Table 3 Characteristics and findings of studies that explored factors that contributed to the effective implementation of mental health integrated care models in primary care settings
Reference, country, | Type of study | Aim of the study | Findings |
|---|---|---|---|
Martin, White [39] | Systematic review | To review how the following components of integration are implemented and practiced a) collaboration practices, b) program models, c) interventions, d) provider type, e) training and supervision practices, and f) setting | Collaboration practices: are implemented in the form of communication between primary care providers [PCP] and behavioural health providers [BHP], or PCPs providing referrals to onsite BHPs or referral to BHPs as a “warm handoff.” BHPs also offered treatment recommendations to PCPs or psychiatrist consultations were made available to PCPs through a shared-decision making process Program Models: Use of treatment guidelines or a pre-existing model such as the PRISM-E or IMPACT Behavioural Health Interventions: include psychoeducation, psychotropic medication, care management strategies, follow-up contact with BHPs with patients after treatment, some type of psychotherapy (e.g., behavioural, cognitive– behavioural, brief, group) and family therapy used alone or in combination with others Behavioural Health Training and Supervision: Some type of behavioural health training or supervision was common. Those who were trained included BHPs, and PCPs to deliver mental health treatment, some type of supervision for model fidelity, a psychiatrist or psychologist supervisor, weekly supervision, team-based supervision, or the use of a treatment manual Behavioural Health Provider Types: included nurses, psychiatrists, psychologists, and social workers. Nurses either worked alone or together with social workers or psychologists Setting: Most studies reported a primary care setting but other settings included Veteran’s Affairs Medical Centre, rural communities, suburban communities, urban communities, community health centres and outpatient patient hospital networks |
Grazier, Smiley [40] USA | Systematic review | To identify characteristics of organizations that have successfully integrated mental health and primary care | Prioritized underserved and vulnerable populations Used data-driven best practices Community-Wide Collaboration Support from Influential Leaders and Established Institutions Team Approach That Includes the Patient and Family Diverse Funding Streams |
Wood, Ohlsen [41] UK | Systematic review | To determine patient, staff or organisational factors that act as barriers/facilitators o the implementation of Collaborative Care for patients with depression in primary care | Barriers Organisations’ readiness for change Lack of understanding of Collaborative Care Patients finding it challenging to engage with screening tools and self-help material Breakdowns in networks and communication pathways Facilitators Positive staff attitudes to change particularly when one of the senior physicians took the role of championing the service to his/her colleagues Clearly developed and defined role of case manager seen as efficient and effective Key characteristics needed within the role of the case manager Having structured management plans for patients Staff involved have sufficient training on the intervention and what can be expected from it Finding the right screening and outcome tools and training all staff in how and why these tools were being used Having a standardised care pathway; GPs were more likely to be happy to talk about depression if they knew what to do once it was identified Case managers and staff reported confidence in the specific interventions available and being able to see their benefits Co-location improved communication and helped de-stigmatise mental health treatment Integrated information systems also helped as it made it easier to share notes and pass messages to colleagues A supportive, constructive and regular supervision schedule helped the case managers deliver care and talk over difficult cases or ask questions about referral on to mental health services where required Scheduled follow ups and someone taking responsibility to ensure that happened was beneficial The CC intervention had to be seen either as revenue neutral or revenue enhancing for organisation's financial buy in |
Ramanuj, Ferenchik [22] UK | Narrative review | Recent mechanisms to incentivize integration efforts between health and social services in primary care | Novel approaches to integrated care are uncommon Most current models have been facilitated by research funding, pump primed grants, or other time-limited financial levers Few valid and feasible process and outcomes measures exist to support integrated care Current quality-outcome measures that do exist tend to focus on single-disease entities or populations, rather than reflecting the reality of multimorbidity in this population The need for payment reform and the development of quality metrics need to be addressed Telemedicine, along with incentives to recruit and retain providers, could be a means to address workforce challenges New health information technology (IT) strategies must also be employed to support continuous and coordinated care and monitoring Integrated electronic health records (EHR), are needed to integrate medical and behavioural health information streams with telehealth, social services, prisons, and schools, for example Successful implementation of integrated care must be supported at multiple levels—policy, practice and provider and are usually built around shared goals and formal partnerships between providers |
Coates, Coppleson [42] Australia | Integrative review | To identify factors that support the implementation of integrated care between physical and mental health services in real-world settings | Adequate resourcing: Care coordinators (particularly in rural areas) were challenged by very busy schedules, with many responsibilities and limited time. An integrated model with shared responsibility, where psychiatric nurses were stationed in a residential home but employed by specialist mental health services, was more effective than a model where the residential home employed their own psychiatric nurses Shared values: Implementation efforts were impeded by differences in opinion and conflict around who controls patient provider relationships, the structure of the care provision, how care notes should be completed, and how patient perspectives should be managed. These differences affected implementation and resulted in high rates of staff turnover Effective communication between staff: Communication between staff was reported as a key barrier to successful implementation particularly when they have different professional backgrounds. Effective communication requires formal and informal opportunities to exchange information so that organizational, clinician, and patient objectives can be met Regular formal meetings between leaders and frontline staff: and responsive e-mail communication helped to address and resolve conflicts as they arose IT infrastructure: The ability to share electronic medical records, is critical, for successful integration and can facilitate communication between staff. However, the roll out of integrated IT systems can take time, is complicated, and costly Flexible administrative organizations: For integrated care to be effective, organizations and employees need to be flexible and to step outside of prescribed roles to work together in creative ways. Integration efforts can be impeded by reluctant administrators who are unable or unwilling to be flexible Role clarity and accountability: Complex integrated care models with multi-agency leadership and accountability can lead to concerns over lines of accountability and role confusion for staff, hindering implementation, staff engagement and training. Integrated care coordinators have expressed a lack of understanding of their role and were confused about their responsibilities Staff engagement and training: When staff are not consulted or involved in the planning of the model, or lack confidence or skills required to implement the model, they can become disengaged. Limited knowledge of allied health providers on physical health and limited knowledge of primary care providers on mental health has shown to impede integration. These skills and knowledge gaps can be addressed with training |
Peer and Koren [43] USA | Integrative review | To summarize and critically examine factors that impact the integration of mental health care into primary care settings, to advance evidence-based knowledge, and promote awareness to ensure the successful implementation of such integrative models | Patient-centered care: A focus on the patient’s needs through the use of a tailored care plan is crucial in caring for a complex population with different needs and is noted as an imperative facilitator Targeting vulnerable populations, such as ethnic minorities, children and adolescents, or people with medical comorbidities, who may face unusually great barriers regarding access to care, is important Staff and providers’ attitudes towards the patient’s culture, including any stigma regarding mental health and substance use disorders also affects the success of the program Relationships: among the clinicians themselves is vital to promote collaboration between the disciplines, such as interdisciplinary huddles and ‘warm hand-offs’. A second was the relationship between the leadership and the clinicians and staff. Without ongoing support from the leadership and stakeholders, integration will not succeed, and motivation for its success will decrease among staff. A third relationship was between the clinicians and the patients, where the lack of a good relationship that fosters trust was found to pose a barrier to effective treatment. Finally, the lack of a strong relationship between the clinic and the community, in the form of collaborations, presented another barrier to successful integration Physical accessibility: The lack of designated and welcoming spaces for behavioural health care was found to be a barrier to engaging patients. Behavioural health services that were not co-located with primary care, and that were sometimes in a different and remote building posed another challenge to service availability and close collaboration between the primary and the behavioural care teams. Remote access to public transportation and lack of parking spaces were also noted as travel-related and accessibility barriers Operation and infrastructure: Flexible scheduling and availability of mental health clinicians in the form of late appointments and walk-ins are vital in the treatment of patients with mental illness or a behavioural crisis. Flexible scheduling that allows for treating all patients with sufficient visit time, regardless of the visit type, is a key element for the successful integration of behavioural treatment into primary care A standardized workflow plan: that monitors outreach, progress, and outcomes for each patient, in addition to the performance of standardized mental health screening; all of these can be incorporated into the EMR as tracking tools. Clinics that developed a protocol for mental health screening and followed a standardized work-flow plan, including a plan for transitioning between different care groups, managed to better engage in the care of mentally ill patients Electronic medical records: Underperforming templates and insufficient technology support, has been reported as a major barrier to a successful implementation of the integrated model in many studies. An inadequately integrated EMR that fails to allow access to all clinicians and staff was noted as an additional barrier. Both the primary and the behavioural care staff reported that workarounds in a non-integrated EMR resulted in wasted staff time, particularly when accessing multiple data resources. Technology support could provide appropriate protection for sensitive data Training: Adequate staff training, specifically in behavioural health, is crucial for caring for patients with mental illnesses. Ill-prepared staff, staff that lacked motivation, and new graduates that had not been prepared or trained to treat the complexity of these illnesses were among the challenges encountered in training the staff. Cross-training between the primary care and the behavioural staff was found to be beneficial in preparing the staff and increasing empathy towards patients Team approach: Collaboration between the primary care and the mental health clinicians and staff, such as an interdisciplinary team and shared care plans, is an important advantage that integrated care has over two separate care teams. The advantage of a larger care team that included case management, patients, and the families of patients allowed for a more comprehensive and holistic view of the patient’s needs Staffing: A diminished workforce, specifically, staff trained in behavioural health, can result in staff burnout and high turnover. Psychological relief through group cohesion and working on personal growth through education has benefits. Issues of retaining the staff also stemmed from unclear staff roles. The resulting confusion occurred mainly between primary care staff and the behavioural team staff. Primary care providers have reported uncertainty about their responsibilities regarding diagnosing and treating mental illnesses. One of the solutions offered was the assistance of an integration champion, which can further facilitate integration and can address any confusion, thus benefiting the organization Funds and health insurance: Insufficient reimbursement is a key barrier to a successful integration; either in the form of low Medicaid/ Medicare rates, fee-for-service, or insufficient coverage by private insurance. For example, clinicians have reported being reimbursed the same for behavioural services as for primary care, although behavioural services require longer visits and staff time. Because of the lack of equitable billing regulations and reimbursement for behavioural care, many clinics could not sustain integrated care. In addition, limited sources of funds and insufficient funds were barriers to sustainability and for retaining clinicians and staff especially in small clinics |