Finding 'Win' Factors for People with Serious Mental Illness in New York: a qualitative analysis of primary care provision in behavioral health settings

Introduction : People with serious mental illness (SMI) like schizophrenia tend to be high-need high-cost patients. They use health care services disproportionately, often due to physical health conditions, but receive lower quality of care. A leading proposal to challenge this disparity is to integrate primary care services into specialist behavioral health systems. Yet the implementation of integration initiatives is not always realized, and after implementation, the benefits are not always sustained. Theory : Focusing on integration of primary care services into behavioral health settings, this project analyzes the structural, process, cultural and external factors that help or hinder programs providing comprehensive care to people with SMI and how these factors interact. Methods : This is a qualitative research study. Focusing on New York State we identified 11 sites of innovative mental health-primary care integration practice through federal registries. We conducted semi-structured interviews with 52 individuals (senior clinicians, administrators and frontline staff) at these sites on organizational, structural, integration and implementation factors. Qualitative thematic analysis identified common facilitators and barriers to integration. A causal loop diagram is being developed to explore interactions between themes. Results and Discussions : Factors that helped integration divided into structural, process and cultural facilitators. A key structural facilitator was co-location of care; however, this did not always stimulate or motivate integration. Process factors such as multi-disciplinary practices, prescribed case conferences and informal huddles had to be in place to ensure effective cross-disciplinary communication.  An integrated health record was a key facilitator to care but used in different ways from simply a communication tool to a sophisticated outcomes monitoring database. Cultural factors such as having a vision for integration, disseminating this vision throughout the organization and making time and resources available were fundamental to successful implementation. Barriers to integration broadly divided into clinical, organizational and external factors. Clinical barriers included difficulties in engaging patients and in recruiting clinicians. Organizational barriers included high administrative burden taking clinicians away from the frontline. External barriers such as fragmentation amongst regulatory authorities and short-term funding arrangements were most commonly reported and most difficult to resolve. Conclusions : (1) In New York no integration sites are situated in rural areas and most were concentrated in New York City. Of these, most were located in socially deprived neighborhoods with high ethnic minority populations. (2) Primary care organizations had access to a range of different mechanisms and incentives to integrate care, but behavioral health organizations were limited to short-term grants. These were mainly used to increase capacity or buy time whilst providers developed more sustainable integration efforts. Lessons Learned : Delineating the key components of mental health integration could help align funding and service delivery to overcome some of the sustainability and regulatory barriers to integration. Limitations :  All the sites identified were situated in New York City limiting the generalizability of our findings outside large urban centres. Suggestions for Future Research : Should we expect all practices to integrate mental health and physical care to the same degree, or should we focus/initiate integration strategies in well-resourced, well-networked centres?