Systems issues and barriers

Although the need for improved integration of primary medical care and behavioral health care is well documented, and models such as those described previously are being developed and tested, numerous systems issues and barriers continue to impact effective integration adversely at multiple levels, involving all six key stakeholder groups (Fig. 8) [59].

At the patient level, stigma, resistance to diagnosis, and health beliefs that tend to emphasize somatic presentations act as barriers to recognition and treatment of behavioral disorders in the primary care setting. In many cases, the illness itself causes feelings of pessimism, nihilism, and low energy that interfere with help-seeking behaviors or result in unemployment or loss of insurance coverage. For primary care providers, limited time as well as limitations in background, training, and the capacity and interest to reflect introspectively may also act as barriers to appropriate treatment for behavioral health disorders in primary care settings. There is wide variation in how primary care practices are organized to care for people who have behavioral health problems, how they allocate resources in this regard, and how they are linked to behavioral health specialty care. Often there is

• Enhance self-management/participation

• Link with community resources

• Evaluate preferences and demand effective care

• Improve knowledge/skills

• Provide decision support

• Link to specialty expertise and change behaviors

• Establish chronic care model and reorganize practice

• Link with improved information systems

• Adapt to varying organizational contexts

• Enhance monitoring capacity for quality/outliers

• Develop provider/system incentives

• Link with improved information systems

• Educate regarding importance/impact of depression

• Develop plan incentives/monitoring capacity

• Use quality/value measures in purchasing decisions

• Engage community stakeholders; adapt models to local needs

• Develop community capacities

• Increase demand for quality care; enhance policy advocacy

Fig. 8. The "6P" conceptual framework. (From Pincus HA, Hough L, Knox Houtsinger J, et al. Emerging models of depression care: multilevel ("6P") strategies. Int J Methods Psychiatric Res 2003;12:54-63; with permission.)

• Enhance monitoring capacity for quality/outliers

• Develop provider/system incentives

• Link with improved information systems ambiguity about who is responsible for care, and there is limited communication and teamwork between primary care and mental health practices. Typically, primary care practices focus on acute management and referral for what are often chronic or recurrent conditions. Moreover, existing diagnostic systems (ie, The Diagnostic and Statistical Manual for Mental Disor-ders-IV), instruments, and screening tools generally have not been geared toward primary care practice. At the plan/payer level, fragmentation of care through "carve-out" arrangements (ie, in which primary care and behavioral health networks are entirely separate) limit collaboration and communication between primary care and specialty practices and providers and even discourage it with financial and structural disincentives. Approaches for improving care for mental health disorders in both integrated and network managed-care plans have been developed and tested, but these collaborative arrangements are unlikely to remain in place after a demonstration is concluded unless they are tied to financial incentives [60-62]. Although public (eg, Medicare and Medicaid) and private purchasers (eg, business coalitions) exert significant influence over insurance benefit design and coverage decisions, they often fail to consider quality of care as the basis for purchasing decisions. Despite the growing evidence of the increasing value of behavioral health care, awareness of the substantial indirect costs that accrue through absenteeism, presenteeism, and disability remains limited [63]. Behavioral health disorders also place enormous burdens at the population or community level, especially among socially disadvantaged and vulnerable groups. There have not, however, been efforts to link public health approaches more broadly with customized community development models in the service of improving recognition, management, and outcomes [40,48].

Training physicians and nurses in biopsychosocial medicine and communication skills

From the very beginning, one of the aims of C-L psychiatry and psycho-somatics was to enhance the biopsychosocial attitudes and communication skills of physicians and nurses to achieve a better holistic care of patients through a "snow-ball effect" created by C-L work [64,65]. The aim of this section is not to review these educational efforts systematically but to provide some examples so that the reader gains an impression of these methods, which may be considered as complementary to the previously mentioned clinical models. Different methods of transferring psychologic knowledge and skills have been developed and integrated in clinical care; among them are the traditional models, such as the so-called "Balint groups" or patient-centered team supervision. More structured approaches appeared more recently, for example the development and implementation of guidelines on specific psychiatric disorders, such as the management of delirium or depression in the medically ill [66]. Although most of these approaches were not evaluated scientifically, training courses developed over the last

2 decades to improve communication skills of physicians and nurses have become the object of scientific interest and have been found highly effective [67]. Such training has been especially developed in two clinical fields in particular, oncology and somatization. Training in communication skills is based mainly on role playing, feedback on audio- or video-taped interviews with simulated patients, and case discussion; designed for oncologists and oncology nurses, they have been successfully implemented and evaluated [68-70]. Training in communication skills is considered relevant and as enhancing patient-centered communication, and the work with videotaped interviews with simulated patients is appreciated. Such training therefore has been developed in different countries, and in one country, Switzerland, is mandatory for oncologists [71].

A comprehensive program has also been introduced at the Memorial Sloan-Kettering Cancer Center in New York City. A dedicated communication skills training and research laboratory has been established at the Memorial Sloan-Kettering Cancer Center, where surgeons, oncologists, nurses, and a range of related clinicians caring for medically ill patients who have cancer are given an applied program of experiential learning. The core program of six modules constitutes a basic oncology curriculum: breaking bad news; discussing prognosis; shared decision making about treatments and clinical trials; responding to distress and anger; transition to palliative care; and obtaining do-not-resuscitate directives and talking with the dying. The consolidation program comprises four modules on geriatric oncology: sensitivity to the elderly; third-party consultations; multidisciplinary teams; and obtaining consent from the cognitively impaired. Other elective modules cover gaining informed consent for phase one trials, genetic risk consultations, working with interpreters, and promoting adherence to treatments. Train-the-Trainer programs ensure facilitators come from the clinical discipline undergoing training. The faculty involved at Memorial Sloan-Kettering Cancer Center expect this training will become the norm for comprehensive cancer centers across the next decade (www.mskcc.org/mskcc/html/44.cfm).

With regard to somatization, the Research Clinic for Functional Disorders and Psychosomatics at Aarhus University Hospital, Denmark, developed a model for training general practitioners to assess and treat patients who present with functional somatic symptoms. The aim of this education model (The Extended Reattribution and Management Model) is to provide knowledge about somatoform disorders and to train general practitioners in interview techniques and communication skills specifically designed for the treatment of patients who have functional disorders [72-74]. The training consists of a 2-day course followed by five follow-up sessions. The program is fitted into a carefully designed research program to assess the effects on the outcome of patients.

In Germany, training courses in basic psychosomatic care, including 20 hours of theoretical seminars, 30 hours of communication skills training, and 30 hours of participation a Balint group, have been broadly implemented during the last decade and now are mandatory for all residents in internal/general medicine.

in the united States Web-based training facilities have been developed (www.impact.ucla.edu) to distribute the methodology of influential studies more effectively [75].

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