Availability of Integrated Primary Care Services in Community Mental Health Care Settings

Over the past two decades, health systems across the country have taken steps to position primary care services within community mental health centers (CMHCs) and outpatient mental health facilities (OMHFs) to increase access to care for chronic medical conditions such as diabetes and hypertension. These efforts have included state initiatives to develop behavioral health homes that provide comprehensive care (1, 2), grant-funded programs such as the Primary and Behavioral Health Care Integration program sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA) (3–5) and the Certified Community Behavioral Health Clinic Demonstration (6).

These and other integration initiatives span multiple states and involve hundreds of facilities. However, the extent to which CMHCs and OMHFs have adopted integrated care models is unknown. Research has not quantified the uptake of integrated primary care in these settings across states or examined the characteristics of facilities that offer such services. Such information would help policy makers and other stakeholders understand the spread of integrated care and target future integration efforts.

To fill this gap in the literature, this brief report used national survey data to examine the availability of integrated primary care and other wellness services within CMHCs and OMHFs. This study also examined whether facility-level characteristics were associated with the availability of integrated primary care services. Given that providing integrated primary care typically requires additional resources, the analysis tested the hypothesis that integrated primary care would be more common among facilities that had greater organizational capacity, engaged in more quality improvement practices, and offered other wellness services.

Methods

The study used the 2016 National Mental Health Services Survey (N-MHSS) public use file. N-MHSS, sponsored by SAMHSA, includes all known mental health treatment facilities in the United States. N-MHSS collects information on facilities’ services, ownership, accreditation, quality improvement practices, accepted forms of payment, and client counts. Ninety-one percent (N=12,745) of the 13,983 facilities surveyed in 2016 completed the survey. Among these facilities, 2,546 identified as CMHCs that served adults (defined by the survey as facilities that met applicable licensing and certification requirements for CMHCs in their state); another 4,471 facilities identified as OMHFs that serve adults (defined by the survey as facilities that primarily provide ambulatory clients with less than 24-hour outpatient mental health services for generally less than 3 hours at a single visit).

The study used descriptive statistics to examine the proportion of CMHCs and OMHFs that offered integrated primary care services, tobacco screening, smoking and tobacco cessation counseling, nicotine replacement therapy and nonnicotine tobacco cessation medications, diet and exercise counseling, and chronic disease and illness management. The N-MHSS item asks whether the facility provides “integrated primary care services.” However, N-MHSS also provides respondents with a detailed definition in supplementary materials, which describes integrated primary care services as those that “address the general health care needs of persons with mental health and substance use problems. These general health care needs include the prevention and treatment of chronic illnesses (e.g., hypertension, diabetes, obesity, and cardiovascular disease) that can be aggravated by poor health habits such as inadequate physical activity, poor nutrition, and smoking. The services include screening, coordinating care among behavioral health care staff and medical staff; and providing linkages to ensure that all patient needs are met in order to promote wellness and produce the best outcomes.”

SAMHSA’s 2014 and 2015 N-MHSS public reports provide information on the proportion of facilities that offered these services to examine change over this time period (7, 8).

The study used logistic regression to model the odds that a facility offered integrated primary care as a function of facility ownership (private for-profit, private nonprofit, or public nonprofit), accepted forms of payment (cash or self-pay, private health insurance, Medicare, or Medicaid), the number of clients served by the facility (as a proxy for facility size or capacity), whether smoking was permitted anywhere on the facility campus (which may provide an indication of the facility’s commitment to wellness), and whether the facility had special programs for populations with serious mental illness, older adults, veterans, individuals with HIV/AIDS, or individuals with co-occurring mental and substance use disorders, given that these populations are often targeted by primary care integration programs, and therefore, integration may be more common among facilities that specifically serve these populations. Each regression also included whether the facility offered smoking and tobacco cessation counseling, diet and exercise counseling, or chronic disease and illness management, given that these facilities may have a stronger commitment to integration. This study reports two separate regressions with the same set of variables: one among CMHCs and another among OMHFs. Each regression included additional variables that may function as indicators of a facility’s commitment to the quality of care, including accreditation status and the number of quality improvement practices reported by the facility. These analyses of publicly available deidentified data did not require institutional review board approval.

Results

Across states, 23% (N=588) of CMHCs and 19% (N=838) of OMHFs offered integrated primary care in 2016. These findings were generally consistent from 2014 to 2016 based on the N-MHSS public reports (5, 6); 20% of CMHCs and 17% of OMHs offered integrated primary care in 2014.

The proportion of CMHCs that offered integrated primary care ranged from 0% in Delaware and North Dakota to 56% in the District of Columbia (the District of Columbia, Oklahoma, Connecticut, Texas, Arizona, and Colorado were the only states in which 40% or more of CMHCS offered integrated primary care; see online supplement to this report). Likewise, the proportion of OMHFs that offered integrated primary care ranged from 0% in Kansas and Wyoming to 71% in North Dakota (North Dakota, Missouri, Hawaii, and South Dakota were the only states in which 40% or more of OMHFs offered integrated primary care). The proportion of CMHCs that offered integrated primary care ranged from 20% in the South to 26% in the Midwest; the proportion of OMHFs that offered integrated primary care ranged from 17% in the South and Northeast to 21% in the Midwest.

In 2016, 48% of CMHCs and 42% of OMHFs offered screening for tobacco use (see the online supplement). Only about one third of these facilities offered smoking and tobacco cessation counseling. Slightly fewer than 15% of these facilities offered nicotine replacement therapy or nonnicotine tobacco cessation medications. Fewer than one quarter of these facilities offered diet or exercise counseling or chronic disease and illness management. These findings were generally consistent from 2014 to 2016 based on the N-MHSS public reports (5, 6).

Controlling for other variables in the model, the odds that a CMHC offered integrated primary care were statistically significantly higher among facilities that did not allow smoking on campus; reported all quality improvement practices listed in the survey; served a larger number of clients; and offered smoking and tobacco cessation counseling, diet or exercise counseling, chronic disease and illness management services, or services for co-occurring substance use disorders (Table 1). The findings were similar among OMHFs with one exception—the odds of providing integrated primary care were not statistically significantly higher among facilities that served a larger number of clients. In addition, among OMHFs, the odds of integrated primary care were statistically significantly higher among private nonprofit facilities or public agencies (compared with private for-profit facilities), facilities that accepted Medicare, and facilities accredited by The Joint Commission. The odds of providing integrated primary care were also higher among OMHFs that had special programs for individuals with HIV/AIDs, but this finding was statistically significant only at the level of p=0.04.

Discussion

Integrated primary care and other wellness services remain uncommon in outpatient mental health treatment settings. The proportion of facilities that reported providing integrated primary care on the N-MHSS is somewhat consistent with findings from a 2013 survey of 435 psychiatrists who work in CMHCs; 38% of those psychiatrists reported that their CMHC provided primary care services and 25% reported that the CMHCs employed a primary care provider (9).

Taken together, the findings from the regression analyses point to several facility characteristics that suggest integrated primary care is more common among facilities that have more capacity (as indicated by their number of clients) and a stronger commitment to wellness and quality improvement (as indicated by the availability of wellness services, nonsmoking policy, quality improvement activities, and accreditation status). This finding may reflect the fact that the implementation of integrated care usually involves engaging in quality improvement processes and putting into place structures to support the delivery of primary care (10).

Given the many integration initiatives across the country, the seemingly low adoption of integrated primary care is somewhat surprising. There could be several explanations to explore in future research. The spread of integrated primary care may be concentrated in a handful of states. Indeed, there was wide variation across states in the availability of integrated primary care within CMHCs and OMHFs. (However, readers should interpret with caution the state-level proportions because of the small number of facilities in some states.) It may also be that a single facility participates in multiple integration initiatives, and therefore, despite various integration initiatives or grant programs within a state, integrated primary care services could be somewhat concentrated among a smaller group of facilities (N-MHSS alone does not contain variables to examine this). For example, some integrated primary care grant programs or state medical home initiatives require facilities to have already demonstrated some level of integration as a condition of participation, which could have an unintended consequence of limiting the spread of integration to facilities that have not yet started integration activities. In addition, although the definition of integrated primary care services included in N-MHSS is broad and does not refer to a single model of care, it may not capture all of the care coordination models or referral practices that facilities use to address general medical and wellness needs (8). Finally, facilities that offer integrated primary care may encounter challenges to sustaining these services (9, 11). The lack of year-to-year changes in the proportion of facilities that offer integrated primary care could reflect these sustainability challenges; some facilities may be newly adopting integrated primary care while other facilities are ceasing to offer these services.

Within a particular state, the proportion of CMHCs and OMHFs that offered integrated primary care services often differed substantially. For example, within Texas 49% of CMHCs offered integrated primary care, whereas only 17% of OMHFs did so. However, in other states such as Missouri, a higher proportion of OMHFs than CMHCs within the state offered integrated primary care. Although a full exploration of this state variation is beyond the scope of this brief report, these differences may reflect where states have chosen to position primary care or Medicaid reimbursement policies in the state.N-MHSS provides a snapshot of services within all known CMHCs and OMHFs (not a sample of facilities) by using self-reported data, but it does not provide detailed information on how these services are implemented or the number of clients who receive them. The findings identified several facility characteristics associated with the availability of integrated primary care services. It is possible that the statistical significance of the coefficients could be driven by the number of facilities and variables included in the regression models. However, the variables included in the models were selected on the basis of their theoretical relationship with the availability of integrated care, many of the findings were statistically significant at a level of p<0.01 or lower, and the statistical significance, direction, and magnitude of the findings were mostly consistent across the two models (which included the same set of variables), all of which help to bolster that the findings are not merely the result of chance. The public use N-MHSS files do not contain facility address, zip code, or county to facilitate examining variation in the availability of integrated primary care services beyond the state level (such as rural versus urban areas). The definition of integrated care in N-MHSS is broad and does not refer to a specific model of care. As a result, respondents may have different interpretations of integrated primary care when answering the survey question. The presence of a specific type of service within a facility does not necessarily equate better access to care for the population served by a facility, given that many factors influence whether clients have access to services. Nonetheless, the findings provide insight into the extent to which integrated primary care and wellness services have been adopted within these settings. The findings are useful to benchmark the future adoption of integrated care.

Conclusions

In most states, integrated primary care remains uncommon in CMHCs and OMHFs, and it appears more common among facilities with specific characteristics. These findings point to further opportunities to expand the availability of integrated primary care.