Integrating Behavioral Health Into Primary Care For Homeless & Uninsured Individuals in Atlanta: A Program Evaluation Open Access

Lamb, Mark (Fall 2017)

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Mercy Care is a grant and donation-funded federally qualified health center and patient-centered medical home. In 2015, the organization provided health and social services for 11,965 patients in Fulton, DeKalb, and Chamblee counties of Atlanta, Georgia. 9,100 patient visits were for mental health. 66% of patients were homeless. 95.5% were uninsured.

Integrated Behavioral Health (IBH) involves screening all primary care patients for depression. Primary care providers (PCP) treat patients screening positive for depression or refer them to a specialist. In 2012, Mercy Care piloted a grant-funded IBH program that since expanded to all its health centers.

From May to August, 2016, the author interviewed clinical and administrative staff at Mercy Care’s five, fixed site clinics. Chart reviews of around 1,000 patients yielded variables assessing various aspects of IBH at each location. The author used structured observations and informal conversations with staff to supplement findings from interviews and chart reviews. This report presents: organizational background on Mercy Care; a literature review of the integrated behavioral health and health services for homeless and uninsured individuals; the program evaluation’s methodology; a summary of key findings; conclusions; limitations of the data; and recommendations for Mercy Care.

Table of Contents

Section 1 – Introduction. 8

Section 2 – Literature Review: Conclusions. 8

Section 3 – IBH Program Evaluation: Methods. 12

Section 4 – Chart Review Findings. 15

Section 5 – Findings from Interviews & Observations. 19

Section 6 – Limitations. 23

Section 7 – Conclusions. 26

Section 8 – Recommendations. 28

Table 1 – Site Characteristics: Summary description of participating clinic sites. 30

Table 2: Clinic Characteristics. 31

Table 3 – Summary of time allocation and evaluation activities at each Mercy Care site. 31

Figure 1 – Interviewed Clinicians, Years of Experience at Mercy Care. 32

Figure 2 – Interviewed Staff, by Clinical Role. 32

Figure 3 – Average Number of Patients Seen Per Day, By Clinic. 33

Figure 4 – Comparison of Male and Female Patients, By Clinic. 33

Figure 5 – Percentage of Eligible Patients Receiving a BH Screen, By Clinic. 34

Figure 6 – Percentage of Screened Patients Testing Positive, By Clinic. 34

Figure 8 – Percentage of BH Patients Whose BH Issue is Unclear Per Documentation.. 35

Figure 9 – Percentage of All Patients with Documented Evidence of a Substance Use Issue, By Clinic. 36

Figure 10 – Percentage of All Patients with Documented Evidence of 3 or More BH Conditions. 36

Table 4: BH Screens & Documented BH Issues, by Clinic. 37

Figure 11 – Average Estimated Time Lapse Between a BH Referral & the Patient Seeing a BHS.. 38

Figure 12 – Percentage of Patients Referred to BH with Documented Same-Day Contact. 38

Figure 13 – Percentage of Patients Referred to BH with No Documented Contact with BH... 39

Table 5: Documented BH Referrals & Time to Being Seen, by Clinic. 40

Figure 14 – Percentage of BH Patients with a Documented Psychotropic. 41

Table 6: Psychotropic Medications & BH Management, by Clinic. 41

Figure 15 – Percentage of Patients Whose Initial PHQ-9 Was Re-Evaluated.. 42

Table 7: PHQ-9 Score Trends, by Clinic. 43

Appendix 1: Key Informant Interview Guide. 44

Appendix 2: Additional Recommendations. 47

References. 54

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