APNA Position: Integrated Care

Despite growing recognition of the need for integrated care services to meet the diverse mental and physical health needs of United States adults, integrated care models have not been adopted by all primary care settings in which many of those with mental health conditions present. Individual providers may feel inadequately prepared to address the full range of care for their patients. The high prevalence of co-morbidities and diverse cultural backgrounds within community populations make it imperative that we implement strategies to strengthen a collaborative, interprofessional approach to care through integrated care models to minimize barriers and improve quality of services across a range of mental and physical health problems. Expanded access to these models can be achieved through telehealth services.

It is APNA’s position that integrated care consistent with patient-centered concepts is critical to improving patient outcomes and achieving a whole health approach to care.

Introduction

By 2030, depression will be the leading cause of the total global disease burden, followed by cardiovascular disease (World Health Organization [WHO], 2011). The United States Department of Health and Human Services (USDHHS) acknowledges that mental health is essential to well-being, and cultural considerations combined with complex social factors result in fewer help-seeking behaviors (USDHHS, 2001). Health care professionals who work in silos often cannot manage the multifaceted physical, mental, and concurrent social needs of vulnerable populations. These complex needs require that mental health professionals utilize effective integrated care strategies to engage interprofessional teams in collaboratively addressing chronic mental and physical conditions as part of a whole health approach (Frenk et al., 2010). In pursuit of whole health, responding to the growth in patients living with or at risk for co-occurring chronic physical and mental conditions will require redesigning the delivery of primary care services from siloed and fragmented to integrated and socio-culturally relevant (Millender, 2020). An in-depth understanding of patients’ collective barriers that may influence health behaviors is critical to facilitating successful implementation of integrated care models that bring together interprofessional members to address the needs of individuals and families living with mental and behavioral health conditions (APNA, 2021).

Individuals with mental or behavioral health issues are often assessed and treated exclusively in primary care settings (Petterson et al., 2014), but three challenges have risen to the top for many health care providers’ ability to meet the mental health needs of the 20% of adults and 17% of youth seen in primary care settings within a given year (NAMI, n.d.):

1. Education and training: Many providers feel ill-prepared to intervene, lacking the knowledge, skills, and resources to detect mental health problems in primary care settings. Similarly, mental health providers, including PMH-APRNs and psychiatrists, perceive that they have not acquired the necessary skills or knowledge to address their patients’ physical health needs (Cunningham et al., 2013).
2. Identification of mental health symptoms: In primary care settings, mental health problems are not detected in two-thirds of these patients, and when detected, many refuse referrals to mental health care.
3. Barriers to access: Kaufman and colleagues (2012) found several barriers to accessing physical care concerns for individuals with severe mental illness (SMI), often associated with significant physical comorbidities and a 33% loss in life expectancy (Lerbaek et al., 2019). A national shortage of mental health care providers contributes to a lack of access to mental health services.

The current health care system increases the challenges inherent in treating mental health, substance use, and medical health problems simultaneously and adequately in conjunction with addressing social needs. Integrated care models decrease barriers to quality care, increase access to care, decrease emergency room admissions, and lower primary and mental health provider burden—which leads to better patient outcomes. It is APNA’s position that integrated care consistent with patient-centered concepts is critical to improving patient outcomes and achieving a whole health approach to care.

Discussion

There is no gold standard for implementing integrated physical and mental health care, resulting in confusion and misconceptions. SAMHSA developed a framework that utilizes previous levels of implementation and overarching categories to describe a process from the initial concept of coordination to comprehensive integrated health care in three categories, each with two levels. These categories are Coordinated Care (minimal to basic collaboration at a distance; level 1–2), Co-located Care (basic to close collaboration onsite; level 3–4), and Integrated Care (close to full collaboration/practice merger; level 5–6) (Heath et al., 2013). Level one describes the first level of integrated care, while level six describes full integrated care services.

Mental health is foundational to whole health, making integrated health care models imperative to improve overall well-being, however education and training for existing and future mental health professional workforces are needed to promote adoption of these models. National initiatives have attempted to meet the need for integrating physical and mental health care, but many providers have not been exposed to integrated health care models. Quality care provided in integrated care models is driven by interprofessional teams. Traditional health care education and practice models are often limited to a single discipline, presenting many barriers to collaboration. Unfortunately, if providers do not understand the roles and responsibilities across relevant professions, implementing any level of integration will be difficult. Instead, all health care providers should be trained in interprofessional, integrated health care models early in their education to prepare them for a collaborative workforce. In developing interprofessional learners from two or more professions, team members learn about, from, and with each other, with the object of cultivating collaborative practice for providing client- or patient-centered health care (WHO, 2010; Centre for the Advancement of Interprofessional Education, 1997).

To date, evidence-based models of integrated care have been shown to increase access to care, improve the overall quality of care, and decrease the stigma associated with mental health care. One model, the Collaborative Care model (CoCM), has more than 90 randomized controlled trials and several meta-analyses have demonstrated that the integrated care model is more effective for patients with depression, anxiety, and other mental health and substance use conditions compared to usual care (University of Washington, 2023). Young and colleagues (2018) reported outcomes from an integrated care model currently being studied at the VA clinic in Los Angeles. Enhancements to the care of individuals with SMI included more extended visits and better coordination between physical and mental health care providers, a patient outreach messaging system, and weekly dedicated time. In an example of effective reverse co-location, the mental health based primary care program provides mental health based integrated care services in New York City (Breslau et al., 2018). Based partly on claims data, the findings show that these integrated clinics reduced inpatient services most often for unmet medical reasons and emergency department services for psychiatric reasons.

Innovative Approaches

The world is facing a crisis in the rising burden of chronic conditions including mental illness and substance use disorders. Unfortunately, mental health care services are not available to all. Hence, innovative adoption and implementation of integrated health care practices are needed to meet these needs in new, creative, and cost-effective ways. Technological advances can be utilized to expand access to integrated care services. A prime example is telehealth services, which include both audio and video secure connections. Telehealth can be utilized for multiple services, including care coordination and collaboration, evaluation, therapy, medication management, and consultations in emergency departments, primary care clinics, and long-term care facilities. When providing telehealth services, physical distance can create ethical and safety challenges. Regulations for training health care providers in telehealth care vary across states but obtaining continuing education in this technique is prudent. For example, The American Psychological Association offers A practitioner’s guide to telemental health: How to conduct legal, ethical and evidence-based telepractice with support through HRSA, including several models that have been implemented in Advanced Practice Nursing (APRN) education to develop practical integrated care skills. Some have focused on creating collaborative clinical practice experiences for Family Nurse Practitioner (FNP) and Psychiatric-Mental Health Nurse Practitioner (PMHNP) students in primary care settings. Furthermore, we now have dually certified APNs in psychiatric-mental health and other advanced practice nurse specialty areas, which fosters the ability to provide integrated care. Furthermore, others have established teams of PMHNP students, medical residents, and pharmacy students to deliver integrated care services in community mental health centers.

Conclusion

It is essential to address the sociocultural disparities that affect clients’ physical and emotional well-being and their overall morbidity and mortality. Integrated care within various settings enables clients to access mental health services with fewer barriers. Integrated care also facilitates community outreach and mental health promotion, as well as long-term monitoring and support for physical and mental health needs. This can potentially decrease mental health stigma and begin a trajectory of building and strengthening resilience and mental health among all communities including underserved populations. Interprofessional nurse-led teams have demonstrated the ability to improve outcomes by understanding team members’ roles (Franklin et al., 2015). Interprofessional teams are one of the important drivers of quality care in integrated care models. Valuing the contributions of others promotes interprofessional collaboration and greater job satisfaction. In caring for complex patients, providers practicing within an integrated care model are better able to respond collectively than they could individually.

Hence, APNA supports the position that integrated care models should be utilized to improve health equity by collaboratively and comprehensively addressing the complex physical, mental, and sociocultural needs of patients to decrease morbidity and mortality.

APNA Committee on Integrated Care and Professional Practice

Eugenia Millender, PhD, RN, PMHNP-BC, CDE, FAAN (co-chair)
Sara Jones, PhD, APRN, PMHNP-BC, FAAN (co-chair)
Donna Rolin, PhD, APRN, PMHCNS-BC, PMHNP-BC
Joyce Shea, DNSc, APRN, PMHCNS-BC, FAAN
Gail Stern, RN, MSN, PMHCNS-BC

Approved by the APNA Board of Directors January 10, 2023.

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