When Help Becomes a Hindrance: Mental Health Referral Systems as Barriers to Care for Primary Care Physicians Treating Patients With Alzheimer's Disease

Abstract

OBJECTIVES To describe structural barriers to mental health specialists and consequences of these barriers to care for patients with dementia and neuropsychological symptoms and their primary care physicians (PCPs). DESIGN Cross-sectional qualitative interview study of PCPs. SETTING Physicians’ offices, primarily managed care. PARTICIPANTS 40 PCPs in Northern California. MEASUREMENTS Open-ended interviews lasted 30–60 minutes. The interview guide covered clinician background, practice setting, clinical care of a particular patient, and general approach to managing patients with Alzheimer’s disease or related dementias. Interviews were transcribed and themes reflecting referrals identified. RESULTS 93% of the PCPs described problematic access to and communication with mental health specialists (in particular psychiatrists and neuropsychologists) as impediments to effective care for dementia patients. Thematic analysis identified structural barriers to mental health referrals ranging from problems with managed care and reimbursement policies to lack of trained providers and poor geographic distribution of specialists. Structural barriers compromised care for patients with dementia because the barriers limited PCP treatment options, and resources, impacted office staff and time with other patients, impeded and delayed care, and fostered poor communication and lack of coordinated care. Negative consequences for PCPs included increased frustration, conflict, and burnout. CONCLUSION PCPs viewed problems created by onerous referral systems, such as mental health carve-outs, as particularly burdensome for elderly patients with co-morbid dementia and neuropsychiatric problems. These problems were cited by PCPs across different types of practice settings. PCPs managed treatment of neurobehavioral symptoms as best they could despite lack of specialist support.

Integration of Depression and Primary Care

“…29 Because children with serious physical illnesses may have negative feelings toward medical facilities, they may be uncomfortable receiving mental health care is such settings. 29 Family medicine physicians and pediatricians report that they feel 53 Reduction in public funding 54 Lack of financial incentives 55 Increase in out of pocket copays for patients and families for multiple procedures 52 Space and staffing costs for integrated treatment 56 Economic impact on operations 56 Organizational issues Confusion in "medical home" 57 Availability and sustainability of quality improvement initiatives 58,59 Networking community-based providers 60 Implementing organizational and educational interventions within primary care settings 61 Psychiatrists' access to medical providers 62 Depression screening in obstetrics practices 32 Lack of organized or automated referral systems 63 Importance of patient experience 64 less competent caring for children with autism than for children with other chronic medical conditions. 31 Among elderly patients, the difficulties of diagnosis can make initiation into treatment, whether integrated or not, a challenge as many older adults present depression with a variety of somatic symptoms.…”

Alzheimer´s Disease associated with Psychiatric Comorbidities

“…Moreover, there is an increased risk of the incidence of dementia in later life, which is associated with the prevalence of diseases such as AD, mainly occurring in the seventh or eighth decade of life (Reitz et al 2011). This demands that better organizational and assistive solutions are required from the health professionals and public health systems that are dealing with these patients, which would help reduce the burden being placed on the patients' families, as well as decrease the high costs involved in the treatment of this disease (Franz et al 2010).…”

Curing and Caring

“…“He’s a good psychiatrist, [but] he didn’t see the whole picture to realize that this patient was really demented.” Eventually, most PCPs would refer the patient to a specialist such as a neurologist, and less frequently to a psychiatrist. In this process, PCPs typically played the roles of coordinators, mediators, and generalists treating the patient for a miscellany of diverse health issues, with the specialist focusing on confirming the diagnosis and supervising pharmacologic treatment (see also Franz et al, 2010; Hinton et al, 2007). Because of their frequent contact with patients, however, PCPs often initiated medications.…”

“…Other systemic problems exist in access to adequate consultation and support in formal health care settings and the community. U.S. physicians face great gaps in social service availability and organizational pressures that curtail their ability to take the time needed to deal with the complexity of psychosocial issues presented by dementia patients (Franz et al, 2010; Hinton et al, 2004; Hinton et al, 2007). Amidst controversies about their cause and the efficacy of available treatments, AD and other degenerative dementias are conceptualized as biomedical phenomena associated with pathophysiological processes.…”