Primary Care Clinicians Evaluate Integrated and Referral Models of Behavioral Health Care For Older Adults: Results From a Multisite Effectiveness Trial (PRISM-E)

Abstract

BACKGROUND Recent studies have shown that integrated behavioral health services for older adults in primary care improves health outcomes. No study, however, has asked the opinions of clinicians whose patients actually experienced integrated rather than enhanced referral care for depression and other conditions. METHODThe Primary Care Research in Substance Abuse and Mental Health for the Elderly (PRISM-E) study was a randomized trial comparing integrated behavioral health care with enhanced referral care in primary care settings across the United States. Primary care clinicians at each participating site were asked whether integrated or enhanced referral care was preferred across a variety of components of care. Managers also completed questionnaires related to the process of care at each site.RESULTS Almost all primary care clinicians (n = 127) stated that integrated care led to better communication between primary care clinicians and mental health specialists (93%), less stigma for patients (93%), and better coordination of mental and physical care (92%). Fewer thought that integrated care led to better management of depression (64%), anxiety (76%), or alcohol problems (66%). At sites in which the clinicians were rated as participating in mental health care, integrated care was highly rated as improving communication between specialists in mental health and primary care.CONCLUSIONS Among primary care clinicians who cared for patients that received integrated care or enhanced referral care, integrated care was preferred for many aspects of mental health care. INTRODUCTIONT o address patient, physician, and health system barriers to adequate care of depression and other mental health conditions of late life, innovative models are being tested to enhance the recognition and management of mental health problems in primary care.1-3 The Primary Care Research in Substance Abuse and Mental Health for the Elderly (PRISM-E) study was a multisite effectiveness trial designed to assess the use of a mental health and substance abuse (MH/SA) specialist co-located in the primary care practice to enhance treatment (the integrated care model) and the use of direct referral to specialty care (the enhanced referral model) for older adults with depression, anxiety, or alcohol use problems. We asked the clinicians to offer their perspectives on the specifi c interventions tested in PRISM-E. Given the heterogeneity of how primary care clinicians manage depression, 4 it is important to be aware of systems of care that clinicians Our study differs from previous studies of attitudes of primary care clinicians regarding MH/SA treatment given to patients in primary care. First, most studies have focused on depression, 5-7 whereas we were able to examine several conditions that affect older adults in relation to primary health care. Second, we have focused on the mental health care of older adults, in contrast with other studies that have not considered the specifi c needs of older persons. [5][6][7] Most importantly, unlike stu...

The Effect of a Primary Care Practice–Based Depression Intervention on Mortality in Older Adults

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Outcomes of Integrated Behavioral Health with Primary Care

“…[1][2][3][4][5][6][7][8][9][10][11] Behavioral health care, in this context, encompasses care for mental disorders, substance use problems, psychosocial and family problems, and health behavior change. 12,13 However, the adoption of integrated care 14 has been slow because of challenges implementing it in community settings, and relatively little research is available on context-specific implementation strategies.…”

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“…This leads to less stigmatization of staff and patients, better screening, improved treatment of mental disorders associated with medical problems, and less costs due to the shared infrastructure (WHO, 2001). Collaborative care models in which mental health professionals are integrated within primary healthcare have also been shown to be preferred by primary care clinicians due to improved communication between mental health providers and primary care physicians, coordinated care of mental and physical health, and less stigma towards patients with mental disorders (Gallo et al, 2004). Although there is no single best practice model for all countries to follow, the World Health Organization states the integration should include training of primary care workers, the presence of a mental health service coordinator, the availability of specialist mental health facilities and professionals, and access to basic psychiatric medication in primary care (WHO/Wonca, 2008).…”