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~ ,) ~ SECTION V AN INTEGRATED S _ Y OF INVITATIONAL WORKSHOP DISCUSSIONS Each conferee and observer participated in one of three workshop sessions on the second day of the conference. The discussions, con- ducted simultaneously and ranging across the entire subject matter of the conference, are summarized here under five major topics.

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123 PROVIDER ROLES AND FUNCTIONS A discussion of appropriate functions and roles for primary care and mental health care providers in general health settings brought out two points of view. One, more implied than stated, foresaw a very limited role for psychiatry in primary care settings, and that primary care practitioners could, with, training in the requisite diagnostic and case management skills, largely absorb the functions of the mental health specialists The second point of view was that mental health care in the primary care context would revise and perhaps increase the role for psychiatrists. Increasing the diagnostic skills of primary care physicians was expected to increase the cases of mental disorders recognized, making it likely that more cases would be referred to the mental health specialty sector. In the second view, psychiatrists would be needed: (1) to assist primary care providers in acquiring and maintaining skills necessary for diagnosis of mental disorders and management of emotional complaints; (2) to collaborate with primary care practitioners both (a) to facilitate their coping with the anxieties and frustrations of caring for patients with psychiatric disorders, (b) to provide direct service to patients; and (3) to serve as referral resources. Close collaboration between psychiatrists and primary care physicians was seen as a promising oppor- tunity for ensuring appropriateness of patient care and minimizing dis- ruption of the continuity of care, which is a hazard in the process of referral. There was consensus among the participants that a widely recog- nized and acceptable concept for the division of labor in mental health treatment does not exist. The range in complexity and severity of pro- blems for which patients seek care precludes facile distinctions of the roles and functions of providers. A useful framework for defining roles and functions of providers should be developed in future research. There are recurrent difficulties in delineating the kinds, complexity, and severity of the problems that should be in the purview of various primary care providers, as well as the complexity and severity of the problems that are likely to require secondary or tertiary specialized care by mental health professionals. Difficulties with these distinc- tions seem to occur more frequently in the ambulatory primary care setting, where the relationship between mental health specialists and primary care practitioners is less clearly defined, than in the hospi- tal, where the roles and functions of "liaison psychiatry" and general health care seem fairly well circumscribed.

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124 In a discussion of how best to determine the appropriate match of patients to providers for optimal care of mental health problems, it was agreed that not all persons with emotional disturbances would be treated appropriately by psychiatrists, and that the goal for the primary care practitioner should not simply be to sort out the emo- tionally disturbed and refer them to specialty practice. It was suggested that such activities as counseling with parents on child development, psychological preparation for surgery, or counseling the post-myocardial infarct patient by primary care practitioners, are to be expected in the course of general health care. However, criteria have not been established to determine which non-psychotic but identifiably mentally disordered persons could be served opti- mally by primary care providers. In the matter of defining the general skills required of provid- ers of mental health care in non-specialty settings, it was emphasized that mental health care begins with diagnosis. The gamut of mental disorders in patients who present to general health care providers makes it essential that the primary physician have a system with fairly broad applicability to make appropriate diagnoses. Especially in ambulatory settings, primary care providers should be able to discern both the patient's underlying disorder and the more immediate reasons for seeking care. Several participants noted that -- with some exceptions -- com- plex cases and chronic mental illness requiring long-term care are best treated by mental health specialists. Thus, primary providers should be skilled at referring their patients, when diagnosis so indicates, to mental health specialists or to other social support systems. The general health care providers can then focus on counsel- ing, which serves the functions of interim, crisis-type support and preventive mental health care. Although the need for primary care providers to give attention to patients' mental health needs was mentioned repeatedly, a cautionary question was raised: Is there a risk, in trying to make primary care providers more sensitive and better therapists in the psychiatric sense, of weakening their skills and abilities to manage the medical problems with appropriate attention? A balance is required between the medical and mental health skills of providers of general health care. Although there was agreement on some of the general skills neces- sary for providing mental health care in general health care settings, the "turf" issues remained controversial. A number of participants cited role differentiation as the principal policy issue to be faced, and the discussions of an appropriate "division of labor" focused on the discrete functions of three types of providers: (1) primary care physicians, (2) psychiatrists, and (3) non-physician mental health professionals.

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125 Primary Care Physicians Whether or not it is theoretically optimal, a large part of mental health care is and will continue to be provided by physicians who are not mental health specialists, it was conceded. In rural areas, where approximately one-quarter of the U.S. population lives, the general practitioner often is the sole provider of health care in any form, including mental health care. Emphasis on the pragmatic issues of how to help those who are providing care to deliver better care was seen preferable to continued debate about who is best quali- fied to provide mental health care. It was proposed that the basic mental health skills required by most general health care providers are relatively simple: warm, humane interests in the patient and the patient's problems, and a willingness to use psychotherapeutic and crisis intervention as well as pharmacological intervention to help people through acute crises. Beyond these basic skills, the general health care practitioner needs to obtain knowledge from social and behavioral sciences. This knowledge can promote a more humanistic approach to patients, increase skills in recognition and diagnosis of mental disorders and determining their severity, and encourage use of specialty resources in collaboration and consultation. Although physicians recognize that much of their practice has a psychological framework, it was suggested that many tend to be dubi- ous about the usefulness of collaborating with mental health special- ists. In addition, some primary care physicians fail to collaborate or consult with mental health professionals for much the same reason their patients do not seek care from that specialty sector: they do not know enough about what the mental health specialist does. There was consensus that collaboration in some form must be estab- lished. One promising approach to productive interaction between health and mental health practitioners is the interdisciplinary team, in ambu- latory medical settings such as those found in some primary care and psychiatric training programs. These programs have shown psychiatry and primary care are not incompatible because of differing approaches to the multiplicity of patient problems. It was also pointed out that the whole primary care team, especially in the absence of other contacts, may become essential parts of the coping mechanisms of patients. Psychiatrists An increasing involvement of the general health care sector in providing mental health care has raised a need to redefine some aspects of psychiatry~s role. Conferees noted that some health policy-makers had presumed that increasing the numbers and quality

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126 of training of primary care physicians would result in their caring for a greater proportion of the population with mental disorders and a concomitant reduction in the need for mental health specialists. But it was agreed that experience to date does not support the pre- sumption. Private practice and hospital-based liaison psychiatrists are expected to continue to provide specialty care for severe psychopatho- logy, and to fulfill the traditional function of handling mental health referrals from the general health care sector. There is, however, a growing need for psychiatrists as consultants in ambulatory health care settings. Consultation or liaison psychiatry, in addition to promoting the improved management of a broad range of mental disorders can be a valuable means of continuing education for both general health care physicians and psychiatrists. The role of psychiatrists as educators in residency training pro- grams may represent the current most effective linkage between psychia- try and the general health care sector, given the still relatively limited opportunities for direct collaboration in the actual delivery of care in established settings. Important contributions of psychiatry to the training and practice of primary care practitioners include teaching diagnostic, therapeutic, and preventive skills, along with guidelines for appropriate referral for specialty care, and explaining the new emphasis on the biopsychosocial or holistic approach to patient care. The practice of psychiatry in the primary health care setting was seen as an opportunity to revise and broaden the perspective of the psychiatrist on formats for therapeutic intervention. In contrast to specialty mental health services, in which patients are ordinarily seen for prolonged episodes over a relatively brief span of time (such as two or three visits a week over an eighteen-month period), primary health care providers generally follow patients in brief episodes of care over long periods of time (such as two or three visits a year over the course of several years). A successful outcome of specialty mental health service typically has been based on the expectation that the patient will not return-after the completion of psychothera- peutic intervention. The definition of successful outcome in primary care is quite the opposite: the primary health care provider assumes that patients will continue to return for health care as needed. It was suggested that psychiatrists in primary health care settings might employ a "string of beads" approach, in which the patient would work on a theme in a succession of crisis episodes for which he or she would return to the same therapists to pick up the treatment. The treatment course in this approach is not terminated but is considered to have do ant phases. This course could be a workable alternative

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127 for patients who previously deemed psychotherapeutic intervention unacceptable because of the prolonged and costly involvement. Most psychiatrists, however, have not been trained in this kind of task- centered modality, and psychiatric training programs would have to be modified for it to become a part of the psychiatrist's thera- peutic resources. This kind of approach may not be feasible for some patients, such as the chronically mentally ill who may need consistent and continuous care. Non-physician Providers of Mental Health Care Variability in the type and severity of mental disorders pre- sented by patients seeking help in the primary health care sector has implications for employment of a variety of non-physician providers of mental health care, such as social workers, nurse-practitioners, psychologists, and physician assistants. Conferees noted that for the less differentiated states of mental morbidity, which may often require extensive time and attention, non-physicians in fact may be the most appropriate providers. A number of participants pointed out that non-physician mental health professionals are particularly skilled at assessing and managing psychosocial problems e Examples were cited of several British primary health care settings where the use of medical social workers has achieved some positive results in the economy and efficiency of care for psychosocial problems. It was suggested that perhaps the most important role of these social workers was a coordinative one between the health, mental health, and social service sectors. The participation of non-physician mental health specialists in general health care settings, both as primary care providers and as consultants, can encourage preventive health programs and patient involvement. The non-physicians also can be effective educators of medical residents. The economic benefits of employing non-physician mental health personnel also were discussed. There was agreement on the potential advantages of this mode of care, but several participants expressed concern that the quality of care could be compromised to save money. The observation also was made that the training in some of these fields may not necessarily provide adequate skills for many psycho- logists and social workers, to step into a primary care setting and be helpful. EDUCATION AND TRAINING The discussion of education and training focused principally on the needs of non-psychiatrist providers of mental health care in general health settings. The development of adequate programs, workshop participants agreed, probably will require fundamental

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128 shifts in-the traditional attitudes and orientation of medical educators. At present, there is great variation in the mental health knowledge, skills, and attitudes of practicing primary care professionals and wide diversity in the mental health training available in medical schools and residency training programs. The implications for the training of psychiatrists of the growing emphasis on integrated health and mental health care also were discussed. Departments of psychiatry are beginning to consider alternative roles for psychiatrists in relation to the general health care sector, and training programs are likely to place increased emphasis on skills in indirect care and consultation in many kinds of practice settings. The inadequacy of current programs in medical education and training at a number of levels was discussed. It was suggested that premedical undergraduate education generally pays insufficient attention to the be- havioral and social aspects of human biology, and that selection of medi- cal school applicants tends to downplay or disregard "whatever it is that would indicate that they would like to take care of people's needs beyond a purely physical ailment level." There was general agreement that medical school curricula tend to neglect the behavioral sciences. Perhaps the strongest criticism of the current system, however, concerned the limited opportunities for appropriate practical experience in inte- grated health/mental health care facilities during residency training. Opportunities for health care personnel to get continuing education also were observed to be limited. Suggested ways to improve medical education and training programs primarily were: (1) revising the content of the standard medical school curriculum, in terms of both orientation and instruction in specific skills; (2) offering more appropriate clinical training experiences to prepare medical students and residents for the practice of integrated health/mental health care; (3) providing appropriate and effective role models throughout the educational and training process; and (4) upgrading continuing education for practicing physicians. Funding and other fac- tors in making such changes also were discussed. (1) Content Education and training of general health care prac- titioners should include knowledge from many disciplines that are not necessarily considered "medical," including psychiatry. Fields such as anthropology, economics, and particularly the behavioral sciences and sociology, should contribute to both premedical and medical school curricula; greater emphasis on behavioral medicine should be reflected in the National Board Examinations. A developmental life cycle approach to studying health in relation to mental health was endorsed by several participants. There was general agreement that awareness of patients' social contexts is an important component of integrated health care.

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129 Although promoting a less "biotechnical" orientation and approach among health care providers is essential, the teaching of behavioral medicine also must include instruction in the specific mental health skills that enable physicians to deal effectively with the behavioral aspects of their patients' problems. Three related types of skills were emphasized: detection of mental health problems; accurate assess- ment and diagnosis of those problems; and appropriate management of them, which requires both an understanding of psychotherapeutic tech- niques--counseling and medication--and when to make appropriate refer- rals. (2) Clinical training Effective application of the skills men- tioned above requires practical experience. Several participants observed that, even when students are motivated to become providers of integrated health and mental health care, most training programs do not furnish adequate clinical preparation for the practice of mental health care in general health care settings. For most medical students who do not choose to specialize in psychiatry, practical ex- perience in applying mental health skills under supervision is limited to the psychiatric rotation as a small and discrete part of their medi- cal education, rather than as an ongoing process. There was general agreement that, to promote effective integra- tion of mental health and general health care, residency training of all potential primary care providers -- including those specializing in psychiatry -- should be available and encouraged in integrated care settings, such as neighborhood health centers, continuing clinics, and other primary care settings that include mental health services. Resi- dents should be integrated into primary care teams with psychiatric social workers, nurse practitioners, staff physicians, and the like to encourage sharing of skills and responsibilities. Traditional hospital-based residencies tend to train physicians to interact episod- ically with their patients, providing limited opportunities to establish the longer-term relationships in which health and mental health care most successfully are combined. Linking such academic centers with various community care systems was suggested as an effective way to provide training in integrated care. Appropriate practical training will become increasingly necessary, several participants commented, as more physicians are required to ful- fill "payback" obligations in underserved areas in return for financial support of medical education. Health care in such areas characteris- tically lacks the backup support resources associated with better served communities. (3) Continuing education Concern was expressed that some primary care physicians tend to ignore or minimize the mental health needs of their patients. Another view was that primary care physicians recognize that there are psychosocial components of patient care, but also are

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aware of the inadequacy of their training in mental health skills. There was general agreement that improved programs in continuing education are needed. Most participants felt that collaboration among specialist and non-specialist providers of mental health care is the most effective forum for continuing education. Programs in collaborative postgraduate training for providers who practice in more traditional, non-integrated settings also were described. One model that has been fairly successful on a regional basis involved psychiatrists working with pediatricians in regular collaborative arrangements. "Balint" groups also were mentioned; in these, the consulting psychiatrist does not see patients but helps primary care providers as a group to explore their own sensitivities and feelings related to patient care. (4) Role models The point was made that there are not enough role models for practitioners of the type of integrated care discussed at the conference. Even with models, learning in this area is difficult because the concepts are complex and exhausting psychological effort is involved in applying them. The prevailing disease-oriented medical models discourage attempts to integrate health and mental health care. It was suggested that role models must be sufficiently numerous to form a "critical mass" of professionals who believe in and can practice integrated care in order to demonstrate commitment to health/mental health linkages at all levels of care. Participants also emphasized the importance of engaging medical faculty with additional background in psychiatric skills, and psychiatrists and other mental health professionals who have experience working with nonpsychiatric physi- cians, in the training of primary care residents in mental health skills. Policies for Education and Training Although training health professionals to provide integrated care apparently is a major objective of both educators and federal policymakers, current strategies to improve education and training often are not realistic, a number of conferees indicated. State and federal funding policies for medical education and training were particularly questioned. An increasing proportion of federal funds for psychiatric train- ing is being moved from the psychiatric specialties to primary care programs. Although the purpose of this shift is to improve mental health training in more general programs, the quality of such training was questioned, both in terms of the qualifications of the trainers (low levels of funding necessitate hiring faculty at junior levels) and in terms of available training settings. One educator observed that ambulatory care training for psychiatrists and primary care

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131 providers, in which experience with collaboration in patient care or appropriate referral would be meaningful, is not now funded to any real extent. Training in general medicine is hospital-based and has relative- ly little emphasis on ambulatory care. Similarly, liaison psychiatry in academic medical centers and general hospitals is largely focused on care of hospitalized patients. There also was concern that the policy emphasis on mental health as part of primary care will downgrade psychia- tric programs and discourage the practice of specialty mental health care. Such a trend, it was noted, ultimately would erode the quality of overall integrated care. The issue of state and federal requirements for payback service by new physicians whose medical education was paid for by the government also was discussed. Several participants expressed concern about in- appropriate placements of both general care providers and mental health specialists, and urged that a variety of eligible service settings be considered by policymakers. REIMBURSEMENT Workshop participants registered a strong consensus that current patterns of financing do not support an optimal, integrated health/ mental health care system in this country. Insurance benefits for treatment of mental disorders are sharply limited, compared with re- imbursement offered for the care of other kinds of illnesses. Often there is no provision for out-patient treatment, either by general health care providers or by mental health specialists. Furthermore, the partial reimbursement benefits for mental health care provided by various public and private health insurance programs are so incon- sistent as to be viewed as deterrents to the coordination of primary care and mental health care. The variety of sources of reimbursement for mental health care was discussed: (1) some federal Title XIX and Title XX Social Security Act monies ? although limited primarily to direct services provided in federally-funded care settings; (2) Medicare and Medicaid, which again are limited; (3) prepaid health plans, such as offered by health main- tenance organizations; and (4) private third-party insurance coverage, which varies in scope among different plans. Obtaining adequate reim- bursement for one patient, particularly in comprehensive programs that include mental health care, can entail a complex administrative process of getting funds from several sources. A more uniform national health insurance mechanism of reimbursement, as a prospective plan for the United States and as currently practiced in Great Britain and Canada, was considered a possible solution to problems of funding coordinated health/mental health services. Conferees highlighted several situations which further compli- cate reimbursement: (1) a lack of uniform criteria for standard types of care, providers, and provider settings; (2) reimbursement for

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132 mental health care typically is restricted to specialty care and direct services; (3) counseling, especially when provided as preventive care in general health care settings, usually is not reimbursable; (4) in- direct services, such as the consultation and coordinating activities that are crucial for providing integrated health/mental health care, almost always are excluded frog reimbursement coverage as well. Limited sources of reimbursement also appear to discourage the development and support of ambulatory care, preventive care, outreach, case management, health education, and certain social support services. It was emphasized that lack of reimbursement deters the involvement both of psychiatrists and primary care practitioners in efforts to inte- grate health and mental health care. Although there increasingly is coverage for specialty care of mental health disorders by psychiatrists in private practice or specialty inpatient settings, there are minimal financial incentives for spending time in important consulting and am- bulatory liaison psychiatry. Also, there is a general lack of reimburse- ment for mental health care provided by nonpsychiatrists in general health settings. Determining appropriate rates of compensation for such care further complicates the issue: simply equalizing the hourly rates for men- tal health care by primary care physicians and psychiatrists still will entail a loss for the "ordinary general practitioner who needs to gen- erate more income per hour . . . because of very greatly increased over- head." Care by nonphysician mental health professionals is even less likely to qualify for reimbursement, except in certain prepaid medical plans. Several participants expressed concern about the effects of cur- rent patterns of reimbursement on the quality of mental health care, particularly in the general health care sector. Incentives to diagnose in terms of what is reimbursable, it was felt, has led to widespread masking of mental health problems in this country. Because psychiatric illness typically remains a "non-reimbursable disease" the use of reim- bursable labels for mental health problems and treatments is thought to be common. There is increasing awareness of the value of humanistic approaches to general medical care, but inadequate reimbursement continues to dis- courage many primary care physicians from investing the time required to care for their patients' emotional and mental health needs. In prac- tical terms, often "it is the time clock that runs the system," one par- ticipant said. The tendency to under-diagnose and under-treat mental health problems, particularly under the financial disincentives of some health maintenance organizations and other prepaid plans, was recognized as having implications for the quality of care.

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133 Reimbursement presupposes quantification of the care process to some extent. But thus far, the input factors of mental health care are more easily defined, measured, and regulated than are patient out- comes. Some caution was expressed regarding reimbursement for services that have not been proven effective. Most participants also criticized the "body count" and "corporate" mentalities they considered to be associated with current policies of accountability and reimbursement. Participants discussed a number of alternatives to the current system of reimbursement for mental health care: (1) A proposal that has been considered by DREW would permit federally-funded reimbursement only for mental health services provided after referral from primary care pro- viders, thus establishing a triage function for the primary care system to control mental health services. In view both of the longstanding tradition of direct consumer access to specialty care and the lack of a uniformly well-developed primary care system in this country, this pro- posal generally has been considered inappropriate. (2) Further support of prepaid health plans that include in-house mental health care was suggested by several participants, although they recognized the need to examine potential trade-offs between adequate care and incentives for cost-containment in such plans. (3) Several participants saw a possi- bility for including a broader range of mental health services in hospital-based primary care settings; they urged more systematic ex- ploration of "piggy-backing" the costs of currently nonreimbursable activities, such as consultation and care by nonmedical personnel, on services that are reimbursed. (4) Grants to link primary care settings and federally-funded community mental health centers were mentioned as a means of tapping existing mental health care resources without, as one speaker put it, "worrying so much about the larger issue of third-party payments." Several participants suggested that studies be planned for future consequences of increased availability of reimbursement for mental health care in the general health care sector. Changes in utilization and probably increases in costs will result from a reduced need for masking of mental health care by primary care providers. Assuming that limited reimbursement represents a current means of rationing scarce mental health resources, one participant suggested that lessen- ed restrictions on reimbursement will require tighter definitions of need for mental health care. There was general agreement that reimbursement issues should be a policy concern, but it was suggested that revised reimbursement practices alone may not have a major impact on the success of efforts to integrate health and mental health care. For consumers in the United States, quality of care may be the ultimate criterion in utiliz- ing mental health services, as suggested by evidence that enrollees

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134 in prepaid medical plans seek such care in other settings and pay sepa- rately for them. Greater commitment to quality of care, rather than reduced concern about reimbursement, among providers may be the force that moves mental health care into general health practices. SOC IAL SUPPORT SYSTEMS A number of workshop participants urged more effective use of social support systems in health/mental health care. The linkage of formal health care systems with both formal and informal social support systems was seen as essential for care to be integrated at all levels. Such linkages could aid physicians in providing appropriate health and mental health care to their patients and also would promote use of a broader range of non-medical care resources. There was general agreement that understanding of patients' social contexts at various levels is an essential component of integrated care For diagnosis, knowledge both of individual and epidemiological factors is necessary. For therapy, the patient's own closest social supports of family and friends often can work effectively with the care provider while such community resources as social agencies, churches, or schools can be involved to promote continued care. Although social support is clearly an important function of the physician - especially in inte- grated health and mental health care settings -- it was suggested that the problems of many patients may be managed as effectively or even more effectively by schools, welfare departments, clergymen, and other non-medical service systems. Health care providers should be trained to make referrals to other settings when appropriate, and opportunities for such linkages through referral should be explored more completely. Community support systems are particularly important when mental health care under medical auspices is impractical or infeasible. This often is the case in inner city areas, and presents a particular problem for persons with chronic mental disorder who are no longer likely to receive institutionalized care. If primary care physicians are not available or accessible, the community and the entire social welfare system could absorb and maintain individuals who need mental health care. Two models of collaboration between health care providers and social support systems were described by one conferee. In the first, primary care providers work with their patients' immediate social supports; in the instance of a black extended family, to promote com- pliance with hypertension medication. The second model is a "cultural specialty" program being developed in a cross-cultural care setting in Newark, New Jersey. During the past year, five social scientists have worked in a psychiatric reception center and crisis unit on an extensive assessment of patients' natural community support

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135 systems. The program was designed to examine how those support systems -- extended families, churches, indigenous healers -- function as coping resources for patients within the community. The point was made that other outside of the traditional health and mental health care systems also provide mental health services. In Virginia during 1977, for example, $3 million was spent under Title XX of the Social Security Act to fund mental health services in welfare departments, as compared with $500,000 in Title XIX funding for mental health services in mental health centers. The British system, with a single integrated Department of Health and Social Services, was discussed as a model for organizing linkages between the health care and social welfare systems in this country. Although some states have organized human services under single depart- ments, separation of federal support for social service and health have discouraged most attempts to establish comprehensive health/mental health care facilities. Some of the more fortunate and entrepreneurial neighborhood health centers, including several represented at this conference, have been able to provide multiservice, comprehensive care. However, as funding decreases for the indirect patient services that constitute a large part of mental health care, one participant foresaw major difficulties for these centers as well. There was general agreement that the provision of appropriate mental health care to the entire population in need will require more than formal linkages of health and mental health. It was pointed out that a wide variety of community institutions that are not labeled or identified in our society as health institutions, should be considered in the design of a truly comprehensive health care system. Knowledge relevant to the involvement of social support systems in integrated care programs at all levels is already well-developed in traditionally non-medical disciplines.* Several participants urged systematic and useful application of that knowledge. RESEARCH Many participants expressed concern that major policy decisions about health manpower development, organization of the health/mental health system, and methods and extent of financing both for training and service delivery are being made on the basis of inadequate re- search data. There was agreement that health services research, *See President's Commission on Mental Health, Report of the Task Panel on Community Support Systems, Vol. II, pp. 139-235. Washington, D.C.: U.S. Government Printing Office, 1978.

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136 epidemiological studies' and studies combining behavioral and health services research are needed for systematic development of knowledge that can contribute to assuring the quality and comprehensiveness of health care.* More knowledge also is needed for the development of standardized mental health indices, such as levels of distress and levels of psycho- social dysfunction that could be used: (1) by primary care physicians in diagnosing the gravity of patients' complaints; (2) by health and mental health service planners and policymakers; and (3) to determine the incidence of mental illness. Many participants thought that extend- ing treatment assessment from the specialty mental health sector to pri- mary care practice will require all forms of health services research clinically-oriented, institutionally-oriented, and systemic studies. Clinically-oriented studies could be designed to determine how con- ditions of practice influence effectiveness of both health and mental health services and develop a broad range of outcome criteria including patient satisfaction and the cost of care as well as effectiveness of treatment, specifically: (1) collect more data on mental disorders that primary care providers may identify, misidentify, treat, not treat, or refer; (2) focus on the natural history of mental disorders in general practice populations; (3) examine the treatment methods employed by general health care providers for patients whom they identify as men- tally disordered; (4) determine characteristics of providers and patients and the combinations of resources that are employed in various practice settings in which health and mental health care are provided and that affect the processes and outcomes of care. Institutionally-oriented studies would bear on such issues as determinants of utilization patterns of various providers of mental health services, or the organizational and administrative features of primary care settings in which health and mental health services are delivered. There was debate whether an assumption is warranted that average medical utilization Is proper medical utilization, or that a reduction in medical utilization is a measure of effectiveness. Re- search was urged for human as well as economic factors, such as inter- professional working arrangements, including clinical team organization and functioning, practitioner training, and competency. Some issues of the organization of services could be resolved by comparing a number of setting for their effectiveness. Other questions are how staff time is spent, who is being served, what services are provided, accessibility of those services, client satisfaction and level of functioning before and after services. *Note: No attempt has been made to prioritize the areas identified by conference participants as needing futher research.

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137 Systemic studies would concentrate on such issues as the influences of various financing mechanisms on the delivery of services. Of parti- cular importance is examination of the economic incentives and disincen- tives in primary care settings as they differ among fee-for-service, prepaid health plans, neighborhood health centers, and so forth. Evaluation research is need on training methods for primary care physicians who require modified forms of mental health specialty skills to provide appropriate mental health care. An example of this kind of study would be one in which "Balint" groups are evaluated as a training modality and as a mechanism for- improving provider satisfaction, particu- larly in settings such as HMOs or clinics, where there is considerable turnover of professional staff. Epidemiological research was suggested by a number of participants who saw a lack of precision in definition, identification, and classifi- cation of mental disorders as a major problem. More accurate data on in- cidence and prevalence of disorders, identification of risk factors, and the range and natural history of emotional difficulties of patients seen in primary care settings were mentioned as other areas for investigation. There is a need for better outcome studies to determine criteria for the effectiveness of different kinds of mental health interventions as they vary among kinds of providers and kinds of patients. Development of better ways to measure outcome was seen as a necessary first step. Research on outcome is made difficult by the many definitions of positive outcome. The observation was made that certain types of interventions may have a beneficial effect on the system for instance in efficiency and the cost of the process and not do anything meaningful to the patient. Quality assurance research was emphasized by many participants. Studies should develop both definitions of quality care and techniques to measure it. Discussion in this conference did not take into account the role of specialist physicians such as obstetricians/gynecologists, cardiolo- gists, allergists, and gastroenterologists who have been called part of a "hidden system" for delivering general care in the United States. Recent data from two national studies have indicated that "one of every five Americans now receives continuing general medical care from a specialist physician." 1/ It would appear appropriate to investigate (1) to what extent physician specialists are able to identify mental disturbances in their patients; (2) the incidence of specific disorders; (3) the kinds of mental health interventions medical specialists are most inclined to adopt; (4) mental health skills of specialist physi- cians; and (5) mental health content of medical specialty training programs. 1/ Linda H. Aiken, et al. "The Contribution of Specialists to the Delivery of Primary Care: A New Perspective." New England Journal of Medicine. Vol. 300, No. 24 pp. 1363-1370.

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