A Qualitative Study on Primary Care Integration into an Asian Immigrant-specific Behavioural Health Setting in the United States

Study setting

This study took place in a large non-profit community mental health clinic in a metropolitan area of California. The clinic provided comprehensive outpatient behavioural health services to more than 2,000 patients annually. Their patients were mainly low-income Asian immigrants of which 90% spoke a primary language other than English.

Program description

In 2010, the clinic obtained government funding to initiate their Primary Care Integration program. The program collocated services in which primary care providers were embedded in the behavioural health setting [15]. The interdisciplinary team was comprised of thirty-six behavioural health providers (including one psychiatrist) from the community mental health clinic and three primary care providers from the adjacent federally qualified health centre that provides medical services to a large Asian population in the area. Patients, who were 18 or above, self-identified Asian Americans, and receiving mental healthcare through the clinic, were recruited by their care managers to enrol in this program.

Through this program, patients received primary care services and regular behavioural health care management in the same facility. Patients attended appointments with their assigned primary care physicians every three months. Bilingual/bicultural behavioural health care managers also joined primary care visits with patients to aid on language translation and follow-up on recommendations. The interdisciplinary team used an electronic health record system to coordinate appointments, obtain and share patients’ lab results, and to provide e-prescription. The psychiatrist, wellness coordinator, integrated care program administrators, care managers and primary care providers also held regular case conferences to discuss patients’ treatment goals and outcomes. As part of the program, integration of physical health care and wellness education was expected to be included in routine care. Patients might also be recommended to join various wellness activities based on their needs and availabilities. These wellness activities were typically staffed by a bilingual instructor and co-facilitated by a peer worker. Peer workers, who have lived experience of serious mental illness, were trained and supervised by behavioural health providers.

The primary care integration program was a four-year effort. During the final year, the authors collaborated with the staff in recruitment and data collection for this qualitative study to examine factors that supported (i.e. facilitators) or hindered (i.e. barriers) the implementation of the program.

Theoretical framework and study design

The Health Behaviour Framework provides an overview of both contextual and individual factors that could influence patients’ health behaviours and outcomes [28]. It is commonly used in studies of health disparities among chronically ill populations. Based on this framework, the present study gathered perspectives from both providers/administrators and patients to capture factors at the system, organisation, provider and individual levels that could potentially influence the integrated care implementation. Components of the Health Behaviour Framework were used to generate interview questions. Questions for providers intended to elicit their perspectives on the implementation of the program, including the provider characteristics, practice patterns, and structural support and systemic barriers. Providers/administrators were interviewed individually as they came from different disciplines that might represent different perspectives. Questions designed for patients focused on understanding their access to, experiences and perceptions of care in the program. Focus group discussion was selected for patients as a format to encourage participation and in-depth discussion [29]. The study protocols were approved by DePaul University’s Institutional Review Board. Informed consent was obtained from each participant prior to participation.

Sampling and recruitment

The authors emailed and recruited five providers/administrators (4 from behavioural health and 1 from primary care) for interviews. There were in total 36 behavioural health providers and 3 primary care providers in the program. These five providers/administrators were purposively selected for the study, based on their knowledge of and involvement in the planning and implementation of various aspects of the program, which allowed for rich and diverse perspectives [30]. Provider characteristics and roles were presented in Table 1.

At the time of recruitment, 250 patients were enrolled in the program, 41 joined focus group discussions via convenience sampling. Recruitment flyers were distributed in individual and group meetings at the clinic. Patient characteristics were summarized in Table 2. All patients participated in the program were adults with monthly income less than $900 and were eligible for the state’s free or low-cost health coverage (i.e. Medi-Cal).

Data collection

Between March and May 2015, the authors conducted five one-hour semi-structured interviews with providers/administrators in English over the phone. In July 2015, the second author and bilingual staff conducted seven semi-structured focus group discussions with patients. Each one-hour group consisted of six to seven participants, with one bilingual staff as the interpreter. The groups were administered in languages concordant to participants. These languages were Cantonese, Vietnamese, Khmer, Mien and English. Participants were compensated with a $20 gift card. All interviews and discussions were audio-recorded.

Data analysis

Bilingual/bicultural researchers transcribed the recordings into English. Constant comparison method was used [31], wherein analytic themes were generated independently by multiple trained coders, then refined and agreed upon in study team meetings via group discussion. Six trained coders independently read the transcripts and generated initial codes guided by the study aim. Following an iterative coding process [32], coders reviewed and compared the codes in team meetings to generate a codebook. Based on the same codebook, pairs of coders revisited the transcripts to understand the meanings and ideas of the codes. The authors, guided by the Health Behaviour Framework, met with the coders to discuss the abstract meanings, patterns and interconnections among the codes, as well as explored possible factors beyond the framework. After the team reached theoretical saturation at which no additional data could provide more information to the codes [33], no further focus groups and interviews were conducted. The team inductively generated themes and reached consensus on the meanings and importance of the themes. NVivo 10.0 [34] was used for the analytic process.

To enhance the credibility of the findings and ensure they are reflective of participants’ experiences, strategies to triangulate data sources and analysts were used [35]. First, multiple pairs of coders were employed to cross check data and achieve reliability. Coding reliability was assessed by comparing codes assigned to the same transcript by two different coders. Discrepancies in coding were discussed and clarified between the paired coders and in study team meetings. Second, we acknowledged potential differences in the information collected from focus groups and individual interviews, so similar and/or differing perspectives of patients and providers/administrators were taken into consideration in the process of coding and generating themes. Third, member checking was conducted through sharing the findings with six participants after data analyses. Participants agreed that the themes reflected their experiences and perspectives.

Limited Preconditions at the System-level

From the outset, providers identified four gaps in the macro system of healthcare that challenge optimal implementation of integrated care. A foremost struggle was the lack of training in clinicians regarding primary care behavioural health integration. Other providers said that in an integrated care setting, additional training and time were required to modify interventions in ways that best engaged their patients and responded to patients’ needs.

Second, particularly in the context of serving a multilingual and diverse patient population, providers reported a constant struggle with inadequate resources to overcome cultural and linguistic barriers unique to the Asian immigrant population. Behavioural health providers said it was difficult to recruit multilingual clinicians who had knowledge, experience and willingness to work with non-English speaking populations with serious mental illness. The behavioural health clinician said she ended up being the instructor for most of the wellness activities because she was not able to find other instructors who felt comfortable to do so.

Third, behavioural health and primary care providers expressed concerns about the current reimbursement system that does not compensate for increased workload in integrated care setting. A behavioural health provider said:

The primary care physician stated her belief that the primary care clinic was losing money from their involvement in the integrated care program because it was difficult to obtain reimbursement for services rendered. Furthermore, other providers reported that the paucity of continuous funding hindered sustainability of the program. The program coordinator said many staff viewed the funding for the program as time-limited and therefore were not willing to make more permanent changes in support of integrated care efforts.

Despite the clinic could secure a space for providing colocation of services, patients and providers discussed the challenge of physical capacity, specifically access to facilities large enough to hold wellness groups as part of the integrated care program. A behavioural health provider explained that they had been using donated space at a church to conduct some wellness group activities. However, this facility was small and not always available. Whereas there was an intention to increase wellness programming, the existing physical barriers limited the variety of wellness activities held and the number of patients that could benefit from them.

Cross-Organisation Dynamics

The primary care integration program was the first formal working relationship between the primary care and behavioural health providers serving mutual patients. Providers on both sides admitted that the differences between two organisations made it difficult to work together and put the integrated care model in practice. The primary care physician said:

Providers raised challenges in creating a shared vision of integrated care, clarifying roles and responsibilities between behavioural health and primary care, and developing a mutual understanding of the administrative procedures (i.e. enrolment, scheduling, and billing) required for the integrated care program. Providers also reported working under constraints due to different protocols in two organisations. For example, the primary care physician mentioned they had to work around the issue of patient eligibility and billing for this program because primary care followed a different set of admission and insurance criteria required by federally qualified health centre. Providers expressed the importance of an interdisciplinary team to share vision, goals and priorities. They wished they had spent more time and opportunities on staff networking to build a cohesive team.

Changes in Organisational Culture and System

Despite the myriad of organisational challenges, providers agreed that there were gradual changes that led to a new culture and operational system for integrated care. Behavioural health clinician reported seeing an increased willingness in care managers to work with medical providers. Primary care physician, on the other hand, took initiative to communicate more frequently with care managers and acknowledge the importance of behavioural health interventions. Providers recognized a change in mentality from “your patient, my patient” into “our patient” and viewed their patients as shared within the team. Providers also reported changes in the conventions of their jobs to improve service delivery. Care managers conducted more follow-ups with their patients on primary care providers’ recommendations; whereas primary care physicians spent more time with patients learning about their mental health conditions.

Behavioural health providers explained that these changes occurred in the context of continuous access, exposure and education on each other’s work. The behavioural health clinician and program coordinator said they took time to educate the care managers and primary care physicians about holistic wellness and invite them to see the different parts of the program and how they could apply in their practice. The program coordinator said:

Improved Patient-Provider and Provider-Provider Communication

Both behavioural health and primary care providers reported using formal and informal communication channels to exchange information and provide structures for accountability, differentiation and coordination of care. The psychiatrist, primary care providers, care managers and other behavioural health staff held regular case conferences to discuss patients’ treatment goals and progress. A few providers mentioned using daily informal check-ins amongst themselves to avoid patients falling through the cracks of the system and ensure services from different parties were provided to meet the patients’ needs. Information exchange allowed providers to integrate their services for patients and be better informed about the feedback of their recommendations. Additionally, some patients saw their linguistic barriers and discomfort with primary care providers in discussing mental health issues being removed by having linguistically matched care managers at primary care appointments, thus improving patient-provider understanding.

Providers reported using an information sharing system to facilitate the integration between behavioural health and primary care. In the second year of the program, behavioural health providers obtained funding to develop their electronic health record system. The program coordinator explained that they used the system in three ways: (1) psychiatrists made e-prescriptions and checked for potential interactions among patient’s different medications; (2) behavioural health providers obtained lab results to keep track of patients’ health and progress; (3) primary care providers had access to the system to schedule patients’ appointments. Despite some legal and technical barriers, providers valued the electronic health record system as it allowed immediate access to information at anytime from anywhere, and to coordinate appointments or treatment efforts, which was “especially important in this hard-to-reach population when no-shows are common”.

Increased Patient Involvement

All providers recognized the importance of involving patients’ knowledge, strengths, needs, perspectives and participation in supporting the implementation of integrated care and enhancing patients’ clinical outcomes. They saw patients as “navigator[s] of their own recovery” and valued patients’ awareness and abilities to manage their health. Providers reported more discussion with patients regarding their vital signs and health data. Family members were also invited to wellness activities with patients in order to reinforce health and wellness management at home.

Peer involvement was another initiative in the integrated care program. Several patients shared their experiences in volunteering and assisting certain parts of the integrated care program, such as recruiting patients, co-facilitating wellness activities, and providing support in language translation. These patients reported their experiences of leadership motivated them and their peers. Behavioural health providers said they created positions for peer leaders and recruited patients who had received training from the clinic. Parts of the training focused on culturally responsive and therapeutic engagement, and being sensitive to legal as well as ethical issues. The clinic encouraged peer involvement by providing supervision and acknowledging their services with stipend or gift cards. Providers described peer leaders as “valuable workforce member[s]”, since peer leaders provided additional resources and unique expertise to support integrated care implementation under an already taxed environment.