Medical Care Services in Community Mental Health Centers: a National Survey of Psychiatrists Ruth S. Shim, MD, MPH Cathy Lally, MSPH Rebecca Farley, MPH Chuck Ingoglia, MSW Benjamin G. Druss, MD, MPH Introduction Behavioral health conditions can be severely disabling, with increased morbidity and mortality associated with these conditions often stemming from poor physical health.1,2 Individuals with serious mental illnesses treated in the public mental health sector die earlier from chronic morbidity (pulmonary disease, cardiovascular disease, and infectious diseases) than individuals without serious mental illnesses.3 Addressing the chronic health issues of individuals who are treated for behavioral health disorders is an urgent public health priority. Historically, community mental health centers (CMHCs) have had little capacity to provide medical services to their clients. A national survey conducted in 2007 found that although CMHCs considered the improvement of their clients’ medical care to be a high priority, and despite having protocols and procedures in place to screen for common medical problems, few CMHCs were able to provide adequate treatment, either on site or through a referral process.4 Recently, there has been a growing interest in increasing the availability of a full range of medical services to clients of public mental health facilities.3 Primary Behavioral Health Care Integration (PBHCI) grants, funded by the Substance Abuse and Mental Health Services Administration (SAMHSA), have supported 100 nationwide demonstration projects that provide
Address correspondence to Ruth S. Shim, MD, MPH, Department of Psychiatry, Lenox Hill Hospital, 111 E. 77th Street, New York, NY 10075, USA. Phone: 212-434-6887; Email: [email protected]. Cathy Lally, MSPH, Center for Behavioral Health Policy Studies, Rollins School of Public Health at Emory University, Atlanta, GA, USA. Phone: 404-712-3456; Email: [email protected] Benjamin G. Druss, MD, MPH, Center for Behavioral Health Policy Studies, Rollins School of Public Health at Emory University, Atlanta, GA, USA. Phone: 404-712-9602; Email: [email protected] Rebecca Farley, MPH, National Council for Behavioral Health, Washington, DC, USA. Phone: 684-7457; Email: [email protected] Chuck Ingoglia, MSW, National Council for Behavioral Health, Washington, DC, USA. Phone: 202-684-7457; Email: [email protected]
)
Journal of Behavioral Health Services & Research, 2014. 1–5. c 2014 National Council for Behavioral Health. DOI 10.1007/s11414-014-9453-4
Medical Care Services in Community Mental Health Center
co-located physical health care in CMHCs.5 These grants, which were first awarded in September 2009, have helped to improve access to primary care services, increase the availability of integrated care for physical and behavioral disorders, and improve patients’ mental health.6 Also, the Affordable Care Act (ACA) includes provisions for health homes for people with serious mental illnesses, which, to date, have been rolled out in various stages of planning and implementation in 30 states, with 15 states currently operating approved health home models.7,8 These health homes can help to address barriers to providing medical care for patients with mental illnesses by integrating physical and behavioral health care for Medicaid enrollees. Still, little is known about the impact of these reforms on medical care delivery in typical community mental health settings. In an attempt to develop an understanding of these gaps in knowledge, psychiatrists actively practicing in CMHCs were surveyed on the physical health care provided to individuals treated in CMHCs for behavioral health disorders. The goal was to provide a current overview of how community mental health settings are addressing the problem of poor physical health in their client populations.
Methods Sample A convenience sample of 435 practicing psychiatrists responded to an online solicitation by the National Council for Behavioral Health and the National Alliance on Mental Illness (NAMI). Psychiatrists were included in the survey if they were actively practicing in CMHCs, and if they had knowledge of their organization’s clinical programs. Based on these exclusion criteria, responses from 248 psychiatrists were ultimately analyzed. The sample of psychiatrists surveyed resided in 37 states and the District of Columbia, with the most respondents coming from New York (17), Colorado (17), Michigan (16), Arizona (14), and Pennsylvania (14). Upon successful completion of the survey, psychiatrists were given the option to receive a $10 gift card incentive. The online survey was administered from June 2013 to August 2013.
Measures Respondents were asked several questions to assess barriers to effective practice, including the following: 1. Which, if any, of the following types of providers does your organization employ to care for your patients’ general medical (i.e., non-psychiatric) needs? Answer options included primary care physicians, other specialist physicians, mid-level medical providers (e.g., nurse practitioners, physician assistant), nurses, peer specialists, none, do not know, and other. 2. Have you encountered any of the following barriers in delivering integrated services? Answer options included reimbursement, staff resistance, patient resistance, liability issues, space/physical facilities, confidentiality requirements, workforce limitations (skills, capacity), and lack of referral relationships. 3. Which, if any, of the following medical services do you personally provide to your patients? 4. Which, if any, of the following medical services do other clinicians at your organization provide to your patients? 5. What percentage of the patients enrolled in your clinic for the last year have received the following services onsite at your clinic (answer options included 75–100%, 50–75%, 25– 50%, 0–25%, not sure, or not applicable). For question 2, respondents were asked to determine if the barriers identified were related to psychiatrists themselves providing physical health care in their community mental health center, or
The Journal of Behavioral Health Services & Research
2014
if these barriers were perceived for psychiatrists delivering behavioral health services in primary care settings. For questions 3–5, respondents were told to select all that apply from the following list: blood pressure screening, obesity screening, cholesterol/lipids screening, diabetes screening, prescribe medications for high blood pressure, prescribe medications for high cholesterol, prescribe medications for diabetes, provide influenza vaccines, and provide education on physical health and lifestyle issues. Analysis Percentages were calculated on the basis of the total number of psychiatrists who answered each question. Descriptive statistics were analyzed using the SAS version 9.3 statistical software package.
Results Few psychiatrists reported that their CMHCs provide primary care services (38.6%), and even fewer reported that their CMHC employs primary care workers (24.8%). Most psychiatrists surveyed provide education to their patients on the importance of physical health and wellness (72.3%). Psychiatrists reporting that they provide education to their patients also report that they are more likely to personally conduct cholesterol/lipid screenings (63.0%) and diabetes screenings (60.0%) when a screening occurs. However, they report that less than half of patients actually receive these screenings. They also reported that other clinicians (non-psychiatrists) in their CMHCs were more likely to perform blood pressure screenings (70.2%) and obesity screenings (63.9%). Almost none of the surveyed psychiatrists working in CMHCs manage blood pressure (7.1%), cholesterol/lipids (5.0%), or diabetes (5.9%). A summary of the types of physical health services provided in CMHCs are shown in Table 1. Psychiatrists’ opinions on the most common barriers to physical health care in community mental health settings are shown in Figure 1. The psychiatrists surveyed cited several limitations to their patients receiving adequate primary care and physical health care services. Space/physical facility limitations (46.6%), workforce limitations (39.5%), and reimbursement issues (39.1%) were considered the most common barriers to the provision of physical health services in community behavioral health settings. Liability issues were also a common concern (26.1%). These issues were also cited as the most prevalent obstacles for psychiatrists delivering behavioral health services in primary care settings, although reimbursement (33.2%) was more commonly mentioned than space/physical facility barriers (24.8%) and workforce limitations (24.0%).
Discussion Although many psychiatrists practicing in CMHCs address physical health in patients through counseling, education, and screening for certain common physical health conditions, the majority does not directly provide treatment for these conditions. These findings are consistent with previous surveys of the nation’s CMHCs.4 Since 2007, there has been increased attention and initiatives focused on improving medical care for people with serious behavioral health conditions.7,9–12 Unfortunately, many psychiatrists who practice in public mental health settings have not seen significant progress and continue to report barriers (reimbursement, workforce limitations, and space) to provide effective medical care for their patients.13 These challenges, especially insurance-related barriers, are often unique to CMHC providers, as more than half of office-based psychiatrists do not take Medicaid or Medicare, and almost half of psychiatrists do not accept private insurance.14
Medical Care Services in Community Mental Health Center
Table 1 Provision of physical health services for patients in community mental health centers (CMHCs) Primary care service Service provided Blood pressure screening Obesity screening Cholesterol/lipid screening Diabetes screening Meds for blood pressure Meds for cholesterol/lipids Meds for diabetes Influenza vaccine Education physical health and lifestyle
Psychiatrist personally provides care 133 (55.88) 138 (57.98) 150 (63.03) 143 (60.08) 17 (7.14) 12 (5.04) 14 (5.88) 10 (4.20) 172 (72.27)
Other clinicians provide care 167 (70.17) 152 (63.87) 133 (55.88) 123 (51.68) 64 (26.89) 62 (26.05) 59 (24.79) 59 (24.79) 149 (62.61)
950% of patients receive service 134 (56.30) 130 (54.62) 113 (47.48) 109 (45.80) 15 (6.30) 12 (5.04) 11 (4.62) 18 (7.56) 127 (53.36)
The most common barriers to the effective management of patients’ medical conditions were space/physical facility and workforce limitations. These barriers represent ongoing impediments to care for today’s public sector psychiatrists. Unfortunately, space challenges cannot easily be addressed by changes in policy or practice, and increasing demand and need for behavioral health care will continue to cause space limitations for providers and patients. Similarly, workforce shortages have been an ongoing challenge in addressing the growing need for public sector mental
Figure 1
Percentage of Psychiatrists’ Perceived Barriers to Care Delivery. NPS = Non-Psychiatric Services 50 45 40 35 30 25 20 15 10 5 0
% Barriers to NPS in CMHCs
The Journal of Behavioral Health Services & Research
2014
health care.15 CMHC administrators may need to focus on effective ways to utilize existing space in facilities in a more efficient manner and may need local and federal support to prioritize medical care in CMHCs. This may require designating a physical examination room in CMHC facilities, purchasing medical equipment, and hiring or reallocating staff to provide medical care services. Reimbursement was another common barrier to the provision of medical care for individuals with behavioral health disorders. Public sector mental health financing is an ongoing challenge that may be better addressed by the ACA through expansion of Medicaid, and with full implementation of mental health parity. Integrated care and health home models, which endeavor to address both behavioral and physical health concerns, are emphasized in the ACA and with federal PCBHI grants. However, future efforts should focus on expanding these integrated care demonstration projects to wide-scale implementation. Some limitations should be discussed when considering the findings of this study. First, the survey used a convenience sample of psychiatrists, and as a result, the survey may not have been representative of all psychiatrists practicing in CMHCs. In addition, psychiatrists were evaluated regarding services for patients, and thus may fail to capture receipt of medical services outside of CMHCs or about which practicing psychiatrists were not aware. Nevertheless, this survey provides a broad overview of the practice and challenges of psychiatrists working in the nation’s CMHCs and enhances the understanding of strengths and weakness surrounding attempts to improve medical care for individuals treated in public behavioral health-care settings.
Implications for Behavioral Health Despite recent emphasis on integration of behavioral health and primary care services, many psychiatrists working in community behavioral health settings perceive continuing barriers to receipt of adequate physical health care for their patients. Behavioral health providers, policymakers, and administrators should redouble their efforts to address poor physical health in patients with behavioral health issues, particularly around issues of space allocation, workforce development, and reimbursement.
Conflict of Interest The survey and data analysis was jointly funded by Sunovion, Takeda Pharmaceuticals, USA, Inc., and Lundbeck LLC, in partnership with the National Council for Behavioral Health and NAMI.
Credits and Disclaimers No credits or disclaimers to report.
References 1. Jones DR, Macias C, Barreira PJ, et al. Prevalence, severity, and co-occurrence of chronic physical health problems of persons with serious mental illness. Psychiatric Services 2004; 55(11): 1250-1257 2. Colton CW, Manderscheid RW. Congruencies in increased mortality rates, years of potential life lost, and causes of death among public mental health clients in eight states. Preventing Chronic Disease. 2006; 3(2): A42-A42 3. Parks J, Svendsen D, Singer P, et al. Morbidity and Mortality in People with Serious Mental Illness. National Association of State Mental Health Program Directors (NASMHPD) Medical Directors Council Alexandria, VA; 2006 4. Druss BG, Marcus SC, Campbell J, et al. Medical services for clients in community mental health centers: results from a national survey. Psychiatric Services. 2008; 59(8): 917-920 5. Scharf DM, Eberhart NK, Schmidt N, et al. Integrating primary care into community behavioral health settings: programs and early implementation experiences. Psychiatric Services. 2013; 64(7): 660-665 6. SAMHSA-HRSA Center for Integrated Health Solutions. SAMHSA PBHCI Program. Making Integrated Care Work. 2014. Available online at: http://www.integration.samhsa.gov/about-us/pbhci. Accessed August 29, 2014
Medical Care Services in Community Mental Health Center
7. Mechanic D. Seizing opportunities under the Affordable Care Act for transforming the mental and behavioral health system. Health Affairs. 2012; 31(2): 376-382 8. Centers for Medicare and Medicaid Services. State Health Home CMS Proposal Status. 2014. Available online at: http://www.medicaid.gov/ State-Resource-Center/Medicaid-State-Technical-Assistance/Health-Homes-Technical-Assistance/Downloads/HH-MAP_v34.pdf. Accessed August 29, 2014 9. Allison DB, Newcomer JW, Dunn AL, et al. Obesity Among Those with Mental Disorders. American Journal of Preventive Medicine. 2009; 36(4): 341-350 10. Horvitz-Lennon M, Kilbourne AM, Pincus HA. From silos to bridges: meeting the general health care needs of adults with severe mental illnesses. Health Affairs. 2006; 25(3): 659-669 11. Katon WJ, Lin EHB, Von Korff M, et al. Collaborative care for patients with depression and chronic illnesses. New England Journal of Medicine. 2010; 363(27): 2611-2620 12. Druss BG, von Esenwein SA, Compton MT, et al. A randomized trial of medical care management for community mental health settings: the Primary Care Access, Referral, and Evaluation (PCARE) study. American Journal of Psychiatry. 2010; 167(2): 151-159 13. Shim RS, Lally C, Farley R, et al. Datapoints:Psychiatrists’ Perceptions of Insurance-Related Medication Access Barriers. Psychiatric Services. 2014; 65(11): 1296. 14. Bishop TF, Press MJ, Keyhani S, et al. Acceptance of insurance by psychiatrists and the implications for access to mental health care. Journal of the American Medical Association - Psychiatry. 2014; 71(2): 176-181 15. Thomas KC, Ellis AR, Konrad TR, et al. County-level estimates of mental health professional shortage in the United States. Psychiatric Services. 2009; 60(10): 1323-1328
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2014
Address correspondence to Ruth S. Shim, MD, MPH, Department of Psychiatry, Lenox Hill Hospital, 111 E. 77th Street, New York, NY 10075, USA. Phone: 212-434-6887; Email: [email protected]. Cathy Lally, MSPH, Center for Behavioral Health Policy Studies, Rollins School of Public Health at Emory University, Atlanta, GA, USA. Phone: 404-712-3456; Email: [email protected] Benjamin G. Druss, MD, MPH, Center for Behavioral Health Policy Studies, Rollins School of Public Health at Emory University, Atlanta, GA, USA. Phone: 404-712-9602; Email: [email protected] Rebecca Farley, MPH, National Council for Behavioral Health, Washington, DC, USA. Phone: 684-7457; Email: [email protected] Chuck Ingoglia, MSW, National Council for Behavioral Health, Washington, DC, USA. Phone: 202-684-7457; Email: [email protected]
)
Journal of Behavioral Health Services & Research, 2014. 1–5. c 2014 National Council for Behavioral Health. DOI 10.1007/s11414-014-9453-4
Medical Care Services in Community Mental Health Center
co-located physical health care in CMHCs.5 These grants, which were first awarded in September 2009, have helped to improve access to primary care services, increase the availability of integrated care for physical and behavioral disorders, and improve patients’ mental health.6 Also, the Affordable Care Act (ACA) includes provisions for health homes for people with serious mental illnesses, which, to date, have been rolled out in various stages of planning and implementation in 30 states, with 15 states currently operating approved health home models.7,8 These health homes can help to address barriers to providing medical care for patients with mental illnesses by integrating physical and behavioral health care for Medicaid enrollees. Still, little is known about the impact of these reforms on medical care delivery in typical community mental health settings. In an attempt to develop an understanding of these gaps in knowledge, psychiatrists actively practicing in CMHCs were surveyed on the physical health care provided to individuals treated in CMHCs for behavioral health disorders. The goal was to provide a current overview of how community mental health settings are addressing the problem of poor physical health in their client populations.
Methods Sample A convenience sample of 435 practicing psychiatrists responded to an online solicitation by the National Council for Behavioral Health and the National Alliance on Mental Illness (NAMI). Psychiatrists were included in the survey if they were actively practicing in CMHCs, and if they had knowledge of their organization’s clinical programs. Based on these exclusion criteria, responses from 248 psychiatrists were ultimately analyzed. The sample of psychiatrists surveyed resided in 37 states and the District of Columbia, with the most respondents coming from New York (17), Colorado (17), Michigan (16), Arizona (14), and Pennsylvania (14). Upon successful completion of the survey, psychiatrists were given the option to receive a $10 gift card incentive. The online survey was administered from June 2013 to August 2013.
Measures Respondents were asked several questions to assess barriers to effective practice, including the following: 1. Which, if any, of the following types of providers does your organization employ to care for your patients’ general medical (i.e., non-psychiatric) needs? Answer options included primary care physicians, other specialist physicians, mid-level medical providers (e.g., nurse practitioners, physician assistant), nurses, peer specialists, none, do not know, and other. 2. Have you encountered any of the following barriers in delivering integrated services? Answer options included reimbursement, staff resistance, patient resistance, liability issues, space/physical facilities, confidentiality requirements, workforce limitations (skills, capacity), and lack of referral relationships. 3. Which, if any, of the following medical services do you personally provide to your patients? 4. Which, if any, of the following medical services do other clinicians at your organization provide to your patients? 5. What percentage of the patients enrolled in your clinic for the last year have received the following services onsite at your clinic (answer options included 75–100%, 50–75%, 25– 50%, 0–25%, not sure, or not applicable). For question 2, respondents were asked to determine if the barriers identified were related to psychiatrists themselves providing physical health care in their community mental health center, or
The Journal of Behavioral Health Services & Research
2014
if these barriers were perceived for psychiatrists delivering behavioral health services in primary care settings. For questions 3–5, respondents were told to select all that apply from the following list: blood pressure screening, obesity screening, cholesterol/lipids screening, diabetes screening, prescribe medications for high blood pressure, prescribe medications for high cholesterol, prescribe medications for diabetes, provide influenza vaccines, and provide education on physical health and lifestyle issues. Analysis Percentages were calculated on the basis of the total number of psychiatrists who answered each question. Descriptive statistics were analyzed using the SAS version 9.3 statistical software package.
Results Few psychiatrists reported that their CMHCs provide primary care services (38.6%), and even fewer reported that their CMHC employs primary care workers (24.8%). Most psychiatrists surveyed provide education to their patients on the importance of physical health and wellness (72.3%). Psychiatrists reporting that they provide education to their patients also report that they are more likely to personally conduct cholesterol/lipid screenings (63.0%) and diabetes screenings (60.0%) when a screening occurs. However, they report that less than half of patients actually receive these screenings. They also reported that other clinicians (non-psychiatrists) in their CMHCs were more likely to perform blood pressure screenings (70.2%) and obesity screenings (63.9%). Almost none of the surveyed psychiatrists working in CMHCs manage blood pressure (7.1%), cholesterol/lipids (5.0%), or diabetes (5.9%). A summary of the types of physical health services provided in CMHCs are shown in Table 1. Psychiatrists’ opinions on the most common barriers to physical health care in community mental health settings are shown in Figure 1. The psychiatrists surveyed cited several limitations to their patients receiving adequate primary care and physical health care services. Space/physical facility limitations (46.6%), workforce limitations (39.5%), and reimbursement issues (39.1%) were considered the most common barriers to the provision of physical health services in community behavioral health settings. Liability issues were also a common concern (26.1%). These issues were also cited as the most prevalent obstacles for psychiatrists delivering behavioral health services in primary care settings, although reimbursement (33.2%) was more commonly mentioned than space/physical facility barriers (24.8%) and workforce limitations (24.0%).
Discussion Although many psychiatrists practicing in CMHCs address physical health in patients through counseling, education, and screening for certain common physical health conditions, the majority does not directly provide treatment for these conditions. These findings are consistent with previous surveys of the nation’s CMHCs.4 Since 2007, there has been increased attention and initiatives focused on improving medical care for people with serious behavioral health conditions.7,9–12 Unfortunately, many psychiatrists who practice in public mental health settings have not seen significant progress and continue to report barriers (reimbursement, workforce limitations, and space) to provide effective medical care for their patients.13 These challenges, especially insurance-related barriers, are often unique to CMHC providers, as more than half of office-based psychiatrists do not take Medicaid or Medicare, and almost half of psychiatrists do not accept private insurance.14
Medical Care Services in Community Mental Health Center
Table 1 Provision of physical health services for patients in community mental health centers (CMHCs) Primary care service Service provided Blood pressure screening Obesity screening Cholesterol/lipid screening Diabetes screening Meds for blood pressure Meds for cholesterol/lipids Meds for diabetes Influenza vaccine Education physical health and lifestyle
Psychiatrist personally provides care 133 (55.88) 138 (57.98) 150 (63.03) 143 (60.08) 17 (7.14) 12 (5.04) 14 (5.88) 10 (4.20) 172 (72.27)
Other clinicians provide care 167 (70.17) 152 (63.87) 133 (55.88) 123 (51.68) 64 (26.89) 62 (26.05) 59 (24.79) 59 (24.79) 149 (62.61)
950% of patients receive service 134 (56.30) 130 (54.62) 113 (47.48) 109 (45.80) 15 (6.30) 12 (5.04) 11 (4.62) 18 (7.56) 127 (53.36)
The most common barriers to the effective management of patients’ medical conditions were space/physical facility and workforce limitations. These barriers represent ongoing impediments to care for today’s public sector psychiatrists. Unfortunately, space challenges cannot easily be addressed by changes in policy or practice, and increasing demand and need for behavioral health care will continue to cause space limitations for providers and patients. Similarly, workforce shortages have been an ongoing challenge in addressing the growing need for public sector mental
Figure 1
Percentage of Psychiatrists’ Perceived Barriers to Care Delivery. NPS = Non-Psychiatric Services 50 45 40 35 30 25 20 15 10 5 0
% Barriers to NPS in CMHCs
The Journal of Behavioral Health Services & Research
2014
health care.15 CMHC administrators may need to focus on effective ways to utilize existing space in facilities in a more efficient manner and may need local and federal support to prioritize medical care in CMHCs. This may require designating a physical examination room in CMHC facilities, purchasing medical equipment, and hiring or reallocating staff to provide medical care services. Reimbursement was another common barrier to the provision of medical care for individuals with behavioral health disorders. Public sector mental health financing is an ongoing challenge that may be better addressed by the ACA through expansion of Medicaid, and with full implementation of mental health parity. Integrated care and health home models, which endeavor to address both behavioral and physical health concerns, are emphasized in the ACA and with federal PCBHI grants. However, future efforts should focus on expanding these integrated care demonstration projects to wide-scale implementation. Some limitations should be discussed when considering the findings of this study. First, the survey used a convenience sample of psychiatrists, and as a result, the survey may not have been representative of all psychiatrists practicing in CMHCs. In addition, psychiatrists were evaluated regarding services for patients, and thus may fail to capture receipt of medical services outside of CMHCs or about which practicing psychiatrists were not aware. Nevertheless, this survey provides a broad overview of the practice and challenges of psychiatrists working in the nation’s CMHCs and enhances the understanding of strengths and weakness surrounding attempts to improve medical care for individuals treated in public behavioral health-care settings.
Implications for Behavioral Health Despite recent emphasis on integration of behavioral health and primary care services, many psychiatrists working in community behavioral health settings perceive continuing barriers to receipt of adequate physical health care for their patients. Behavioral health providers, policymakers, and administrators should redouble their efforts to address poor physical health in patients with behavioral health issues, particularly around issues of space allocation, workforce development, and reimbursement.
Conflict of Interest The survey and data analysis was jointly funded by Sunovion, Takeda Pharmaceuticals, USA, Inc., and Lundbeck LLC, in partnership with the National Council for Behavioral Health and NAMI.
Credits and Disclaimers No credits or disclaimers to report.
References 1. Jones DR, Macias C, Barreira PJ, et al. Prevalence, severity, and co-occurrence of chronic physical health problems of persons with serious mental illness. Psychiatric Services 2004; 55(11): 1250-1257 2. Colton CW, Manderscheid RW. Congruencies in increased mortality rates, years of potential life lost, and causes of death among public mental health clients in eight states. Preventing Chronic Disease. 2006; 3(2): A42-A42 3. Parks J, Svendsen D, Singer P, et al. Morbidity and Mortality in People with Serious Mental Illness. National Association of State Mental Health Program Directors (NASMHPD) Medical Directors Council Alexandria, VA; 2006 4. Druss BG, Marcus SC, Campbell J, et al. Medical services for clients in community mental health centers: results from a national survey. Psychiatric Services. 2008; 59(8): 917-920 5. Scharf DM, Eberhart NK, Schmidt N, et al. Integrating primary care into community behavioral health settings: programs and early implementation experiences. Psychiatric Services. 2013; 64(7): 660-665 6. SAMHSA-HRSA Center for Integrated Health Solutions. SAMHSA PBHCI Program. Making Integrated Care Work. 2014. Available online at: http://www.integration.samhsa.gov/about-us/pbhci. Accessed August 29, 2014
Medical Care Services in Community Mental Health Center
7. Mechanic D. Seizing opportunities under the Affordable Care Act for transforming the mental and behavioral health system. Health Affairs. 2012; 31(2): 376-382 8. Centers for Medicare and Medicaid Services. State Health Home CMS Proposal Status. 2014. Available online at: http://www.medicaid.gov/ State-Resource-Center/Medicaid-State-Technical-Assistance/Health-Homes-Technical-Assistance/Downloads/HH-MAP_v34.pdf. Accessed August 29, 2014 9. Allison DB, Newcomer JW, Dunn AL, et al. Obesity Among Those with Mental Disorders. American Journal of Preventive Medicine. 2009; 36(4): 341-350 10. Horvitz-Lennon M, Kilbourne AM, Pincus HA. From silos to bridges: meeting the general health care needs of adults with severe mental illnesses. Health Affairs. 2006; 25(3): 659-669 11. Katon WJ, Lin EHB, Von Korff M, et al. Collaborative care for patients with depression and chronic illnesses. New England Journal of Medicine. 2010; 363(27): 2611-2620 12. Druss BG, von Esenwein SA, Compton MT, et al. A randomized trial of medical care management for community mental health settings: the Primary Care Access, Referral, and Evaluation (PCARE) study. American Journal of Psychiatry. 2010; 167(2): 151-159 13. Shim RS, Lally C, Farley R, et al. Datapoints:Psychiatrists’ Perceptions of Insurance-Related Medication Access Barriers. Psychiatric Services. 2014; 65(11): 1296. 14. Bishop TF, Press MJ, Keyhani S, et al. Acceptance of insurance by psychiatrists and the implications for access to mental health care. Journal of the American Medical Association - Psychiatry. 2014; 71(2): 176-181 15. Thomas KC, Ellis AR, Konrad TR, et al. County-level estimates of mental health professional shortage in the United States. Psychiatric Services. 2009; 60(10): 1323-1328
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2014
