Strengthening the delivery of integrated care for individuals experiencing serious mental illness within mental health settings: a qualitative description of health provider perspectives | BMC Psychiatry

We recruited 28 participants (13 health administrators and 15 clinicians) from Ontario, Nova Scotia, Quebec and Alberta. Eight community mental health-based clinicians and administrators, and 22 psychiatric hospital-based clinicians and administrators participated in the study. Demographic details of study participants are presented in Table 1. We identified four central themes, and alignment across healthcare administrator interview and clinician focus group data: (1) the need for integrated care delivery within mental health settings; (2) organizational readiness for integrated care; (3) moving integration forward: addressing challenges; and (4) leveraging opportunities to advance integrated care. The themes, along with associated sub-themes, are further described below.

The need for integrated care delivery within mental health settings

Both clinicians and administrators acknowledged the importance of addressing the unmet physical health needs of adults with SMI within mental health settings, describing complex unmet physical health needs among their patients, multiple barriers in accessing primary care in the community, and highlighting the inherent difficulties that come with living with SMI, including stigma and discrimination. These subthemes are further described below.

Addressing unmet health needs

Both clinicians and administrators described increasing complexity of physical health needs among their patients over time, and multiple unmet health needs, from preventative health care to the management of acute and chronic health conditions and palliative care. As one administrator described: “Many of our patients are coming in more medically complex…just in the last week, for instance, we’ve had 3 patients with metastatic cancer, we’ve had one with a fracture, 2 have had to go to neurosurgery.” (HA5).

A frontline clinician similarly highlighted that, “We’ve had a handful of patients that have active hepatitis C, and now they need to see a specialist and sometimes that could have been monitored by their family physician, but they don’t have one.” (C6).

In this context, several organizational leaders saw the importance of integrating primary care within their setting, as this leader from a large community mental health organization described:

Back in 2010, we looked at our data of our existing clients and our services. At the time, in 2010, 73% of our client deaths were a result of chronic disease; the average age of those deceased clients was just over 48 years old, and 81% were male … so that really created this launch of sort of our primary care initiative … because we wanted to make sure that that initiative would enhance primary care and the management of chronic diseases for our clients. (HA6)

Both clinicians and administrators identified mental health services as uniquely positioned to offer integrated physical and mental healthcare and address the health needs of this population comprehensively, given staff’s ability to engage individuals with SMI that may have been reluctant or otherwise unable to receive physical health care in primary care settings. As this administrator highlighted:

We (in specialty mental health settings) tend to be the people they trust…we were often the only people who see them longitudinally, as opposed to, you know, emergency visits, or walk-in clinic visits, or whatnot. And we also understand their world better, which I think makes providing primary care, much more effective for these people [living with SMI]. (HA3)

Access and structure of primary care

Participants expressed that people living with SMI face numerous barriers in accessing primary care in the community, even with case management or family support. They highlighted several key challenges, including a shortage of family physicians, long wait times for care, and generally a poor fit between primary care practices and the needs of individuals with SMI. Easier-to-access walk-in clinics were also deemed inadequate, due to their limited scope, and inability to offer longitudinalor preventive care. As one administrator highlighted:

20% of people don’t have a family physician, I mean, I’m just quoting it off the top [of my head]. If you’ve got chronic mental health problem, then you know, that might possibly be higher, and then going to a walk-in clinic is not going to be helpful, because, you know, the walk-in doctor … they may not really understand the complexity of your needs. (HA4)

As another administrator highlighted: “So, you know, when I go to my doctor, I got 10 minutes to go through whatever two problems I have…and if I need a longer appointment, I should have booked it, or she’s going to tell me to book another one to come back. You can’t do that with these clients.” (HA3).

Frontline clinicians shared similar perspectives and experiences, as one clinician described:

“I can see that many of our clients do not have primary care physicians. If they do, [they do] not have a good working relationship with those primary care physicians because of their personal complexities and so on, or simply because they would require more time than the family physicians have the luxury to offer.” (C1).

Additionally, participants identified that the siloed nature of mental health and primary care services hinders continuity of care and complicates care transitions and timely follow-up of acute and chronic health conditions upon discharge from hospital, as this administrator highlighted:

In my role, we’ll try to reconnect that person with their oncologist and have things kind of looked after, but sometimes as a result of their mental illness, and as a result of systemic failures, they are lost to follow up [upon discharge], and these diseases end up being poorly managed…and I think there’s a lot of preventative health that can be done. (HA7)

Stigma and discrimination

Finally, participants identified stigma and discrimination associated with mental illness as barriers to accessing primary care in the community, which underscores the appropriateness of offering integrated care in SMI settings. As these participants described: “In terms of mental health, there’s a lot of stigma, and clinicians (family physicians) need to empower our patients” (C11) and “Stigma against mental health, you know, that itself can be a barrier [to access].” (C15).

Participants described that in addition to access barriers, stigma led to poor quality care, including diagnostic overshadowing. As this participant described:

“And when I did his admission physical, [he was] profoundly itchy. But the [physician] that sent him attributed his itchiness to drug withdrawal, didn’t do any investigations. I did a chest X-Ray, he had a huge hilar mass … and he was re-diagnosed with Hodgkin’s lymphoma and unfortunately not treatable at this point.” (HA3).

Another participant expanded: “I believe that the stigma and the willingness to care for someone who isn’t necessarily caring for themselves have always been a complex issue. This is something that must be continually addressed and advanced as a social responsibility to care for everyone.”(HA8).

Organizational readiness for integrated care

Clinicians and administrators emphasized that both strong organizational leadership and a supportive organizational culture are needed to advance integrated care delivery within mental health settings, along with appropriate infrastructure and resources, and training and staff development opportunities, as described below.

Organizational culture and leadership support

Health administrators noted that promoting the inclusion of physical health assessments from each initial patient encounter underlined an organizational commitment to comprehensive, patient-centered care from the onset. This approach was perceived as key to promoting integrated physical and mental health care delivery within mental health settings. As this administrator voiced: “We’re trying … to get[it] right from the start saying that the physical monitoring has to start right from the beginning, right at that initial assessment or contact.” (HA8).

A third of the participants described leveraging quality improvement tools and infrastructure to advance integrated care. Emphasizing routine monitoring of health indicators and process measurement as part of a culture of continuous quality improvement was thought to support holistic health management, as this clinician described:

We did that [integrated care] through a number of different [quality improvement] initiatives, creating health promotion, disease and injury prevention, and then chronic disease management. And so we used existing positions on some of our teams that have nursing [background] to make sure that we’re continuing to offer services that promote the overall health and well-being of the client. (C14)

Participants further identified that without leadership support and an enabling organizational culture, it would be hard to motivate staff to expand their scope of practice or take on additional tasks without new resources, as these participants identified: “Integration of physical health monitoring within the behavioral health setting is viewed as a priority, however, it’s not always easy. What I mean by that is … there’s always a lack of resources” (C7); and: “If my manager or leadership isn’t prioritizing this, why would I?” (HA11).

Finally, in the absence of policy levers, mandates, or reporting requirements for integrated care delivery, nearly half of the participants described advocacy efforts to promote integrated, comprehensive care as part of organizational strategic plans or as an organizational priority, as this administrator described: “We have been fighting very hard for the past year and a half to bring it on the strategic plan. So physical health, reverse integration is part of this new strategic plan, which kind of already shows and highlights that the advocacy we’ve been doing is helping.” (HA8).

Infrastructure and resources

Study participants emphasized the importance of adequate staffing and infrastructure to deliver comprehensive, integrated care, along with clear staff roles and expectations, and staff training. Within psychiatric hospitals, where some patients have long stays, such as in forensic psychiatric units, participants described that physical health care delivery has evolved over time to include preventive health care, such as cancer and infectious diseases screening, in addition to managing acute and chronic health conditions. As this clinician reported: “We become the primary care physicians for patients who stay at [mental health hospital] for more than a year. So, a lot of the cancer screening, primary care work that we’re doing belongs to the fact that we do become the primary care providers for our patients.” (C8).

As another participant noted, psychiatric hospitals are better resourced than community mental health organizations to deliver integrated care and facilitate access to specialists. As this hospital-based clinician related:

We have a whole bunch of physical health care providers, we have family physicians, we have nurse practitioners, we have physician assistants. And we also have an internist on tap for more complex things. And, you know, we have access to a dentist once a week, which is within our area, we have access to a shopping list [of health professionals], we have access to a physiotherapist, and a dietitian. (C7)

Participants from large community mental health organizations described recruiting local family physicians or nurse practitioners to provide primary care to their patient population, in addition to leveraging nursing roles to support the physical health needs of their patients. As this administrator explained: “So the nurses on the ACT team, for example, they do a lot more traditional nursing [beyond mental health] because they have access to a clinic in a building, which allows them to perform those types of services.” (HA6).

Where resources were lacking, partnerships and collaborations were considered central to advancing integrated care and care coordination in both hospital and community settings, with some organizations building partnerships with local primary care teams or paramedic services to better coordinate care. As this participant highlighted: “We wanted to make sure that initiative would enhance … the management of chronic diseases for clients…The other [priority] was partnership development and working with our community. The third was education and health promotion. And the last was coordination of health service delivery.” (C8).

For psychiatric hospitals, partnerships focused on facilitating access to specialists, imaging, or timely diagnostic services, to avoid transfers to general hospitals and improve patient experiences. As noted by one administrator: “We’ve been fortunate to develop a partnership with [Hospital Name team], which is a wonderful group of providers of internal medicine doctors and a wonderful clinic, where oftentimes we send individuals who need a kind of subacute workup.” (HA1).

Training and skill development

Study participants described offering or participating in staff training to enable the delivery of integrated care in their setting, given the traditional narrow scopes of practice within mental health services, and the necessity to equip staff with the knowledge and skills to provide comprehensive care. As this administrator highlighted: “Giving staff the opportunity to identify integrated care as an issue and providing them with the skills and resources to address it are crucial.” (HA5).

Another administrator emphasized the need for nuanced training to engage the diversity of patients in their care: “Culturally competent care and managing unconscious biases are extremely important.” (HA10).

Primary care clinicians in mental health settings expressed that, through their work in a mental health setting, they became adept at engaging patients who might otherwise find it difficult to engage in physical health care. They described practice approaches that are empowering and trauma-informed, reflective of their additional training in the mental health specialty setting. As one clinician noted:

I also am mindful of the fact that like, when I’m examining them, I’m entering their personal bubble in their space, right, I’m putting my stethoscope to listen. And so that itself can be anxiety provoking for them. And I, but I always try to make sure that I’m, you know, asking for permission for every step explaining what I’m doing, why I’m doing it. And then kind of summarizing at the end of the encounter. (C10)

Another clinician highlighted the importance of rapport building for meaningful interaction with people living with SMI: “I ensure that I take time to build the rapport and take that effort, so then we’re able to have very…meaningful conversation. So rapport building is like, super huge.” (C3).

Psychiatric hospital providers expressed that comprehensive medical training is crucial for students to understand integrated care delivery in mental health settings, and described engaging in training of the next generation of psychiatrists and family physicians, to increase comfort in caring for this population comprehensively: “Medical training is–it’s busy for, for the students. It is eye opening when they come to, like, [Hospital A] or if they come to[Hospital B}, and they–and they get immersed in it, in the primary care part of, you know, when all the patients have major mental illness.” (HA13).

Moving integration forward: addressing challenges

Participants described several challenges in promoting or delivering integrated care in their setting, including government inaction, and lack of adequate resources or funding models to support integrated care delivery. For some community mental health organizations, a major challenge has been the lack of compatibility of commonly used electronic health records with the provision of physical health care. Finally, lack of health information continuity across levels of care was a shared challenge across hospital and community settings.In the absence of dedicated funding, smaller agencies seemed to struggle more, compared to larger, multiservice organizations, in allocating resources to integrated care delivery. As this administrator highlighted: “But that was probably easier for us [to deliver integrated care] as a larger agency with multiservice than it would be for a smaller agency to do this.” (HA7).

The overall lack of adequate funding for integrated care across the sector further impedes efforts, as this participant identified: “There’s been no increased investment in our services and if anything, services have been withdrawn.” (HA6) Similarly, making integrated care a priority in the context of resource constraints was challenging, without practice standards or accountabilities for integrated care. As this participant expressed: “I think, integrated care isn’t part of our formal standards or job plans so it doesn’t get prioritized.” (HA7).

Resource disparities led to inequitable access to integrated care initiatives across organizations and settings, underscoring the importance of targeted funding envelopes along with standards of care to promote equitable access to integrated care for persons with SMI. Within community mental health teams, health administrators identified unrealistic workloads as a barrier to providing adequate care for individuals with SMI. Hiring additional support staff was deemed essential to meet patient care requirements effectively. “We still have the requirement that every nurse practitioner has to carry a caseload of 850. And so are you able to provide adequate care for people with severe mental health needs to be addressed, and still carry that long of a caseload? It’s not realistic.” (HA11).

Furthermore, one participant highlighted how the current fee-for-service model for physician reimbursement does not work well for physicians working with persons experiencing SMI, who necessitate lengthier assessments and time to coordinate care: “The fee-for-service system is a really challenging one to work in, whether you’re a primary care provider or a specialist, because you’re not encouraging—again, you’re not encouraging providing high-quality care to people in the most effective way.” (HA3).

Additional barriers identified included lack of informational continuity within and across settings and limitations within electronic health record systems, which complicated integration efforts: “The biggest … challenge to delivering good integrated care is, is the lack of informational continuity.” (HA7); and “You know, so I think one of the things that we definitely need to improve upon is the access of communication between clinicians and different clinical settings, as well as amongst the team.” (HA5).

Challenges with electronic health records were identified primarily by community mental health organizations, as this participants noted: “We also have limitations within our EMR [electronic medical records] … We have found a temporary solution anyway, at least having two EMRs…one that works with the [family] physician that he’s most familiar with.” (C2).

Finally, the perception of government inaction on an important health equity issue was commented on by some participants, calling for greater efforts to address the mortality gap as a policy priority. “I feel like we’re missing opportunities. I think we’re missing a lot of opportunities, and a lot of that has to do with a government that doesn’t see–and a government and policymakers that don’t seem to have the attention span to make a commitment.” (HA13).

Leveraging opportunities to advance integrated care

To advance the delivery of integrated care for individuals living with SMI, participants highlighted the need for policy development, practice standards, and continuous innovation to break down silos and enhance care coordination. They also proposed greater involvement of people with lived experience and family members in service redesign.

Making integrated care a priority

Study participants discussed the importance of making integrated care a priority, both in practice and at the macro, meso and micro policy levels across the sector. Despite the current absence of policies, reporting requirements, or accountabilities, participants noted multiple efforts to support the physical health needs of individuals with SMI in their organizations, setting the stage for scaling up of integrated care initiatives.

In addition to supportive policies and dedicated funding and resources, advocacy for systemic change was deemed necessary to support integration efforts and improve patient outcomes. As this health administrator expressed: “We have to rethink the way we deliver services to try and bring in physical health services into situations where people are receiving mental health care.” (HA12) Others, as this health administrator, described the need for aligning government funding and incentives with integrated care goals and for involving key stakeholders in policy development:

And so, you know, how do we help bring … healthcare providers and systems of care with the Ministry to actually think in an intentional way, about good use of funding and incentives, that makes sense, both from a Ministry perspective, but it’s got to make sense to the healthcare provider, and then the patient, where’s the patient voice in all of that as well. (HA11)

Community mental health organizational leaders additionally saw the value of co-located service hubs in the community, as this administrator highlighted: “One is the co-location and the integration of health and social and community and mental health services … buildings where there are different services under the same roof at the same time offering different services.” (HA9).

In addition, to guide the scale and spread of integration initiatives, clinicians identified the need for in-depth program descriptions and evaluation of these efforts: “These programs need to describe what they’re doing, how it’s working, and what the model of service delivery is.” (C4) They also identified the need for additional health human resources and related infrastructure, as this participant identified: “I also think more on-the-ground resources. So I would love to see more physical health providers on the units working alongside psychiatry, participating in rounds, completing assessments with patients, and kind of making a plan together.” (C3).

Expanding the involvement of people with lived experience and family members

Both clinicians and administrators stressed the importance of involving people with lived experience and their families in both individual- and program-level care planning to ensure interventions are person-centered and accessible. They highlighted practices such as building strong relationships with service recipients, incorporating family input, and utilizing lived experience advisory groups for program planning and policy development. As one clinician described: “I really emphasize too if families are involved, you know, working with the client on how to understand how we can best incorporate their family members into their care.” (C1).

Both clinicians and administrators valued the role of family and people living with SMI advisory groups in developing care programs in their settings: “We have a very strong client and family advisory group. And so when we design programs, it’s always done in partnership with. It’s never [happened that] we designed something and tell the client or family; they help us design, it’s co-designed with all of our programs.” (HA5).

The advisory committees were thought to be essential to provide feedback on sustainability and expansion of integrated care efforts, as this participant expressed: “The advisory committee has provided some feedback around sustainability models or expansion or whatever the case may be down the road.” (HA8).

Another clinician identified an urgent need to involve people with lived experience in policy development at all levels: “I think there needs to be a few really important players at the [policy development] table. First of all, patients and patient representatives.” (C6).