The Role of Integrated Primary Care in Increasing Access to Effective Psychotherapies in the Veterans Health Administration

IPC is a population-based model of care in that it seeks to serve the entire population of a primary care clinic, rather than a small subset of patients with the most significant mental health concerns (20, 21). To ensure continued access in the system for new patients, treatment is time limited, and stepped care is emphasized. That is, individuals who do not benefit sufficiently from brief treatment can be stepped up to a higher level of care, such as specialty mental health treatment.

IPC is also highly collaborative in that behavioral health providers are integrated as part of the care team to provide consultation to medical staff about how to manage behavioral health concerns and coordinate care for behavioral health and physical conditions (22). Ideally, IPC services are both measurement based and evidence based (14). Goals of IPC include improving detection of behavioral health problems, increasing access to and engagement in appropriate care, improving quality and coordination of care through collaboration between behavioral health and medical providers, and decreasing mental health stigma (18).

Although there are many IPC models, two specific models are most commonly used (19). The primary care behavioral health (PCBH) model is most widely implemented in clinical care, and the collaborative care (CC) model has been most widely researched. In PCBH, sometimes referred to as colocated collaborative care or the behavioral health consultant model, a licensed mental health clinician, such as a psychologist or clinical social worker, is embedded in the primary care team to provide brief assessment and intervention for a wide range of mental health, substance use, and health behavior concerns (23). The prototypic course of treatment ranges from one to six 15- to 30-minute appointments, spaced every two to four weeks.

CC, also referred to as care management and disease management, typically involves nurse care managers providing education and psychosocial support around the use of medications for specific behavioral health concerns (e.g., depression), in consultation with the primary care provider as well as a supervising psychiatrist (24, 25). The support provided in CC is protocol driven and guided by algorithms for stepping care up or down on the basis of the patient’s progress over time. In contrast, brief psychotherapy in PCBH is typically guided by the individual clinician’s judgment.

Many types of behavioral health providers deliver IPC, and they often play different roles on an integrated care team. IPC teams may include primary care providers; nurse care managers; licensed practical nurses; health technicians; nonprescribing behavioral health providers; and others, such as clinical pharmacists, registered dieticians, medical social workers, and peer support specialists (26). Psychiatrists serve several key roles in IPC care teams. In the CC model, consultant psychiatrists provide caseload review, curbside consultation, and education. This allows the psychiatrist’s expertise to be extended to a larger proportion of the patient population. For instance, primary care providers can be encouraged to do more psychiatric prescribing with ready access to psychiatrist expertise (27). Psychiatrists practicing in the CC model have been described as meeting the triple aim of health care: simultaneously improving access to care and care quality while keeping costs low (28). Psychiatrists are less frequently integrated into the PCBH model; psychologists or clinical social workers typically provide consultation to the primary care team as well brief psychotherapy directly to patients. However, in PCBH, psychiatrists may begin a patient on psychiatric medication with the intention that the primary care provider will continue prescribing once the patient is stabilized (29).

Some unique aspects of the U.S. Department of Veterans Affairs (VA) system enable IPC. VA has one shared electronic medical record that all providers use. This allows easier communication and coordination between behavioral health and medical providers (14). The medical record also includes a component in which patient status can be assessed with common psychological assessments, which enables IPC to be measurement driven.

In addition, the pay structure of VA allows easier access to IPC, because IPC is considered a primary care service, and typically special copays for mental health treatment do not apply. Also, veterans incur one copay per day of service, so “warm handoffs” do not result in additional copays. As described in the previous paragraph, VA also has a diverse behavioral health work force, ranging from licensed independent providers to dependent providers, such as health technicians and peer support specialists (26). VA also has well-developed systems to provide IPC to rural veterans, including community-based clinics and telehealth. Although other health care systems share some of these same features, it is likely that, combined, these features have made IPC successful in VA.

It is clear from the existing literature that IPC in general, and CC and PCBH in particular, improve access to mental health services. Access occurs on a continuum from initial access to behavioral health services in primary care to initiation, engagement, and completion of specialty mental health care. Access outcomes can also include gaining access to psychiatric medication and receiving guideline-concordant care. In IPC, access to behavioral health care is not limited to direct in-person or phone contact with a behavioral health provider. Behavioral health providers, such as psychiatrists or psychologists, consult with members of the primary care team to enable them to deliver behavioral health care in the form of psychiatric medication or health behavior coaching.

The research evidence that CC improves access is very strong. A 2012 meta-analysis of 79 CC studies concluded that CC not only increases access to pharmacotherapy and care manager support but also improves depression, anxiety, and quality of life outcomes for primary care patients (30). Much less research has investigated whether CC improves access specifically to evidence-based psychotherapy.

CC models have been increasingly including cognitive-behavioral therapy (CBT) as part of stepped-care delivery models (31), thereby increasing access to CBT, an evidence-based treatment. For instance, the STEPS-UP model for depression and posttraumatic stress disorder (PTSD) among active-duty military members includes CBT delivered in a variety of modalities and has resulted in patients using more mental health care (21). However, data on engagement in specific evidence-based psychotherapies resulting from STEPS-UP have not been reported.

Another CC intervention that included CBT in a stepped-care model found that veterans with PTSD who were randomized to CC were 18 times more likely to receive cognitive processing therapy (CPT) than those receiving usual care (29). This CC intervention delivered CPT by telephone to rural veterans to improve access to care. This study demonstrates the potential for carefully designed CC models to increase engagement in evidence-based psychotherapy.

Relatively less research has investigated whether PCBH increases access to care. However, a recent systematic review of 23 PCBH studies found that PCBH increased initial and sustained access to behavioral health services in primary and specialty care (32). Effect sizes were small to medium, and most studies used naturalistic, uncontrolled designs. For instance, one large national VA study found that primary care patients who received same-day PCBH services were eight times more likely to initiate psychotherapy and two times more likely to initiate antidepressant treatment than patients receiving usual primary care (33). Another national VA study found that patients referred by PCBH providers were three times more likely to engage in specialty mental health treatment than patients referred by primary care providers (34). These studies demonstrate how PCBH increases access to the continuum of mental health services. However, the field has yet to study whether PCBH increases access specifically to evidence-based psychotherapies either within primary care or as part of stepped care.

There are several ways that IPC likely improves access to mental health care. First, IPC enables better access by virtue of being a population-based model of care (35). In this approach, a larger number of patients, and thus a larger proportion of the population, use the service, compared with specialty care models. IPC services tend to involve briefer visits, fewer visits, and longer intervals between visits compared with higher intensity specialty care (20).

In addition to these structural differences, the approach to treatment differs, with population-based care in IPC employing more of a “consultant” rather than “treatment” orientation (20). The goal is to support the care team in helping the patient improve his or her functioning, rather than to treat to the point of complete remission. Care is therefore more focused, which ensures that individuals’ engagement is more episodic, in turn allowing frequent turnover in cases to facilitate access. Also, when mental health providers support other primary care team members in delivering behavioral health services, this further increases access to the primary care population. For instance, a psychiatrist can provide education and support to a primary care provider prescribing an antidepressant, or a psychologist may teach nurses motivation-interviewing strategies to encourage more health-promoting behaviors.

Another way IPC facilitates access to care is by addressing patient treatment preferences. Patients prefer to receive care for mental health concerns in the primary care setting rather than the specialty mental health setting (36–39). IPC leverages the patient’s relationship with the primary care provider to facilitate acceptance of referrals within the team (40). Treatment offered in the primary care setting as part of routine health care (20) may be more acceptable to patients because they are already familiar with the primary clinic, do not have to expend extra effort to seek services, and may perceive less stigma compared with the specialty mental health setting.

Patients also prefer services that are convenient. IPC facilitates access to care by increasing ease and convenience for patients, eliminating delays and hassles, and facilitating immediate action on problem recognition to capitalize on motivation and thereby optimize engagement. In general, IPC reduces barriers to treatment, particularly when IPC is executed in the ideal fashion with same-day access, in which the mental health appointment is completed immediately following the primary care appointment in which a treatment need is identified (20, 41). Same-day access eliminates many common practical treatment barriers, such as contacting the provider or clinic, setting up another appointment, finding child care or transportation, and taking time to return to the clinic (42).

IPC is also believed to improve the quality of primary care by expanding the breadth of expertise offered, because it uses an entire team of providers rather than one single provider. This interdisciplinary approach requires a high level of communication and collaboration (19, 43). Because of their specialized training, embedded behavioral health providers contribute expertise in psychopharmacology and behavioral treatments to the primary care team, which can complement the primary care provider’s and nurse’s ability to be credible sources of medical information (44).

Collaboration can take many forms in a primary care visit. At the most minimal level, warm handoffs occur (a tenet of the PCBH model), such that the primary care provider introduces and transfers patient care to the behavioral health provider after the primary care visit (45). Additional collaborative efforts in IPC can take the form of group medical visits or shared medical appointments involving multiple care team members interacting with patients during the same visit (46, 47).

Not only does IPC provide the opportunity to increase access to psychotherapy in specialty mental health settings, but it also allows for provision of brief evidence-based treatments to be delivered in primary care without increasing the burden on the primary care team. The evidence base supporting treatments that are feasible to deliver in primary care is limited yet growing. Here, we review research on interventions for the most common presenting concerns in primary care.

IPC increases access to initial and continued mental health treatment using a wide variety of services supported by behavioral health providers located in the primary care setting. Although this review describes two widespread models of IPC (CC and PCBH), increasingly components of these models are being blended. Traditionally, CC has targeted specific prevalent disorders and focused on pharmacotherapy supplemented by patient education and psychosocial support. PCBH, in contrast, has sought to modify full-length psychotherapies to be delivered briefly for the full range of behavioral health concerns seen in primary care. Several innovative IPC interventions include psychiatric medication, evidence-based psychotherapies, and other components (e.g., self-management tools), often delivered in a stepped-care fashion. The research reviewed here demonstrates that these blended approaches are often superior to traditional CC models (e.g., 29, 58, 69) for depression, anxiety, and PTSD. A notable feature of blended approaches is that they require psychiatrists, psychotherapists, and nurse care managers each to play unique roles in care delivery while working collaboratively with the larger primary care team. The multiple integrated roles in a blended model can be complicated to implement, but the research demonstrates that the payoff of successful implementation is increased access to effective psychotherapies and improved patient well-being.

The review of PCBH services shows that brief psychotherapies in primary care have excellent potential to decrease mental health symptoms, hazardous alcohol and tobacco use, and insomnia. However, the field of PCBH research is at a different developmental stage for each of these presenting concerns. For depression and anxiety, most of the CBT interventions tested need to be further shortened so they are feasible for PCBH providers to deliver. When PCBH providers have treatments that are longer than they can feasibly deliver, they make idiosyncratic choices regarding what to deliver; consequently, they may leave out active components, reducing the effectiveness of the treatment. PCBH research focused on PTSD treatment has many promising early studies, but larger, full-scale RCTs are needed for researchers to be confident that specific PCBH interventions reduce PTSD symptoms. PCBH interventions for hazardous alcohol use, tobacco use, and insomnia are well developed but not implemented widely enough. More implementation-science studies are needed for researchers to understand how to overcome barriers and capitalize on facilitators for implementation.

Practitioners are using a variety of technological and e-health tools to assist in delivering behavioral health services to primary care patients. Research has demonstrated that telephone-delivered care, websites, and mobile apps that deliver CBT content are important components of IPC services (e.g., 50, 58, 69, 73, 102). More research is needed to understand the optimal way to incorporate e-health into IPC. It is important to understand that e-health consists of tools used to deliver an intervention and is not a stand-alone intervention.

The supportive accountability model offers a useful framework on how to incorporate technology into clinical services. It describes how adding professional support increases patient engagement in self-management materials (electronic or paper based) through accountability to a clinician who is seen as trustworthy, helpful, and experienced (105). More research is needed on how to strike the correct balance between clinician support and e-health materials in IPC services.

IPC improves access to mental health services by providing brief, focused treatment to many primary care patients with a wide variety of presenting concerns. More patients engage in care when it can be accessed immediately and is offered in a less-stigmatizing setting where many patients prefer to receive treatment. Our review describes how interventions that blend components of CC and PCBH, often in a stepped-care approach, have advantages over traditional CC models. Future PCBH research will benefit from focusing on brief psychotherapies that are feasible to deliver in primary care and from conducting implementation-science studies. E-health holds great promise for expanding the reach and depth of IPC services, and future research should focus on finding the best combination of e-health and professional support.