Authors:

Abstract

Introduction

Integration of primary care and behavioral health has been shown to enhance engagement in mental health services, while improving experience of care (Berwick, Nolan, Whittington, 2008; Davis et al., 2016). The model for primary care-mental health integration (PC-MHI) typically champions brief session duration, which centers on optimizing availability for warm hand-offs (Larkin et al., 2016). Efforts have been made toward setting metrics for the proportion of 30 minute appointments that are delivered compared to longer sessions (e.g., 75%). However, there are no identifiable studies that examine factors contributing to session duration and the feasibility of this in clinical settings.

Aims Objectives Theory or Methods

The present study aims to delineate clinician decision-making, as well as patient and system variables that impact the duration of assessments and deviation from the 30 minute standard. Eighteen clinicians completed a brief questionnaire following functional assessments over a three month period. We utilized both quantitative and qualitative approaches to understand how providers navigate factors such as competing demands of behavioral health clinicians, complex diagnostic presentations, patient ambivalence, and mental health risk.

Highlights or Results or Key Findings

We examined data from 110  functional assessments coming from primary care at a VA medical center.  The most common provisional diagnoses were PTSD, depressive disorders, and anxiety. The sample appeared fairly symptomatic, with depression  and anxiety screen scores in the moderate range and PTSD screens well above the cut-off suggestive of PTSD (for PHQ=9,  M = 10.45, SD = 5.81; GAD-7, M = 10.40, SD = 5.77,  for PCL-5, M = 41.11,  SD = 20.80). In terms of session duration,  42% of all of the functional assessments fell within the target (30 minutes or equivalent CPT code). The average session duration was 42 mins (SD = 13.38, range 17-90 mins), only slightly outside the established recommended duration.  We will further describe qualitative data on factors that appear to have impacted session duration including patient complexity, patient ambivalence, and suicide risk.

Conclusions

While PC-MHI services are generally brief in duration, there are questions related to the feasibility of a 30-minute model in some cases. Data suggests that less than half of the functional assessments fell within the recommended range. Factors that may impact duration include symptom severity, patient complexity, and patient ambivalence.

Implications for applicability/transferability sustainability and limitations

This study helps to elucidate factors involved in conducting brief, functional assessments in integrated care.  This has implications for understanding time needed for assessment which can impact clinic development, staffing, and warm hand-off availability. This study highlights the need for flexibility in clinic structure and time allotted for patients.