Medical Homes for SMI Associated With Greater Use of Primary Care

Enrollment in a primary care–based medical home appears to be associated with increased use of primary and specialty care, better medication adherence, and reduced use of emergency department care by individuals with serious mental illness (SMI).

And among patients with major depression, enrollment in a medical home was associated with increased use of certain preventive services, according to the report “Serving Persons With Severe Mental Illness in Primary Care Medical Homes.” The report was published February 17 in Psychiatric Services in Advance.

Primary care–based medical homes are a component of system reform envisioned in the Affordable Care Act and are gaining traction as an important means of providing coordinated care. North Carolina’s Medicaid program has been a leader nationally in developing medical homes for patients with complex health problems.

Researchers at the Department of Health Policy and Management and the Cecil G. Sheps Center for Health Services Research at the University of North Carolina conducted a retrospective secondary data analysis of medication adherence, outpatient and emergency department visits, and screening services used by adult Medicaid enrollees with diagnoses of schizophrenia (n=7,228), bipolar disorder (n=13,406), or major depression (n=45,000) as recorded in North Carolina Medicaid claims from 2004 to 2007.

A variety of statistical tools was used in the analysis to control for selection and other biases and confounders. Outcomes included an indicator of any visit and the number of visits to primary care providers, any visit and the number of visits to specialty mental health providers, medication adherence for each target medication class, and emergency department visits.

The researchers examined Healthcare Effectiveness Data and Information Set indicators for preventive general medical care using procedure codes in the claims data files, including the receipt of cholesterol screening and cancer screening for age- and gender-appropriate populations according to the American Cancer Association guidelines. These included colorectal cancer screening for enrollees aged 50 and older, breast cancer screening for women aged 40 and older, and cervical cancer screening for women aged 21 to 65.

Results indicated that medical-home enrollees had greater use of both primary and specialty mental health care, better medication adherence, and reduced use of the emergency department. Interestingly, better rates of preventive lipid and cancer screening were found only for persons with major depression.

The association between being enrolled in a medical home and having any primary care visits was similar across diagnostic groups, ranging from an increase of 24 percent to 26 percent in the probability of one or more primary care visits a month, compared with rates for individuals not in medical homes. The effects of being enrolled in a medical home on the number of primary care visits were also similar across groups, amounting to about half a primary care visit a month. Enrollees in medical homes had slightly increased use of specialty mental health care.

“Evidence suggests that such enhanced health care use will decrease symptomatology and the need for emergent care,” the researchers wrote. “Of interest, these access gains translated into increased use of preventive services only for persons with a major depressive disorder in medical homes. This difference across groups might reflect the greater integration of depression treatment in primary care and greater physician understanding and comfort in managing depression as opposed to psychotic conditions.”

They noted also that the relatively large effects on primary care use were associated with fairly modest incentives provided by the state’s Community Care of North Carolina program—amounting to $5 per-member per-month, split equally between practices and networks.

“Enrollment in a medical home was associated with substantial changes in patterns of care among persons with severe mental illness,” they wrote. “These changes were associated with only a modest set of incentives, suggesting that medical homes can have large multiplier effects in the primary care of persons with severe mental illness.” ■

“Serving Persons With Severe Mental Illness in Primary Care–Based Medical Homes” can be accessed here.