integrating mental health services into primary health care

Up to 70% of mental health (MH) patients are followed-up in primary health care (PHC) settings. Outcomes of a partnered facilitation strategy to implement primary caremental health. Dogherty EJ, Harrison MB, Baker C, Graham ID. 2016;22(2):1719. Further, the extent to which some activities were doing versus enabling varied by network. Integrating behavioral health and primary care is a cost-effective way of increasing access to behavioral health services, treatment adherence, and follow-up; addressing mental and physical co-morbidities, recognizing that mental illness and substance abuse can be at the root of physical ailments and vice-versa; and helping to reduce stigma . Your privacy choices/Manage cookies we use in the preference centre. We found that our facilitators engaged in all of these with some caveats, as well as some that previous researchers had not identified and that may be specific to our context. FacilitationActivities in Literature and Debriefing Notes. The site is secure. The mhGAP programme has seen successful integration in pilot district-level programs, but wider implementation has stalled due to stigma and lack of clinical engagement, resources, MH specialists, and policy support. 3rd ed. She provides 15 minutes of counseling on stress management techniques and schedules another appointment in three days. Article Qualitative Research & Evaluation Methods. We explored two of their dimensions for describing the operationalization of strategies: action (the activities facilitators conducted) and temporality (i.e., the order or sequence of strategy use across the phases of implementation). -, Amin-Esmaeili M, Motevalian A, Rahimi-Movaghar A, Hajebi A, Sharifi V, Mojtabai R, et al. Integrated behavioral health model: After you talk with Cecelia about her stress and anxiety, you ask your BHC, whose name is Eleanor, to come in for a quick visit. And in doing so, we may be able to more specifically target interventions to particular contexts or to effectively design and tailor implementation strategies. Before When applying a facilitation strategy, understanding characteristics of the facilitation process may help facilitators to stay focused on the intended purpose of their efforts and how they might best operationalize that purpose. The EF (JEK) was a psychiatrist with expertise in PCMHI care models, implementation science, facilitation, and mentoring. Castelo Family Healthcare Unit (usf Castelo), ACeS Arrbida, Sesimbra, Portugal * . Google Scholar. We advocate for federal and state funding, new and innovative care delivery and payment models, and a strong mental health and substance use treatment workforce. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. Implement Sci. A Norwegian-Russian long-standing collaboration initiative has significantly improved treatment for anxiety and depression (A&D), with 58% reliable recovery rate. World Health Organization. Cykert S, Keyserling TC, Pignone M, DeWalt D, Weiner BJ, Trogdon JG, et al. Keywords: Scholars have long agreed that although the implementation of evidence-based practices and programs will improve the quality of healthcare [1,2,3], the process of implementing and sustaining them is challenging [4,5,6]. However, activities facilitators select may also be influenced by their skills and other characteristics. Thus, both interviewers coded all sites in both networks for quarters one through four, one interviewer coded all sites in one network for quarters 5, 7, and 9 and the other network for quarters 6, 8, and 10. Implement Sci. The https:// ensures that you are connecting to the Implement Sci. While primary care staff should be trained to identify, treat and manage the majority of cases of mental disorders, some more severe cases may need to be referred to specialists at the secondary level of care. This study has several limitations. Sufficient resources (financial and human) are also a pre-requisite for effective mental health treatment at this level of care. Copyright 2021 by the American Academy of Family Physicians. Ritchie, M.J., Parker, L.E. Davis M, Balasubramanian BA, Waller E, Miller BF, Green LA, Cohen DJ. Facilitating implementation of primary care mental health over time and across organizational contexts: a qualitative study of role and process, https://doi.org/10.1186/s12913-023-09598-y, https://doi.org/10.1007/s10488-010-0327-7, https://doi.org/10.1111/j.0887-378X.2004.00325.x, https://doi.org/10.1007/s10488-013-0481-9, https://doi.org/10.1186/s13643-018-0734-5, https://doi.org/10.3122/jabfm.2013.05.130028, https://doi.org/10.3122/jabfm.2015.S1.150054, https://doi.org/10.1080/23288604.2015.1077301, https://doi.org/10.1176/appi.ps.201400054, https://doi.org/10.1007/s11606-018-4581-9, https://doi.org/10.1186/s13012-019-0876-4, https://doi.org/10.1186/s13012-016-0398-2, https://doi.org/10.1111/j.1741-6787.2010.00186.x, https://doi.org/10.1186/s13012-015-0323-0, https://doi.org/10.1186/s13012-015-0252-y, https://doi.org/10.1097/hmr.0000000000000145, https://doi.org/10.1097/xeb.0000000000000008, https://doi.org/10.1046/j.1365-2648.2002.02126.x, https://doi.org/10.1186/s12913-015-0722-6, https://doi.org/10.1186/s12913-017-2537-0, https://doi.org/10.1007/s11606-014-3027-2, https://doi.org/10.1186/s12913-017-2217-0, https://doi.org/10.1002/1098-240X(200008)23:4%3C334, https://openlibrary-repo.ecampusontario.ca/xmlui/bitstream/handle/123456789/296/Principles%20of%20Sociological%20Inquiry.pdf?sequence=1&isAllowed=y, https://doi.org/10.1186/s43058-020-00006-8, https://doi.org/10.1186/s43058-021-00138-5, https://doi.org/10.1186/s43058-021-00180-3, https://doi.org/10.1007/s11606-019-05350-7, https://doi.org/10.1186/s13063-015-1141-z, http://creativecommons.org/licenses/by/4.0/, http://creativecommons.org/publicdomain/zero/1.0/, bmchealthservicesresearch@biomedcentral.com. Aspects of the newly designed infrastructure, along with specification of duties of the various human resources, and its relation with Iran's Comprehensive Mental and Social Health Services (the SERAJ Program), will also be presented Method : This is a study on service design and three methods of literature review, deep interview with stakeholde. Previous studies related to this project demonstrated that this strategy increased the reach and adoption of PCMHI [40] and improved PCMHI program uptake, quality and adherence to evidence [41]. 2004;82(4):581629. And, for people in treatment, the average number of mental health . Both IRFs were network level employees who initially had no implementation science or implementation facilitation expertise. Th ey are com- Integrating mental health services into primary health care - a review of challenges and outcomes in the international setting April 2021 European Psychiatry 64(S1):S401-S402 It is both a role, related to the overall purpose of facilitation, and a process (i.e., how a facilitator operationalizes the role) [24, 25]. Homepage - National Council for Mental Wellbeing The report provides policy makers and planners of health services with the rationale and know-how for moving from an institutional model of mental healthcare to a more holistic, comprehensive integrated delivery system at the primary healthcare level. Cite this article. Thus, Network A sites were generally more receptive to the general concept, although not initially the particulars of PCMHI than were those in Network C, and the Network A facilitator engaged more in the day-to-day work of collaborating with sites on implementing the program than the Network C facilitator. Fam Syst Health. Facilitators supporting implementation often conduct a wide variety of activities [25,26,27]. https://doi.org/10.1186/s13012-016-0398-2. Implement Sci Commun. When making referrals to the BHC becomes part of the clinic's normal daily workflow, the BHC becomes an integrated part of the team and the normalization of behavioral health care destigmatizes the process of working with a behavioral health provider. Continued professional development (CPD) training courses of primary healthcare workers should also include a strong mental health component. Key components of external facilitation in an acute stroke quality improvement collaborative in the Veterans Health Administration. In this study, activities did not occur according to a defined series of ordered steps or phases but were responsive to context. Preparing the workforce for behavioral health and primary care integration. 2012;7:9. https://doi.org/10.1186/1748-5908-7-9. Process evaluation of a knowledge translation intervention using facilitation of local stakeholder groups to improve neonatal survival in the Quang Ninh province Vietnam. Future work should identify these. Additionally, scholars have suggested that the activities facilitators conduct to operationalize their roles also lie on a continuum. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The other IRF was a master level social worker who had clinical training and extensive experience in program quality improvement. The Nuance Dragon Ambient eXperience, or DAX for short, is a voice-enabled, ambient clinical intelligence solution that automatically captures patient encounters securely and accurately at the point of care. For example, changing the type of medications that providers use for managing cholesterol levels may not require the entire set of implementation facilitation activities we have identified. Chapter For example, one small clinic lost one of their traditional mental health providers and there were no plans to replace him. Integrating mental health therapy into primary care Health is now widely acknowledged as having both a physical and mental health dimension. All authors edited, reviewed, and approved the final manuscript. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Role of external facilitation in implementation of research findings: a qualitative evaluation of facilitation experiences in the Veterans Health Administration. On the other end of the continuum, the purpose of facilitation, and thus the role of the facilitator, is holistic, e.g., to develop and empower individuals and teams and create a supportive context for change [29, 33, 35, 36]. The difference in our findings may be related to the complexity of PCMHI and the primary care environment, the high staff turnover rate, or the approaches to exploring activities (e.g., types versus discrete activities). In Peru, a similar initiative allowed early detection, referral, and treatment of MH patients attending PHC services. http://creativecommons.org/licenses/by/4.0/. https://doi.org/10.1111/wvn.12098. official website and that any information you provide is encrypted Also, some BHC work, such as curbside consults, may not qualify for separate reimbursement.2. It may be that patterns of activities in facilitation phase models are based on when activities start rather than when they are provided most intensely. & Kirchner, J.E. Both the particular clinical context, primary care, and the evidence-based program being implemented, PCMHI, are highly complex. Concordant with this purpose and their intended roles, facilitators conducted some activities primarily focused on doing things for sites and others focused primarily on enabling sites to do things for themselves. Many activities did not fall primarily toward one end of the doing/enabling continuum. The VA Central Institutional Review Board (#0905) approved the conduct of the study and provided regulatory oversight, including the documentation of facilitators quality improvement activities through debriefing interviews without documentation of informed consent. On the other hand, when people receive treatment in primary healthcare facilities the likelihood of better health outcomes, and even full recovery, as well as maintained social integration is increased. Additionally, the characteristics of primary care settings, including their capacity for change, vary extensively. Thus, facilitators will need the knowledge and skills to be able to flexibly move along the doing for/enabling to continuum with a goal of sites ultimately being able to take responsibility for facilitation activities. Primary healthcare is the first level of contact of individuals, the family and community with the national health system, the closest and easiest form of care available, located near to peoples' homes and communities.2 In many countries however, psychiatric institutions are the only form of mental health-care available to the population. Ritchie MJ, Parker LE, Kirchner JE. Bookshelf First Edition. 2000;23(4):33440. New York, NY: Springer; 2013. This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (, The Author(s), 2021. There may be other dimensions of implementation facilitation that need to be specified, applied, and evaluated. See this image and copyright information in PMC. Finally, the purpose of implementation facilitation in this study was both task-focused and holistic. We also found that some activities could be either something that the facilitator did for or enabled the clinic to do for themselves, depending on needs, skills, and other organizational circumstances. Using implementation facilitation to foster clinical practice quality and adherence to evidence in challenged settings: a qualitative study. Integrated behavioral health in primary care. For example, if the purpose of facilitation is partially or entirely holistic, then facilitation activities selected to operationalize the related role must include a large measure of enabling activities. You talk to Cecelia on the phone and prescribe a selective serotonin reuptake inhibitor. Other countries have developed their own evidence-based interventions. volume23, Articlenumber:565 (2023) Although studies have been documenting the range of activities facilitators perform, scholars continue to call for a better understanding of what facilitators do [28, 29]. Psychiatric Beds in the Health System of Iran. the contents by NLM or the National Institutes of Health. Against the backdrop of renewed international attention on primary healthcare and the upcoming 2008 World Health Report on the same topic, WHO and WONCA are developing a Report on Integrating Mental Health into Primary Health Care. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Integration of mental health into primary health care1 Mental, neurological, and substance use disorders are common in all regions of the world, affecting every community and age group across all income countries. 2016;11(1):113. Article Integrated behavioral health has been shown to improve depression scores and improve the patient and physician experiences.3 Small studies have also demonstrated cost savings from lower rates of emergency department visits and improved health outcomes.4, There are some barriers to integrating behavioral health. Integrating behavioral and physical health care in the real world: early lessons from Advancing Care Together. Unable to load your collection due to an error, Unable to load your delegates due to an error. It may be that there are other dimensions of implementation facilitation strategies that should be specified and reported. Arch Iran Med. London: Routledge; 2015. Chapter 11. A randomized trial of practice facilitation to improve the delivery of chronic illness care in primary care: initial and sustained effects. There was turnover at every level in key positions such as clinical leaders and PCMHI providers. Islamic Republic of Iran. One of the IRFs was a doctoral level psychologist who had been a mental health therapist and educator. Aarons GA, Hurlburt M, Horwitz SM. RPCC | Integrating Behavioral Health & Primary Care To address this challenge, the facilitator had to spend more time over a longer period in stakeholder engagement and overcoming resistance to change activities. The Final results were discussed with experts, during which the main five-domain questions were asked and the experts' opinions were observed. 2015;28(Suppl 1):S4151. https://doi.org/10.1007/s11606-014-3027-2. Policies, delivery models, and lessons learned from integrating mental health and substance abuse services into primary health care in Ethiopia FASEB Bioadv . The integration of mental health into primary health care can pose various challenges to facilities, health care providers, and mental health service users. official website and that any information you provide is encrypted It is not meant to be a handoff of care, but a team-based approach supporting the work of the primary care physician. When autocomplete results are available use up and down arrows to review and enter to select. 2017;4(6):1126. Qual Health Care. Those that occurred primarily at the beginning, were ones that logically either only could (i.e., baseline data collection) or should (e.g., planning) occur during the beginning of the implementation process. 2013;26(5):588602. Coding consisted of 1) identifying which facilitation activities occurred in each quarter; 2) rating the level of intensity (high, moderate, or minor) of each activity in each quarter; and 3) documenting whether facilitators were doing these activities for sites, enabling site members to perform these activities themselves, or doing a combination of the two. https://doi.org/10.1037/a0020130. Mental healthcare, available in primary healthcare, means that people are able to access the treatment and care that they need near to their homes, and thus keep their families together, maintain their support systems, remain integrated and active in the community and continue to contribute to household productivity. Cucciare MA, Marchant K, Lindsay J, Craske MG, Ecker A, Day S, et al. transportation to facilities located in urban areas, loss of productivity related to the time spent in accompanying the patient to hospital, etc) are avoided, making primary healthcare the most affordable option both for patients, the community and the country.2 In addition, in most countries, primary care services are either free or at least less expensive than secondary or tertiary care. PubMed 173 (Prepared by the Minnesota Evidence-based Practice Center under Contract No. Only with a formal commitment at the highest level of government can this undertaking really succeed. The Quebec MH reform promoted integrated service networks, improving accessibility and quality of care (QoC). BMC Health Serv Res. PCMHI models are complex and implementing them requires structural and process changes to care delivery [7,8,9]; changes in providers roles, skills, values, and attitudes [8, 10,11,12]; and changes in organizational culture [13, 14] and work processes [8, 11]. Department for Mental Health and Substance Abuse. Here are some resources that can help: Agency for Healthcare Research and Quality: What is integrated behavioral health?. Funk M, Saraceno B, Drew N, Lund C, Grigg M. Commentary on The Israeli Model of the District Psychiatrist A fifty-year perspective', Israel Journal of Psychiatry Related Sciences, A framework for mental health policy, legislation and service development: addressing needs and improving services, WHO Module on Human Resources and Training in Mental Health, WHO Module on Organization of Services for Mental Health, www.who.int/governance/eb/who_constitution_en.pdf, www.who.int/hpr/NPH/docs/declaration_almaata.pdf. Services were prioritized and the master flowchart for mental health service delivery was designed. 2010;7(2):7689. From classification to causality: advancing understanding of mechanisms of change in implementation science. From novice to expert: methods for transferring implementation facilitation skills to improve healthcare delivery. Millbank Q. Some PCMHI providers struggled to make the transition from a mental health service model with lengthy wait-times, lengthy appointments, and long-term follow-up to a PCMHI model with same-day access, briefer appointment times, and briefer interventions. Disclaimer. Furthermore, because primary care facilities are in or near people's communities, many indirect health expenditures associated with seeking care further afield (e.g. In 2008, the Substance Abuse and Mental Health Services Administration began working with state mental health authorities to pilot a model for the integration of behavioral health and primary care services to improve access to care. Stop exclusion, dare to care, National Institute for Health Care Excellence, Depression: management of depression in primary and secondary care, Treatment and prevention of mental disorders in low-income and middle-income countries. Objective: The main objective of this study was to review aspects of the current situation and structure of the integrated mental health care services for planning a reform. However, several barriers impact wider implementation and scale-up. Download (3.8 MB) Overview This report provides the rationale and know-how on successfully integrating mental health into primary health care. J Gen Intern Med. Overviewing countries' strategies towards integrating MH services into PHC, their outcomes and challenges. Ever evolving context, rather than implementation phase, however, dictated the presence and intensity of most activities at particular times and in particular places. Baker N, Lefebvre A, Sevin C. A framework to guide practice facilitators to building capacity. This report is divided into distinct parts, with different needs in mind. Our findings are a first step but are intriguing enough, we believe, to suggest that further longitudinal research across a broad range of clinical and organization contexts would help us deepen our understanding of how facilitation fosters evidence-based practice implementation. The Quebec MH reform promoted integrated service networks, improving accessibility and quality of care (QoC). Accessibility Although facilitation is described as dynamic, activities are often framed within the context of a staged process. This study was part of a large project that successfully tested a facilitation strategy within the context of a Department of Veterans Affairs (VA) national initiative to implement evidence-based PCMHI care models [38]. A Danish collaborative care intervention provided high-quality treatment of moderate A&D. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. Types of internal facilitation activities in hospitals implementing evidence-based interventions. In that case, it's essential for patients to be . The intended role of a facilitator can lie anywhere along this continuum. Solberg LI, Crain AL, Jaeckels N, Ohnsorg KA, Margolis KL, Beck A, et al. The purpose of this facilitation strategy was both task-focused (i.e., to support PCMHI implementation) and holistic (i.e., to build capacity for future implementation efforts). When you see him two months later, he has stopped smoking and credits Eleanor's constant support. Close this message to accept cookies or find out how to manage your cookie settings. To create a list of activities with definitions, they conducted a content analysis of activity definitions in selected articles and combined those that used different labels but described the same actions. We created a comprehensive list of implementation facilitation activities based on our literature review and our debriefing notes (see Additional file 1). 2014;41(4):45568. Exploring the importance of predisposing, enabling, and need factors Mental Health Services Healthcare organization primary health care Mental Health integration. Health Res Policy Syst. The purpose of this study was to understand stakeholder perspectives regarding barriers and facilitators to integration of mental health services into . Facilitators primarily enabled sites members to do other activities themselves, i.e., these activities were more toward the enabling end of the continuum. sharing sensitive information, make sure youre on a federal The project utilized a two-person facilitation team consisting of an expert external facilitator (EF) and an internal regional facilitator (IRF). The .gov means its official. Washington (DC): The International Bank for Reconstruction and Development / The World Bank; 2017 Nov 3. Mental illness accounts for about one-third of the worlds disability, a burden that many health systems cannot adequately respond to. Proctor E, Powell B, McMillen J. 2003;1(2). This study explored Veteran and family member perspectives on factors that drive post-traumatic stress disorder (PTSD) therapy engagement within constructs of the Andersen model of behavioral health service utilization. INTEGRATING MENTAL HEALTHCARE INTO PRIMARY HEALTH CARE SERVICES: A CALL TO STRENGTHEN THE PRIMARY HEALTHCARE LEVEL By Peter Eyram Kuenyefu, Snr. To bridge the treatment gap, the World Health Organization developed mhGAP, a guidance package for integrated management of priority MH disorders in lower-income countries. Eriksson L, Huy TQ, Duc DM, Ekholm Selling K, Hoa DP, Thuy NT, et al. Inclusion in an NLM database does not imply endorsement of, or agreement with, 2006;1:23. https://doi.org/10.1186/1748-5908-1-23. Thousand Oaks, CA: Sage Publications, Inc.; 2002. Comprehensive, integrated and responsive collaborative care models are a cost-efficient strategy to improve QoC for many MH conditions across diverse populations. Anyone you share the following link with will be able to read this content: Sorry, a shareable link is not currently available for this article. psychiatrists or mental health nurses) must be made available to primary care staff to give advice and guidance on the management and treatment of people with mental disorders.11. Integrating Mental Health Into Primary Care - Google Books In fact, for most activities, there was no pattern to their occurrence. https://doi.org/10.1097/hmr.0000000000000145. Indeed, as far back as 1948, WHO's constitution recognised health as a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity.1 Despite this, many primary healthcare systems in countries around the world focus on physical care, failing to provide mental healthcare to their populations. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

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