Does use of primary care-based behavioral health programs differ by race and ethnicity? Evidence from a multi-site collaborative care model.

BACKGROUND: Collaborative care models (CoCM) that integrate mental health and primary care improve outcomes and could help address racial and ethnic mental health disparities. We examined whether use of these programs differs by race/ethnicity. METHODS: This retrospective study examined two CoCM interventions implemented across primary care clinics in a large health system in Massachusetts: 1) a primary care-based behavioral health program for depression or anxiety (IMPACT model) and 2) referral to community-based specialty care services (Resource-finding). Outcomes included enrollment, non-completion, and symptom screening rates, and discharge status for Black, Hispanic and White patients referred for CoCM, 2017-2019. RESULTS: Black and Hispanic vs. White patients referred to CoCM (n = 17,280) were more likely to live in high poverty ZIP codes (34% and 40% vs. 9%). Rates of program enrollment, non-completion, and symptom screening were similar across groups (e.g., 76%, 77%, and 75% of Black, Hispanic, and White patients enrolled). Hispanic vs. White patients were more likely to be enrolled in IMPACT (56%) vs. Resource-finding (43%). Among those completing IMPACT, Hispanic vs. White patients were more likely to be stepped to psychiatry vs. discharged to their primary care provider (51% vs. 20%, aOR = 1.55, 95% CI: 1.02-2.35). CONCLUSIONS: Black and Hispanic patients referred to CoCM were similarly likely to use the program as White patients. Hispanic patients completing IMPACT were more frequently referred to psychiatry. IMPLICATIONS: These results highlight the promise of CoCMs for engaging minority populations in mental healthcare. Hispanic patients may benefit from additional intervention or earlier linkage to specialty care.

The essential role of population health during and beyond COVID-19.

The coronavirus disease 2019 (COVID-19) pandemic has fundamentally changed how health care systems deliver services and revealed the tenuousness of care delivery based on face-to-face office visits and fee-for-service reimbursement models. Robust population health management, fostered by value-based contract participation, integrates analytics and agile clinical programs and is adaptable to optimize outcomes and reduce risk during population-level crises. In this article, we describe how mature population health programs in a learning health system have been rapidly leveraged to address the challenges of the pandemic. Population-level data and care management have facilitated identification of demographic-based disparities and community outreach. Telemedicine and integrated behavioral health have ensured critical primary care and specialty access, and mobile health and postacute interventions have shifted site of care and optimized hospital utilization. Beyond the pandemic, population health can lead as a cornerstone of a resilient health system, better prepared to improve public health and mitigate risk in a value-based paradigm.

Exploring Asian American attitudes regarding mental health treatment in primary care: A qualitative study.

BACKGROUND: In this exploratory study, we examined attitudes regarding mental health treatment among 10 Asian American patients in an urban primary care setting to better understand contextual barriers to care. METHODS: Ten semi-structured telephone interviews were conducted with Asian Americans recruited from primary care practices in an urban medical center. RESULTS: The study's qualitative data suggest that focusing on specific cultural concerns is essential for increasing mental health access for Asian Americans. Although few participants initially expressed interest in a culturally focused mental health program themselves, when phrased as being part of their primary care practice, 8 expressed interest. Furthermore, most felt that the program could help family or friends. Many participants preferred to seek care initially from social systems and alternative and complementary medicine before seeking psychiatric care. CONCLUSIONS: Because Asian Americans face notable barriers to seeking mental health treatment, addressing cultural concerns by providing culturally sensitive care could help make mental health treatment more acceptable, particularly among less acculturated individuals. To our knowledge, this is the first qualitative study exploring barriers to Asian Americans accessing integrated mental health services in primary care.

An Update on Telepsychiatry and How It Can Leverage Collaborative, Stepped, and Integrated Services to Primary Care.

INTRODUCTION: In this era of patient-centered care, telepsychiatry (TP; video or synchronous) provides quality care with outcomes as good as in-person care, facilitates access to care, and leverages a wide range of treatments at a distance. METHOD: This conceptual review article explores TP as applied to newer models of care (e.g., collaborative, stepped, and integrated care). RESULTS: The field of psychosomatic medicine (PSM) has developed clinical care models, educates interdisciplinary team members, and provides leadership to clinical teams. PSM is uniquely positioned to steer TP and implement other telebehavioral health care options (e.g., e-mail/telephone, psych/mental health apps) in the future in primary care. Together, PSM and TP provide versatility to health systems by enabling more patient points-of-entry, matching patient needs with provider skills, and helping providers work at the top of their licenses. TP and other technologies make collaborative, stepped, and integrated care less costly and more accessible. CONCLUSION: Effective health care delivery matches the intensity of the services to the needs of a patient population or clinic, standardizes interventions, and evaluates both process and clinical outcomes. More research is indicated on the application of TP and other technologies to these service delivery models.

Lessons Learned: Implementation of a Culturally Focused Psychiatric Consultation Service for Latino Americans and Asian Americans.

Novel interventions have been developed to bridge disparities in accessing mental health care for minority populations. However, challenges arise when trying to implement and study novel interventions in real-world community settings. Our objective is to describe the challenges implementing the Culturally Focused Psychiatric (CFP) Consultation Program for depressed Latino and Asian Americans in four urban primary care practices. Issues discussed at regular on-site meetings were used to inform improvements in the program's implementation, and interviews were conducted with intervention and practice staff at the end of the program to address additional avenues for improvement. Despite thoughtful planning, multiple challenges arose, highlighting the need for extended time piloting the intervention, additional staffing of the intervention, and maintaining flexibility when working with busy primary care sites to implement mental health interventions. The CFP program highlights the challenges of implementing mental health interventions for minority populations in primary care.

Association of Race, Ethnicity and Language with Participation in Mental Health Research Among Adult Patients in Primary Care.

Racial and ethnic minorities remain underrepresented in clinical psychiatric research, but the reasons are not fully understood and may vary widely between minority groups. We used the Z-test of independent proportions and binary logistic regression to examine the relationship between race, ethnicity or primary language and participation in screening as well as interest in further research participation among primary care patients being screened for a depression study. Minorities were less likely than non-Hispanic Whites to complete the initial screening survey. Latinos and Blacks were more likely to agree to be contacted for research than non-Hispanic Whites. Among Latinos, primary language was associated with willingness to be contacted for research. Associations between research participation and race, ethnicity and language are complex and vary across different enrollment steps. Future research should consider stages of the research enrollment process separately to better understand barriers and identify targets for intervention.

Race/ethnicity and other social determinants of psychological well-being and functioning in mental health clinics.

Significant racial and ethnic differences exist in the receipt of psychiatric care and help-seeking. We examined the relationship between race/ethnicity and psychological well-being and functioning in psychiatric outpatients. We analyzed intake data for 8,697 adult patients in psychiatry clinics in New England between 2008 and 2010. Patients rated psychological wellbeing using the Schwartz Outcome Scale (SOS-10); clinicians rated the Global Assessment of Functioning (GAF). In an analysis of variance with covariates, race/ethnicity exhibited a small but statistically significant association with GAF (F(4,8481)=17.902, p<.001) and SOS-10 scores (F(4,8165)=7.271, p<.001). However, after adjustment for physical health and socioeconomic variables, these differences became insignificant or were reversed. Our findings suggest that the relationship between race/ethnicity and mental health may be confounded by other socioeconomic or health differences and may be small compared with the effect of those variables. Future studies on race and psychological well-being should take social determinants of health into consideration.

Evaluating patient acceptability of a culturally focused psychiatric consultation intervention for Latino Americans with depression.

Significant disparities exist in both access to and quality of mental health care for Latino Americans with depression compared to Caucasians, resulting in a greater burden of disability in this underserved population. Our aim is to evaluate participant acceptability of a Culturally Focused Psychiatric (CFP) consultation program for depressed Latino Americans. Latino American adult primary care patients endorsing depressive symptoms on a screening questionnaire were targeted in their primary care clinic. The intervention addressed participants' depressive symptoms using culturally adapted clinical assessments and toolkits. Acceptability was evaluated using a treatment satisfaction scale and in-depth semi-structured interviews. Overall, 85% of participants responded positively to all questions of the satisfaction scale. In in-depth interviews, the vast majority of participants reported the program met expectations, all stated providers were culturally sensitive, and most stated recommendations were culturally sensitive. The CFP program was found to be acceptable to a group of depressed Latino American primary care patients. Further research is needed to evaluate if the CFP intervention can improve depressive symptoms and outcomes.

A study of a culturally focused psychiatric consultation service for Asian American and Latino American primary care patients with depression.

BACKGROUND: Ethnic minorities with depression are more likely to seek mental health care through primary care providers (PCPs) than mental health specialists. However, both provider and patient-specific challenges exist. PCP-specific challenges include unfamiliarity with depressive symptom profiles in diverse patient populations, limited time to address mental health, and limited referral options for mental health care. Patient-specific challenges include stigma around mental health issues and reluctance to seek mental health treatment. To address these issues, we implemented a multi-component intervention for Asian American and Latino American primary care patients with depression at Massachusetts General Hospital (MGH). METHODS/DESIGN: We propose a randomized controlled trial to evaluate a culturally appropriate intervention to improve the diagnosis and treatment of depression in our target population. Our goals are to facilitate a) primary care providers' ability to provide appropriate, culturally informed care of depression, and b) patients' knowledge of and resources for receiving treatment for depression. Our two-year long intervention targets Asian American and Latino American adult (18 years of age or older) primary care patients at MGH screening positive for symptoms of depression. All eligible patients in the intervention arm of the study who screen positive will be offered a culturally focused psychiatric (CFP) consultation. Patients will meet with a study clinician and receive toolkits that include psychoeducational booklets, worksheets and community resources. Within two weeks of the initial consultation, patients will attend a follow-up visit with the CFP clinicians. Primary outcomes will determine the feasibility and cost associated with implementation of the service, and evaluate patient and provider satisfaction with the CFP service. Exploratory aims will describe the study population at screening, recruitment, and enrollment and identify which variables influenced patient participation in the program. DISCUSSION: The study involves an innovative yet practical intervention that builds on existing resources and strives to improve quality of care for depression for minorities. Additionally, it complements the current movement in psychiatry to enhance the treatment of depression in primary care settings. If found beneficial, the intervention will serve as a model for care of Asian American and Latino American patients.