title: Barriers to physical and mental condition integrated service delivery.
abstract: OBJECTIVE
  To assess pragmatic challenges faced when implementing, delivering, and sustaining models of integrated mental health intervention in primary care settings. Thirty percent of primary care patients with chronic medical conditions and up to 80% of those with health complexity have mental health comorbidity, yet primary care clinics rarely include onsite mental health professionals and only one in eight patients receive evidence-based mental health treatment. Integrating specialty mental health into primary care improves outcomes for patients with common disorders, such as depression.
  
  
  METHODS
  We used key informant interviews documenting barriers to implementation and components that inhibited or enhanced operational success at 11 nationally established integrated physical and mental condition primary care programs.
  
  
  RESULTS
  All but one key informant indicated that the greatest barrier to the creation and sustainability of integrated mental condition care in primary care settings was financial challenges introduced by segregated physical and mental health reimbursement practices. For integrated physical and mental health program initiation and outcome changing care to be successful, key components included a clinical and administrative champion-led culture shift, which valued an outcome orientation; cross-disciplinary training and accountability; use of care managers; consolidated clinical record systems; a multidisease, total population focus; and active, respectful coordination of colocated interdisciplinary clinical services.
  
  
  CONCLUSIONS
  Correction of disparate physical and mental health reimbursement practices is an important activity in the development of sustainable integrated physical and mental condition care in primary care settings, such as a medical home. Multiple clinical, administrative, and economic factors contribute to operational success.
authors.affiliation: Department of Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA. katho001@umn.edu
authors.forename: Roger G
authors.initials: RG
authors.lastname: Kathol
authors.forename: Mary
authors.initials: M
authors.lastname: Butler
authors.forename: Donna D
authors.initials: DD
authors.lastname: McAlpine
authors.forename: Robert L
authors.initials: RL
authors.lastname: Kane
mesh_terms: D000368:Aged; D001291:Attitude of Health Personnel; D003156:Community Mental Health Services / Q000191:economics / Q000458:organization & administration; D015897:Comorbidity; D019033:Delivery of Health Care, Integrated / Q000191:economics / Q000458:organization & administration*; D003866:Depressive Disorder / Q000628:therapy; D006279:Health Maintenance Organizations / Q000191:economics / Q000458:organization & administration / Q000592:standards; D006297:Health Services Accessibility; D006699:Home Care Services; D006801:Humans; D001523:Mental Disorders / Q000191:economics / Q000628:therapy*; D017146:Models, Organizational; D019982:Organizational Case Studies; D011320:Primary Health Care / Q000191:economics / Q000458:organization & administration*; D016730:Program Development / Q000191:economics / Q000592:standards; D011613:Psychotherapy; D012051:Reimbursement Mechanisms / Q000458:organization & administration / Q000592:standards; D016896:Treatment Outcome; D014481:United States; D014493:United States Department of Veterans Affairs