Primary Care Integration of Psychiatric and Behavioral Health Services: A Primer for Providers and Case Report of Local Implementation.

Mental health conditions are common, disabling, potentially life-threatening, and costly; however, they are mostly treatable with early detection and intervention. Unfortunately, mental healthcare is in significantly short supply both nationally and locally, and particularly in small, rural, and relatively isolated communities. This article provides physicians and other health practitioners with a primer on the basic rationale and principles of integrating behavioral healthcare - particularly psychiatric specialty care - in primary care settings, including effective use of teleconferencing. Referring to a local-based example, this paper describes the programmatic components (universal screening, telephone availability, mutually educational team rounds, as-needed consultations, etc) that operationalize and facilitate successful primary care integration, and illustrates how these elements are applied to population segments with differing needs for behavioral healthcare involvement. Lastly, the article discusses the potential value of primary care integration in promoting quality, accessibility, and provider retention; discusses how new developments in healthcare financing could enhance the sustainability of primary care integration models; and summarizes lessons learned.

Telemental Health Training, Team Building, and Workforce Development in Cultural Context: The Hawaii Experience.

OBJECTIVE: The goal of the University of Hawaii (UH) child and adolescent psychiatry telemental health (TMH) program is to train child and adolescent psychiatry fellows to provide behavioral health services for the children of Hawaii and the Pacific Islands in the cultural context of their rural communities using interactive videoteleconferencing (IVTC). The training experience balances learning objectives with community service. Learning objectives include: Understanding mental health disparities in rural communities, leveraging community resources in ongoing treatment, providing culturally effective care, and improving health care access and delivery through TMH service research and evaluation. METHODS: We describe the UH experience. Several UH faculty are experienced with IVTC technology. They are triple-board trained, are recognized for their research in program evaluation and mental health disparities, and are committed to serving Hawaii's rural communities. We demonstrate the role of TMH in linking children and their families living in rural communities with multiple mental health treatment providers. The service-learning curriculum and a unique collaboration with Mayo Clinic provide the opportunity to examine the role of TMH in global service, and training, education, and research. RESULTS: TMH provides direct services to patients and consultation on Hawaii Island and Maui County. The collaboration with the Mayo Clinic brings further consultation in complex diagnostics, pharmacogenomics, and cross-cultural psychiatry. A curriculum provides trainees experience with IVTC with the goal of potential recruitment to underserved rural communities. The TMH program at UH is unique in its team building and workforce development by joining multiple entities through IVTC and translating expertise from the Mayo Clinic to rural communities, and strengthening collaboration with local child and adolescent psychiatrists, and primary care and other mental health providers. CONCLUSIONS: The UH psychiatry program is a model program to develop an expert mental health workforce in cultural context for children living in rural communities.

Sociodemographic characterization of ECT utilization in Hawaii.

OBJECTIVES: Minimal research has been done on sociodemographic differences in utilization of electroconvulsive therapy (ECT) for refractory depression, especially among Asian Americans and Pacific Islanders. METHODS: This study examined sociodemographic and diagnostic variables using retrospective data from Hawaii, an island state with predominantly Asian Americans and Pacific Islanders. Retrospective data were obtained from an inpatient and outpatient database of ECT patients from 2008 to 2010 at a tertiary care community hospital on O'ahu, Hawaii. RESULTS: There was a significant increase in overall ECT utilization from 2008 to 2009, with utilization remaining stable from 2009 to 2010. European Americans (41%) and Japanese Americans (29%) have relatively higher rates of receiving ECT, and Filipino Americans and Native Hawaiians have relatively lower rates in comparison with their population demographics. Japanese Americans received significantly more ECT procedures than European Americans. CONCLUSIONS: Electroconvulsive therapy is underutilized by certain sociodemographic groups that may benefit most from the treatment. There are significant differences in ECT usage based on ethnicity. Such differences may be related to help-seeking behavior, economic differences, and/or attitudes regarding mental illness. Further research is needed to elucidate the reasons for differences in utilization.

Proportional differences in emergency room adult patients with PTSD, mood disorders, and anxiety for a large ethnically diverse geographic sample.

Underserved populations often utilize the emergency room in place of primary care, particularly for short term behavioral health services. This study examined emergency department (ED) utilization rates for rurality, insurance, sex, and ethnicity in a large sample of adult patients in Hawai'i hospitals from 2000-2010 with a diagnosis of post-traumatic stress disorder (PTSD), mood disorder, or other anxiety disorder. Findings showed a higher rate of use by rural and suburban residents with a diagnosis of PTSD or other anxiety than by urban residents. Utilization of EDs by African Americans and Other Pacific Islanders with PTSD was proportionally higher than for those with mood disorders or other anxiety disorders. Military ED visits were also proportionally higher for individuals with PTSD than for those with mood or other anxiety disorders. Limited economic resources and increasingly costly mental health disorders such as PTSD highlight the importance of better understanding the needs for behavioral health services for underserved populations.

Rural mental health: implications for telepsychiatry in clinical service, workforce development, and organizational capacity.

In Hawai'i, rural residents suffer disproportionately from poor health and mental health outcomes. Hawai'i's island geography makes rural health service disparities especially compelling. Physician workforce shortages are projected to increase, despite 30 years of programs aimed at recruiting physicians to rural areas. Telepsychiatry has been shown to be a feasible way to provide a variety of health services to individuals living in rural areas with limited access to healthcare. The University of Hawai'i Rural Health Collaboration (UHRHC) was established by the Department of Psychiatry to address the need for workforce development and rural access to mental health services across the State of Hawai'i by using telepsychiatry. Partnerships with community health clinics have been formed to provide patient care and consultation-liaison services through telepsychiatry technology. In addition, UHRHC focuses on workforce development in its residency training curriculum by utilizing a service-learning approach to rural mental health. Evaluation of these efforts is currently underway, with preliminary evidence suggesting that UHRHC is a promising strategy to increase access to critical mental health services and reduce health disparities in rural Hawai'i.

Public-academic partnerships: the University of Hawai'i Rural Health Collaboration: partnerships to provide adult telepsychiatry services.

To address the twofold problem of mental health disparities and limited access to health resources in rural areas, the University of Hawai'i Rural Health Collaboration aims to increase access to behavioral health services to rural areas across the state, primarily via telepsychiatry. The authors highlight lessons learned in regard to forging a university-community partnership, specifically community engagement for patient referral, the shift toward integrated services and away from a specialty clinic model, the importance of community diversity and contextual relevance, and ethical research and practice with indigenous communities.