Psychiatry and Primary CareIntegration of mental health resources in a primary care setting leads to increased provider satisfaction and patient access
Introduction
Evidence shows that patients often present to primary care with mental health concerns [1], [2], but primary care providers have mixed success in identifying and managing these needs on their own [3], [4], [5], [6]. Patients have a variety of preferences and barriers associated with mental health treatment, suggesting the need for easy access to a range of treatments and providers [7], [8]. To enhance acceptability and availability of mental health services available in this setting, where ideally doctors and patients collaborate in managing multiple health conditions, clinics may turn to an integrated model of primary and mental health care.
There are many models of integration and strategies that range from simple colocation of services to fully integrated care. More fully integrated models include consultation and information sharing between mental health and primary care providers [9]. Studies that integrate primary and on-site mental health care have shown improvement in patient outcomes, treatment and costs [10], [11]. When patients with lower severity of impairment due to mental health problems are able to stay in the primary care setting, there may be better access to specialty care for more complex patients [12]. A few long-term studies show continued positive results 1–2 years after implementation of an integrated model in the primary care settings [11], [13], [14].
To ensure that system and resource changes implemented by mental health providers in the primary care setting actually meet the needs of the primary care providers and their support staff, we identified the need for planned evaluation of opinions and experiences before and after a resource change. Because systems and providers revert back to familiar practice patterns, even following introduction of additional education or resource [15], [16], key stakeholder feedback from the onset of system change can guide the acceptability, feasibility and, perhaps, maintenance of system changes. Our objective was to gather provider and staff feedback using one-on-one interviews in order to assess opinions of on-site mental health service access, availability and integration, before and after resource and system changes at a primary care clinic. We also aimed to identify issues impacting implementation of these changes. Provider feedback was used to inform initial system changes and to evaluate whether the system and resource changes that were made actually addressed the issues that they were intended to improve. This before and after evaluation was part of a larger study to measure other outcomes of mental health service changes in the primary care setting.
Section snippets
Setting
This project took place at Mayo Family Clinic Northeast (Rochester, MN), hereafter called the Northeast Clinic, an urban primary care satellite clinic with services in community pediatric and adolescent medicine, family medicine and primary care internal medicine. Primary care providers refer to specialty care as needed.
Results
We interviewed 13 individuals (100% of those invited to participate) in the first round, including 2 registered nurses, 2 nurse practitioners, 1 physician assistant, 2 clinical assistants and 6 physicians with an average interview length of 14 min. We interviewed 12 of these 13 individuals in the second round, including 1 registered nurse, 1 physician assistant, 2 nurse practitioners, 2 clinical assistants and 6 physicians with an average interview length of 19 min.
Themes emerged in two domains
Discussion
We used a before and after approach to evaluate an expansion of integrated mental health services in a primary care clinic. Our aim in our first round of data collection was to gather information about current conditions, prior to implementing changes, but without solicitation, many staff and providers also described how services could improve. The clinic had recently implemented DIAMOND care coordination for patients with depression, and that model was repeatedly cited as a successful example.
Conclusion
Expanding the availability of integrated mental health services in primary care resulted in increased access for patients and more satisfied staff and providers, at least in the short term. We were able to identify key components of satisfaction, including on-site collaboration and assistance triaging patient needs. The sustainability of integrated models of care requires additional study though, as does the practical implication of increasingly complex models of care on the provider experience.
Acknowledgments
The authors wish to thank the primary care providers and staff for sharing their time and opinions. We are grateful to Debi Judy for transcription services and manuscript preparation.
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