Evidence Report/Technology Assessment Number 173 Integration of Mental Health/Substance Abuse and Primary Care Prepared for: Agency for Healthcare Research and Quality U.S. Department of Health and Human Services 540 Gaither Road Rockville, MD 20850 www.ahrq.gov Contract No. 290-02-0009 Prepared by: Minnesota Evidence-based Practice Center, Minneapolis, Minnesota Investigators Mary Butler, Ph.D., M.B.A. Robert L. Kane, M.D. Donna McAlpine, Ph.D. Roger G. Kathol, M.D. Steven S. Fu., M.D., M.S.C.E. Hildi Hagedorn, Ph.D. Timothy J. Wilt, M.D., M.P.H. AHRQ Publication No. 09-E003 October 2008 This report is based on research conducted by the Minnesota Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-02-0009). The findings and conclusions in this document are those of the authors, who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services. The information in this report is intended to help clinicians, employers, policymakers, and others make informed decisions about the provision of health care services. This report is intended as a reference and not as a substitute for clinical judgment. This report may be used, in whole or in part, as the basis for the development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied. This document is in the public domain and may be used and reprinted without permission except those copyrighted materials noted for which further reproduction is prohibited without the specific permission of copyright holders. Suggested Citation: Butler M, Kane RL, McAlpine D, Kathol, RG, Fu SS, Hagedorn H, Wilt TJ. Integration of Mental Health/Substance Abuse and Primary Care No. 173 (Prepared by the Minnesota Evidence-based Practice Center under Contract No. 290-02-0009.) AHRQ Publication No. 09- E003. Rockville, MD. Agency for Healthcare Research and Quality. October 2008. No investigators have any affiliations or financial involvement (e.g., employment, consultancies, honoraria, stock options, expert testimony, grants or patents received or pending, or royalties) that conflict with material presented in this report. ii Preface The Agency for Healthcare Research and Quality (AHRQ), through its Evidence-based Practice Centers (EPCs), sponsors the development of evidence reports and technology assessments to assist public- and private-sector organizations in their efforts to improve the quality of health care in the United States. This report was requested and funded by AHRQ; the Health Resources and Services Administration; Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, Center for Substance Abuse Treatment; as well as the Office of Women’s Health and the Office of Minority Health at the Department of Health and Human Services. The reports and assessments provide organizations with comprehensive, science-based information on common, costly medical conditions, and new health care technologies. The EPCs systematically review the relevant scientific literature on topics assigned to them by AHRQ and conduct additional analyses when appropriate prior to developing their reports and assessments. To bring the broadest range of experts into the development of evidence reports and health technology assessments, AHRQ encourages the EPCs to form partnerships and enter into collaborations with other medical and research organizations. The EPCs work with these partner organizations to ensure that the evidence reports and technology assessments they produce will become building blocks for health care quality improvement projects throughout the Nation. The reports undergo peer review prior to their release. AHRQ expects that the EPC evidence reports and technology assessments will inform individual health plans, providers, and purchasers as well as the health care system as a whole by providing important information to help improve health care quality. We welcome written comments on this evidence report. They may be sent to the Task Order Officer named below at: Agency for Healthcare Research and Quality, 540 Gaither Road, Rockville, MD 20850, or by email to [email protected]. Carolyn M. Clancy, M.D. Jean Slutsky, P.A., M.S.P.H. Director Director, Center for Outcomes and Evidence Agency for Healthcare Research and Quality Agency for Healthcare Research and Quality Beth A. Collins Sharp, R.N., Ph.D. Charlotte Mullican, M.P.H. Director, EPC Program EPC Program Task Order Officer Agency for Healthcare Research and Quality Senior Advisor for Mental Health Research Agency for Healthcare Research and Quality Elizabeth M. Duke, Ph.D. Administrator A. Kathryn Power, M.Ed. Health Resources and Services Administration Director, Center for Mental Health Services Substance Abuse and Mental Health Services H. Westley Clark, M.D, J.D., M.P.H., C.A.S., Administration F.A.S.A.M. Director, Center for Substance Abuse Treatment Garth Graham, M.D., M.P.H. Substance Abuse and Mental Health Services Deputy Assistant Secretary for Minority Health Administration Office of Minority Health Office of the Secretary Wanda K. Jones, Dr.P.H. Department of Health and Human Services Deputy Assistant Secretary for Health Office of Women’s Health Office of the Secretary Department of Health and Human Services iii Acknowledgments We would like to thank Li Tao for assistance with the literature search and data abstraction; Tatyana Shamliyan, M.D., M.S., for her assistance with data analysis; Rebecca Schultz for her help with editing and formatting this report; and especially Marilyn Eells for her editing, formatting, and organizational skills, and her professionalism. Thanks also to Macaran Baird, M.D., M.S., Benjamin Druss, M.D., M.P.H., Wayne Katon, M.D., David Mechanic, Ph.D., Harold Pincus, M.D., Lisa Rubenstein, M.D., M.S.H.S., Herbert Schulberg, Ph.D., John Williams, M.D., M.H.S., and the staff at NAMI, who reviewed a draft of the document, for their time and the suggestions and comments that improved the quality of the report. We would also like to thank the staff at the following organizations who so generously gave of their time to help coordinate and complete the case studies: AETNA CorpHealth Hartford, CT Fort Worth, TX www.aetna.com www.corphealth.com The DIAMOND Initiative Eastern Band of Cherokee Health Minneapolis, MN Cherokee, NC www.icsi.org www.nc-cherokee.com Group Health Cooperative Intermountain Healthcare Seattle, WA Salt Lake City, Utah www.ghc.org http://intermountainhealthcare.org/xp/public/ Northern California Kaiser Permanente MaineHealth San Francisco, CA Portland, ME www.kpcmi.org http://www.mmc.org/mh_homepage.cfm RESPECT-Depression Cherokee Health of Tennessee www.depression-primarycare.org Knoxville, TN www.cherokeehealth.com Veterans Administration Washtenaw County Health Organization www.hsrd.research.va.gov/queri/ Ypsilanti, MI http://www.ewashtenaw.org/government/departments/wcho v Structured Abstract Objectives: To describe models of integrated care used in the United States, assess how integration of mental health services into primary care settings or primary health care into specialty outpatient settings impacts patient outcomes and describe barriers to sustainable programs, use of health information technology (IT), and reimbursement structures of integrated care programs within the United States. Data Sources: MEDLINE®, CINAHL, Cochrane databases, and PsychINFO databases, the internet, and expert consultants for relevant trials and other literature that does not traditionally appear in peer reviewed journals. Review Methods: Randomized controlled trials and high quality quasi-experimental design studies were reviewed for integrated care model design components. For trials of mental health services in primary care settings, levels of integration codes were constructed and assigned for provider integration, integrated processes of care, and their interaction. Forest plots of patient symptom severity, treatment response, and remission were constructed to examine associations between level of integration and outcomes. Results: Integrated care programs have been tested for depression, anxiety, at-risk alcohol, and ADHD in primary care settings and for alcohol disorders and persons with severe mental illness in specialty care settings. Although most interventions in either setting are effective, there is no discernable effect of integration level, processes of care, or combination, on patient outcomes for mental health services in primary care settings. Organizational and financial barriers persist to successfully implement sustainable integrated care programs. Health IT remains a mostly undocumented but promising tool. No reimbursement system has been subjected to experiment; no evidence exists as to which reimbursement system may most effectively support integrated care. Case studies will add to our understanding of their implementation and sustainability. Conclusions: In general, integrated care achieved positive outcomes. However, it is not possible to distinguish the effects of increased attention to mental health problems from the effects of specific strategies, evidenced by the lack of correlation between measures of integration or