Recent years have seen increasing recognition that the integration of mental health services into the primary care arena is an essential step for improving quality of mental health care [
At its broadest level, PC/MHI involves the implementation of structural organizational changes to policies, procedures, and practices that are intended to promote collaboration between primary care and clinical mental health experts in the assessment, treatment, and management of common mental health conditions [
Along with the rapid spread of PC/MHI throughout VA medical centers, research has investigated the factors important for successful PC/MHI implementation. For example, recent studies have explored the challenges faced by providers and clinics (within and outside VA) in transitioning to a PC/MHI model. These challenges include clarifying the responsibilities of PC/MHI versus specialty mental health clinics [
With a few exceptions, PC/MHI research has been conducted in the context of implementations aimed at maintaining fidelity to a specific model or form of PC/MHI [
The potential conflict between top-down-planned organizational changes and the autonomy of local practices has long been a concern in integrated health care systems such as VA, but the question of how to balance local needs for adaptation to mandated organizational changes with standardizing pressures is also broadly important to the private sector. For example, the Systems of Care program for children’s mental health is similar to PC/MHI in that both are national programs that provide funding and guidelines for integrated care, while granting considerable autonomy to local sites/communities in tailoring the organizational changes [
The present paper addresses this gap in knowledge about the ability of local sites to respond to mandated organizational changes regarding mental health coordination processes. Rather than focus on fidelity to a specific model of PC/MHI (e.g., SLI2CE), this study extends the scope of extant PC/MHI research by investigating the factors that may affect the ability of local clinical leaders to implement the structures and processes needed to coordinate mental health care across different VA clinics. There are several implementation models that have been used in the VA context [
The current study used an organizational coordination framework to guide our inquiry. We conceptualized the coordination processes involved in managing interdependent tasks across professional and team/unit boundaries to achieve integrated care. Organizational coordination can be achieved through standardized or interpersonal coordination processes [
Effective integrated care must be clinically appropriate as well as financially and operationally viable [
Regarding the operational dimension, we conceptualized PC/MHI as an organizational coordination intervention because it involves planned changes to the task-based standardized and interpersonal interactions between healthcare staff across team or unit boundaries (i.e., primary care and mental health). These operational changes represent structural integration of services that are exogenous to our framework of PC/MHI. Structural integration has been identified as a mechanism to promote coordination of patient care, but as noted in recent reviews, organizational changes that are intended to integrate services may not translate into either improved patient experiences [
Interview questions and specific probes.
Interview question | Specific probes |
---|---|
(1) Imagine that a patient with depression symptoms comes to the clinic. Can you walk me through a typical process of care | Referral process, differences between diagnoses? |
(2) How has this process changed over the past 10 years? (or since you arrived in the clinic)? | Recent changes, challenges, failures, leadership support, referrals, interpersonal interactions, physical structure? |
(3) Tell me about your sense of the need for coordination between PC and MH. | Examples of good and poor coordination? |
(4) How would you change your clinic to better coordinate care? | Communication, collaboration, resource barriers? |
(5) Have you or anyone you know had to develop your own coordination procedures to ensure that patients receive the best care? | Work-arounds, ad-hoc coordination procedures? |
(6) Can you tell me about the relationship between the people in the PC and MH clinics? | Face to face contact, trust? |
(7) In what situations would you say that teamwork is most important? | Coworkers back each other up |
Key informants included 30 clinic leaders (12 PC physicians, 10 psychologists, 5 psychiatrists, 4 nurses, 3 social workers, 1 physician assistant) who were recruited from 16 PC/MHI clinics across eight VA medical centers as shown in Table
Sampling of key informants across the sixteen sites.
Leaders | Physician | Psychologist | Psychiatrist | Nurse | Social worker | Physician assistant | |
---|---|---|---|---|---|---|---|
Hospital-based clinics | |||||||
| |||||||
Site 1 | 2 | 1 | 2 | ||||
Site 2 | 2 | 2 | 1 | ||||
Site 3 | 2 | 1 | 1 | ||||
Site 4 | 2 | 1 | 2 | ||||
Site 5 | 1 | 1 | 1 | ||||
Site 6 | 2 | 1 | 1 | ||||
Site 7 | 2 | 1 | 1 | ||||
Site 8 | 2 | 1 | 1 | ||||
| |||||||
Large outpatient clinics | |||||||
| |||||||
Site 9 | 2 | 1 | 1 | ||||
Site 10 | 2 | 1 | 1 | ||||
Site 11 | 2 | 1 | 1 | ||||
Site 12 | 1 | 1 | 1 | ||||
Site 13 | 2 | 1 | 1 | ||||
Site 14 | 2 | 1 | 1 | ||||
Site 15 | 2 | 1 | 1 | ||||
Site 16 | 2 | 1 | 1 |
Psychologists, psychiatrists, nurses, social workers and the physician assistant were all associated with the PC-MHI clinic. These providers represent 51% of PC/MHI staff at these sites.
Semistructured telephone interviews were conducted between July and August 2009 to measure influences of implementation progress and effectiveness. Stratified purposeful sampling was used by first interviewing both PC and MH leaders who then, respectively, identified primary care and colocated mental health staff. Leaders used their understanding of the local clinic contexts to select professionals representing different clinical backgrounds who could best speak to coordination procedures or who were most closely involved with mental health treatment based on their local context judgment. The purpose of these interviews was to understand the implementation of colocated, collaborative care in local sites. Although some sites also implement depression care management, these models are less common in VA. Interviews required up to 45 minutes with a note taker instructed to record responses verbatim where possible.
In-depth interviews allow for intensive exploration of a phenomenon with individuals who have experienced it [
The data analysis methodology was chosen to elaborate extant theory regarding the role of organization and leadership factors in intervention implementation. Very little theory has been developed regarding how healthcare organizations react to mandated organizational changes; however, we recognized that research on intervention implementation [
The purpose of the first two stages was to immerse ourselves in the data. In the first stage, we read through the interviews in their entirety to develop site summaries in order to begin theorizing about the factors that impacted PC/MHI implementation and to understand the gestalt PC/MHI implementation. These site summaries were needed to ensure that coded data were interpreted within the specific context of each site. In the second stage, the first author coded the raw data without any preconceived framework, looking for similarities across our key informants and across our sites. The purpose of this step was to identify similar types of data that could be analyzed in more depth. The output of this step was a set of codes that represented descriptive characteristics of PC/MHI (e.g., types of referral processes).
The purpose of the last two stages was to develop conceptual codes that represented potential causal factors that might impact the PC/MHI implementation (see Table
Emergent codes.
Code | Definition |
---|---|
(A) Leadership | Leadership does/does not provide direction, coordinate between different services, obtain needed resources, make timely decisions, communicate with staff. |
(B1) Resources (space) | Lack of space includes barriers due to physical structure of facility, includes lack of space and distance barriers. |
(B1) Resources (staffing) | Not enough staff available to provide coordinated mental health care. |
(B1) Resources (knowledge and skills) | Specific mention of staff knowledge, skills, or abilities. It includes general comments such as “good staff” |
(B2) Training | Training for MH procedures, including training of admin personnel |
(B3) Work design | Intentional choices regarding how care is provided; description of how tasks are divided between staff and/or clinics including informal systems work systems designed to overcome other barriers, including mandated tasks and same day appointments |
(C1) PC/MH boundaries | Perceived physical and/or psychological barriers between primary care and mental health clinics provide barriers to care. |
(C2) Time pressure | Overworked staff, working through admin/lunch time |
(C3) Staff participation | Staff “buy-in”, perceptions of mutual PC and MH participation, comfort with PC/MH referrals. It includes the use of formal and informal meetings to increase participation. |
(D) Referral systems | Processes used to coordinate care may include specific barriers to the referral process. It including the use of electronic medical record, paging systems, checklists. |
(E) Communication | Interpersonal communication, communication between PC and MH. |
Patient complexity | Challenges due to complicated mental health conditions and/or medical comorbidities; patients have many health needs, including noncompliance issues |
Theoretical framework of barriers and facilitators to locally-adapted PC/MHI implementation.
Triangulation is valued in qualitative research because parallel perspectives across key informants can increase the credibility of qualitative analyses [
We have developed a theory to understand that the leadership and organizational factors create barriers and facilitators to a locally adapted intervention designed to provide mental health care in the primary care setting (Figure
Communication between providers was relational, starting at the front lines. Primary care providers reported interacting with mental health staff on a personal level, building relationships, in order to generate trust and effective communication. At some sites, where the mental health worker was a psychologist rather than a psychiatrist, primary care providers indicated that they would have preferred MD to MD relations with a psychiatrist. Yet reported communication patterns varied. The source of this variation was not clear from the analyses, but may have been due to individual differences in preferences and attitudes.
Primary care providers who discussed communication barriers indicated that time pressures made it difficult to build relationships (Path C2→E). Communication between PC and MH typically increased incrementally during the implementation of PC/MHI as the psychological boundaries between services decreased and staff increased their participation and involvement in integrated mental health care. As mental health staff started to work to address primary care needs, primary care began communicating more with mental health (Path C3→E).
The VA electronic medical record provides tools and templates so PC and MH providers can better communicate about patients and, when necessary, see patients sooner. Some examples included a consult screen being successful in increasing patient access and referrals; a triage checklist for PC to handle patients in crisis right away; and integrated medication lists to flag medication interactions. The electronic medical record provides information about how PC and MH are coordinating services for a patient through automated notification processes. This electronic communication appeared to facilitate interpersonal communication regarding patient care (Path D→E). Staff reported barriers due to inadequate information in the electronic medical record which included the quick consult screen not being detailed enough to provide needed information, follow-up appointments not being scheduled appropriately by specialists, and lack of certain fields which could provide increased coordination (e.g., the name of the primary mental health provider).
Appropriate staffing and funding to hire new employees were reported as important for referral system effectiveness (Path B1→D). Some sites emphasized the need to hire more MH and PC providers. Staffing limitations were reported as barriers to implementing the desired work design for PC/MHI. For example, staffing limited colocation of psychologists that in turn limited the availability of same day access to mental health care or short-term therapies. Space resources were needed to allow staff to be colocated within the same space (Path B1→B3) and to provide the staff needed to handle the additional mental health consults (Path B1→D). Notably, leaders often reported that available space in primary care limited the amount of mental health staff that could be hired. Other staffing issues which may impact referral system effectiveness were staff turnover, inability to fill vacant positions, and Human Resources delays inhibiting timely hiring.
Referral systems were also reported to be affected by time pressure and training. Referrals through the electronic medical record were seen as more efficient when workload was high (Path C2→E). Other sites reported that a lack of knowledge of the appropriate mental health referral processes limited the effectiveness of electronic referrals. Strategies for increasing referrals mentioned were training primary care staff (Path B2→D) and developing referral templates (i.e., standardizing coordination) for the electronic medical record (Factor D). Primary care staff reported needing additional training for evidence-based mental health treatment. Staff from various sites reported receiving broad training regarding changes in work design (Path B2→B3) and referral processes (Path B2→D) but not necessarily in-depth training for how to handle specific problems (Path B2→F). In one site, staff reported that training was needed for nurses (e.g., dealing with crisis patients during triage) and clerks (e.g., interacting with angry patients) in addition to primary care providers.
Unresolved conflicts between work design and patient mental health needs were identified as barriers to patient access that limited referral system effectiveness and efficiency. Primary care providers noted that formulary restrictions often made it difficult for them to adjust medications for mental health conditions (prescribing authority in VA is often limited by provider specialty) that increased the need for specialty care referrals (Path B3→D). One mental health clinician reported that competing demands to focus improvement efforts on returning Veterans and traumatic brain injury led to a divided focus on primary care integration (Path B3→D). Having an on-site mental health clinician was noted to help alleviate same day appointment concerns through warm hand-offs (Path B1→B3→D), where primary care providers would introduce patients to MH staff, who would then perform a short assessment. However, some primary care participants reported the use of beepers as an alternative method to manage scheduling and same day appointment access (Path B3→D). Mental health at many sites responded to high demand for care by designing work (i.e., templates and protocols) to manage this demand (Path B3→D). For example, at one site, mental health required a patient to be on the maximum medication dosage before being seen. Another site handled high demand for substance abuse care by mandating that mental health conditions be resolved before addressing substance abuse. In some sites, primary care staff reported ad-hoc workarounds to meet the criteria of the template to manage these access restrictions.
The intentional choices regarding how primary care and mental health work are organized (i.e., work design) created the potential for conflicts when coordination procedures were revised. Conflicts between intended improvements to work design with the broader patient care system created unintended consequences in referral systems (Path B3→D). One type of conflict was observed between the design of routine and urgent mental health care. Some sites implemented an electronic scheduling system where open slots are available and patients in need of MH services can be given immediate access, but increasing the number of open appointment slots was reported to decrease access for regularly scheduled patients. A second type of conflict was observed in how referral systems were specified between services. Interservice referrals in VA were specified by formal or informal agreements, and these prior agreements set the context for unintended consequences when PC/MHI was implemented. In two sites, emergency room staff reacted to the addition of PC/MHI staff by attempting to shift responsibility for urgent mental health care to primary care. Other sites reported that specialty mental health staff began restricting access to only patients with the most severe conditions. Yet another site reported difficulties managing referrals to substance abuse for patients who also had mental health conditions.
The knowledge, skills, and abilities of staff were frequently mentioned as an important organizational resource for integrated care. Some examples of key relevant staff characteristics were motivation to work with and care for Veterans in particular, primary care providers who understand psychology, and competent mental health liaison nurses. Interviewees reinforced the need for collaboration among providers with differing levels and types of primary care and mental health skills. Interviews suggested that mutual awareness of collaboration opportunities was sufficient to create interactions. Persistence of colocated mental health staff in developing relationships and learning about how to address mental health needs in primary care was reported to slowly change primary care providers’ participation (Path B1→C3). At the point of the interviews, mental health staffing was not yet sufficient to handle the volume of work in many sites (B1→C2). Time pressure was closely related to work design, where several sites reported efforts to redistribute workload across PC and MH (B3→C2).
Mental health staff members were frequently colocated with primary care staff. Colocation was perceived as improving integration, referrals, and clinician accessibility in part because proximity increased familiarity between primary care and mental health staff (B3→C3). Mental health providers reported that informal conversations with primary care providers, such as in hallways or over lunch, were particularly important in engaging primary care providers. Preexisting collaborative relationships between primary care and mental health were reported to facilitate the intervention (Path B3→C3). In sites without these preexisting relationships, mental health providers reported actively seeking opportunities to demonstrate how mental health could help primary care. Mental health staff attendance at monthly primary care meetings was reported to increase primary care participation and engagement (Path B3→C3). Employees noted that during these meetings, discussions about appropriate consults occurred, and leadership could provide a consistent message regarding the importance of coordinated mental health care.
Cultural norms and work patterns differ between PC and MH, so defining the boundaries of patient care responsibilities and dealing with preconceived notions of how patient mental health care should be coordinated are challenges that require on-going upkeep. Deterioration of interactions across PC and MH boundaries that arose over time was repeatedly described as turf wars and sometimes attributed to lack of resources (Path B1→C1). For example, primary care providers were reported to be worried that PC/MHI would increase demand on their scarce resources, and at one site mental health providers were reported to redirect large numbers of patients to primary care for treatment who were previously treated in specialty mental health (e.g., personality disorders). Colocated mental health staff, who worked on the boundary between primary care and mental health, provided detailed information regarding these conflicts. The general theme is that boundary issues are not static but require continuing attention over time so as not to break down as staff and circumstances change.
PC/MHI implementation required collaboration between service leaders. At a minimum, engagement of both primary care and mental health leaders in a collaborative effort was needed to support the intervention. Clinic leaders indicated that the intervention benefitted from collaboration with leaders in administration, human resources, nursing service, and specialists in the needs of Veterans returning from Iraq and Afghanistan. Leadership was reported to be effective in bridging boundaries between services, resolving conflicts, requesting and allocating resources, and setting responsibilities for new staff.
PC/MHI is designed to act for multiple constituencies (e.g., PC, MH, and patients), and changes to work design and resources through the PC/MHI intervention affected how those constituencies perceived the intervention. In some cases, these issues were resolved by leader involvement and interservice negotiations. Leaders helped clinicians cross boundaries between PC and MH through formal and informal meetings (Path A→C1). In contrast, other leaders maintained or even strengthened these boundaries between PC and MH by acting as an intermediary between services rather than promoting direct interaction. Leaders were particularly important when conflicts arose across these PC/MH boundaries (i.e., turf wars) over responsibility for patients with urgent mental health needs.
Leadership was broadly identified as important in focusing available resources toward PC/MHI goals (Path A→B1). Sites that reported leaders to be supportive indicated that leadership was particularly valuable for staff recruitment and space allocation. Informants who reported poor leadership support reported long delays for necessary resources, such as changes in the referrals systems that would improve communication. Further, leaders at all levels (e.g., service chiefs, nurse managers) were reported to have an important role in developing training programs that provided mental health knowledge, skills, and abilities needed for the intervention (Path A→B2→B1).
Informants also reported that leadership was an important factor in adjusting work design to improve patient access to mental health care (Path A→B3). Leadership was also reported to have some impact on staff participation (Path A→C3). Leaders were reported to have minimal direct influence in the intervention as changes in care required changes to provider behaviors, but active frontline leader engagement was reported as critical in supporting highly motivated providers (e.g., providing co-located space, supporting work redesign) thereby maintaining but not necessarily creating staff participation (Path A→B1→C3).
Data indicated that patient factors may affect the utilization and effectiveness of referral systems (Factor D), as well as the amount of communication needed between providers (Factor E). Informants reported the importance of differentiating patients with on-going chronic needs who need to see providers in a MH setting versus patients with short-term needs that can be handled in a PC setting. Providers would like to refer some of these complex patients to treatment programs or long-term care facilities but sometimes have difficulty finding the open slots. Regarding the effectiveness of referral systems, staff reported that patients were frequently noncompliant to prescribed treatment and missed appointments. In addition, complex patients require medication coordination that may increase the amount of communication needed between primary care and mental health.
We developed a theory that posits leadership, provider experiences, and organizational factors as key influences on the successful implementation of new mental health coordination practices in real-world healthcare settings. Specifically, factors associated with leadership and organizational characteristics shaped provider experiences, all of which affected the degree to which mental health care was coordinated through referral mechanisms and communication among providers. Organizational factors and provider experiences were important because they set the structural and relational conditions that facilitated and hindered PC/MHI implementation. Though the relationships between individual provider attributes and intervention implementation are often meaningful, our findings suggest that the organizational processes supporting/constraining implementation are extremely important.
Leaders were able to affect provider experiences by providing opportunities for staff to work across professional boundaries, by resolving conflicts, and otherwise supporting staff who were working to implement the intervention. Leaders also were able to modify organizational factors by obtaining and allocating critical resources (e.g., personnel, space), developing training to close staff knowledge or skill shortages, and adjusting work responsibilities to address implementation challenges as they arose. Provider experiences and organizational factors directly impacted how referral systems and interprovider communication were implemented.
This study is a first step toward an explanatory model of organizational coordination intervention implementation that could be applied to a wide range of mental health coordination problems. For example, in addition to outpatient coordination of depression care, transitions of mental health care between inpatient settings and primary care are important. A recent VA study suggests that transitions of mental health care after general medical hospitalizations are particularly important for patients with mental health conditions [
This study has direct, practical implications for mental health providers and managers who are considering implementing changes to how patient care is coordinated across multiple healthcare providers and especially when those providers operate across organizational boundaries (i.e., professional silos). In the context of local responses to a mandated intervention, both leadership and organizational factors (i.e., resources, training and work design) were identified as potential antecedents for the implementation of new referral systems and patterns of communication across providers. Provider factors (i.e., perceived PC/MHI boundaries, and staff participation in the intervention) were reported to be important but only indirectly affected by leaders. Sites in the current study either took advantage of preexisting collaborative relationships between primary care and mental health or utilized highly engaged key individuals to attenuate the boundaries between services and increase staff participation.
The PC/MHI intervention was designed to cross intraorganizational boundaries in that coordination procedures were implemented across PC and MH units within one healthcare facility. However, organizational boundaries can also be interorganizational. For example, coordination procedures could be implemented between independent fee-for-service PC and MH providers or provider groups. We propose that our model is also relevant for these types of interventions. That is, communication patterns between independent facilities such as these will likely depend on the strength of organizational boundaries, the time pressure experienced by staff, and the degree to which staff choose to participate in the intervention. Without a common health system as in VA, organizational boundaries may be stronger and participation may be more variable, but we suggest that the concepts will be similar. Accountable care organizations and medical homes being created in the private sector, for example, may have environments amenable to these types of interventions. Resources, training, and work design may also vary more across independent units and therefore implementing standardized referral procedures may be more challenging, but the key relationships between these concepts are likely to be the same. Because we expect increased variation in both organizational factors and provider experiences when implementing interventions across independent facilities, we expect that leadership will be even more important. Shared vision for the organizational change across independent facilities is likely to be particularly important when redesigning work, allocating resources, and bridging interorganizational boundaries.
The dependent variable for our study was coordination, an operational dimension of integrated care, but we acknowledge that the clinical and financial dimensions of integration are important outcomes of PC/MHI. Patient experiences, patient access, patient outcomes, and cost data would be needed to judge whether the intervention was successful or not. Our study was only able to identify the factors that influenced the implementation process. That is, leadership, organization factors, and provider experiences may be important in changing coordination processes, but those processes may have negligible impact on outcomes. Thus, further research on the clinical, financial, and patient-centered impacts of the PC/MHI model in actual practice settings is recommended.
We did not design this study to measure the impact of patient factors on the intervention implementation. Healthcare integration is typically conceptualized as an organizational factor, but patient experiences of integrated care are an important dimension that is often overlooked in both theoretical and empirical work [
This study was limited in that sites were all sampled from VA, a healthcare network with unique organizational structures compared to other healthcare providers in the United States. Aspects such as its hierarchical structure and the influence it has on different medical centers, the degree to which it is a closed system, and its size, may limit the transferability of findings to other settings [
We acknowledge that clearly specified interventions with stronger evidence may be more easily marketed to clinicians and may be viewed as easier to adopt by local leaders [
Future research on the implementation of interventions designed to improve coordination would benefit from careful initial measurement of the identified organizational, leadership and provider/cultural/social factors to assess baseline capacities relevant for implementation. Repeated measurements of these and related factors over time would allow for exploration of the extent to which they mediate/moderate key intervention outcomes. For example, organizational boundaries due to social and cognitive differences between professions may interfere with intervention implementation [
We used grounded theory to develop a conceptual framework that identifies leadership, provider experiences, and organization factors as key antecedents to local changes when new coordination practices are implemented in healthcare settings. Our results suggest that current organizational resources, training, and work design along with psychological barriers between units, time pressure, and barriers to staff participation in the new coordination procedures at a site are each important factors to consider before implementing an organizational coordination intervention. Results may apply to any local changes intended to improve organizational coordination.
Financial support was provided in part from Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development Grant (IIR no. 05-221) and three VA Office of Academic Affiliations HSR&D postdoctoral fellowships. The views expressed in this paper are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.