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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH
THE ROLE OF PRIMARY CARE
Primary care has been defined by the Institute of Medicine (IOM) as follows:
Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community (IOM, 1996, p. 32).
In this definition, integrated care refers to comprehensive, coordinated, and continuous services whose processes are seamless across different levels of care. Accountability refers to the responsibility for quality of care, patient satisfaction, efficient use of resources, and ethical behavior. The context of family and community refers to an understanding of the importance of living conditions, cultural background, and the impact of family dynamics on health status and also recognizes the caregiving role of families. The committee agrees with this definition and endorses it.
In a given year, an estimated 10 to 20 percent of the general population consult with a primary care physician about a mental health problem (Hankin and Otkay, 1979; IOM, 1996; Schulberg and Burns, 1988). More than a dozen studies have looked at the rate of recognition of mental health and substance abuse problems in primary care settings (IOM, 1996). Most often a person will present with a physical complaint, and about half the time the primary care clinician will recognize the underlying behavioral health issues (Bridges and Goldberg, 1985; Kirmayer et al., 1993). In the small number of cases in which the presenting problem is emotional or psychological, the mental health or substance abuse diagnosis is correctly determined about 90 percent of the time (Bridges and Goldberg, 1985).
Depression is the best known and most widely studied behavioral health problem in primary care, and the only guidelines for behavioral health treatment in primary care settings are for depression (AHCPR, 1993). The Medical Outcomes Study (Sturm and Wells, 1995) followed individuals with severe depression and compared the treatment effectiveness of treatment by primary care physicians, psychiatrists, and other mental health professionals. The quality of care provided by psychiatrists was found in that study to be significantly better than the quality of care given by primary care practitioners, but the cost of care was significantly less in the general medical sector.
Some studies have demonstrated that the integration of mental health and substance abuse professionals into primary care settings can improve patient outcomes with minimal changes in costs (Katon et al., 1995; Schulberg et al., 1995). For this integration to work, clear clinical protocols and standards of care are needed, the mental health professionals should be on-site, and the relationship between the patient and the primary care provider should continue (IOM, 1996). In summary, there is evidence that treatment in primary care settings given by behavioral health professionals can be effective and cost-effective.