|Implemented in this survey?|
Mental health integration, or MHI, refers to mental health care that is fully integrated into routine primary care practice, and that engages a variety of partners in identifying and addressing patient and family mental health problems. Data from a mental health integration program in place for a decade in Utah and increasingly the subject of national scrutiny reveals that integration improves patient and provider satisfaction and quality of care while lowering costs.
A decade ago, Intermountain Healthcare (IH), a non-profit health care system serving metropolitan Salt Lake City, Utah, began a pilot project to integrate mental health care services into primary care practice. The project has since been rolled out to more than half of the clinics (primary care medical group practices) in the 130-clinic system; it is also being replicated in settings beyond IH in several states, including Mississippi, Maine, New Hampshire and Oregon as well as the local Utah state health agencies. Leaders stress that the program is not one of co-location - that is, mental and primary health care in simple co-existence under one roof - but rather integration, in which mental health care is made a key component of all primary health care including prevention and wellness.
At Intermountain Health, mental health integration was initially undertaken and has since been scaled up in order to address challenges primary care physicians have reported facing when encountering patients and families with mental health concerns. Time constraints, lack of training, and financial barriers have often been cited as barriers to effectively addressing patients' mental health needs in the primary care setting. At the same time, more and people report receiving mental health treatment from their primary care physicians. Yet, there is evidence that primary care physicians underuse evidence-based treatments for patients with mental health conditions. Many mental health conditions, notably depression, often present in tandem with other chronic conditions, and yet they routinely go untreated. In addition to the factors cited above, these trends have been attributed to the fragmentation of the health care system; they have also been attributed to a medical culture that commonly fails to acknowledge the link between mental wellness and somatic complaints.
The mental health integration approach has been adopted and honed by Intermountain Healthcare to address these shortcomings of health care with respect to mental health treatment, in addition to others: Some key objectives of integration have been to improve providers' ability to treat mental health conditions, improve their confidence in and satisfaction with such treatment, improve detection of mental health conditions among patients and families, and reduce both costs of and barriers to accessing effective mental health care services.
|Degree of Innovation||traditional||innovative|
|Degree of Controversy||consensual||highly controversial|
|Structural or Systemic Impact||marginal||fundamental|
|Public Visibility||very low||very high|
Intermountain Healthcare MHI program has been implemented without controversy, and while it has significantly changed the delivery of care, it has not adversely impacted the system as a whole.
Mental health integration was brought to national attention following the release of the first-ever Surgeon General's report on mental health in 1999. The report, by then-Surgeon General David Satcher, called attention to mental health conditions as a leading cause of morbidity and mortality and identified the most significant barriers to their effective treatment, including stigma and financial disincentives. The report highlighted the fact that primary care offered a key - though underutilized - opportunity for both identifying and preventing mental illness. One outcome of the report was a meeting, called for by Surgeon General Satcher and held the following year, on the integration of mental health services into primary practice. The meeting attempted to define core principles and a strategy for action in order to promote the integration of mental health into primary care nationally. The final report of the meeting emphasized, among other elements, engaging consumers and their families in treatment, encouraging a team approach to care, utilizing information technology, and building on existing models of care.
Growing attention to the need for integrated mental health care also evolved in part as a response to the growing number of people with mental illness and substance abuse disorders who were getting care from their family doctors or hospital emergency rooms and the fact that more and more patients with mental conditions, some of them serious, were as a result often going without the evidence-based, specialized care they needed. At the same time, many health care settings and research centers had been implementing and testing collaborative care models as one means of care redesign with the potential to improve quality and control costs. By the late 1990s, collaborative care through a clinical integration structure was already long in place at Intermountain Healthcare, helping providers triage patients with a variety of chronic conditions. The collaborative care model provided a foundation for implementing a mental health integration program.
In 1999, the same year in which the Surgeon General's landmark report was released, a mental health integration program was pilot tested at Bryner Clinic, an urban family health center in Salt Lake City, Utah which had already implemented collaborative care for several chronic conditions. Based on their experience with collaborative care, physicians at the clinic, part of the Intermountain Healthcare system, had pressed IH for the resources to help integrate mental health into everyday practice as well. Ultimately, the clinic physicians contacted Brenda Reiss-Brennan, an independent psychiatric nurse practitioner who was practicing with a multidisciplinary team as a family therapist in a suburb south of Salt Lake City, who had begun training primary care physicians to identify family mental health conditions in their patients and provide preliminary treatment before referring patients to mental health specialists. In fall of 1999, Reiss-Brennan was invited to replicate the model at Bryner Clinic. The program piloted at Bryner developed screening criteria to help all care providers identify potential mental health conditions in patients and families and a set of process guidelines for integrated practice. Mental health specialists and care managers were realigned with primary care providers to work as a team with patients and families on-site, and all staff with patient contact, from administrative to medical, received mental health integration training. In 2001, the board of Intermountain Healthcare announced plans to scale up the program, with Reiss-Brennan taking a leadership role.
|Implemented in this survey?|
Mental health integration at Intermountain Healthcare built on an existing model of clinical integration for chronic conditions, which had been in place in the health care system for close to three decades. Clinical integration at Intermountain Healthcare is based on a model of collaborative care, which helps care providers triage all patients. In this model, physicians and medical assistants are equipped with disease-specific treatment tools that enable them to effectively treat approximately two-thirds of incoming patients for such chronic conditions as diabetes. Half of the remaining one-third of patients are scheduled for follow-up with a specialized educator or care manager; the other half of the remaining third are referred to a care manager and specialist as needed.
The recognition that primary care physicians at Intermountain Healthcare were ill equipped to effectively manage patients with mental health conditions, despite the clinical integration model of care, prompted a group of leaders to establish the organization's Mental Health Integration quality improvement program. The program, as described above, replicated and built upon a collaborative model of mental health care developed by Brenda Reiss-Brennan in the suburb of West Jordan, Utah.
The mental health integration program enjoys widespread support from community partners and state health agencies in the state of Utah and partnering communities. Physicians directly involved report improved satisfaction with care and greater confidence in their own ability to identify and manage mental health problems. A variety of community groups have lent their support to mental health integration not just in Utah, but in other states where providers are implementing the model as well. In Utah, the National Alliance for Mental Illness, a consumer group, has emerged as a key partner in the program; in Mississippi, clergy members and the non-profit organization Big Brothers Big Sisters provide community support; in New Hampshire, several legislators have pledged their support to the model of care.
|Utah Department of Health||very supportive||strongly opposed|
|Intermountain Healthcare||very supportive||strongly opposed|
|IH Patients||very supportive||strongly opposed|
|IH Patient families||very supportive||strongly opposed|
|NAMI||very supportive||strongly opposed|
|Other community partners||very supportive||strongly opposed|
|Utah Department of Health||very strong||none|
|Intermountain Healthcare||very strong||none|
|IH Patients||very strong||none|
|IH Patient families||very strong||none|
|Other community partners||very strong||none|
As of fall 2009, 69 clinics in the Intermountain Healthcare system have implemented mental health integration to varying degrees. Ultimately, mental health integration will be implemented at all 130 clinics in the 22-hospital, 675-physician system.
In all implementing clinics, mental health integration involves a "cascade" treatment approach. All patients entering clinics are assessed not only for physical ailments but also for mental health, using a questionnaire that assesses the patient and family's level of risk; providers are trained to consult with patients and their families and MHI team members and determine a mutual clinical decision regarding the appropriate combination and level of services for the complexity and severity of the family health concerns. . All medical and non-medical clinic staff receive ongoing training in mental health, and all comprise part of the mental health integration team-which also includes the patients themselves, their families, and community partners, who help identify patient needs and encourage treatment compliance.
Over the past decade of implementation, Intermountain Healthcare has identified five key components for successful mental health integration: leadership, workflow integration, community resources, information systems, and comprehensive consideration of all financial costs. To date, five clinics are fully "routinized"-that is, five of the 69 implementing clinics have full mental health teams in place, routinely conduct mental health screenings, use electronic medical records to code and share all patient information, engage community partners as integral parts of the treatment team, and are fully operational at no added cost to the clinic.
Adoption and implementation of electronic medical records (EMRs) and disease registries for such mental health conditions as depression have enabled the Intermountain Healthcare system's in-house evaluation team to conduct routine and ongoing evaluation of all care delivery programs, including integrated mental health services delivery. The in-house team also works in collaboration with evaluation teams at community partners to assess the impact of integration. Data collected through routine use of EMRs is enabling the evaluation team to track detection, patient functional improvement and satisfaction, and cost over time. Monitored outcomes are mapped to the five key components listed above (leadership, workflow integration, etc.) and include such measures as provider satisfaction, patient satisfaction, emergency room use, prescription drug refill rate, and number of supports used by the patient and his or her family.
Preliminary evaluations indicate that patient health and satisfaction are improved in clinics with mental health integration programs relative to those without. Care and service providers have also reported increasing confidence in their ability to manage patients with mental health conditions.
A retrospective cohort study accepted for publication in 2010 in the Journal of Healthcare Management, demonstrated significant cost savings and decreased ER, primary care, and inpatient psychiatric use among depressed patients treated in clinics with fully routinized mental health integration programs in place compared to those treated in conventional clinics.
In his 2009 Congressional address on health care reform, President Barack Obama cited Intermountain Healthcare as an example of a health care system that offered "high quality" care at "costs below average." The system as a whole has since received increased scrutiny of its practices, including its clinical integration care model, of which its mental health integration program is a part. Reiss-Brennan is now Mental Health Integration Director at Intermountain Healthcare, and has served as a consultant to the Surgeon General's Office on the subject of integrated mental health care. Intermountain Healthcare continues to implement plans to roll out mental health integration at all 130 network clinics. Evidence-to-date suggests that health care systems will continue to replicate the model in local health care settings across the nation. Whether aspects of the mental health integration model will serve to inspire adopted national reforms in any way remains to be seen.
|Quality of Health Care Services||marginal||fundamental|
|Level of Equity||system less equitable||system more equitable|
|Cost Efficiency||very low||very high|
Preliminary findings suggest that patients are more satisfied with their care, and that the integration of mental health care into routine primary care results in measurable cost savings and improved patient outcomes.
Reiss-Brennan B. "Can mental health integration in a primary care setting improve quality and lower costs?" Journal of Managed Care Pharmacy (12) Suppl 2: 14-20, 2006.
Reiss-Brennan B, Briot P, Cannon W, James B. "Mental Health Integration: Rethinking Practitioner Roles in the Treatment of Depression: The Specialist, Primary Care Physicians, and the Practice Nurse." Ethnicity and Disease (16) 2 Suppl 3: 37-43, 2006.
Reiss-Brennan B, Briot PC, Savitz LA, Cannon W, Staheli R. Cost & Quality Impact of Intermountain's Mental Health Integration Program." Forthcoming 2010.
Reiss-Brennan B, Savitz L, Briot P, Cannon W. "Excessive Drinking in Young Women: Reducing harm through quality improvement interventions." British Medical Journal, (336) 7650: 952-953, 26 April 2008.
U.S. Department of Health and Human Services. Report of a Surgeon General's Working Meeting on the Integration of Mental Health Services and Primary Health Care. 2001. http://www.surgeongeneral.gov/library/mentalhealthservices/mentalhealthservices.html.