There is a great deal of good international evidence about what elements are likely to be most effective for meeting the needs of people with mental health and addiction problems in primary care. Grazier and colleagues (2016) studied the key factors and common themes in successful models, in a systematic review. Common features of successful integration models that were found, included:
- prioritised underserved vulnerable populations (including homeless families and individuals, veterans and their families, women with HIV, and incarcerated youth)
- extensive community-wide collaboration (unique to each organisation)
- ensuring strong leadership early in the process
- implementing a team-based approach
- including the patient as an active participant
- diversifying funding sources, and
- implementing data-driven approaches and practices.
One New Zealand study of clinical decision making and primary health care delivery for multimorbidity (where a person has two or more chronic conditions), reported on interviews with 12 GPs and four primary care nurses (PCNs) in Otago, a part of the country where the national Care Plus initiative was being complemented by regional health service initiatives, in an effort to improve care co-ordination and integration between primary and secondary care (Stokes, Tumilty et al., 2017). GP respondents described:
- a level of complexity that created problems with the time available – generally 15 minutes for a consultation
- problems with clinical guidelines which are generally developed for single conditions
- strategies to address multiple problems in a short timeframe included – ‘satisficing’ – defined as “settling for chronic disease management that was satisfactory and sufficient, given the particular circumstances of that patient”; and relational continuity of care (an ongoing therapeutic relationship which addressed problems sequentially over time)
- the mixed capitation/co-payment model as a barrier to delivering care to people with multimorbidity
- flexible use of Care Plus funding – to (a) subsidise GP visits only; (b) visits with GP and PCN.
- fragmentation of health care provision – both within general practice and across the primary/secondary care interface. The latter was described as systematic and pervasive, caused by a ‘disconnect’ between primary and secondary care, including a lack of shared information systems.
A key finding was that the co-payment funding model in New Zealand primary care services was seen by GPs as a barrier to the delivery of care as it discourages sequential consultations. The problem of cost was only partially addressed by Care Plus. Stokes and colleagues (2017) also commented that no independent evaluation of Care Plus had been undertaken since it was established in 2004.
Cost is definitely a barrier to care for people on a low income; one national New Zealand survey found that 15.5 per cent of respondents had put off seeing their doctor at least once in the previous 12 months because of the cost, and those with more than two co-existing health problems were even more likely to defer visits to the doctor (Jatrana & Crampton, 2009).
References: Grazier, K. L., Smiley, M. L., & Bondalapati, K. S. (2016). Overcoming Barriers to Integrating Behavioral Health and Primary Care Services. Journal of Primary Care & Community Health, 7(4), 242-248; Jatrana, S., & Crampton, P. (2009). Primary health care in New Zealand: who has access? Health Policy, 93(1), 1-10; Stokes, T., Tumilty, E., Doolan-Noble, F., & Gauld, R. (2017). Multimorbidity, clinical decision making and health care delivery in New Zealand Primary care: a qualitative study. BMC family practice, 18(1), 51.