The Challenge of Integrated Care for Mental Health: Leaving the 50 minute hour and Other Sacred Things

Abstract

A growing body of research has demonstrated the effectiveness of integrating mental/behavioral healthcare with primary care in improving health outcomes. Despite this rich literature, such demonstration programs have proven difficult to maintain once research funding ends. Much of the discussion regarding maintenance of integrated care has been focused on lack of reimbursement. However, provider factors may be just as important, because integrated care systems require providers to adopt a very different role and operate very differently from traditional mental health practice. There is also great variability in definition and operationalization of integrated care. Provider concerns tend to focus on several factors, including a perceived loss of autonomy, discomfort with the hierarchical nature of medical care and primary care settings, and enduring beliefs about what constitutes "good" treatment. Providers may view integrated care models as delivering substandard care and passively or actively resist them. Dissemination of available data regarding effectiveness of these models is essential (e.g. timeliness of treatment, client satisfaction). Increasing exposure and training in these models, while maintaining the necessary training in traditional mental health care is a challenge for training at all levels, yet the challenge clearly opens new opportunities for psychology and psychiatry.

Psychometric assessment of the Primary Care Behavioral Health Provider Adherence Questionnaire (PPAQ)

“…CCC is frequently described as a patient-centered, highly flexible model that addresses a wide range of patient concerns [28][29][30]. Because of this patient-centered emphasis, identifying behaviors that should be prohibited in CCC presented a challenge because they are seldom discussed in the literature [31]. Nonetheless, some very time-consuming practices that might occur routinely in specialty mental health settings should be discouraged in CCC to maintain a population-based, brief treatment focus.…”

The role of mental and behavioral health in the application of the patient-centered medical home in the Department of Veterans Affairs

“…The program was expanded in 2008 to be a routine expectation of care with larger VA primary care settings required to have blended programs incorporating both colocated collaborative care and care management [24]. Strong, preexisting research and quality improvement provided best practices that support PC-MHI including the White River Model for colocated collaborative care [25,26], and Translating Initiatives for Depression into Effective Solutions (TIDES) and the Behavioral Health Laboratory for care management [27][28][29].…”

Functional Roles and Foundational Characteristics of Psychologists in Integrated Primary Care

“…Primary care can be a challenging for psychologists on a medical team (Pomerantz, Corson, & Detzer, 2009). The training of psychologists is largely compartmentalized to the behavioral health professional culture, leaving them illprepared to function in primary care settings (Bluestein & Cubic, 2009;Kessler et al, 2009;O'Donohue, Cummings, & Cummings, 2009).…”

“…They have different conceptual orientations and use a different language (Hunter & Goodie, 2010;McDaniel et al, 2002). Psychologists need to adapt to the primary care culture, not expect the culture to adapt to the psychologist's way of operating (Pomerantz et al, 2009). Psychologists who are not willing or able to adapt to the primary care culture can be devalued and marginalized by their primary care colleagues.…”

“…For example, psychologists must tolerate the disciplinary isolation of living professionally outside of psychology's own disciplinary home (Pomerantz et al, 2009). As a newcomer, psychologists are operating in a culture that speaks a different and perhaps unfamiliar professional language; one that uses frequent shorthand (e.g., ''Patient is a G2 P1 at 12 weeks with an A1C of 9 and a history of bipolar disorder who is presenting today with lumbar pain'').…”