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Barriers to Physical and Mental Condition Integrated Service Delivery

Kathol, Roger G. MD; Butler, Mary PhD; McAlpine, Donna D. PhD; Kane, Robert L. MD

doi: 10.1097/PSY.0b013e3181e2c4a0
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Objective: To assess pragmatic challenges faced when implementing, delivering, and sustaining models of integrated mental health intervention in primary care settings. Thirty percent of primary care patients with chronic medical conditions and up to 80% of those with health complexity have mental health comorbidity, yet primary care clinics rarely include onsite mental health professionals and only one in eight patients receive evidence-based mental health treatment. Integrating specialty mental health into primary care improves outcomes for patients with common disorders, such as depression.

Methods: We used key informant interviews documenting barriers to implementation and components that inhibited or enhanced operational success at 11 nationally established integrated physical and mental condition primary care programs.

Results: All but one key informant indicated that the greatest barrier to the creation and sustainability of integrated mental condition care in primary care settings was financial challenges introduced by segregated physical and mental health reimbursement practices. For integrated physical and mental health program initiation and outcome changing care to be successful, key components included a clinical and administrative champion-led culture shift, which valued an outcome orientation; cross-disciplinary training and accountability; use of care managers; consolidated clinical record systems; a multidisease, total population focus; and active, respectful coordination of colocated interdisciplinary clinical services.

Conclusions: Correction of disparate physical and mental health reimbursement practices is an important activity in the development of sustainable integrated physical and mental condition care in primary care settings, such as a medical home. Multiple clinical, administrative, and economic factors contribute to operational success.

HMO = health maintenance organization; VA = Veterans Administration.

From the Departments of Internal Medicine and Psychiatry (R.G.K.), Evidence-based Practice Center (M.B., R.L.K.), Clinical Outcomes Research Center (R.L.K.), University of Minnesota, and the Division of Health Policy and Management (D.D.M., R.L.K.), University of Minnesota School of Public Health, Minneapolis, Minnesota; and Cartesian Solutions, Inc. (R.G.K.), Burnsville, Minnesota.

Address correspondence and reprint requests to Roger G. Kathol, MD, Cartesian Solutions, Inc., 3004 Foxpoint Road, Burnsville, MN 55337. E-mail: katho001@umn.edu

Received for publication February 7, 2010; revision received March 2, 2010.

This study was supported, in part, by Contract #290-02-0009, Evidence Report #173, Publication #09-E003 from the Agency for Healthcare Research and Quality.

Dr. Kathol is President of Cartesian Solutions, Inc., a health management consulting company, which specializes in assisting with the development of programs for patients with health complexity and the integration of general medical and mental health care.

Copyright © 2010 by American Psychosomatic Society
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