ORIGINAL PAPER
An Examination of Perceptions in Integrated Care Practice
Victor Ede • Martha Okafor • Rosemary Kinuthia •
Zena Belay • Teclemichael Tewolde •
Ernest Alema-Mensah • David Satcher
Received: 1 June 2014 / Accepted: 28 January 2015 / Published online: 7 February 2015
Springer Science+Business Media New York 2015
Abstract Successful integration of behavioral health and
primary care services is informed by perceptions of its
usefulness to the consumer. An examination of provider,
staff and patient perceptions was conducted across five
integrated care sites in order to describe and examine
perceptions and level of satisfaction with integrated care. A
quantitative study was conducted with data collected
through surveys administered to 51 patients, 27 support
staff, and 11 providers in integrated care settings. Survey
responses revealed high levels of satisfaction with integration
of primary and behavioral health services. Integrated
care can be enhanced by addressing provider
competency and confidence concerns through continued
education, increased collaboration and utilization of diagnostic
tools. This analysis provides evidence to support that
successful integration increases access to mental healthcare,
which is instrumental in reduction of the mental
health treatment gap by scaling up services for mental and
substance use disorders among individuals with chronic
medical conditions.
Keywords Integrated care Primary care Behavioral
health Perception Satisfaction
Introduction
Approximately one fourth of adults in the United States
have some form of mental illness, and nearly half will
develop at least one mental illness during their lifetime
(Kessler et al. 2005). Mental illness is a significant community
and public health burden, both in its own right and
because the condition is associated with other chronic
diseases such as Hypertension and Diabetes Mellitus; and
V. Ede (&) M. Okafor R. Kinuthia
Satcher Health Leadership Institute, Division of Behavioral
Health, Morehouse School of Medicine, 720 Westview Drive
S.W., Atlanta, GA 30310, USA
e-mail: [email protected]
M. Okafor
e-mail: [email protected]
R. Kinuthia
e-mail: [email protected]
Z. Belay
Master of Public Health Program, Morehouse School of
Medicine, 720 Westview Drive S.W., Atlanta, GA 30310, USA
e-mail: [email protected]
T. Tewolde
Clinical Research Center, Morehouse School of Medicine, 720
Westview Drive S.W., Atlanta, GA 30310, USA
e-mail: [email protected]
E. Alema-Mensah
Community Health and Preventive Medicine/Clinical Research
Center/R-Center Biomedical Informatics Unit, Morehouse
School of Medicine, 720 Westview Drive S.W., Atlanta,
GA 30310, USA
e-mail: [email protected]
D. Satcher
Satcher Health Leadership Institute, 16th Surgeon General of the
United States, Morehouse School of Medicine, 720 Westview
Drive S.W., Atlanta, GA 30310, USA
e-mail: [email protected]
123
Community Ment Health J (2015) 51:949–961
DOI 10.1007/s10597-015-9837-9
their resulting morbidity and mortality (Reeves et al. 2011).
Almost 20 years ago, the Institute of Medicine (IOM) declared
primary care and behavioral health to be inseparable
(National Research Council 1996). The 16th US Surgeon
General, indicated that due to the decentralized and complex
nature of mental health care, improvements must rely
on partnerships between primary care providers and mental
health centers to ensure coordinated treatment (Satcher and
Druss 2010). The Agency for Health care Research Quality
(AHRQ) (Croghan and Brown 2010) and other state and
federal agencies have also advocated for integrating delivery
of physical and behavioral health services as a way
to improve the quality of patient care. Evidence from
randomized controlled trials demonstrates that integrated
care improves process of care (Katon et al. 2004) and
clinical outcomes for patients with common medical and
behavioral conditions (e.g., diabetes, depression, and
anxiety), (Unutzer et al. 2002) including patients’ overall
quality of life. Furthermore, AHRQ reported on an extensive
analysis of studies regarding various forms of integrated
behavioral and primary health care services (Butler
et al. 2008) and tried to measure improvement in client
outcomes. This report concluded that in general, the integration
of mental health, substance abuse, and primary care
has a positive effect on client outcomes (Butler et al. 2008).
Now, with the implementation of the Affordable Care Act
(ACA), integration of mental health and substance use
disorder services with primary care services is projected to
be a focus of the healthcare delivery system. This is because
the ACA requires a set of comprehensive essential
health benefits, establishes ‘‘health homes’’ wherein states
can receive Medicaid support for providing integrated
health services, and encourages multidisciplinary teams.
The ACA also has established the Innovation Center to
look at possible new funding mechanisms to pay for integrated
care which is crucial to the successful implementation
of integrated care. While the ACA is expected to
accelerate the movement toward integration of care (Buck
2011), little is known about the perceptions of patients,
staff, and providers who are involved in both integration of
behavioral health services in primary health settings, and
integration of primary health services into mental health
settings (reverse integration).
Successful implementation of integration of primary
health services in behavioral health settings or vice versa
depends on the integrated efforts of various types of staff,
such as mental health/substance use disorder staff, support
staff, and primary care providers (Urada et al. 2012). Patients’
perceptions and level of satisfaction also, is a key
factor in the successful implementation of integration. Staff
members’ and patients’ perceptions of and satisfaction with
integration of care are therefore important measures of
progress towards integration. However, there are limited
studies (Levine et al. 2005; Unutzer et al. 2002) that have
looked at perceptions and levels of satisfaction with integrated
care services holistically, i.e. assessed patients, and
considered both integration and reverse integration settings.
We aimed to: (1) describe providers’, staff, and patients’
perceptions and level of satisfaction with integrated
behavioral health services; (2) examine providers’, staff,
and patients’ perceptions and level of satisfaction with
primary and behavioral health integration, and/or reverse
integration.
Methods
The Satcher Health Leadership Institute (SHLI), through a
partnership with Kaiser Permanente implemented an Integrated
Care Practice Change and Quality Improvement
initiative (ICPCQI). Through a competitive request for
proposal process, five integrated care community health
centers were selected to participate in the SHLI-ICPCQI by
a peer review team. By definition, integrated care involved
behavioral health working within and as part of primary
care. These community health centers included two behavioral
health centers (reverse integrated care centers),
i.e., Cobb County Community Service Board (The Circle)
and McIntosh Trail Community Service Board, and three
primary health centers, i.e., Saint Joseph’s Mercy Care
Services, Asa G. Yancey Family Practice Center, and
North Fulton Service Center.
A Community of Practice (CoP) for the ICPCQI was
formed by the five integrated care community health centers
and the SHLI to engage in collective shared learning
with a common interest and commitment to improve health
outcomes of their patients with both medical and behavioral
health problems using an integrated care practice
model. These five community health centers shared,
learned and implemented changes in their health centers to
transform their practice to be more integrated. All aspects
of this study were approved by the Morehouse School of
Medicine Institutional Review Board.
Description of Integrated Care Practice Change
and Quality Improvement Initiative
Primary Healthcare Sites- Integration
Saint Joseph’s Mercy Care Services Saint Joseph’s
Mercy Care Services (SJMCS) is a Federally Qualified
Health Center (FQHC) which provides primary health
services to the homeless and underserved in metro Atlanta
through a combination of fixed and mobile clinic sites.
SJMCS’ primary service area is comprised of Fulton and
DeKalb counties which includes the city of Atlanta.
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SJMCS serves approximately 11,856 homeless and underserved
patients yearly. Medical services and behavioral
health services were provided within the clinics by a team
of primary care physicians, nurses, behavioral health clinicians,
and embedded psychiatrist. Patients with medical
needs who had behavioral health complaints were referred
to the co-located psychiatrist or behavioral health clinician
(see Table 1). In addition, the SHLI implemented the
ICPCQI through a series of five eight-week group psychoeducational
sessions held for patients with hypertension
and depression over the 12-month grant period. The expected
outcomes included: Increased mental health
screening rates; increased satisfaction rate with the overall
improvement project among participants; increased
knowledge of integrated care among providers trained using
the SHLI Integrated Care Curriculum; improved health
outcomes among patients with hypertension and co-occurring
depression and; increased adherence to their prescribed
treatment regimen.
Asa G. Yancey Family Practice Center Asa G. Yancey
Family Practice Center (AGY) serves approximately 18,000
patients per year, majority of who are underserved. AGY has
a mission to improve the health of the community by providing
quality, comprehensive primary and preventive
healthcare in a compassionate, culturally competent, ethical
and fiscally responsible manner. As an integrated site, AGY
used a co-location model of care in the delivery of medical
and behavioral health services. Medical and behavioral
health services were coordinated by family physicians, internists,
nurses, and an on-site embedded psychiatrist (see
Table 1). The psychiatrist held weekly didactic sessions on
common mental health and substance use disorder topics
(depression, anxiety, and bipolar disorder) with the physicians.
There also were regular on-site consultations between
the psychiatrist and medical providers to increase the skills
of both groups. AGY obtained and implemented a computerized
kiosk for the screening and assessment of all patients
for Depression, Post Traumatic Stress Disorder, Bipolar
Disorder, Psychosis, and Substance Abuse. The expected
outcomes included: increased rate of clinic screening for
targeted mental health conditions; improved quality of depression
care as a result of automated symptom severity
assessment; improved rates of referrals to internal and external
mental health treatment; and improve health outcomes
of those under treatment.
The North Fulton Health Service Center The North Fulton
Health Service Center (NFHSC) provides integrated
social and primary health care services to a largely
Table 1 Summary of primary care—behavioral health integration models used in the ICPCQI sites
Location St. Joseph’s
Mercy Care
Services
Asa G. Yancey Family
Practice Center
Cobb county
Community
Service Board
North
Fulton
Health
Center
McIntosh Trail Community
Service Board/Hope Health
Clinic
Model Co-location Co-location Reverse colocation
Co-location Collaborative care
Added quality
improvement services
Group psychoeducation
Computerized kiosk for
mental health and substance
use screening
Relaxation and
wellness
Group
psychoeducation
Depression management for
patients with congestive
heart failure
Type of setting FQHC Community primary health Community
mental health
Community
primary
health
Community mental health
Provider of behavioral
health care/mental
health team
Psychiatrist
LPC, LCSW
Case manager
Psychiatrist Psychiatrist
Case manager
LPC, LCSW, CPS
Psychiatrist
LPC
Psychiatrist
Clinical psychologist
Nurse
LCSW, LPC, LAPC
Provider of medical care Nurse
practitioner
Family physician
Internist
Nurse
Nurse practitioner Family
physician
Nurse
Physician assistant
Nurse practitioner
Clinical survey
Instruments
Patient
satisfaction
Staff
satisfaction
Provider
satisfaction
Patient satisfaction
Staff satisfaction
Provider satisfaction
Patient
satisfaction
Staff satisfaction
– –
FQHC Federally Qualified Health Center, LPC Licensed Professional Counselor, LAPC Licensed Associate Professional Counselor, LCSW
Licensed Clinical Social Worker, CPS Certified Peer Specialist
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minority population. An embedded psychiatrist and behavioral
health clinicians were co-located to provide care
to patients referred for mental health evaluations by the
primary care physician. To augment this co-location integrated
care model, SHLI-ICPCQI supported the implementation
of a psycho-educational group therapy program
(see Table 1). Patients that presented to NFHSC with a
diagnosis of Diabetes, Hypertension and/or Obesity were
screened for depression using the PHQ-9 Screening
Questionnaire. Those that screened positive were offered
the group sessions with the psychologist and of those that
consent, a referral was generated. The psychologist had 1 h
long psychotherapy sessions once a week with the group
for a total of 8 sessions. The expected outcomes of this
initiative included: increased awareness/knowledge of
Hypertension, Diabetes, Obesity and co-occurring Depression;
improved patient satisfaction with integrated behavioral
health care services; increased access to
behavioral healthcare; increased health outcomes among
those undergoing group therapy, i.e., reduced severity of
depressive symptoms; maintenance of healthy blood pressures
and HbA1c,; and maintenance of healthy body mass
indexes
Mental Health Sites- Reverse Integration
Cobb County Community Services Board-The Circle The
Cobb County Community Services Board (CCSB) is a
provider of public behavioral healthcare services in Cobb,
Douglas, and Cherokee counties, Georgia. Cobb CCSB
provides care to ‘‘hard to service’’ populations and the
most in need relative to mental health, developmental
disability, and substance abuse services. Cobb CCSB
serves between 13,000 and 14,000 patients annually. A
majority of these patients have Severe and Persistent
Mental Illness (SPMI) such as Schizophrenia, Schizoaffective
disorder, Delusional disorder, Psychosis, Bipolar
disorder, Severe depression and co-morbid chronic medical
disease. A reverse co-location integrated care approach
(Table 1) in which a nurse practitioner is stationed
in the facility to monitor physical health, and provide
medical treatment to patients with serious mental illness
who have medical comorbidities was used. The behavioral
health team (Psychiatrist, Behavioral Health Clinicians,
Case manager, Intensive Care Managers, and
Certified Peer Specialists) coordinate the mental health
and substance use care delivery to patients. To complement
these integrated care efforts, the SHLI provided
support to Cobb CCSB to specifically implement a Relaxation
and Wellness program that focused on building
relaxation and stress management skills to individuals
with serious mental illness or a co-occurring substance
abuse disorder and one of the following cardio-metabolic
disorders: Diabetes, Hypertension, or Cardiovascular
disease and ensured that they were able to practice these
skills as often as necessary. The project had 3-month
cohorts of 20 individuals and projected to serve a total of
60 individuals over the course of the grant period. The
expected outcomes included to: Increased level of satisfaction
with the wellness and relaxation program; increased
mental health screening rates; improved health
outcomes; increased ability to implement a regular relaxation
routine among participants and; increased confidence
in handling stressful situations among participants
McIntosh Trail Community Service Board Spalding
Health Initiative (SHI) was established to improve the
health of individuals who have psychiatric disorders and
significant health risks by coordinating care through community
resources. McIntosh Trail Community Service
Board through its SHI, addresses the needs of individuals
who have SPMI and chronic medical conditions through an
integrated approach, while identifying those individuals
without health benefits as being a priority. The spectrum of
presenting psychiatric diagnoses seen range from
Schizophrenia, Bipolar disorder and Major depression, to
Anxiety disorder and Post Traumatic Stress Disorder, with
SPMI being more prevalent. The Hope Health Clinic is the
primary care provider (PCP) for those individuals seen at
McIntosh Trail CSB who meet these criteria.
The target population was those individuals who present
at the emergency department with congestive heart disease
and screen positive for depression. This initiative provided
health homes which include primary care services, behavioral
health interventions, comprehensive care management
and care coordination, transitional care from inpatient to the
primary care setting and follow up. The behavioral health
consultant (BHC) provided a comprehensive mental health
evaluation. Individualized treatment plans were developed
with the individuals, the BHC, and the medical staff ensured
that both the medical and behavioral health needs were included
in the plan. The BHC worked with the individuals to
identify barriers to success and assist the individual in developing
strategies to improve their overall health. Peer
groups were established with the identified individuals and
each also received nutrition counseling, group support,
family groups, and individual therapy and linked with other
community resources. The BHC also provided follow up and
tracked these individuals to address adherence with the
treatment plan. The expected outcomes included: improved
clinical outcomes among congestive heart failure individuals
co-morbid depression; increased awareness/knowledge regarding
prevalence congestive heart failure with co-occurring
mental health issues and; reduction in hospitalization
and readmission rates.
952 Community Ment Health J (2015) 51:949–961
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Procedure
A descriptive cross-sectional study design, with a convenience
sampling method was used. A total of three surveys
that assessed perceptions, satisfaction, and acceptability
toward integrated care services among patients, support
staff, and providers were administered. E-mails were sent
out in July–August 2013, approximately 2 weeks apart, to
members of the CoP to introduce the surveys and request
for involvement in the recruiting process at respective sites.
Provider satisfaction surveys were administered at two
integrated care sites. To obtain the provider satisfaction
data, an embedded psychiatrist met individually with the
PCPs at one integration site to briefly describe the survey
objectives and obtain verbal consent for participation. The
surveys were distributed in paper form to all providers
during regularly scheduled PCP meetings. The providers
were not given any compensation, or required to sign an
informed consent for participation. In the other site, one
CoP representative facilitated the distribution of the surveys
to the site’s providers.
To obtain patient and support staff satisfaction data, a
CoP representative administered paper forms of the survey
to patients and support staff at each integration site between
July and October, 2013. The patients surveyed were
mainly those that directly benefited from the ICPCQI initiative.
The patients were recruited to participate in the
study during their group psycho-educational sessions, relaxation
and wellness session, or came for their follow-up
visit. The support staffs were mainly those that were involved
in the ICPCQI initiative. Support staff participants
were recruited by an assigned CoP representative located in
their site. Administration of the surveys was preceded by
brief descriptions of the survey objectives and verbal
consent. The surveys were anonymous and no incentives
were given.
Participants
The following groups were targeted at all five ICPCQI
sites, each with their own surveys: (1) Providers (Physicians,
Nurse practitioners, Psychiatrists); (2) Support staff
(Medical assistants, Licensed professional counselors,
Administrative assistants, Front office staff, and Medical
records staff); and (3) Patients.
Only three of the five sites collected survey data. There
were a total of 51 patient, 27 support staff, and 11 provider
respondents. A total of 330 patients received care at four
ICPCQI sites. Patients were not surveyed at one site due to
logistical reasons. Of the 330 patients who were eligible to
participate in the patent satisfaction survey, a response rate
of 15.7 % (n = 51) was obtained. This response rate was
lower than the rates seen in similar integrated care patient
satisfaction surveys (Funderburk et al. 2012).
All providers involved in the ICPCQI were eligible to
complete the provider satisfaction survey. Eleven participants
did so, yielding a 78.6 % response rate. This response
rate closely mirrors the rates seen in a similar
provider satisfaction survey (Funderburk et al. 2012). Because
of the small number of providers at our ICPCQI
clinics and the need to maintain their anonymity to encourage
higher response rates, demographic information
was not collected from the participants.
Twenty seven support staff completed the staff satisfaction
questionnaire from 3 of 5 ICPCQI sites. There were
no responses from support staffs at 2 sites. It was difficult
to determine the response rate among the support staff
because some of the sites were in a transition phase, while
some were at different levels of integration and were unsure
about completing the survey.
Measures
The support staff and patient surveys were adapted from
questionnaires developed by the Tides Center’s Integrated
Behavioral Health Project, and modified by (Urada et al.
2012). The support staff and patient questionnaires were
further modified to include demographics items. Provider
satisfaction tools were adapted from the Integrating Primary
Care and Mental Health Services: Final Evaluation
Report on the ICARE Integration Pilot Sites (Morrissey
et al. 2009). The provider satisfaction survey used was not
modified.
Patient Satisfaction Survey
Participants answered six demographic questions (i.e., age
range, gender, ethnicity, race, education level, and insurance
status), and to indicate their ICPCQI site and number
of clinic visits. Patients rated their level of agreement with
9 statements related to satisfaction and comfort levels with
treatment and treatment settings. These questions were on a
Likert scale ranging from (1) strongly disagree to (3) neither
disagree nor agree to (5) strongly agree. For those
participants who completed the Likert aspect of the questionnaire,
Cronbach’s alpha for the nine items was 0.83.
Support Staff Survey
Participants answered two demographic questions (i.e.,
ethnicity and race), and were asked to indicate their
ICPCQI site. The following fourteen questions assessed the
perceptions and satisfaction levels with integration efforts
at their site. These questions were on a Likert scale ranging
from (1) strongly disagree to (3) neither disagree nor agree
Community Ment Health J (2015) 51:949–961 953
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to (5) strongly agree. For those participants who completed
the Likert aspect of the questionnaire, Cronbach’s alpha for
the fourteen items was 0.84.
Provider Survey
Participants answered 34 Likert scale questions pertaining
to the topics of treatment patterns, clinical algorithms/best
practice, physical proximity, temporal proximity, communication,
patient care, appropriate care processes, and
provider satisfaction with integrated care.
Data Analysis
Data were entered into a Research Electronic Data Capture
(REDCap) database and analysis was conducted using SAS
9.2 statistical software. The analysis was descriptive
statistics, including frequencies, medians, standard deviations
and ranges for the individual survey items. A bivariate
analysis was performed for all patient survey
participants to analyze and compare responses from integration
versus reverse integration sites.
Results
Patients, support staff, and PCPs from three of the five
ICPCQI sites participated in this study. Two (AGY and
SJMCS) were primary care integration sites. Of the 51
patients who participated, the majorities (58.8 and 74.5 %)
were black/African American and had no insurance respectively
(see Table 2). More than 80 % of the patients
had at least one clinic visit. Most (91.7 %) support staff
participants were of non-Hispanic ethnicity, and predominantly
minorities. Racial-ethnic, gender, and race
demographic data for providers were not collected as these
variables were not relevant to the study objectives.
Patient Satisfaction
A majority of the patients reported having a high level of
satisfaction with the delivery of behavioral health services at
their clinic site (see Table 3). All 51 (100 %) participants
attempted all satisfaction items on the questionnaire. As
shown in Table 3, overall, participants perceived highly that
they were treated the same as other people who get care at the
clinic, and were comfortable receiving mental health services
at their respective sites (M = 5.0). The participants also
noted with high agreement that they felt they were learning
the skills needed to deal with their problems (M = 5.0), and
would follow through if they were referred outside their clinic
for mental health care. Although at a lower median than the
other patient satisfaction items, participants responded within
a level of agreement (M = 4.0) when it came to preference to
receive mental health services at the location where they
receive medical care.
Support Staff Satisfaction
Median responses for each survey item are shown in
Table 4. The listed satisfaction items are in the same order
as they appeared on the survey. Overall, majority of support
staff were satisfied and comfortable with the behavioral
health services being offered at the clinic site. The
participants reported that behavioral health services was
helpful for their patients, and noted that working with
people with mental health disorders, substance use disorders,
and/or other psychosocial issues has a positive impact
on their practice (see Table 4). In terms of access and
usefulness of service, the participants indicated good satisfaction
(M = 4.18) with their access to behavioral health
staff, and highly agreed that the behavioral health staffs
provide the kinds of services they want for their patients.
Participants also reported valuing integrated behavioral
services, and strongly indicated they would recommend
that other primary care providers integrate behavioral
health services into their facilities (M = 5.0).
Provider Satisfaction
Regarding treatment patterns, more than half (54.2 %) of
the participants indicated that they managed over 40 % of
their patients whom they believed had clinically relevant
psychiatric diagnosis without any referrals. With regards to
referrals, only 9.1 % of the participants indicated that they
would refer over 40 % of their patients for help to a specialty
mental health provider located outside of their office.
Also, less than half (46.3 %) of the participants indicated
that they would refer over 40 % of their patients for help to
a co-located provider mental health provider.
In terms of utilization of clinical algorithms/best practices,
the participants reported a high level (81.8 %) of use
of published, evidence based diagnostic tools for depression
among physicians in their practice. There was a great
level of variability in the participants’ responses in terms of
perceptions of physician’s utilization of best practices in
Bipolar disorder and Anxiety diagnoses. The participants
strongly agreed that majority (70 %) of physicians did not
use evidence based diagnostic tools when a patient presented
with ADHD/ADD symptoms.
Physical and temporal proximities to behavioral health
services were assessed. Over half (54.5 %) of the participants
reported using a co-location integrated care
model. A majority (90 %) of the respondents noted that
there was adequate space in their primary care office for
integrated mental health treatment that is also used for
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123
other purposes. The participants reported that it takes
weeks to months between a PCP referral and a patient’s
first specialty mental health visit outside of the primary
care practice, which contrasts with same day to few weeks
interval seen in an integrated care setting.
As shown in Table 5, there were variations in the responses
among participants regarding the frequency of
communication with the co-located mental health provider
in their practice (i.e., How often does the referring PCP
initiate written/oral communication with the co- located
mental health provider prior to a patient’s first co-located
mental health visit?) There was a greater level of variability
in responses when it pertained to the frequency of acknowledgement
of appointments kept by referred patients.
Majority of participants reported that 81–100 % of the time,
the co-located mental health provider clarified diagnosis and
Table 2 Demographics of
survey participants
Patients N (%) Support staff N (%) Providers N (%)
ICPCQI sites
Asa G. Yancey Family Practice Center 7 (15.6) 15 (55.6) 5 (45.5)
Saint Joseph Mercy Care Services 23 (51.1) 11 (40.7) 6 (54.5)
Cobb County Community Service Board 15 (33.3) 1 (3.7) –
Age
B20 – – –
21–30 5 (10.0) – –
31–40 10 (20.0) – –
41–50 9 (18.0) – –
51–60 20 (40.0) – –
61–70 6 (12.0) – –
71\ – – –
Gender
Male 21 (41.2) – –
Female 30 (58.8) – –
Ethnicity
Hispanic – 2 (8.3) –
Non-hispanic 49 (100.0) 22 (91.7) –
Race
White 19 (37.2) 2 (8.3) –
American Indian/Alaska Native 1 (1.9) 3 (13.0) –
Asian – – –
Black/African American 30 (58.8) 18 (78.3) –
Hawaiian/other Pacific Islander 1 (1.9) – –
Education
Middle school 7 (14.0) – –
High school 26 (52.0) – –
College/university 15 (30.0) – –
Graduate school 2 (4.0) – –
Insurance
No insurance 38 (74.5) – –
Medicaid 5 (9.8) – –
Medicare 5 (9.8) – –
Private insurance 1 (1.9) – –
Other 2 (3.9) – –
Number of clinic visits
None 8 (16.3) – –
1–5 24 (48.9) – –
6–10 13 (26.5) – –
10 and above 4 (8.2) – –
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recommended treatment plans for referred patients, and
provided adequate responses to referral questions.
Pertaining patient care, most participants (90.9 %) noted
that the co-located mental health provider very often creates
individualized care plans for patients referred for behavioral
health problems. Nearly two-thirds of the participants
reported that there was some sharing, but mostly the mental
health provider takes responsibility for implementing and
following-up on the individualized care plan. The participants
did not take full responsibility, or most of the responsibility
relative to implementing and follow-up of the individualized
care plan created by the mental health specialist.
Overall, more than half (54.5 %) of the participants
were moderately satisfied with the level of integration, and
access to behavioral health services at their integrated care
sites. Sixty-four percent of participants were moderately
satisfied with the existing services at their sites. This survey
revealed very low levels of dissatisfaction with the level of
integration, existing services, and access to behavioral
health services among the participants.
Table 3 Patient ratings of ICQPCI acceptability and satisfaction
Questions Median (M) SD N Range
I am satisfied with the amount of time the staff spends with me during my visit 4.00 0.91 51 (1–5)
My beliefs about health and well-being were considered as part of the help (services) that I received 4.00 0.88 51 (1–5)
I would follow through if I were referred outside this clinic for mental health services 4.00 1.11 51 (1–5)
Any concerns I may have had regarding my mental health treatment plan were quickly taken care of 4.00 1.16 51 (1–5)
Treatment and information were provided to me in a language or way I could easily understand 4.33 0.99 51 (1–5)
I am comfortable receiving mental health services here at this clinic 5.00 1.13 51 (1–5)
I am treated the same as other people who get care at the clinic 5.00 0.78 51 (1–5)
I prefer to receive my mental health services at the location where I receive my medical care 4.00 1.22 51 (1–5)
I feel I am learning the skills I need to deal with my problems 5.00 0.95 51 (1–5)
1 = strongly disagree, 2 = disagree, 3 = neither disagree nor agree, 4 = Agree, 5 = strongly agree
Table 4 Support staff ratings of ICQPCI acceptability and satisfaction
Satisfaction items Median
(M)
SD N Range
I am satisfied with the ability of the medical staff at my clinic to address the needs of patients with mental health
disorders, substance use disorders, and/or other psychosocial issues
4.00 0.66 27 3–5
I am effective in addressing the needs of patients with mental health disorders, substance use disorders, and/or
other psychosocial issues
4.00 0.60 26 3–5
I am comfortable being the first-line response for people with mental health disorders, substance use disorders,
and/or psychosocial issues
4.00 0.93 27 1–5
I am effective working with patients with low motivation to change, e.g. patients who are NOT making needed
behavioral changes, or patients who are NOT adhering to their medical treatment
4.00 0.91 27 1–5
Behavioral health services are helpful for our patients 5.00 0.57 27 3–5
Working with people with mental health disorders, substance use disorders, and/or other psychosocial issues has
a positive impact on our practice
4.00 0.71 26 3–5
I am satisfied with my access to behavioral health staff 4.00 0.73 27 2–5
The behavioral health staffs provide the kinds of services I want for our patients 4.00 0.71 27 3–5
Communication between medical and behavioral health staff at my clinic is good 4.00 0.78 27 3–5
I would recommend that other primary care providers integrate behavioral health services into their facilities 5.00 0.74 27 3–5
The integrated behavioral health model increases ease of access to behavioral health services for the patients our
clinics serves
4.00 0.60 27 3–5
Consultation between medical and behavioral health staff is helpful to our patients 5.00 0.69 27 3–5
Feedback supplied by behavioral health staff regarding patients is adequate 4.00 0.81 27 2–5
1 = strongly disagree, 2 = disagree, 3 = neither disagree nor agree, 4 = Agree, 5 = strongly agree
956 Community Ment Health J (2015) 51:949–961
123
Bivariate Analysis
Of the total patient respondents, 30 were from integration
sites and 15 from reverse integration sites. There were no
significant demographical differences among gender,
education level, or age between patients in each group site.
There were statistically significant differences between
patients’ health insurance status and race between sites.
All the participants had comparable results between both
group sites for most questions, with little to no difference
in satisfaction level, except for preference on receiving
mental health services at the location where medical care is
received. Participants at integration sites had a higher
preference for receiving mental health services at the location
they receive medical care compared to participants
from reverse integration sites (P = 0.029; Table 6).
Discussion
In this study we hypothesized positive perceptions and high
acceptability with the Integrated Care Practice Change and
Quality Improvement Initiative among patients, support
staff, and providers. We also hypothesized that there was
no difference in the perceptions/satisfaction of patients,
providers and staff in integration of behavioral health into
primary care settings, and reverse integration settings. To
support our hypothesis, this study found that patients,
support staff, and providers reported positive experiences
with the overall integrated care program. It revealed that
the concept of integration of care was welcomed in both
primary care and mental health settings. Our findings
provide further evidence that this model of care can be
implemented in community health centers, Federally
Table 5 Primary care provider acceptability and satisfaction ratings of ICQPCI
Satisfaction items Frequency
0–20 % 21–40 % 41–60 % 61–80 % 81–100 %
N (%) N (%) N (%) N (%) N (%)
Treatment patterns
Watchfully wait without intervening? 10 (90.9) 1 (9.1) – – –
Manage yourself? 2 (18.2) 3 (27.3) 3 (27.3) 1 (9.1) 2 (18.2)
Refer for help to the co-located provider? 4 (36.4) 2 (18.2) 1 (9.1) 1 (9.1) 3 (27.3)
Refer for help to a specialty mental health provider located outside of your office? 7 (63.6) 3 (27.3) 1 (9.1) – –
Clinical algorithms/best practices
Depression 2 (18.2) 9 (81.8)
Anxiety 3 (27.3) – 2 (18.2) 3 (27.3) 3 (27.3)
ADHD/ADD 7 (70.0) – – 1 (10.0) 2 (20.0)
Bipolar disorder 4 (36.4) 1 (9.1) 1 (9.1) 1 (9.1) 4 (36.4)
Substance abuse 5 (50.0) 1 (10.0) – 1 (10.0) 3 (30.0)
Communication
How often does the referring PCP initiate written communication (referral letter or
e-mail) with the co-located mental health provider and PCP prior to a patient’s
first co-located mental health visit?
4 (40.0) – 2 (20.0) – 4 (40.0)
How often does the referring PCP initiate oral communication (phone call, face-toface
conversation) with the co- located mental health provider prior to a patient’s
first co-located mental health visit?
How often does the co-located mental health provider send the following feedback
to the PCP?
2 (20.0) – 1 (10.0) 4 (40.0) 3 (30.0)
Acknowledgement of appointment kept by referred patient 1 (10.0) 1 (10.0) 2 (20.0) 4 (40.0) 2 (20.0)
Clarified diagnosis for referred patient 1 (10.0) – 1 (10.0) – 8 (80.0)
Recommended treatment plan for referred patient 2 (20.0) – – – 8 (80.0)
Adequate response to a referral question 1 (10.0) – – 2 (20.0) 7 (70.0)
Patient care
After a patient is seen by a co- located mental health provider, how often is an
individualized care plan created for the patient?
– 1 (9.1) – 1 (9.1) 9 (81.8)
The following preceding question/statements were used for treatment patterns, clinical algorithm/best practices, and patient care constructs: (1)
Treatment Patterns: For those patients whom you believe to have a clinically relevant psychiatric diagnosis, what percentage do you; (2) Clinical
Algorithms/Best Practices: When a patient presents with symptoms, physicians in our practice use a published, evidence-based diagnostic tool
for; (3) Patient Care: question pertain to those patients for whom you refer to the co-located mental health provider
Community Ment Health J (2015) 51:949–961 957
123
Table 6 Comparison of patient
perceptions of integrated care
services in integration versus
reverse integration settings
Variables Integration N (%) Reverse integration N (%) P value
Age group (years)
21–40 7 (50.0) 7 (50.0) 0.177
41–70 22 (73.3) 8 (26.8)
Gender
Male 10 (62.5) 6 (37.5) 0.746
Female 20 (69.0) 9 (31.0)
Ethnicity
Non-hispanic 30 (66.7) 15 (33.3) –
Race
White 7 (38.9) 11 (61.1) 0.003
Black/African American Native 21 (84.0) 4 (16.0)
American Indian/Alaska Native 1 (100.0) –
Hawaiian/Other Pacific Islander 1 (100.0) –
School level attained
Middle school 5 (83.3) 1 (16.7) 0.171
High school 12 (52.2) 11 (47.8)
College/graduate school 12 (80.0) 3 (20.0)
Health insurance status
No insurance 26 (78.8) 7 (21.2) 0.006
Medicaid/medicare 4 (40.0) 6 (60.0)
Private insurance/other – 2 (100.0)
Number of visits to the integrated behavioral health clinic
None 5 (71.4) 2 (28. 6) 0.733
1–5 15 (68. 2) 7 (31.8)
6–10 8 (80.0) 2 (20.0)
10 and above 2 (50.0) 2 (50.0)
I am satisfied with the amount of time the staff spends with me during my visit (s)
Strongly disagree/disagree 1 (33.3) 2 (66.7) 0.558
Neither disagree nor agree 3 (75.0) 1 (25.0)
Strongly agree/agree 26 (68.4) 12 (31.6)
My beliefs about health and well-being were considered as part of the help (services) that I received
Strongly disagree/disagree 1 (50.0) 1 (50.0) 0.579
Neither disagree nor agree 4 (57.1) 3 (42.9)
Strongly agree/agree 25 (69.4) 11 (30.6)
I would follow through if I were referred outside this clinic for mental health services
Strongly disagree/disagree 4 (80.0) 12(0.0) 0.530
Neither disagree nor agree 2 (40.0) 3 (60.0)
Strongly agree/agree 24 (68.6) 11(31.4)
Any concerns I may have had regarding my mental health treatment plan were quickly taken care of
Strongly disagree/disagree 3 (50.0) 3 (50.0) 0.688
Neither disagree nor agree 4 (66.7) 2 (33.3)
Strongly agree/agree 23 (69.7) 10 (30.3)
Treatment and information were provided to me in a language or way I could easily understand
Strongly disagree/disagree 2 (66.7) 1 (33.3) 1.000
Neither disagree nor agree 2 (66.7) 1 (33.3)
Strongly agree/agree 26 (66.7) 13 (33.3)
I am comfortable receiving mental health services here at this clinic
Strongly disagree/disagree 2 (50.0) 2 (50.0) 0.546
Neither disagree nor agree 5 (83.3) 1 (16.7)
Strongly agree/agree 23 (65.7) 12 (34.3)
958 Community Ment Health J (2015) 51:949–961
123
Qualified Health Centers, and other underserved
communities.
Similar to recent research (Laderman and Mate 2014;
Funderburk et al. 2010), our findings support a trend towards
higher patient satisfaction and acceptability with
integrated care services they received in their clinics. The
providers and supporting staff also showed high levels of
acceptability to integrate behavioral and primary health
care into community health settings. The supporting staff
expressed high levels of comfort being the first-line response
for people with mental health disorders, substance
use disorders, and/or psychosocial issues. This perception
is consistent with previous supporting staff survey (Urada
et al. 2012) where they rated their own comfort as being
first-line responder of mental health and substance use issues
very highly. These supporting staff expressed their
satisfaction with access to behavioral health staff and
perceived highly, that the integrated behavioral health
model increases ease of access to behavioral health services
for patients.
While we recognize the difficulties of navigating the
health care system, professionals in both the physical and
behavioral health fields have affirmed the benefit of having
an informed companion help patients with this challenge,
and Medicaid programs are exploring opportunities to use a
new cadre of ‘‘navigators’’ to serve in this role (Nardone
et al. 2014). Our results support the adapting of innovative
integrated care models such as those used in the ICPCQI,
by other health systems. These cost-effective innovative
care models incorporate interventions like group psychoeducational
therapy, automated screening kiosks, and the
use of a navigator workforce (relaxation and wellness experts,
licensed clinical social workers, licensed professional
counselors, and certified peer specialists).
Regarding treatment patterns for patients seen in primary
care settings who were believed to have clinically
relevant psychiatric diagnoses, our findings revealed that
providers either managed by themselves, referred for help
to the co-located provider, or to a specialty mental health
provider located outside, and were less likely to wait
without intervening. Our results are similar to prior studies
that PCPs are particularly likely to refer patients to mental
health specialists when symptoms are severe (Steele et al.
2010), and primary-care pediatricians practicing in clinics
with onsite psychiatrists or other mental health specialists
were more likely to request psychiatric consultation compared
with those without on-site psychiatric services
(Cerimele et al. 2012). However, the primary care providers
in co-located settings seemed to have moderate levels
of comfort relative to managing/treating psychiatric
illnesses.
A previous study revealed that for the third of patients
who receive BH care in the primary care sector, treatment
for only 1 in 9 is evidence-based (Manderscheid and
Kathol 2014). Most providers in the ICPCQI reported that
they used published, evidence-based diagnostic tools when
a patients presents with symptoms of depression. However,
our results suggest that the providers were less likely to use
evidence based clinical algorithms in diagnosing Anxiety
disorder, Bipolar disorder, and Substance abuse. Further,
providers were least likely to utilize evidence-based diagnostic
tools in diagnosing ADHD/ADD. A previous study
found that although PCPs are assuming a greater role in the
management of ADHD, there continues to be a substantial
gap between existing need and the capacity to provide
ADHD services in the context of primary care practice
(Power et al. 2008). Our results agree with the previous
findings (Power et al. 2008) thus suggesting the need for
additional training of primary care providers on ADHD
diagnosis and increased collaboration with the co-located
psychiatrist in order to close this gap.
Our findings highlight the duration of time between PCP
referral and a patient’s first mental health visit with a colocated
mental health provider located inside the primary
Table 6 continued
P value\0.05 signify
statistically significant
difference in patient perceptions
towards ICPCQI in integrated
versus reverse integrated care
settings
Variables Integration N (%) Reverse integration N (%) P value
I am treated the same as other people who get care at the clinic
Strongly disagree/disagree 0 (0.0) 1 (100.0) 0.509
Neither disagree nor agree 2 (66.7) 1 (33.3)
Strongly agree/agree 28 (68.3) 13 (31.7)
I prefer to receive my mental health services at the location where I receive my medical care
Strongly disagree/disagree 4 (57.1) 3 (42.9) 0.029
Neither disagree nor agree 1 (20.0) 4 (80.0)
Strongly agree/agree 25 (75.8) 8 (24.2)
I feel I am learning the skills I need to deal with my problems
Strongly disagree/disagree 2 (66.7) 1 (33.3) 0.791
Neither disagree nor agree 2 (100.0) –
Strongly agree/agree 26 (65.0) 14 (35.0)
Community Ment Health J (2015) 51:949–961 959
123
care practice versus outside of the primary care practice. It
was not surprising that the interval between PCP referral
and visit to the co-located mental health specialist was
relatively shorter than referrals to an external mental health
provider. This further reinforces the benefits of the co-located
integrated care model where the psychiatrist/mental
health specialist is on site at the primary-care clinic and
often available for same say consultation (Cerimele et al.
2012).
Another element of the provider survey was communication
between the PCP and co-located mental health provider.
A majority of the PCPs noted that following a referral
and prior to a patient’s first co-located mental health visit,
‘portions of’ or ‘the full’ medical chart was shared. PCPs
indicated that they were significantly less likely to refer a
patient and ‘not share’ or ‘share some’ information on the
medical chart with the co-located mental health provider.
Within this study, a majority of the PCPs frequently initiated
written communication (referral letter or email) or oral
communication (phone call, face-to-face conversation) with
the co-located mental health provider prior to a patient’s
first co-located mental health visit. In addition, the PCPs
agreed that the co-located mental health provider frequently
clarified diagnosis and recommended treatment plan for
referred patients. These findings are an improvement from
the findings of one integrated care satisfaction PCP/mental
health provider survey (Urada et al. 2012) that noted poor
communication between the PCP and mental health provider
attributable to the tendency for the PCP to ask the
mental health provider for information but not provide information
to the mental health provider.
Although the majority of PCPs reported that they were
not at all knowledgeable on individualized care plans
created for patients who are referred to specialty mental
health providers outside their office, the PCPs had good
knowledge on the individualized care plans for patients
seen by the a co- located mental health provider. In addition,
PCPs noted that co-located mental health provider
very often created an individualized care plan for referred
patients. Similarly, when it came to taking responsibility
for implementing the individualized care plan, the PCPs
indicated some sharing but mostly the mental health provider
takes responsibility. Pertaining to appropriateness of
care, the PCPs appear to be very comfortable with
managing patients with depression. Majority of PCPs reported
the implementation of established screening and/or
diagnosis tools, proper referral and/or treatment protocols,
adequate sharing of information between providers, and
appropriate follow-up for patients presenting with Depression.
Despite practicing in an integrated setting with an
embedded psychiatrist, PCPs felt least confident when it
came to managing ADHD/ADD, which is consistent with
findings from a prior study (Power et al. 2008).
Conclusion
The combination of high prevalence of co-occurring
mental illness among individuals with chronic medical
disease, high cost and adverse impact of uncoordinated
fragmented care, with high levels of satisfaction and acceptability
with this ICQPCI among patients, staffs and
providers makes integration of physical and behavioral
health a top priority in the health care delivery system.
Given the implementation of the Affordable Care Act
(ACA), and potential influx of more individuals with
chronic diseases and co morbid mental illness, integrated
behavioral health models offers a great platform for quality
care that that improves health outcomes and reduces costs.
In light of the data that indicate sub-optimal competencies
and low confidence among PCPs in regard to use of evidence-
based diagnostic tools/clinical algorithms and treating
mental health diagnoses, efforts to increase PCP’s
training on these tools, and effective collaborations and
partnerships between PCPs and mental health providers are
needed.
The indication of high levels of satisfaction and acceptability
of integration of physical health and behavioral
health care especially in community settings is a proxy to
the state of readiness of communities to adopt and expand
integrated care. This data encourages the extension and
propagation of innovative models of integrated care which
incorporates navigators, behavioral health clinicians, and
licensed professional counselors into rural community
health centers to help address existing rural/urban associated
disparities in integrated care implementation (Miller
et al. 2014).
Limitations of this Study
Some limitations of this survey need to be considered.
There were variations in the timing and procedures used to
collect data from different groups of participants. Our response
rate for the patient satisfaction survey was 15.7 %.
Although lower than that found in other research using
similar methodology (Shih and Fan 2009), the response
rate can be attributed to the fact that one of our sites was a
homeless clinic and had challenges collecting data from
these transit patients. This survey used a convenient sampling
methodological approach and a relatively small
sample size thus making the generalizability of the findings
questionable. In addition, the limited range of the scales
used in the patient and supporting staff survey instruments
(1–5), may contribute to variability. Furthermore, the integrated
care sites served a broad range of psychiatric
disorders, however, at the time of the study we did not
capture in detail the number and spectrum of psychiatric
960 Community Ment Health J (2015) 51:949–961
123
disorders presented by the patients served at these sites.
This is a limitation to generalizing the findings of the study
because primary care staff acceptance and satisfaction in
working with patients with co-occurring medical and psychiatric
disorders may be dependent on the range and
severity of the mental disorders presented by the patients.
These limitations should not be ignored when considering
the generalizability of the study. The comparison of perceptions
of the ICPCQI in the integration versus reverse
integration sites considered only patients views. This exclusion
was due to very small sample sizes, and few to no
participant support staff and providers from the reverse
integration sites. Although requests for participation were
sent to all partnering ICPCQI sites, support staff and providers
were not sampled at the mental health community
health centers. This survey is a snap shot representation of
the participants’ perception of the ICQPCI and voids the
ability to assess for changes in the levels of satisfaction or
and acceptability of the ICQPCI. Future studies should
compare pre/post survey data to determine changes in patients’,
providers’, and support staffs’ perceptions, and also
compare participants in an integrated care setting versus
non-integrated.
Acknowledgments Integrated Care Practice Change and Quality
Improvement (ICPCQI) initiative was funded by grants from Kaiser
Permanente and Georgia Department of Behavioral Health and
Developmental Disabilities (DBHDD). We thank the patients, staff,
and providers at Cobb Community Service Board, McIntosh Trail
Community Service Board, Hope Health Clinic, Saint Joseph’s Mercy
Care Services, Asa G. Yancey Family Practice Center, and The North
Fulton Health Service Center for their participation in the ICPCQI.
Conflict of interest All authors certified responsibility for the study.
There are no known conflicts of interest.
References
Buck, J. A. (2011). The looming expansion and transformation of
public substance abuse treatment under the Affordable Care Act.
Health Affairs (Millwood), 30, 1402–1410.
Butler, M., Kane, R. L., McAlpine, D., Kathol, R. G., Fu, S. S.,
Hagedorn, H., & Wilt, T. J. (2008). Integration of mental
health/substance abuse and primary care no. 173. AHRQ
Publication No. 09-E003. Rockville, MD: Agency for Healthcare
Research and Quality, U.S. Department of Health and Human
Services. Retrieved from http://www.ahrq.gov/downloads/.
Cerimele, J. M., Katon, W. J., Sharma, V., & Sederer, L. I. (2012).
Delivering psychiatric services in primary-care setting. Mount
Sinai Journal of Medicine, 79, 481–489.
Croghan, T. W., & Brown, J. D. (2010). Integrating mental health
treatment into the patient-centered medical home (AHRQ
Publication No. 10-0084-EF). Rockville, MD: Agency for
Healthcare Research and Quality.
Funderburk, J. S., Fielder, R. L., DeMartini, K. S., Flynn, C. A., et al.
(2012). Integrating behavioral health services into a university
health center: Patient and provider satisfaction. Families,
Systems, & Health, 30, 130–140.
Funderburk, J. S., Sugarman, D. E., Maisto, S. A., Ouimette, P.,
Schohn, M., Lantinga, L., et al. (2010). The description and
evaluation of the implementation of an integrated healthcare
model. Families, Systems, & Health, 28, 146–160.
Katon, W. J., Von, K. M., Lin, E. H., Simon, G., Ludman, E., Russo,
J., et al. (2004). The pathways study: A randomized trial of
collaborative care in patients with diabetes and depression.
Archives of General Psychiatry, 61, 1042–1049.
Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R.,
& Walters, E. E. (2005). Lifetime prevalence and age-of-onset
distributions of DSM-IV disorders in the National Comorbidity
Survey Replication. Archives of General Psychiatry, 62,
593–602.
Laderman, M., & Mate, K. (2014). Integrating behavioral health into
primary care. Healthcare Executive, 29, 74–77.
Levine, S., Unutzer, J., Yip, J. Y., Hoffing, M., Leung, M., Fan, M.
Y., et al. (2005). Physicians’ satisfaction with a collaborative
disease management program for late-life depression in primary
care. General Hospital Psychiatry, 27, 383–391.
Manderscheid, R., & Kathol, R. (2014). Fostering sustainable,
integrated medical and behavioral health services in medical
settings. Annals of Internal Medicine, 160, 61–65.
Miller, B. F., Petterson, S., Brown Levey, S. M., Payne-Murphy, J. C.,
Moore, M., & Bazemore, A. (2014). Primary care, behavioral
health, provider colocation, and rurality. The Journal of the
American Board of Family Medicine, 27, 367–374.
Morrissey, J. P., Domino, M., Wicher, C., Kilany, M., & Gaynes, B.
(2009). Integrating Primary Care and Mental Health Services:
Final Evaluation Report on the ICARE Integration Pilot Sites.
Nardone, M., Snyder, S., & Paradise, J. (2014). Integrating physical
and behavioral health care: Promising medicaid models. Henry J.
Kaiser Family Foundation. Retrieved from http://kff.org/medi
caid/issue-brief/integrating-physical-and-behavioral-healthcarepromising-
Medicaid-models/.
National Research Council. (1996). Primary care: America’s health
in a new era. Washington DC: The National Academies Press.
Power, T. J., Mautone, J. A., Manz, P. H., Frye, L., & Blum, N. J.
(2008). Managing attention-deficit/hyperactivity disorder in
primary care: A systematic analysis of roles and challenges.
Pediatrics, 121, e65–e72.
Reeves, W. C., Strine, T. W., Pratt, L. A., Thompson, W., Ahluwalia,
I., Dhingra, S. S., et al. (2011). Mental illness surveillance
among adults in the United States. MMWR Surveill Summ,
60(Suppl 3), 1–29.
Satcher, D., & Druss, B. G. (2010). Bridging mental health and public
health. Preventing chronic disease, 7, A03.
Shih, T. H., & Fan, X. (2009). Comparing response rates in e-mail and
paper surveys: A meta-analysis. Educational Research Review,
4, 26–40.
Steele, M. M., Lochrie, A. S., & Roberts, M. C. (2010). Physician
identification and management of psychosocial problems in
primary care. Journal of Clinical Psychology in Medical
Settings, 17, 103–115.
Unutzer, J., Katon, W., Callahan, C. M., Williams, J. W, Jr, Hunkeler,
E., Harpole, L., et al. (2002). Collaborative care management of
late-life depression in the primary care setting: A randomized
controlled trial. JAMA, 288, 2836–2845.
Urada, D., Schaper, E., Alvarez, L., Reilly, C., Dawar, M., Field, R.,
et al. (2012). Perceptions of mental health and substance use
disorder services integration among the workforce in primary
care settings. Journal of psychoactive drugs, 44, 292–298.
Community Ment Health J (2015) 51:949–961 961
123
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Proceed to pay for the paper so that it can be assigned to one of our expert academic writers. The paper subject is matched with the writer’s area of specialization.
You communicate with the writer and know about the progress of the paper. The client can ask the writer for drafts of the paper. The client can upload extra material and include additional instructions from the lecturer. Receive a paper.
The paper is sent to your email and uploaded to your personal account. You also get a plagiarism report attached to your paper.
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Delivering a high-quality product at a reasonable price is not enough anymore.
That’s why we have developed 5 beneficial guarantees that will make your experience with our service enjoyable, easy, and safe.
You have to be 100% sure of the quality of your product to give a money-back guarantee. This describes us perfectly. Make sure that this guarantee is totally transparent.
Read moreEach paper is composed from scratch, according to your instructions. It is then checked by our plagiarism-detection software. There is no gap where plagiarism could squeeze in.
Read moreThanks to our free revisions, there is no way for you to be unsatisfied. We will work on your paper until you are completely happy with the result.
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