Integrating Behavioral Health and Primary Care Services for People with Serious Mental Illness: A Qualitative Systems Analysis of Integration in New York

Abstract

People with co-occurring behavioral and physical conditions receive poorer care through traditional health care services. One solution has been to integrate behavioral and physical care services. This study assesses efforts to integrate behavioral health and primary care services in New York. Semi-structured interviews were conducted with 52 professionals in either group or individual settings. We aimed to identify factors which facilitate or hinder integration for people with serious mental illness and how these factors inter-relate. Content analysis identified structural, process, organizational ("internal") and contextual ("external") themes that were relevant to integration of care. Network analysis delineated the interactions between these. We show that effective integration does not advance along a single continuum from minimally to fully integrated care but along several, parallel pathways reliant upon consequential factors that aid or hinder one another.

Keywords: Integration of care; Primary care; Qualitative analysis; Service delivery.

Figure 1

Most Common Themes. Structural factors are shown in blue, process factors in green, external contexts in red and internal contexts in purple. Each theme is shown with the relative breakdown of the most common sub-themes. These were (in order of frequency): Teamworking – roles & responsibilities, collaborative care, professional regard; Reimbursement – grant funding, billing; Service arrangements – co-location of care, implementation models, affiliation; Integrated practices – care coordination, health promotion; Workforce – workforce adequacy, implementation champions; Screening processes – referral processes, screening, risk stratification; Regulation – licensing, regulatory authority; Communication – informal communication, formal meetings; Patient engagement – intrinsic patient factors, patient motivation; Organizational culture – shared mission.

Figure 2

Network map of factors that influence the integration of behavioral and primary health care in New York. Factors were identified through qualitative content and network analysis, informed by theoretical memoing during the process of coding. The analysis revealed a high degree of inter-relatedness between factors. Particular nodes which influenced a large number of other factors are highlighted in the map. These were co-location of care (structural), formal communication and referral processes (process factors) and regulation/licensing and grant funding (external contexts). Internal factors were found to be integral to how the different themes interacted and mediated many of the interactions.