508983
research-article2013
JPCXXX10.1177/2150131913508983Journal of Primary Care & Community HealthReiss-Brennan
Case Study
Mental Health Integration: Normalizing Team Care
Journal of Primary Care & Community Health 2014, Vol 5(1) 55–60 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/2150131913508983 jpc.sagepub.com
Brenda Reiss-Brennan1
Abstract This article examines the impact of integrating mental health into primary health care. Mental Health Integration (MHI) within Intermountain Healthcare has changed the culture of primary health care by standardizing a team-based care process that includes mental health as a normal part of the routine medical encounter. Using a quantitative statistical analysis of qualitative reports (mixed methods study), the study reports on health outcomes associated with MHI for patients and staff. Researchers interviewed 59 patients and 50 staff to evaluate the impact of MHI on depression care. Patients receiving MHI reported an improved relationship with caregivers (P < .001) and improved overall functioning in their lives (P < .01). Staff providing care in MHI reported that patients experienced improved access to mental health care, improved overall patient productivity in daily functions (P < .01), and access to team care (P < .001). As MHI became routine, patients discussed complementary team interventions more frequently (P < .0001). Mental health problems rank second in chronic disease today. MHI offers promising results for improving the quality and cost of effective treatment for chronic disease. This research provides guidelines for organizing mental health care, staff productivity, and patient satisfaction, using a team approach to improve outcomes. Keywords mental health, integration, team care, standardization, depression, primary care
Introduction Contemporary Western medicine is based on a tradition of treating mental health separate from physical health, with assumptions that diseases occur independently of social context.1,2 Mind–body dualism affects the health exchange experience of both caregivers and receivers. When mental health is treated as separate from physical health, the health care experience is often stigmatized and fragmented. Though these attitudes are changing, the fact remains that 45% of aging Americans have a chronic disease3 and mental health ranks second to cancer in chronic disease prevalence.3 The past decade saw a substantial increase in the proportion of people with serious mental illness and substance abuse disorders who reported receiving care from primary care physicians (PCPs) and hospital emergency rooms.4-7 Depression, the most common mental health condition seen in primary care, often occurs with, and compromises, care of other chronic illnesses; yet stigma and secrecy often cause depression to go undetected, undiagnosed, or undertreated.8-10 Over the past 12 years, Intermountain Healthcare has developed Mental Health Integration (MHI) as a comprehensive team-based innovation for caring for the mental and physical health of patients and their families. “MHI is
defined as a standardized clinical and operational team relational process that incorporates mental health as a complementary component of wellness and healing for life.”11 The MHI team care process model (CPM) has spread a new social message of normalizing mental health as a routine part of everyday health exchanges between patients and their doctors and among clinic staff. The integration model goes far beyond “co-location” of a specialty care provider or “physician solo” care. It is a team-based approach where complementary roles include the patient and family and are operationalized at the clinic improving both physician and staff communication. MHI differs from collaborative care models because it is a standardized system in which a key focus is on the primary care providers continuing to provide appropriate levels of mental health care within a high functioning team. MHI focuses on eliminating the chasm between physical health care and mental health care—rolling both into a comprehensive 1
Intermountain Healthcare, Salt Lake City, UT, USA
Corresponding Author: Brenda Reiss-Brennan, Mental Health Integration Director, Primary Care Clinical Program, Intermountain Healthcare, 36 South State Street, Suite 2100, Salt Lake City, UT 84111, USA. Email: [email protected]
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Journal of Primary Care & Community Health 5(1)
whole that is addressed by a high-functioning team. The MHI team CPM has disseminated a new social message of normalizing mental health as a routine part of everyday health exchanges between patients and their doctors and among clinic staff. This message is propagated through standard protocols of the MHI CPM, which specifies an organized process to guide the allocation and activation of each team role. Physicians are accountable for patients having awareness of informed access to the expanded team care. The MHI team includes all of the PCPs and support staff, in addition to practice managers, mental health professionals, community advocates, the patient, and the family. This multidisciplinary clinical team is organized under the leadership of the clinic physician in partnership with the patient and family; each member of the team is trained in specific responsibilities that contribute to a collective holistic care plan. Team member communication and shared decision making follows standardized CPM protocols and is facilitated by a shared electronic medical record. Patients have direct email or phone access to their physician and team. Team-based care, such as MHI, requires a fundamental change in physicians’ mind-sets.12 Many practices claim to have teams, but the physicians provide all the care and delegate tasks to staff or refer to specialty providers. The end result of this traditional delivery model is fragmented, uncoordinated care and poor health outcomes.13 The MHI innovation has been introduced and adopted across a rapidly growing medical group that provides community care for more than 800 000 patients and their families per year in the state of Utah. MHI has been diffused across diverse (family medicine, pediatrics, and internal medicine) primary care practice settings with positive results,14 and, prior research also shows that patients treated in MHI clinics were 54% less likely to use expensive emergency room services.15 The purpose of this study was to evaluate the quality effectiveness of the transformation of medical care delivery called Mental Health Integration (MHI) by analyzing patient and medical staff outcome perceptions for depression treatment in clinics with varying experience in MHI.14 The specific aims were to identify the key factors in patient and staff social interactions underlying the improved outcomes observed in MHI clinics. Using qualitative and quantitative techniques, this multisite comparative study measured improved engagement, outcomes, and perceived coordination via open-ended interviews. The focus was on examining how MHI (a) improves outcomes for patients, (b) furthers an effective team approach among staff, and (c) alters the culture of health care delivery, based on the following hypotheses: 1. The longer the clinic has been committed to MHI, the more patients are engaged in multiple treatment options.
2. The longer the clinic has been committed to MHI, the better the outcomes for patients reported by patients and observed by staff. 3. The longer the clinic has been committed to MHI, the more patients perceive coordinated team interactions.
Methods The investigation explored the perceptions of staff and patients involved in MHI during 3 phases of MHI diffusion. The study authors identified the 3 phases as a function of a clinic’s stage of implementation commitment to MHI: potential, adoption, or routinized.14 Potential clinics are trained in the MHI CPM, are assessing current resources and readiness for MHI adoption, but do not have an MHI operational plan. Therefore, potential clinics have not yet committed to implementing MHI. Adoption clinics have implemented MHI for at least 2 years. During this time they have engaged leadership champions, recruited and hired team staff, redesigned roles and workflow, and offered MHI care to their patients. Adoption clinics request support from instituional leaders to help resolve barriers and resistance to change. They have operational commitment to pursue MHI goals. Routinized clinics have practiced MHI for more than 6 years. Routinized clinics have habituated the innovation and provide greater access to an integrated health/medical home team with coordinated care for depression. These clinics have established continuous administrative leadership and clinical teams; MHI workflows are considered a clinic norm. Routinized clinics have improved the quality of depression care for patients and reduced uneccessary costs.14
Design The study was a 2-year multiclinic comparative mixed methods study of 9 primary care clinics within Intermountain Healthcare in Salt Lake City, Utah. From 80 clinics implementing MHI, researchers selected 3 groups of clinics used in prior research,14 based on their phase of implementation: 3 potential, 3 adoption, and 3 routinized clinics. Across each of the 3 phased groups, researchers matched clinics for 12 months (2010) by patient visit volumes, numbers and types of provider, and payor percentage mix (commercial, Medicaid, Medicare, uninsured/charity). Researchers further analyzed 12-month visit volumes for the number of mental health–related visit claims. The claims analysis used ICD-9 mental health–related codes documented in the depression registry. All patients treated at the clinics had access to physical and mental health care regardless of their ability to pay.
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Reiss-Brennan Table 1. Patients Receiving Combined Treatment Support. Total (N = 59)
Potential (n = 19)
Adoption (n = 20)
Routinized (n = 20)
P
P Trend
.24 .29 .42 .85 .49 .09
0 0 .53 .84 .42 .21
.25 .35 .35 .75 .65 0
.45 .50 .40 .95 .40 .05
.004** .002** .519 .212 .217 .040*
.001** .001* .605 .338 .875 .076
Contact with care manager Contact with on-site MHI provider Contact with off-site mental health provider Currently taking medication Discussed support needed after leaving clinic ER visits in past 12 months recorded in depression registry Abbreviations: MHI, Mental Health Integration; ER, emergency room. Pearson’s χ2 test and P for trend χ2: *P < .05; **P < .01.
Sampling
Analysis
Staff Recruitment. To understand the impact of MHI on staff, researchers drew a sample of 50 clinic staff from the clinics studied. Staff roles included physicians, clinic managers, nurse care managers, mental health specialists, and medical support staff, selected for balance among all team roles in each phase of clinic.
Researchers aggregated the interview data by MHI clinic phase (potential, adoption, routinized) for both staff and patients and carried out quantitative analysis to identify significant difference in key demographic or theme variables among phased clinic groups. Researchers used Pearson’s χ2 test, Fischer’s exact tests, and analysis of variance to test this level of difference. The study assessed linear trends in proportions across phases of MHI implementation using a P-for-trend χ2 analysis in order to further test that certain outcomes increased over time by duration of commitment to MHI.
Patient Recruitment. To obtain patients’ views, researchers selected a random sample of 59 adult male and female patients older than 18 years who received care for depression from their PCP any time in the previous 12 months—about 20 patients from each of the 3 phased clinic groups. The study excluded patients identified as cognitively impaired or having intent to harm themselves or others, as well as those newly established in a patient–therapist relationship.
Data Collection Researchers collected primary data from interviews conducted face to face and via telephone, and extracted secondary data that pertain to patient visits from the administrative databases. The interview included open-ended questions that probed respondents’ perceptions of their experiences of providing or receiving care for depression or other mental health concerns in the primary care setting. The study asked patients to share their thoughts about what positive outcomes they experienced; what factors, if any, promoted the perceived positive outcomes; what factors may have gotten in the way of positive outcomes; and what improvements they would recommend. Meanwhile, the study asked staff to share their thoughts about what positive outcomes they observed for patients receiving care at their clinics; what factors, if any, promoted the patients positive outcomes; what factors may have gotten in the way of patients achieving positive outcomes; and what improvements for depression care they would recommend to be provided at their clinic.
Results Patients treated in MHI adoption and routine clinics reported significantly more care manager and mental health support (P < .01) in addition to medication and PCP interventions than patients treated in potential clinics (see Table 1).
Patient Responses Patients receiving care for depression and mental health at clinics with a longer committment to MHI reported a greater number of positive outcomes (see Table 2). For 2 outcomes (“overall functioning better in life” and “established personal relationships”), patient responses increased with clinic phase, although not to a statistically significant degree. Among the dimensions of “overall functioning better in life,” patients in routine clinics significantly reported over time being able to “think more clearly” (P < .013; see Table 2). In addition to reporting an established relationship and improved cognitive functioning, patients in routinized clinics reported that that treatment was effective. As the duration of a clinic’s commitment to MHI increased, results were more consistent with effective patient treatment (P < .004; see Table 2). The “functioning better in life” outcome for patients included specific examples of cognitive improvements (self-attitudes and beliefs, negative thinking, focus and
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Journal of Primary Care & Community Health 5(1)
Table 2. Patient Positive Outcomes Reported by Patients and Staff. Total (N = 59)
Patient-Reported Positive Outcomes Improved overall functioning in life Improved overall functioning dimension: “Thinking clearly” Treatment works effectively Treatment works dimension: Connected physical and mental symptoms and team worked together on the same page
Total (N = 50)
Staff-Reported Patient Outcomes Patients receive treatment/access Patients functioning better in life Patients functioning better dimension: Patients more productive at home or work
Potential (n = 19)
Adoption (n = 20)
Routinized (n = 20)
P
P Trend
.89 .16 .53 .16
.85 .25 .55 .25
100 .50 .90 .60
.217 .055 .021* .008**
.231 .013* .013* .004**
Potential (n = 15)
Adoption (n = 17)
Routinized (n = 18)
P
P Trend
.73 .60 .33
.71 .52 .18
.55 .83 .67
.498 .139 .010*
.272 .139 .039*
Pearson’s χ2 test and P for trend χ2: *P < .05; **P < .01.
processing of information, “level headedness”), whereas staff examples included improved productivity at work or home.
Staff Responses Staff providing care in routine clinics reported that patients were more productive and better able to perform at home and at work (P < .01; P < .039; see Table 2). The longer a clinic had been committed to MHI, the more patients perceived coordinated team interactions (P < .0001; see Figure 1). Patients receiving treatment in the routine clinics discussed team themes during their interview significantly more frequently (P < .001). Staff (.84) in all phased clinic groups discussed team themes more frequently than did patients (.49; P < .0001; see Figure 1). Working in a health care team is a common expectation for clinic staff. Patients expect to work with their doctor and may not perceive their doctor and his or her staff as a team. As clinics became more routinized the team themes were more dominant across both staff and patients (see Figure 1). Overall patient and staff subject responses during their interview that included a team theme were counted and tallied across clinic phases (potential, adoption, routinized). Team themes describing joint problem solving and shared decision making related to a common goal with multiple players linked together were noted.
Discussion A consistent qualitative theme among all respondents was the collaborative effort of team members working together with patients to help them with their mental and physical health needs. When specifically asked about patient outcomes, the team theme emerged again, with routine MHI
Figure 1. Differences in patient-perceived coordinated team interactions by Mental Health Integration (MHI) clinic phase.
clinics associated with a higher success rate on all dimensions of improved outcomes and more connected team relationships. This investigation implies the positive value of effective team relationships in helping patients achieve positive health outcomes at lower cost. A key aspect of the lower cost is that patients treated in MHI clinics were 54% less likely to use expensive emergency room services.14 This study found that patients treated in clinics where MHI had become routinized over time experienced more connected team contact and positive outcomes. The longer the clinics were committed to MHI, the more dominant the team themes were across both staff and patient interviews. MHI adds complementary roles to an established relationship between patients, their doctors, and their clinics; and
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59
Reiss-Brennan normalizes mental health as part of overall health. This normalizing process is the result of a combined effort among all team members, and is perceived by patients as a significant outcome: “treatment works.” In routinized MHI clinics, the complex time and emotional energy involved in dealing with depression is spread across or shared by a team who are skilled and prepared to tackle the mental and social stress that often accompanies chronic disease.
Acknowledgments
Limitations
Declaration of Conflicting Interests
Limitations of this study need to be considered when interpreting the results. The qualitative inquiry, although rich with description, is self-reported and the nature and amount of information offered during the interviews depended on subject and interviewer interactions during the interviews, the circumstances surrounding the interview and the subject’s motivation for participating in the interview. Although patient subjects were randomly selected, their agreement to participate in a discussion regarding their depression care may have been influenced by the level of improvement they had been able to achieve. Similarly, although staff subjects were given administrative time to participate, their responses may have been influenced by their current work load and employment arrangements. The qualitative data was also limited to interview one-time responses. Further investigation is required to confirm the relationships between team activity differences reported among the clinic groups and the positive outcomes described by patients and staff.
Conclusion When patients can receive effective care at their familiar clinic setting for their mental and physical health, coordinated between their doctor and their broader health care team, their overall functioning in their life is improved and sustained. Patients in MHI clinics prefer care administered by multiple persons working together with their doctor to address their mental, physical, and family health issues. This study shows that patients value a trusting relationship with their doctor who can get to the root of their problem by treating mind and body together and who can work together with a coordinated treatment team. Further study is needed to define the interacting team factors and organized processes that are occuring in MHI team-based clinics that promote or deter positive outcomes. Research must be conducted to determine how the team works together, how decisions are made, and what is needed to support the operations of these team exchanges without additional costs.
This research was possible as a result of the combined efforts of Polly Wiessner, PhD, at the Department of Anthropology, University of Utah; and Linda Leckman, MD, and Wayne Cannon, MD, at Intermountain Healthcare. Writer Michael D. Britton assisted in the preparation of this article.
Author’s Note The research conducted for this article required and received institutional review board approval.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Lupton D. Medicine as Culture. London: Sage; 2006. 2. Lock M, Farquar J, eds. Beyond the Body Proper: Reading the Anthropology of Material Life. Durham, NC: Duke University Press; 2007. 3. Centers for Disease Control and Prevention. Chronic disease prevention and health promotion. http://www.cdc.gov/chronicdisease/overview/index.htm. Accessed October 15, 2013. 4. Agency for Healthcare Research and Quality. Experts call for integrating mental health into primary care (Research Activities, January 2012, No. 377). Rockville, MD: Agency for Healthcare Research and Quality. http://www.ahrq.gov/ news/newsletters/research-activities/jan12/0112RA1.html. Accessed October 15, 2013. 5. Reforming American health care: heading for the emergency room. The Economist. http://www.economist.com/ node/13899647. Accessed June 25, 2009. 6. Olfson M, Marcus S, Druss B, Elinson L, Tanielian T, Pincus HA. National trends in the outpatient treatment of depression. JAMA. 2002;287:203-209. 7. Wang P, Lane M, Olfson M, Pincus H, Wells K, Kessler R. Twelve-month use of mental health services in the United States: results from the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62:629-640. 8. Mojtabai R. Unmet need for treatment of major depression in the United States. Psychiatr Serv. 2009;60:297-305. 9. Wells KB, Sherbourne C, Schoenbaum M, et al. Impact of disseminating quality improvement programs for depression in managed primary care: a randomized control trial. JAMA. 2002;283:212-220. 10. Rost K, Zhang M, Fortney J, Smith J, Coyne J, Smith GR. Persistently poor outcomes of undetected major depression in primary care. Gen Hosp Psychiatry. 1998;20:12-20. 11. Intermountain Healthcare. Mental Health Integration: how connecting mind and body helps our patients and physicians and makes good financial sense. Pulse with Dr Charles
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Sorenson. https://my.intermountain.net/interblog/pulse/Lists/ posts/post.aspx?ID=56. Accessed March 21, 2010. 12. Bodenheimer T. Lessons from the trenches—a high functioning primary care clinic. N Engl J Med. 2011;365:5-8. 13. Katon WJ, Lin EH, Von Korff M, et al. Collaborative care for patients with depression and chronic illness. N Engl J Med. 2010;363:2611-2620. 14. Reiss-Brennan B, Briot PC, Savitz LA, Cannon W, Staheli R. Cost and quality impact of Intermountain’s Mental Health Integration program. J Healthc Manag. 2010;55:97-114. 15. Rogers EM. Diffusion of Innovations. 4th ed. New York, NY: Free Press; 1995.
Author Biography Brenda Reiss-Brennan is a medical anthropologist and psychiatric nurse practitioner practicing in primary care for over 30 years.
As a principal investigator she is leading Intermountain’s (IH) adoption, diffusion and evaluation of clinical integration for mental health and primary care. The evidence and quality of Mental Health Integration (MHI) program has spread rapidly in over 90 IH medical group clinics including uninsured, rural specialty care clinics and 45 non-IH community clinics throughout the United Sates. Her research has shown that MHI has changed the culture of primary health care by standardizing a team-based care process that includes mental health as a normal part of the routine medical encounter. Patients treated in MHI clinics also show improved satisfaction, lower costs, and better quality outcomes and were 54% less likely to use higher order and expensive emergency room services. MHI sees mental illness through a new lens integrating mind and body and introduces a team approach that values both the patient and staff experiences.
Downloaded from jpc.sagepub.com at Univ of Connecticut / Health Center / Library on June 21, 2015
research-article2013
JPCXXX10.1177/2150131913508983Journal of Primary Care & Community HealthReiss-Brennan
Case Study
Mental Health Integration: Normalizing Team Care
Journal of Primary Care & Community Health 2014, Vol 5(1) 55–60 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/2150131913508983 jpc.sagepub.com
Brenda Reiss-Brennan1
Abstract This article examines the impact of integrating mental health into primary health care. Mental Health Integration (MHI) within Intermountain Healthcare has changed the culture of primary health care by standardizing a team-based care process that includes mental health as a normal part of the routine medical encounter. Using a quantitative statistical analysis of qualitative reports (mixed methods study), the study reports on health outcomes associated with MHI for patients and staff. Researchers interviewed 59 patients and 50 staff to evaluate the impact of MHI on depression care. Patients receiving MHI reported an improved relationship with caregivers (P < .001) and improved overall functioning in their lives (P < .01). Staff providing care in MHI reported that patients experienced improved access to mental health care, improved overall patient productivity in daily functions (P < .01), and access to team care (P < .001). As MHI became routine, patients discussed complementary team interventions more frequently (P < .0001). Mental health problems rank second in chronic disease today. MHI offers promising results for improving the quality and cost of effective treatment for chronic disease. This research provides guidelines for organizing mental health care, staff productivity, and patient satisfaction, using a team approach to improve outcomes. Keywords mental health, integration, team care, standardization, depression, primary care
Introduction Contemporary Western medicine is based on a tradition of treating mental health separate from physical health, with assumptions that diseases occur independently of social context.1,2 Mind–body dualism affects the health exchange experience of both caregivers and receivers. When mental health is treated as separate from physical health, the health care experience is often stigmatized and fragmented. Though these attitudes are changing, the fact remains that 45% of aging Americans have a chronic disease3 and mental health ranks second to cancer in chronic disease prevalence.3 The past decade saw a substantial increase in the proportion of people with serious mental illness and substance abuse disorders who reported receiving care from primary care physicians (PCPs) and hospital emergency rooms.4-7 Depression, the most common mental health condition seen in primary care, often occurs with, and compromises, care of other chronic illnesses; yet stigma and secrecy often cause depression to go undetected, undiagnosed, or undertreated.8-10 Over the past 12 years, Intermountain Healthcare has developed Mental Health Integration (MHI) as a comprehensive team-based innovation for caring for the mental and physical health of patients and their families. “MHI is
defined as a standardized clinical and operational team relational process that incorporates mental health as a complementary component of wellness and healing for life.”11 The MHI team care process model (CPM) has spread a new social message of normalizing mental health as a routine part of everyday health exchanges between patients and their doctors and among clinic staff. The integration model goes far beyond “co-location” of a specialty care provider or “physician solo” care. It is a team-based approach where complementary roles include the patient and family and are operationalized at the clinic improving both physician and staff communication. MHI differs from collaborative care models because it is a standardized system in which a key focus is on the primary care providers continuing to provide appropriate levels of mental health care within a high functioning team. MHI focuses on eliminating the chasm between physical health care and mental health care—rolling both into a comprehensive 1
Intermountain Healthcare, Salt Lake City, UT, USA
Corresponding Author: Brenda Reiss-Brennan, Mental Health Integration Director, Primary Care Clinical Program, Intermountain Healthcare, 36 South State Street, Suite 2100, Salt Lake City, UT 84111, USA. Email: [email protected]
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Journal of Primary Care & Community Health 5(1)
whole that is addressed by a high-functioning team. The MHI team CPM has disseminated a new social message of normalizing mental health as a routine part of everyday health exchanges between patients and their doctors and among clinic staff. This message is propagated through standard protocols of the MHI CPM, which specifies an organized process to guide the allocation and activation of each team role. Physicians are accountable for patients having awareness of informed access to the expanded team care. The MHI team includes all of the PCPs and support staff, in addition to practice managers, mental health professionals, community advocates, the patient, and the family. This multidisciplinary clinical team is organized under the leadership of the clinic physician in partnership with the patient and family; each member of the team is trained in specific responsibilities that contribute to a collective holistic care plan. Team member communication and shared decision making follows standardized CPM protocols and is facilitated by a shared electronic medical record. Patients have direct email or phone access to their physician and team. Team-based care, such as MHI, requires a fundamental change in physicians’ mind-sets.12 Many practices claim to have teams, but the physicians provide all the care and delegate tasks to staff or refer to specialty providers. The end result of this traditional delivery model is fragmented, uncoordinated care and poor health outcomes.13 The MHI innovation has been introduced and adopted across a rapidly growing medical group that provides community care for more than 800 000 patients and their families per year in the state of Utah. MHI has been diffused across diverse (family medicine, pediatrics, and internal medicine) primary care practice settings with positive results,14 and, prior research also shows that patients treated in MHI clinics were 54% less likely to use expensive emergency room services.15 The purpose of this study was to evaluate the quality effectiveness of the transformation of medical care delivery called Mental Health Integration (MHI) by analyzing patient and medical staff outcome perceptions for depression treatment in clinics with varying experience in MHI.14 The specific aims were to identify the key factors in patient and staff social interactions underlying the improved outcomes observed in MHI clinics. Using qualitative and quantitative techniques, this multisite comparative study measured improved engagement, outcomes, and perceived coordination via open-ended interviews. The focus was on examining how MHI (a) improves outcomes for patients, (b) furthers an effective team approach among staff, and (c) alters the culture of health care delivery, based on the following hypotheses: 1. The longer the clinic has been committed to MHI, the more patients are engaged in multiple treatment options.
2. The longer the clinic has been committed to MHI, the better the outcomes for patients reported by patients and observed by staff. 3. The longer the clinic has been committed to MHI, the more patients perceive coordinated team interactions.
Methods The investigation explored the perceptions of staff and patients involved in MHI during 3 phases of MHI diffusion. The study authors identified the 3 phases as a function of a clinic’s stage of implementation commitment to MHI: potential, adoption, or routinized.14 Potential clinics are trained in the MHI CPM, are assessing current resources and readiness for MHI adoption, but do not have an MHI operational plan. Therefore, potential clinics have not yet committed to implementing MHI. Adoption clinics have implemented MHI for at least 2 years. During this time they have engaged leadership champions, recruited and hired team staff, redesigned roles and workflow, and offered MHI care to their patients. Adoption clinics request support from instituional leaders to help resolve barriers and resistance to change. They have operational commitment to pursue MHI goals. Routinized clinics have practiced MHI for more than 6 years. Routinized clinics have habituated the innovation and provide greater access to an integrated health/medical home team with coordinated care for depression. These clinics have established continuous administrative leadership and clinical teams; MHI workflows are considered a clinic norm. Routinized clinics have improved the quality of depression care for patients and reduced uneccessary costs.14
Design The study was a 2-year multiclinic comparative mixed methods study of 9 primary care clinics within Intermountain Healthcare in Salt Lake City, Utah. From 80 clinics implementing MHI, researchers selected 3 groups of clinics used in prior research,14 based on their phase of implementation: 3 potential, 3 adoption, and 3 routinized clinics. Across each of the 3 phased groups, researchers matched clinics for 12 months (2010) by patient visit volumes, numbers and types of provider, and payor percentage mix (commercial, Medicaid, Medicare, uninsured/charity). Researchers further analyzed 12-month visit volumes for the number of mental health–related visit claims. The claims analysis used ICD-9 mental health–related codes documented in the depression registry. All patients treated at the clinics had access to physical and mental health care regardless of their ability to pay.
Downloaded from jpc.sagepub.com at Univ of Connecticut / Health Center / Library on June 21, 2015
57
Reiss-Brennan Table 1. Patients Receiving Combined Treatment Support. Total (N = 59)
Potential (n = 19)
Adoption (n = 20)
Routinized (n = 20)
P
P Trend
.24 .29 .42 .85 .49 .09
0 0 .53 .84 .42 .21
.25 .35 .35 .75 .65 0
.45 .50 .40 .95 .40 .05
.004** .002** .519 .212 .217 .040*
.001** .001* .605 .338 .875 .076
Contact with care manager Contact with on-site MHI provider Contact with off-site mental health provider Currently taking medication Discussed support needed after leaving clinic ER visits in past 12 months recorded in depression registry Abbreviations: MHI, Mental Health Integration; ER, emergency room. Pearson’s χ2 test and P for trend χ2: *P < .05; **P < .01.
Sampling
Analysis
Staff Recruitment. To understand the impact of MHI on staff, researchers drew a sample of 50 clinic staff from the clinics studied. Staff roles included physicians, clinic managers, nurse care managers, mental health specialists, and medical support staff, selected for balance among all team roles in each phase of clinic.
Researchers aggregated the interview data by MHI clinic phase (potential, adoption, routinized) for both staff and patients and carried out quantitative analysis to identify significant difference in key demographic or theme variables among phased clinic groups. Researchers used Pearson’s χ2 test, Fischer’s exact tests, and analysis of variance to test this level of difference. The study assessed linear trends in proportions across phases of MHI implementation using a P-for-trend χ2 analysis in order to further test that certain outcomes increased over time by duration of commitment to MHI.
Patient Recruitment. To obtain patients’ views, researchers selected a random sample of 59 adult male and female patients older than 18 years who received care for depression from their PCP any time in the previous 12 months—about 20 patients from each of the 3 phased clinic groups. The study excluded patients identified as cognitively impaired or having intent to harm themselves or others, as well as those newly established in a patient–therapist relationship.
Data Collection Researchers collected primary data from interviews conducted face to face and via telephone, and extracted secondary data that pertain to patient visits from the administrative databases. The interview included open-ended questions that probed respondents’ perceptions of their experiences of providing or receiving care for depression or other mental health concerns in the primary care setting. The study asked patients to share their thoughts about what positive outcomes they experienced; what factors, if any, promoted the perceived positive outcomes; what factors may have gotten in the way of positive outcomes; and what improvements they would recommend. Meanwhile, the study asked staff to share their thoughts about what positive outcomes they observed for patients receiving care at their clinics; what factors, if any, promoted the patients positive outcomes; what factors may have gotten in the way of patients achieving positive outcomes; and what improvements for depression care they would recommend to be provided at their clinic.
Results Patients treated in MHI adoption and routine clinics reported significantly more care manager and mental health support (P < .01) in addition to medication and PCP interventions than patients treated in potential clinics (see Table 1).
Patient Responses Patients receiving care for depression and mental health at clinics with a longer committment to MHI reported a greater number of positive outcomes (see Table 2). For 2 outcomes (“overall functioning better in life” and “established personal relationships”), patient responses increased with clinic phase, although not to a statistically significant degree. Among the dimensions of “overall functioning better in life,” patients in routine clinics significantly reported over time being able to “think more clearly” (P < .013; see Table 2). In addition to reporting an established relationship and improved cognitive functioning, patients in routinized clinics reported that that treatment was effective. As the duration of a clinic’s commitment to MHI increased, results were more consistent with effective patient treatment (P < .004; see Table 2). The “functioning better in life” outcome for patients included specific examples of cognitive improvements (self-attitudes and beliefs, negative thinking, focus and
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Table 2. Patient Positive Outcomes Reported by Patients and Staff. Total (N = 59)
Patient-Reported Positive Outcomes Improved overall functioning in life Improved overall functioning dimension: “Thinking clearly” Treatment works effectively Treatment works dimension: Connected physical and mental symptoms and team worked together on the same page
Total (N = 50)
Staff-Reported Patient Outcomes Patients receive treatment/access Patients functioning better in life Patients functioning better dimension: Patients more productive at home or work
Potential (n = 19)
Adoption (n = 20)
Routinized (n = 20)
P
P Trend
.89 .16 .53 .16
.85 .25 .55 .25
100 .50 .90 .60
.217 .055 .021* .008**
.231 .013* .013* .004**
Potential (n = 15)
Adoption (n = 17)
Routinized (n = 18)
P
P Trend
.73 .60 .33
.71 .52 .18
.55 .83 .67
.498 .139 .010*
.272 .139 .039*
Pearson’s χ2 test and P for trend χ2: *P < .05; **P < .01.
processing of information, “level headedness”), whereas staff examples included improved productivity at work or home.
Staff Responses Staff providing care in routine clinics reported that patients were more productive and better able to perform at home and at work (P < .01; P < .039; see Table 2). The longer a clinic had been committed to MHI, the more patients perceived coordinated team interactions (P < .0001; see Figure 1). Patients receiving treatment in the routine clinics discussed team themes during their interview significantly more frequently (P < .001). Staff (.84) in all phased clinic groups discussed team themes more frequently than did patients (.49; P < .0001; see Figure 1). Working in a health care team is a common expectation for clinic staff. Patients expect to work with their doctor and may not perceive their doctor and his or her staff as a team. As clinics became more routinized the team themes were more dominant across both staff and patients (see Figure 1). Overall patient and staff subject responses during their interview that included a team theme were counted and tallied across clinic phases (potential, adoption, routinized). Team themes describing joint problem solving and shared decision making related to a common goal with multiple players linked together were noted.
Discussion A consistent qualitative theme among all respondents was the collaborative effort of team members working together with patients to help them with their mental and physical health needs. When specifically asked about patient outcomes, the team theme emerged again, with routine MHI
Figure 1. Differences in patient-perceived coordinated team interactions by Mental Health Integration (MHI) clinic phase.
clinics associated with a higher success rate on all dimensions of improved outcomes and more connected team relationships. This investigation implies the positive value of effective team relationships in helping patients achieve positive health outcomes at lower cost. A key aspect of the lower cost is that patients treated in MHI clinics were 54% less likely to use expensive emergency room services.14 This study found that patients treated in clinics where MHI had become routinized over time experienced more connected team contact and positive outcomes. The longer the clinics were committed to MHI, the more dominant the team themes were across both staff and patient interviews. MHI adds complementary roles to an established relationship between patients, their doctors, and their clinics; and
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Reiss-Brennan normalizes mental health as part of overall health. This normalizing process is the result of a combined effort among all team members, and is perceived by patients as a significant outcome: “treatment works.” In routinized MHI clinics, the complex time and emotional energy involved in dealing with depression is spread across or shared by a team who are skilled and prepared to tackle the mental and social stress that often accompanies chronic disease.
Acknowledgments
Limitations
Declaration of Conflicting Interests
Limitations of this study need to be considered when interpreting the results. The qualitative inquiry, although rich with description, is self-reported and the nature and amount of information offered during the interviews depended on subject and interviewer interactions during the interviews, the circumstances surrounding the interview and the subject’s motivation for participating in the interview. Although patient subjects were randomly selected, their agreement to participate in a discussion regarding their depression care may have been influenced by the level of improvement they had been able to achieve. Similarly, although staff subjects were given administrative time to participate, their responses may have been influenced by their current work load and employment arrangements. The qualitative data was also limited to interview one-time responses. Further investigation is required to confirm the relationships between team activity differences reported among the clinic groups and the positive outcomes described by patients and staff.
Conclusion When patients can receive effective care at their familiar clinic setting for their mental and physical health, coordinated between their doctor and their broader health care team, their overall functioning in their life is improved and sustained. Patients in MHI clinics prefer care administered by multiple persons working together with their doctor to address their mental, physical, and family health issues. This study shows that patients value a trusting relationship with their doctor who can get to the root of their problem by treating mind and body together and who can work together with a coordinated treatment team. Further study is needed to define the interacting team factors and organized processes that are occuring in MHI team-based clinics that promote or deter positive outcomes. Research must be conducted to determine how the team works together, how decisions are made, and what is needed to support the operations of these team exchanges without additional costs.
This research was possible as a result of the combined efforts of Polly Wiessner, PhD, at the Department of Anthropology, University of Utah; and Linda Leckman, MD, and Wayne Cannon, MD, at Intermountain Healthcare. Writer Michael D. Britton assisted in the preparation of this article.
Author’s Note The research conducted for this article required and received institutional review board approval.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Lupton D. Medicine as Culture. London: Sage; 2006. 2. Lock M, Farquar J, eds. Beyond the Body Proper: Reading the Anthropology of Material Life. Durham, NC: Duke University Press; 2007. 3. Centers for Disease Control and Prevention. Chronic disease prevention and health promotion. http://www.cdc.gov/chronicdisease/overview/index.htm. Accessed October 15, 2013. 4. Agency for Healthcare Research and Quality. Experts call for integrating mental health into primary care (Research Activities, January 2012, No. 377). Rockville, MD: Agency for Healthcare Research and Quality. http://www.ahrq.gov/ news/newsletters/research-activities/jan12/0112RA1.html. Accessed October 15, 2013. 5. Reforming American health care: heading for the emergency room. The Economist. http://www.economist.com/ node/13899647. Accessed June 25, 2009. 6. Olfson M, Marcus S, Druss B, Elinson L, Tanielian T, Pincus HA. National trends in the outpatient treatment of depression. JAMA. 2002;287:203-209. 7. Wang P, Lane M, Olfson M, Pincus H, Wells K, Kessler R. Twelve-month use of mental health services in the United States: results from the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62:629-640. 8. Mojtabai R. Unmet need for treatment of major depression in the United States. Psychiatr Serv. 2009;60:297-305. 9. Wells KB, Sherbourne C, Schoenbaum M, et al. Impact of disseminating quality improvement programs for depression in managed primary care: a randomized control trial. JAMA. 2002;283:212-220. 10. Rost K, Zhang M, Fortney J, Smith J, Coyne J, Smith GR. Persistently poor outcomes of undetected major depression in primary care. Gen Hosp Psychiatry. 1998;20:12-20. 11. Intermountain Healthcare. Mental Health Integration: how connecting mind and body helps our patients and physicians and makes good financial sense. Pulse with Dr Charles
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Sorenson. https://my.intermountain.net/interblog/pulse/Lists/ posts/post.aspx?ID=56. Accessed March 21, 2010. 12. Bodenheimer T. Lessons from the trenches—a high functioning primary care clinic. N Engl J Med. 2011;365:5-8. 13. Katon WJ, Lin EH, Von Korff M, et al. Collaborative care for patients with depression and chronic illness. N Engl J Med. 2010;363:2611-2620. 14. Reiss-Brennan B, Briot PC, Savitz LA, Cannon W, Staheli R. Cost and quality impact of Intermountain’s Mental Health Integration program. J Healthc Manag. 2010;55:97-114. 15. Rogers EM. Diffusion of Innovations. 4th ed. New York, NY: Free Press; 1995.
Author Biography Brenda Reiss-Brennan is a medical anthropologist and psychiatric nurse practitioner practicing in primary care for over 30 years.
As a principal investigator she is leading Intermountain’s (IH) adoption, diffusion and evaluation of clinical integration for mental health and primary care. The evidence and quality of Mental Health Integration (MHI) program has spread rapidly in over 90 IH medical group clinics including uninsured, rural specialty care clinics and 45 non-IH community clinics throughout the United Sates. Her research has shown that MHI has changed the culture of primary health care by standardizing a team-based care process that includes mental health as a normal part of the routine medical encounter. Patients treated in MHI clinics also show improved satisfaction, lower costs, and better quality outcomes and were 54% less likely to use higher order and expensive emergency room services. MHI sees mental illness through a new lens integrating mind and body and introduces a team approach that values both the patient and staff experiences.
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