U.S. flag

An official website of the United States government

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

Butler M, Kane RL, McAlpine D, et al. Integration of Mental Health/Substance Abuse and Primary Care. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Oct. (Evidence Reports/Technology Assessments, No. 173.)

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

Cover of Integration of Mental Health/Substance Abuse and Primary Care

Integration of Mental Health/Substance Abuse and Primary Care.

Show details

Executive Summary

Introduction

There is a need to improve care at the interface of general medicine and mental health. 1 Provision of care at this interface is the aim of integrated care. Integrated care occurs when mental health specialty and general medical care providers work together to address both the physical and mental health needs of their patients.

This comprehensive systematic review addresses the evidence for integration of mental health services into primary care settings and primary services into specialty outpatient settings. The research questions were:

1)

What models of integration have been used?

a)

What theoretical models support these programs?

b)

What is the evidence that integrated care leads to better outcomes?

2)

To what extent does the impact of integrated care programs on outcomes vary for different populations (e.g., specific mental illness conditions, chronically ill, racial/ethnic groups, elderly/youth)?

3)

What are the identified barriers to successful integration?

a)

How were barriers overcome?

b)

What are the barriers to sustainability?

4)

To what extent did successful integration programs make use of health information technology (IT)?

5)

What financial and/or reimbursement structure was employed in successful integration programs? Is there evidence to suggest that any specific financial/reimbursement strategy is superior to another?

6)

What are the key elements of programs that have been successfully implemented and sustained in large health systems? To what extent do they follow, or how do they differ from, models that have been studied in published research studies?

The scope of the review included alcohol addiction but not other forms of substance abuse. Inpatient settings are also excluded. The review focuses on four areas: (1) specifying what integration is (and is not); (2) detailing the process through which integrated care may affect clinical outcomes; (3) expanding beyond the scope of prior reviews to include multiple illnesses and patient populations; and (4) specifying the conditions under which various models of integrated care are likely (or unlikely) to work in ‘real-world’ settings. This review also conducted case studies in order to better understand the implementation of integrated care models.

Methods

Randomized controlled trials and high quality quasi-experimental studies conducted in the United States from 1950 to 2007 were reviewed for all questions. Dementia, Alzheimer's, and developmental disorder studies were deemed qualitatively different and were excluded. Descriptive studies were used for the last five questions, including companion articles to included studies; other relevant documents from the grey literature, including websites, conference proceedings, white papers, and governmental reports, were also used to address questions 2, 3, and 5.

The review used both quantitative and qualitative analyses. For quantitative analysis for question 1 we created a taxonomy of integration levels to examine whether integration was associated with improved outcomes. Trials were assigned to one of four levels of provider integration, based on the degree of shared decisionmaking between primary care and mental health providers and whether or not mental health providers were co-located with primary care providers. Simple additive scores were created for integrated process of care based on the presence or absence of ten elements:

  • Screening
  • Patient education/self-management
  • Medication
  • Psychotherapy
  • Coordinated care
  • Clinical monitoring
  • Medication adherence
  • Standardized followup
  • Formal stepped care
  • Supervision

The trials were scored and divided into terciles. We also further categorized the trials into an integration matrix based on their provider and process integration levels. We used Forest plots to examine the association of level of integration with patient outcomes for trials of depression care. There were not enough trials of other patient populations for quantitative analysis.

Results for Integrating Mental Health into Primary Care

We identified 33 trials that examined the impact of integrating mental health specialists into primary care. Twenty-six studies addressed depression care and four addressed anxiety disorders. The remaining studies were single studies for somatizing disorders, Attention Deficit and Hyperactivity Disorder (ADHD), and one study addressed both depression and alcohol-related disorders.

Models of Integration and Outcomes

Integration models used in the trials tended to use the Wagner Chronic Care Model (CCM) as the basis of support. The implication is that integration is needed to address issues related to quality of care that lead to poor outcomes.

The studies reviewed tended to show positive results for symptom severity, treatment response, and remission when compared to usual care. There was wide variation in the levels of provider integration and integrated processes of care. The large majority of trials (N=23) had lower levels of provider integration, and there was a tendency for trials in the higher integration levels to be older. There were also a number of empty cells in the matrix of provider integration by level of integrated process of care.

We did not find any clear patterns in the Forest plots to suggest that outcomes improve as the levels of either provider integration or integrated process of care increase. Significant improvements in symptom severity, treatment response, and remission were consistent across the integration levels. Anxiety disorder studies also exhibited a consistently similar pattern.

Even with the small number of trials in each matrix cell, and some empty cells, the matrix integration provides a more refined integration gradient. Again, we did not see a discernable effect of matrix integration level on outcomes for depression care. The other trials were too few in number for a tenable comparison.

Population Differences

Depression care has by far the most mature literature, with the largest body of evidence and a few trials reporting long-term results of more than 12 months, 2 5 one of 5 years. 6 Anxiety disorder research is still in the process of establishing baseline evidence of efficacy and has not yet taken the step of more naturalistic effectiveness studies, although the larger-scale CALM study 7 currently in the field is moving in that direction. Other disorders minimally addressed in the literature include somatization, at-risk alcohol use, and ADHD. Very little is available for alcohol abuse behavioral programs, in part because studies often used larger substance abuse populations and did not report results separately for alcohol subgroups. Improvements in outcomes weaken over time in general for both depression and anxiety disorders.

The literature provides evidence for both adults and geriatric populations. IMPACT, the study with the strongest results, was designed for the geriatric population, but it has also been effective for the general adult population. The pediatric population is represented with three limited studies with mostly positive findings, two for depressed adolescents and one for ADHD treatment for elementary age children.

Beyond type of illness and patient age, the literature is very spotty. There is limited evidence that integrated care does not increase health disparities and may in fact offer an avenue to decrease disparities. Comorbidities likely have a complicated relationship with integrated care, as increased pain can moderate depression care, 8 and higher levels of comorbidity can moderate anxiety care 9 but not depression care, 10, 11 and diabetes patients with higher complication levels derived greater benefits from depression care than those with lower complication levels. 12 There are also gender differences in which treatment components were most effective, with medication more effective for women and psychotherapy more effective for men. 13

Barriers to Care

The barriers to integrated care are well documented. Financial barriers are a major impediment, primarily because many activities associated with integrated care, such as many care management functions, consultations and other communication activities between providers, and telephone consultation with patients, are not traditionally reimbursed under typical fee-for-service care. Moreover, carve-out programs silo eligible services. Integrated care programs and insurance plans have undertaken a number of strategies to address these barriers, such as having plans credential providers, creative employment and contract structures for care managers, and pay for performance, but these strategies are limited in scope.

Organizational barriers to integrated care include both issues related to change and the process of care. Resistance to change, new staff and new roles, and balancing competing demands are difficult to overcome without strong leadership that is committed to integrated care and champions the program. Gaining expertise in providing mental health treatment programs can be addressed through provider training and support.

Sustainability remains a major concern. Translating integrated programs into real-world clinical settings using models from trials with positive results is a challenge. Implementation has taken place at the cost of model fidelity since financial barriers impede program solvency.

Use of Health Information Technology

We found that reporting on the use of information technology (IT) in integrated care is scant. Programs have used IT for systematic screening and case identification, communication between primary care and specialty mental health providers, decision support, and monitoring of medication adherence and patient clinical status. Telemedicine can bring services to traditionally underserved areas. Perhaps one of the most innovative uses was a computer-based cognitive behavioral therapy program for patients for anxiety management. 7 However, there is not enough evidence to comment on the effectiveness or impact of specific types of health IT for improving integration processes of care.

Financial/Reimbursement Structures

There were a number of effectiveness trials with patient participation from essentially all major provider settings and representing all forms of insured/not insured. However, none reported specifics of reimbursement structures beyond baseline information, nor were results analyzed by type of reimbursement program. Certainly there is currently no evidence to support the effects of one payment strategy over another in terms of outcomes. The most comprehensive information to date on public insurance reimbursement structures and the associated barriers to implementing integrated care is provided in an new government report. 14

Although there is some evidence of potential savings in overall medical expenses, the financing problem is exacerbated by the structure of contemporary primary care, where practices are often dealing with various insurance plans. Inconsistent payment policies across plans make it hard for practices to undertake the necessary investments to implement integrated care.

Results for Integrating Primary Care into Specialty Mental Health

Only three trials were identified, all of which were covered in a recent systematic review. 15 The trials used collaborative care models with intermediate to high levels of involvement by primary care providers and regular contact between medical and mental health staff that may, or may not be, co-located.

The trials were consistent in reporting improvements in medical care, quality of care, and patient outcomes. Two programs were found to be cost-neutral as increases in outpatient expenditures were offset by declines in inpatient and emergency room use. 16, 17 There was also a significant decline in annual costs for a subsample of patients with substance-related mental and medical comorbidities compared to the control group. 18 The trials did not report results for serious mental or substance abuse illnesses by age, gender, or ethnicity.

All three trials took place in large, integrated health systems with considerable advantages in co-locating services and shared operational systems. Integration of primary health care into free-standing community substance use disorders treatment clinics with no immediate access to medical health care facilities would likely face additional barriers and challenges not encountered in the trials. Given the minimal cost savings for the subsample of patients with both medical and mental health comorbidities, a sufficiently large caseload to support medical practice may be the most critical concern for providers who are not part of a large system that assesses costs from a health plan perspective.

Case Studies

Thirteen case studies conducted to supplement the traditional systematic literature review help the reader translate the research covered in the comprehensive literature review into actual clinical and administrative practices. A tipping point is being reached as more programs are implemented. Networks of health care organizations developing and implementing various integrated care models are arising as communities of organizations learn together and share information and lessons learned as integrated care gathers momentum.

Discussion

In general, integrated care achieved positive outcomes. However, it is not possible to distinguish the effects of increased attention in general to mental health problems from the effects of specific strategies. The lack of correlation between measures of integration or specific elements of care processes and the various outcomes reinforces the underlying question about the specific effect of integrated care. All but two studies compared integrated care to usual care. The two studies that directly compared two levels of integration, integrated care and enhance referral or consultation-liaison, found no clear differences in outcomes by study end.

It makes sense that introducing a systematic approach and extra attention to treating mental illness in the context of primary health care should yield a beneficial result. There are possible concerns that raising the average level of practice might come at the expense of losing individually expert care. Some might be concerned that the value of introducing a structured approach might prevent some patients from receiving more individualized care. 19, 20

Efforts to implement integrated care will have to contend with the financial barriers posed by fee-for-service payment. Many of the costs involved are not regularly covered by a payment system based on specific in-person encounters. Integration can be fostered by improved health IT but the case for using this approach has not been well documented to date.

Future Research

A major unresolved issue remains to define just what elements of integration are vital in producing the desired goals. Head-to-head trials testing more explicit variation of integration components and elements of care process might help to resolve this issue.

There is considerable work to be done to understand who benefits from integrated care. The effects of comorbidities, both mental and physical, should be included in multivariate models. Eligibility criteria should be broadened to include patients with multiple mental health conditions. More attention should be given to powering studies and collecting data necessary for subgroup analysis for minority groups. Research aimed at efficiently matching clinical and organizational processes and resources to different levels of care for varying levels of severity, and patients stratified by risk and complexity, would build on the efforts the IMPACT trials and Intermountain Healthcare's examples.

Demonstration projects would advance our understanding of the financial structures that best support sustainable integrated programs. The VA's consortium on quality improvement processes is working towards describing best practices adapted to local requirements that facilitate efficient and effective change processes; more work along these lines in a wider range of settings is needed.

More exploration of the business case for integrated care will be needed if plans are ever going to finance such an approach. Programs will be needed to assure that each practice that works with multiple plans is adequately covered to make changing their approach financially feasible. More needs to be done to assess the effect of patient volume and case mix on financial feasibility.

Policy Implications

The big question is whether to view the cup as half full. There is a reasonably strong body of evidence to encourage integrated care, at least for depression. Encouragement can run the gamut from removing obstacles, to creating incentives, to mandating such care. The encouragement will likely differ between fee-for-service care and managed care, although both must address the issues of paying providers. However, without evidence for a clearly superior integrated model, there is a legitimate reason to worry about premature orthodoxy.

Views

  • PubReader
  • Print View
  • Cite this Page

Recent Activity

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

See more...