Overview

The Report of the President's New Freedom Commission on Mental Health ¹ identified the need for better coordination between primary care and mental health care and called for dissemination of evidence-based models to improve care at the interface of general medicine and mental health. Provision of care at this interface is the aim of integrated care.

Primary care's defining features of continuity, comprehensiveness, and coordination match the needs of persons with chronic illnesses, ²¹ and people with chronic mental illnesses, such as depression and anxiety disorders, often engage with health care by first presenting to the primary care provider. ²² Integrating mental health into primary care settings brings the care to where the patient is. Further, mental health problems, including subsyndromal mental distress, exacerbate the disability associated with physical disorders and may complicate their management. ²³ Thus, integrating mental health providers into primary care settings may improve the treatment of the “whole” patient with concomitant improvement in outcomes and reduced utilization. Mental illnesses have a wide range of severity and responsiveness to treatment, however, and primary care settings may not be the logical medical home for people with severe mental illnesses.

Conversely, specialty mental health centers are often the primary place of contact for people with severe mental illnesses. Yet, persons with severe and persistent mental illnesses often do not have their general medical needs adequately addressed. ²⁴ Thus, some research has focused on integrating primary health care services into specialty substance use treatment settings to better prevent and address the physical comorbidities that often accompany severe mental illnesses and addictive disorders. ¹⁵

At the simplest level, integrated mental and physical health 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. Integration can work in two directions: either (1) specialty mental health care introduced into primary care settings, or (2) primary health care introduced into specialty mental health settings.

The rationale for the first type of integration is predicated on five main findings from the research literature. First, persons with mental health problems often do not receive treatment. ^{22, 25} Second, persons with mental health problems are as likely to be seen in the general medical care sector (23 percent) as in the specialty mental health care sector (22 percent). ²² Third, patients are much more likely to see a primary care physician (PCP) each year than a mental health specialist; ²⁶ therefore, PCPs may be in the best position to recognize and improve rates of appropriate treatment. Fourth, many people with mental health problems have comorbid physical health problems such as cardiovascular or pulmonary disease, diabetes, or arthritis. ^{27 – 29} Mental health problems exacerbate the disability associated with physical disorders, and patients with such comorbidities consume high levels of medical care services and health care costs. ^{30 – 32} Treating mental health problems among patients with physical health problems, therefore, may potentially reduce overall health care costs. Finally, there is a strong body of evidence that effective care for common mental health problems, such as depression and anxiety, can be effectively delivered in the primary care setting, ^{33, 34} although in usual practice the care often falls below quality standards. ^{35, 36}

The second broad type of integration refers to integrating primary health care into specialty mental health care settings. Such efforts have responded to findings that persons with severe and persistent mental illnesses (SPMI), such as schizophrenia, often do not have their general medical needs adequately addressed. Those individuals are at higher risk for medical problems, such as hypertension, coronary heart disease, and diabetes, and have significantly shorter life expectancy than persons without mental illness. ³⁷ Moreover, many of the most effective medications for persons with SPMI are associated with physical health problems, especially metabolic syndrome (e.g., obesity, elevated cholesterol, and blood pressure), that further increase the risk for cardiovascular disease and diabetes. These physical illnesses are also often under-treated for the SPMI population. ³⁸ Persons with SPMI may also have inadequate access to primary care and preventive services. ³⁹ The drastic difference in morbidity and mortality for persons with SPMI documented in the research—up to 25 years shorter life span compared to the general population—has generated a sense of urgency for governmental bodies and consumer advocacy groups to improve overall care. ^{40, 41}

There is also a case for integrating primary health services into specialty substance use treatment settings. ^{15, 24, 42} Physical comorbidities often accompany substance use, ^{43, 44} and often primary care services may improve addiction outcomes. ⁴⁵

Taken together, this literature suggests that the historical practice of separating mental and physical health care may be misguided. Integrated models of care offer the potential to improve access to treatment and improve quality.

Wagner's CCM is widely cited as a way to provide quality care to people with chronic illnesses. ⁴⁶ This model includes system wide changes in practice organizations such as self-management support, delivery system design, decision support, and clinical information systems. Discrete disease management (DM) programs and support services have proliferated for treatment of specific chronic diseases to improve outcomes and reduce costs. ²¹ CCM is complementary to the concept of patient-centered care. Both the CCM and DM focus on changing the organization of services from reacting to acute illnesses to proactively coordinating the provision of care. ²¹ The CCM was conceived to be responsive to needs of patients with multiple comorbidities, and DM has been evolving to acknowledge a “whole person” model as well. ⁴⁷ Integrated care for mental illnesses uses this same proactive perspective but differs in two important ways.

One major difference is the concept of collaboration. The term “collaboration” has been used in two ways in chronic illness literature. One use refers to collaboration between patients and health providers in developing care plans to achieve agreed-on treatment goals and ongoing education and support of the patient's self-management of the disease. ⁴⁸ Patients and their families provide the bulk of care activities for chronic illnesses and are, in fact, the primary caregivers. ⁴⁹

The second use of “collaboration” refers to collaboration between providers, ensuring that the treatment plan and provision of services is appropriate and coordinated across providers with different expertise and treatment domains. This second use is of particular importance in integrated care because the collaboration is taking place between providers from what has been two parallel health systems representing historically different perspectives and approaches to health and health care. Seaburn et al. argue that effective collaboration within the context of integrated care requires an ecological perspective that attends to collaboration with all participating and affected parties. ⁵⁰

The second major difference from the CCM is how this second form of collaboration adds to the complexity of successfully providing sustainable integrated care. The Institute of Medicine's (IOM) Crossing the Quality Chasm report ⁵¹ suggested the health care system as it currently exists may not be sufficient to support proactive, collaborative processes. Models of collaborative integrated care will not be sufficient without system wide integration. Integration takes place at many levels, ^{51, 52} including organizational and financial, and is aided or hindered by the cultural integration of mental health, medical health domains, and world views. For example, the Four Quadrant Clinical Integration Model organizes patients across the medical and mental health spectrums based on their combined medical and psychiatric needs and outlines major system elements needed for that population or subset of the general population.

Terminology around this type of care has become confusing. The terms “integrated care” and “collaborative care” have sometimes been used in what appears to be interchangeable ways, but at other times they reflect subtle but important differences. Historically, the “Collaborative Care Model” was a term used in some of the earliest research on integrated care in the United States by Wayne Katon and his colleagues. Within the United States, the term “integrated care” has tended to be used, perhaps in part to distinguish other models from Katon's Collaborative Care Model, perhaps in part in recognition of bringing together into a unified health care whole what had previously been segregated into mental health and medical health care systems. On the other hand, international research efforts, specifically within the United Kingdom and Canada, have tended to use the term “collaborative care,” again, with the term's foundations in the Katon model. “Complex system interventions” and “multifaceted interventions” are also terms found in research that have been used to get at the comprehensiveness of the programs which may or may not emphasize the collaboration between providers of different health disciplines.

Defining Integration

For the purposes of this report, we will continue to use the terms “integrate” or “integration” when referring to the broader effort to unify care for medical and mental health concerns, and the models being developed to address those concerns. The term “collaboration” will be reserved for the more specific actions that carry out “laboring together” to achieve a common goal. Definitions from the literature for both terms are shown in Table 1. Definitions of integration range from quite broad requiring only a partnership, ⁵³ support, ⁵⁴ or interactions among providers ⁵⁵ to narrow, requiring a fully shared treatment plan. ²³ The common denominator to all definitions is the requirement of some communication or coordination between providers to meet both the mental and general health needs of their patients.

Table 1

Definitions of clinically integrated health care.

Models of integration can be distinguished based upon how they involve the care process. By definition, integration must involve linking primary care providers with mental health providers, but the models differ widely in terms of the nature of these linkages and the strategies used to target various aspects of the care process. Figure 1 shows the elements of integrated care that are assumed to be linked to the process of care.

Figure

Figure 1. Characteristics of Integration Linked to Process of Care.

To capture the full breadth of models that may be considered integrated, we conceptually define integration as the systematic linkage of mental health and primary care providers. This conceptualization most closely reflects the IOM definition of integrated treatment and is inclusive of the five levels of collaboration elaborated by Doherty et al. ⁵⁶ Mental health providers are broadly defined to include not only professionals such as psychologists and psychiatrists, but also providers such as nurses and care managers whose roles focus on the mental health needs of patients, if such providers are supervised by specialty mental health professionals. The nature of the linkages between providers may also vary widely.

The presence of integration needs to be separated from its effects. One of those effects may be implementing a more structured, evidence-based approach to mental health care. Models of integration may not simply rely on linking providers but are multifaceted and target other elements of the care process. Identification of patients with mental health problems in primary care has long been recognized as inadequate, ^{57, 58} and many models of integration include systematic screening as one element to improve care. With a substantial body of evidence indicating that improving case identification alone is not sufficient for improving clinical outcomes, ²³ other elements of the care process are targeted by integration efforts. These include educating patients about the nature of the disorder and self-management, introduction of evidence-based guidelines for care (including stepped care), the availability of new therapies in primary care settings (e.g., psychotherapy), and systematic followup of patients to assess clinical status and/or medication adherence. It is not enough, however, just to have the enhancements to primary care settings. There must be time to implement them and to follow through on evidence-based interventions for patients found to have mental health and substance use disorder problems. This involves restructuring personnel and workflows.

Clinical integration is supported by integration at the system or organizational level. ^{55, 59} Linkages in the administrative functions, clinical records, claims processing, financing, disease management programs, and the like that take place at the organizational or systems level may facilitate clinical integration.

Key Questions

Through consultation with Agency for Healthcare Quality (AHRQ) and the Technical Expert Panel (TEP) (identified in Appendix A), six key questions were defined. They are restated here as:

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 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?

Scope of the Review

While integration may occur in numerous sectors, this review is focused on models that integrate primary care with specialty mental health care in outpatient settings. Studies of integrated care within inpatient settings are beyond the scope of the review. As well, we do not review studies of integrated care that have been conducted in regions outside the United States. However, we utilize reviews of existing models of integrated care (i.e., Bower et al., 2006) ⁶⁰ that include primary research done within and outside the United States. Finally, studies that focus on integrating primary care services with drug abuse services are beyond the scope of the review.

There are a number of excellent theoretical ^{23, 52, 61 – 63} and empirical reviews of integrated care. As shown in Table 2, there are 12 major reviews of integrating mental health care into the primary care setting, all of which focus on depression. There has been one review of the integration of primary care into specialty mental health settings. The reviews vary widely in the scope of studies included, but the definition of integration used in the report most closely echoes the definition of collaborative care used in the review by Gilbody and colleagues. ⁶⁴ Rather than replicating these reviews, we focus 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. In addition to a systematic review of the literature, this review includes several case-studies in order to better understand the implementation of integrated care models.

Table 2

Summary of prior reviews involving some form of integrated care for persons with mental illness.

Footnotes

*

The terms mental health care and behavioral health care are often used interchangeably in the literature; in this report we used the term mental health care, which also encompasses substance use disorders.