This report describes the RAND Corporation's evaluation of the Substance Abuse and Mental Health Services Administration's (SAMHSA's) Primary and Behavioral Health Care Integration (PBHCI) grants program. The PBHCI grants were designed to improve the overall wellness and physical health status of people with serious mental illness (SMI) and/or co-occurring substance use disorders (SUDs) by supporting the integration of primary care (PC) and preventive physical health services into community behavioral health (BH) centers where individuals already receive care. This evaluation provides information about the grantees' implementation of PBHCI, consumer outcomes, and PBHCI program features associated with consumer-level processes and outcomes of care. It also includes implications for programs and the boarder field, plus suggestions for future evaluation that may strengthen ongoing and future implementation of PBHCI.
Excess morbidity and mortality in persons with SMI is a public health crisis. Compared with people without mental illness, individuals with SMI (e.g., schizophrenia, other psychoses, bipolar disorder, and severe depression) have higher rates of chronic medical conditions, including hypertension, diabetes, obesity, cardiovascular disease, and HIV/AIDS; higher frequency of multiple general medical conditions; and more than twice the rate of premature death resulting from these conditions (Kelly, Boggs, and Conley, 2007; Mauer, 2006; Parks et al., 2006; Sokal et al., 2004; Saha, Chant, and McGrath, 2007; Laursen et al., 2013).
Numerous factors contribute to the excess burden of general medical conditions among persons with SMI, including low levels of self-care, medication side effects, substance abuse comorbidity, unhealthy lifestyles, and socioeconomic disadvantage (Burnam and Watkins, 2006; CDC, 2012; Druss, 2007). The organizational and financial separation of the behavioral and general health care sectors contributes to disparities in access to and the quality of general medical care for people with SMI (Alakeson, Frank, and Katz, 2010; Bao, Casalino, and Pincus, 2013; Druss, 2007; Horvitz-Lennon, Kilbourne, and Pincus, 2006).
SAMHSA's PBHCI service grant program is intended to improve the health status among adults with SMI and/or co-occurring SUDs by making available an array of coordinated PC services in community mental health centers and other community-based BH settings. The PBHCI grantees evaluated in this report received $500,000 per year to coordinate access to PC and/or services for which there was no funding source, including four core (required) program features:
- screening/referral for needed physical health prevention and treatment;
- developing a registry/tracking system for physical health needs/outcomes;
- care management;
- prevention and wellness support services.
Grantees could also implement six optional program features (same day physical and BH visits; co-located, routine PC services; a supervising PC physician; an embedded nurse care manager; evidence-based practices for preventive care; and wellness programs), infrastructure development, and performance measurement activities.
In 2009-2010, RAND designed the PBHCI evaluation around a structure-process-outcomes framework (Donabedian, 1966, 1980). The evaluation had three evaluation components, each designed to answer one of three research questions:
Research Question 1 (Process Evaluation): Is it possible to integrate the services provided by PC providers and community-based BH agencies (i.e., what are the different structural and clinical approaches to integration being implemented)?
Research Question 2 (Outcomes Evaluation): Does the integration of primary and BH care lead to improvements in the mental and physical health of the population with SMI and/or SUDs served by these models?
Research Question 3 (Model Features Evaluation): Which models and/or model features of integrated primary and BH care lead to better mental and physical health outcomes?
RAND then won a separate three-year contract to conduct this evaluation work (2010-2013). The results of this PBHCI evaluation are described below.
Research Question 1 (Process Evaluation)
To answer this descriptive, process-oriented question, we measured the extent to which key integration features and strategies were present at each grantee site (program and staff-level analyses) and the degree to which individuals with SMI received appropriate integrated services (consumer-level analysis). Data showed that PBHCI programs had multidisciplinary teams with different staff mixes, and that they had different infrastructures and offered different packages of services. Programs also varied in the extent to which their structures and procedures reflected integrated care, with programs offering variable levels of co-located services, structures, and systems shared by primary and BH care providers, integrated practices, and clinic cultures.
PBHCI programs also served a diverse population of consumers with high rates of need for integrated primary and BH care services. Once enrolled in PBHCI, most consumers had some primary and BH care contact during their first year in the program, and more than half accessed a basic package of integrated services, including screening or treatment planning, PC, and case management; consumers were less likely to have accessed substance abuse-related services and wellness services targeting smoking and weight. Improving consumer access to the full array of PBHCI services, particularly among consumers with identified physical health needs, could be a target for future improvements to PBHCI.
Research Question 2 (Outcomes Evaluation)
We conducted a small, comparative effectiveness study consisting of three matched PBHCI and control clinic pairs. Results of a difference-in-difference analysis showed that, relative to consumers receiving services at control clinics, PBHCI consumers showed improvements in some (diastolic blood pressure, total cholesterol, LDL cholesterol and fasting plasma glucose) but not all (systolic blood pressure, body mass index, HDL cholesterol, glycated hemoglobin, triglycerides, self-reported smoking) of the physical health indicators examined. Compared with consumers served at control-sites, consumers served through PBHCI showed no benefit in terms of indicators of BH.
Research Question 3 (Model Features Evaluation)
Instead of implementing different integrated care models in their entirety (e.g., Cherokee model, Chronic Care Model), our initial work showed that many programs implemented "bits and pieces" or combinations of several integration models (Scharf et al., 2013). As such, our approach to Research Question 3 focused on model features whose presence or absence could be reliably assessed. To answer Research Question 3, we used the full sample of 56 grantee data to first identify program-level predictors of consumer access to PC providers and packages of integrated care. Then we used data from the three intervention sites included in the comparative effectiveness evaluation (Research Question 1) to test the relationship between consumer access to primary, integrated care and consumer physical health outcomes. Overall, results showed that several program features had an effect on consumer access to integrated care (e.g., the number of days a PC clinic was open per week, regularly scheduled integrated staff meetings, and other aspects of program-level integration increased access; rural location decreased access), but consumer access to PC and integrated care was not clearly associated with physical health outcomes.
PBHCI programs were successful in several ways, such as building integrated, multidisciplinary teams that offer an array of integrated primary, BH, and wellness services, and across PBHCI grantee programs, these services were provided to a diverse clientele with high rates of need for integrated care. PBHCI programs also experienced several challenges, including lower-than-expected rates of consumer enrollment, financial sustainability, intra-team communication, and creating an integrated clinic culture. These programs also experienced challenges related to implementing wellness programs and improving consumer smoking and weight outcomes. Ongoing and future cohorts of grantees could consider several options to improve program implementation, such as maximizing data-driven, continuous quality improvement; monitoring implementation fidelity to evidence-based wellness programs; and investing in strategies that improve consumer access to integrated services, among others. Stakeholders in the field of integrated care could benefit from consensus around program performance expectations, and the establishment of national quality indicators for integrated care accountability and core performance monitoring requirements. Finally, technical assistance providers could consider continuing dissemination of emerging best care practices for adults with SMI and supporting grantees navigating concurrent health care reforms. Future evaluations, such as an evaluation of PBHCI utilization and costs, strategies to improve sustainability, and a prospective trial of alternative models of integrated care could help SAMHSA and grantees demonstrate the value of their PBHCI work.
|The Full Report is also available from the DALTCP website (http://aspe.hhs.gov/office_specific/daltcp.cfm) or directly at http://aspe.hhs.gov/daltcp/reports/2013/PBHCIfr.shtml.|