley E, et al. PRISM-E: comparison of integrated care and enhanced specialty referral in managing at-risk alcohol use. Psychiatr Serv. 2006;57(7):954-8. [PubMed]

Bartels SJ, Coakley EH, Zubritsky C, et al. Improving access to geriatric mental health services: a randomized trial comparing treatment engagement with integrated versus enhanced referral care for depression, anxiety, and at-risk alcohol use. Am J Psychiatry. 2004;161(8):1455-62. [PubMed]

Gallo JJ, Zubritsky C, Maxwell J, et al. Primary care clinicians evaluate integrated and referral models of behavioral health care for older adults: results from a multisite effectiveness trial (PRISM-e). Ann Fam Med. 2004;2:305-9. [PubMed]

Footnotes

1 Krahn DD, Bartels SJ, Coakley E, et al. PRISM-E: comparison of integrated care and enhanced specialty referral models in depression outcomes. Psychiatr Serv. 2006;57(7):946-53. [PubMed]. Available at: http://ps.psychiatryonline.org/article.aspx?articleid=96837.
2 Oslin DW, Grantham S, Coakley E, et al. PRISM-E: comparison of integrated care and enhanced specialty referral in managing at-risk alcohol use. Psychiatr Serv. 2006;57(7):954-8. [PubMed]. Available at: http://ps.psychiatryonline.org/article.aspx?articleid=96843.
3 The enhanced specialty care model provided quicker-than-usual access to treatment from an mental and behavioral health specialist at a separate mental health practice and offered transportation if needed and followup calls if appointments were missed. This model is considered to be a "gold standard" comparison, because it is a significant enhancement over usual care for most patients.
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: August 27, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: December 18, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: November 13, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.