Focus on Integrative and Collaborative Care
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IntegratingbehavioralhealthservicesintoauniversityhealthcenterPatientandprovidersatisfaction..pdf
Integrating Behavioral Health Services Into a University Health Center: Patient and Provider Satisfaction
Jennifer S. Funderburk, PhD VA Center for Integrated Healthcare, Syracuse,
New York, Syracuse University, and University of Rochester
Robyn L. Fielder, MS Syracuse University
Kelly S. DeMartini, PhD Syracuse University and Yale University School of
Medicine
Cheryl A. Flynn, MD University of Vermont
The goals of this study were to (a) describe an Integrated Behavioral Health Care (IBHC) program within a university health center and (b) assess provider and patient acceptability and satisfaction with the IBHC program, including behavioral health screening and clinical services of integrated behavioral health providers (BHPs). Fifteen providers (nine primary care providers and six nurses) and 79 patients (75% female, 65% Caucasian) completed program ratings in 2010. Providers completed an anonymous web-based questionnaire that assessed satisfaction with and acceptability of behavioral health screening and the IBHC program featuring integrated BHPs. Patients completed an anonymous web-based questionnaire that assessed program satisfaction and comfort with BHPs. Providers reported that behavioral health screening stimulated new conversations about behavioral health concerns, the BHPs provided clinically useful services, and patients benefited from the IBHC program. Patients reported satisfaction with behavioral health services and reported a willingness to meet again with BHPs. Providers and patients found the IBHC program beneficial to clinical care. Use of integrated BHPs can help university health centers support regular screening for mental and behavioral health issues. Care integration increases access to needed mental health treatment.
Keywords: integrated behavioral health care, integrated primary care, mental health care
Integrated behavioral health care (IBHC), in which primary care providers (PCPs) and be- havioral health providers (BHPs) collaborate to provide coordinated care, is an emerging model of patient care. Over the past decade, research has identified IBHC as a clinically effective and cost-effective method for improving clinical
outcomes within primary care settings (Blount et al., 2007; Bryan, Morrow, & Appolonio, 2009; Cigrang, Dobmeyer, Becknell, Roa- Navarrete, & Yerian, 2006; Goodie, Isler, Hun- ger, & Peterson, 2009). Typically, this research has focused on integrating mental and behav- ioral health care within adult primary care set-
This article was published Online First May 21, 2012. Jennifer S. Funderburk, PhD, VA Center for Integrated
Healthcare, Syracuse, New York, Department of Psychol- ogy, Syracuse University, and Department of Psychiatry, University of Rochester; Robyn L. Fielder, MS, Depart- ment of Psychology, Syracuse University; Kelly S. DeMar- tini, PhD, Department of Psychology, Syracuse University and Department of Psychiatry, Yale University School of Medicine; Cheryl A. Flynn, MD, Center for Health and Wellbeing, University of Vermont.
The views expressed in this article are those of the authors and do not reflect the official policy of the Veterans’ Affairs’ depart- ment or other departments of the U.S. government. This material is based upon work supported by the American College Health Association United Healthcare Student Recourse Initiatives in College Mental and Behavioral Health grant.
Correspondence concerning this article should be ad- dressed to Jennifer S. Funderburk, Center for Integrated Healthcare, 800 Irving Avenue, Room 116C, Syracuse, NY 13210. E-mail: [email protected]
Families, Systems, & Health © 2012 American Psychological Association 2012, Vol. 30, No. 2, 130 –140 1091-7527/12/$12.00 DOI: 10.1037/a0028378
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tings, such as private family medicine practices, academic medical center primary care clinics, and primary care services offered within the Veterans Health Administration or Federal Qualified Centers. However, there is little re- search examining IBHC in university health clinics.
University health centers share many features with standard primary care settings. For exam- ple, university health centers tend to offer am- bulatory care and other basic medical services to a wide range of patients (Christmas, 1995). These clinics tend to be students’ first option when seeking medical care in nonemergency situations. University health centers may coor- dinate referrals to off-campus specialists as nec- essary. Thus, in terms of services offered and general approach to care, university health cen- ters and primary care clinics are quite similar. Nevertheless, compared with typical primary care practices, university health clinics are somewhat unique in that they generally serve a restricted age range (i.e., 18 –24 years of age) for a limited period of time (i.e., academic se- mesters) that has predictable elevations in stress/illness as a result of the increased work- load that occurs toward the end of the semester. In addition, a majority of students are develop- mentally just beginning to take care of them- selves while continuing to maintain significant ties to their parents, sometimes limiting their financial resources and ability to travel off cam- pus for additional specialty services. Another caveat is that most university health clinics pro- vide services to students using a general health fee that is wrapped into their tuition, eliminating difficulties with insurance claims (Mills, Gold, & Curran, 1996).
The lack of research examining the integra- tion of mental health services into university health clinics is surprising because of the alarm- ing rates of mental health issues on college campuses (American College Health Associa- tion [ACHA], 2010a; Mowbray et al., 2006) and the fact that most college students with clini- cally significant psychological distress do not receive mental health treatment (Rosenthal & Wilson, 2008). For instance, only 15% of stu- dents with moderately severe to severe depres- sion or past-month suicidal ideation received any mental health care (Garlow et al., 2008). A recent ACHA white paper (2010b) argued for the integration of campus medical and counsel-
ing clinics, given the great potential for inte- grated care to increase treatment access, en- hance clinical outcomes, and improve patient satisfaction.
Similar to other primary care settings, IBHC in university health centers can provide an av- enue to address many of the obstacles to treat- ment access for college students. For instance, a higher proportion of students use campus health clinics than campus mental health clinics (79% vs. 10% in one recent study; Eisenberg, Golber- stein & Gollust, 2007), and many students feel more comfortable seeing PCPs than therapists (ACHA, 2010b). Moreover, because many mental health issues cause physical symptoms, many students seek evaluation at health clinics first (ACHA, 2010b). The few studies examin- ing IBHC within university health settings have reported numerous benefits, including increased accessibility of mental/behavioral health care, increased referral follow-through, and higher quality patient care (Masters, Stillman, Brown- ing & Davis, 2005; Tucker, Sloan, Vance, & Brownson, 2008; Westheimer & Steinley- Bumgarner, 2008).
Besides clinical outcomes, another vital com- ponent in the process of evaluating a new program of service, and whether others should consider implementing such a program within college health, is obtaining feedback from the “consumers” involved in the program (Gallo et al., 2004; Reiss-Brennan, Briot, Daumit, & Ford, 2006; Runyan, Fonseca, & Hunter, 2003). For IBHC, primary consumers include PCPs and patients. A lack of acceptability and/or sat- isfaction among the PCPs with the various com- ponents of the IBHC program would ultimately sabotage the program because of (a) the pivotal role PCPs have within IBHC (i.e., referring patients to BHPs) and (b) the focus all IBHC programs have on increasing collaboration be- tween PCPs and BHPs. Similarly, it is ex- tremely important that the patients are satisfied with clinical services provided by a new program, otherwise patients may not remain engaged or comply with treatment recommen- dations, which could compromise treatment success. Patient satisfaction is an important out- come measure that identifies problems with health care (Sitzia & Wood, 1997) and is asso- ciated with treatment adherence and provider/ program selection (Fitzpatrick, 1991).
131INTEGRATING BEHAVIORAL HEALTH SERVICES
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Preliminary studies have begun to examine patient and provider opinions about IBHC within the college health setting. Tucker et al. (2008) examined an international student’s ex- perience of the Integrated Health Program at the University of Texas at Austin using a case study design and found his overall experience to be positive. Westheimer and Steinley-Bumgarner (2008) examined provider behaviors, opinions, and experiences during the integration process of IBHC within the same university and found PCPs ascribed a high level of value to the col- laborative effort integrated BHPs could provide in helping with a diverse number of conditions. However, neither of these studies provided a sound understanding of patient or provider sat- isfaction with the IBHC program and its various components.
Two studies have examined the use of screen- ing questionnaires designed to increase discus- sion of mental and behavioral health issues dur- ing university health center visits. In a pilot study, Cowan and Morewitz (1995) found that use of a screening questionnaire prompted dis- cussion of psychosocial concerns that may not have otherwise come up. However, this study did not use a validated screening measure or examine provider or patient satisfaction with use of the screening measure. Alschuler, Hoodin, and Byrd (2008) examined provider and patient satisfaction with the integration of a screening questionnaire for behavioral health issues in a college health center. They found that patients who were randomly assigned to fill out the screening questionnaire reported it helped them discuss concerns with their provid- ers and they would like its use to continue in the future. The providers reported that they also found the screening questionnaire helpful and would be happy to collaborate with integrated BHPs on-site. Although this study provided pre- liminary evidence toward patient and provider satisfaction with IBHC, it focused on integrat- ing the screening measure and it did not involve the actual integration of BHPs, which is a fun- damental component of IBHC programs.
In sum, IBHC is an emerging approach to health care that can increase access to mental and behavioral health care while reducing the burden on PCPs and specialty mental health centers. University health centers are an oppor- tune setting in which to implement the IBHC model. However, despite the importance of en-
suring provider and patient acceptability and satisfaction when implementing new clinical programs, little research has examined these factors with respect to IBHC in university health centers. Therefore, the purpose of this study was to collect feedback from PCPs and patients to assess the acceptability and satisfac- tion with all aspects of integrating an IBHC program at Syracuse University, which included the implementation of a behavioral health screening questionnaire as well as the integra- tion of several BHPs. It was expected that PCPs and patients would indicate a high level of sat- isfaction and acceptability with all aspects of the program.
Method
Our Integrated Behavioral Health Primary Care Program
We developed our IBHC program by adapt- ing a common model of integrated health care called the Primary Mental Health Care model described by Strosahl (1998). Syracuse Univer- sity Health Services (SUHS), which serves ap- proximately 9,038 patients per year, collabo- rated with the Syracuse University doctoral program in clinical psychology to integrate three to five advanced doctoral students as BHPs per academic year (for additional infor- mation regarding this type of collaborative ef- fort, see Masters et al., 2005). The BHPs pro- vided clinical services 20 –35 hours per week as part of an Advanced Practicum course. Working under the supervision of a licensed psychologist and an onsite medical provider, the BHPs saw approximately 152 students per semester for various presenting problems (e.g., insomnia, de- pressive symptoms). BHPs acted as consultants to the PCPs, seeing patients for brief sessions (i.e., one to three sessions lasting approximately 15–30 minutes each; Strosahl, 1998). The aver- age number of sessions per patient was 1.43 (SD � 0.83, range 1–5) for the Spring, 2010 semester and 1.61 (SD � 0.97, range 1– 6) for the Fall, 2010 semester.
In this IBHC model, the PCP ultimately maintains responsibility for patient manage- ment throughout the course of treatment. None- theless, the PCPs can utilize the BHPs in several ways: (a) to conduct further assessment of be- havioral health issues; (b) to provide brief in-
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terventions for patients reporting mild-moderate mental health symptomatology, behavioral health issues (e.g., sleep problems), or symp- toms associated with chronic disease; (c) to triage patients reporting more severe mental health symptoms to more specialized services; and (d) to provide crisis assessment. BHPs maintain an open access schedule, keeping at least 15 minutes free between half-hour ap- pointments to allow PCPs to walk patients down for same-day visits. Assessments and pa- tient progress notes are shared among the team via verbal and/or written communications within the electronic medical record. Therefore, this IBHC model is strikingly different from the colocation of specialty mental health services within a university health clinic, which often continues to maintain separate medical records, provide more intensive treatment (i.e., a higher number of sessions, longer sessions), see pa- tients for more severe symptomatology, and is often unable to accommodate same-day noncri- sis appointments.
To help facilitate referrals and to follow na- tional recommendations regarding screening for depression and at-risk alcohol use among young adults (American Academy of Pediatrics, 2001; Nimalasuriya, Compton, Guillory & Prevention Practice Committee of the American College of Preventive Medicine, 2009; U.S. Preventive Services Task Force, 2009), we implemented a screening tool as part of our IBHC program. Specifically, all students seen by PCPs for any reason were screened for the following symp- toms: (a) depression and suicidal ideation with the Patient Health Questionnaire-9 (PHQ-9; Spitzer, Kroenke & Williams, 1999); (b) at-risk alcohol use with the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C; Saunders, Aasland, Babor, de la Fuente & Grant, 1993); (c) sleep problems with two items from the Insomnia Severity Index (ISI; Bastien, Valliéres & Morin, 2002); and (d) tobacco use with three items to assess smoking habits. Stu- dents were given the screening tool by nurses as they waited for the medical providers follow- ing the nurse obtaining vital signs. The screen- ing tool clearly describes the purpose of the questionnaire, the confidentiality of the infor- mation, and that the items ask about symptoms unrelated to any current acute illness (e.g., cold, flu).
Procedure
This study was approved by the Syracuse University Institutional Review Board. To ob- tain the provider satisfaction data, we sent three recruitment emails, one week apart, to all PCPs and nurses working at the university health clinic over a 4-week period during the Spring semester of 2010. The email provided a brief description of the study and linked the provider to an anonymous web-based questionnaire. Af- ter providing informed consent, participants provided information on whether they were a PCP (MD, NP) or nurse and filled out a provider satisfaction survey. Providers were not given any compensation for participation.
To obtain the patient satisfaction data, we obtained a list of all students who had at least one session with an integrated BHP during the Spring (i.e., January 15 to May 15, 2010) or Fall semester in 2010 (i.e., August 15 to Decem- ber 15, 2010) by pulling a list of all patients who were included in the electronic medical record as having the specific encounter code used only by the BHPs to identify behavioral health visits. Then, email addresses were lo- cated using the publicly available student email address directory. In addition, basic demo- graphics of all IBHC patients were obtained from a tracking database maintained by the BHPs. We sent three recruitment emails, ap- proximately 3– 4 weeks apart, to each identified patient at the end of each semester to their university-provided email address to ask them to participate in an anonymous web-based pa- tient satisfaction survey. After completing in- formed consent, participants completed the questionnaire. As an incentive, participants were offered a chance to win one of 12 $25 gift cards to an online retailer.
Participants
All PCPs (n � 9, two physician and seven nurse practitioners) and nurses (n � 10) work- ing in the university health clinic were eligible to complete the provider satisfaction question- naire. Fifteen participants (nine PCPs and six nurses) did so, yielding a 79% (100% for PCPs and 60% for nurses) response rate. Because of the small number of providers at the clinic and the need to maintain their anonymity to encour- age higher response rates and candid respond-
133INTEGRATING BEHAVIORAL HEALTH SERVICES
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ing, we did not collect demographics from the participants.
A total of 303 (175 Spring semester, 128 Fall semester) unique IBHC patients were identified using the electronic medical record. A total of 27 (23 from Spring semester and four from Fall semester) had recruitment emails returned because of a nonexistent address error likely resulting from the fact that the student left the university for some reason (e.g., graduation). Of the remaining participants who were eligible (n � 276), 79 participants (32 Spring semes- ter, 47 Fall semester) completed the patient sat- isfaction survey, resulting in an overall 29% response rate (n � 152, 21% for Spring semes- ter and n � 124, 38% for Fall semester). The majority of the participants were female (n � 59, 75%), white (n � 51, 65%), and not Hispanic or Latino (n � 72, 91%). To under- stand the representativeness of our sample, Table 1 presents the demographics for those who partic- ipated in the study and for the total sample of patients (n � 303) who saw a BHP during the Spring and Fall semesters of 2010. Because the patient satisfaction survey was anonymous, we were unable to test for demographic differences between responders and nonresponders.
Measures
Provider satisfaction questionnaire. Par- ticipants rated their level of agreement with 18 statements about the acceptability and useful-
ness of each component of the IBHC program on a Likert scale that ranged from strongly disagree (1) to neutral (3) to strongly agree (5). The 18 items (see Table 2) were generated by the first and fourth author and focused on each element of the IBHC program implemented. For several items, the participant could choose “not applicable” because of the lack of relevance of the statement to nurses versus PCPs and vice versa. Cronbach’s alpha for the scale was .80.
Patient satisfaction questionnaire. Par- ticipants answered five demographic questions (i.e., age, sex, race, ethnicity, and class in school), and three yes/no questions (i.e., whether they remembered filling out the screen- ing measure, whether their PCP discussed one of the topics on the screening measure with them, and whether they met with an integrated BHP). Those who remembered filling out the screening measure and meeting with the inte- grated BHP completed an additional six state- ments (see Table 3) which asked participants to rate their level of satisfaction, comfort, or will- ingness on a Likert scale that ranged from (1) extremely unsatisfied/uncomfortable/unwilling to (3) neutral to (5) extremely satisfied/ comfortable/willing on a variety of elements associated with the IBHC program. These items were generated by the first and fourth author. For those participants who completed the Likert portion of the questionnaire, Cronbach’s alpha for those six items was .75.
Table 1 Demographics of Survey Participants and All IBHC Patients
Participant Demographics All IBHC Patients
M SD n % M SD n %
Age 30.0 3.8 79 21.7 4.1 303 Males 20 25.3 121 40.0 Hispanic or Latino 7 8.9 22 7.3 Racea
White 51 64.6 201 66.3 Black 7 8.9 34 11.2 Asian 10 12.7 24 7.9 Other 10 12.7 44 14.5
Classb
Freshman 4 5.1 55 18.2 Sophomore 22 27.8 55 18.2 Junior 17 21.5 47 15.5 Senior 9 11.4 67 22.1 Graduate Student 27 34.2 75 24.8
a One participant left race unknown. b Four patients’ class was unknown.
134 FUNDERBURK, FIELDER, DEMARTINI, AND FLYNN
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Data Analytic Plan
Because of the descriptive nature of the ob- jectives of this study, our data analytic plan focused primarily on examining distributions and calculating the frequencies, modes, means, and standard deviations of individual survey items.
Results
Provider Satisfaction
As shown in Table 2, both PCPs and nurses reported a high level of support for regular implementation of the screening measure across all four screening domains and reported that
patients were comfortable answering the ques- tions on the screening measure. Providers strongly agreed that the screening measure helped stimulate discussion on topics that would not have come up during the visit other- wise. There was a greater level of variability yielding average (i.e., means ranging from 2.5– 3.0) and modal responses within the neutral range for the two items assessing whether the screening measure took too much time away from other clinical duties and was difficult to score and interpret.
PCPs and nurses considered the integrated BHPs a part of the primary care team and felt the IBHC program helped patients receive treat- ment more quickly. PCPs perceived that pa-
Table 2 Provider Ratings of IBHC Acceptability and Satisfaction
Item
PCPs Nurses
n M (SD) Range n M (SD) Range
Rate your level of agreement with the implementation of regular screening at SUHS for
a) Depression 9 4.7 (0.5) 4–5 6 4.7 (0.5) 4–5 b) Sleep problems 9 4.3 (1.0) 2–5 6 4.7 (0.5) 4–5 c) Tobacco use 9 4.2 (0.7) 3–5 6 4.6 (0.5) 4–5 d) Alcohol misuse 9 4.7 (0.5) 4–5 6 4.7 (0.5) 4–5
The items that assessed the problem below were useful in my clinical practice
a) Depressed mood 9 4.4 (0.5) 4–5 2 4.0 (1.4) 3–5 b) Sleep problems 9 3.9 (0.9) 2–5 1 5.0 (0.0) 5 c) Tobacco use 9 3.4 (0.7) 3–5 1 5.0 (0.0) 5 d) Alcohol consumption 9 3.8 (1.0) 2–5 2 4.5 (0.7) 4–5
The screening measure Took too much time away from clinical
duties 9 2.9 (0.8) 2–4 6 2.5 (0.8) 1–3 Was difficult to score and interpret 9 2.6 (1.2) 1–4 5 3.0 (0.7) 2–4 Helped stimulate discussion of topics that
would not have come up during patient visits 9 4.3 (0.7) 3–5 1 5.0 (0.0) 5
A majority of my patients felt comfortable answering the questions on the screening measure 9 4.3 (1.0) 2–5 6 3.8 (0.8) 3–5
The BHPs Were useful within my clinical practice 9 4.7 (0.5) 4–5 3 4.7 (0.6) 4–5 Became part of our primary care team 9 4.1 (0.6) 3–5 6 3.8 (1.0) 3–5 Benefited my patients 9 4.8 (0.4) 4–5 2 5.0 (0.0) 5 Helped my patients receive treatment
more quickly 9 4.8 (0.4) 4–5 6 5.0 (0.0) 5 I would recommend this service to other
colleagues 9 4.4 (0.7) 3–5 6 4.1 (1.0) 3–5 I would like the integrated behavioral health
service to continue 9 4.7 (0.5) 4–5 6 4.7 (0.5) 4–5
Note. The ns vary because some providers chose “Not Applicable” for a response.
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tients benefited from seeing the BHPs. Both PCPs and nurses would recommend this service to other colleagues within college health and would like IBHC to continue in the future.
Patient Satisfaction
Results of the satisfaction assessment indi- cate that a majority of the sample of patients were satisfied with their overall care at SUHS (see Table 3). A number of students did not remember filling out the screening question- naire (n � 13, 17%) or meeting with a BHP (n � 26, 33%), so they did not rate their satis- faction or report on those elements of the IBHC program in Table 3. Of those who remembered completing the questionnaire, the majority re- ported that they talked to the medical provider about a topic on the screening measure (n � 57, 86%). Of those who remembered meeting with a BHP, the majority reported that they felt that the BHP helped them with the topic that they discussed (n � 38, 73%).
As shown in Table 3, overall participants reported a general level of comfort filling out the screening measure, were satisfied with the service provided by the integrated BHP, and would be willing to seek help from the BHP again if necessary. Although the average re- sponse was within a level of agreement
(M � 3.6), there was a greater level of variabil- ity when it came to having the service within the university health setting as compared with a specialty mental health clinic on campus, with a mode of 3.0 indicating a neutral response.
Discussion
As expected, this study found that PCPs, nurses, and patients reported positive experi- ences with the two major components of the IBHC program: the implementation of a behav- ioral health screening assessment and the inte- gration of BHPs into the university health cen- ter. The results provide further evidence that this model of care can be used on college cam- puses with success in terms of provider and patient satisfaction.
Similar to past research (Alschuler et al., 2008; Cowan & Morewitz, 1995), this study found that providers indicated that having brief screening items to assess sleep problems, de- pression, alcohol use, and tobacco use was help- ful to their clinical practice. In addition, the assessment items reportedly helped stimulate discussions with patients about topics that would not have otherwise been discussed. Alschuler and colleagues (2008) found a similar result such that those providers whose patients
Table 3 Patient Ratings of IBHC Satisfaction and Acceptability
Item n Mode M SD Range
Rate your overall level of satisfaction with the visit(s) you had at University Health Service 79 4.0 3.4 1.1 1–5
Rate your level of comfort filling out the screening questionnaire during your visit 66 4.0 3.5 1.1 1–5
Rate your level of satisfaction with the service you were provided during the visits with the integrated behavioral health provider 52 4.0 3.4 1.2 1–5
Rate your level of willingness meet with one of those providers again if something else or that issue continued 52 4.0 3.4 1.4 1–5
Rate your level of comfort meeting with them at University Health Service rather than some other location on campus (e.g., SU Counseling Center) 52 3.0 3.6 1.0 2–5
Rate your level of comfort with the length of the meetings (i.e., typically less than 40 minutes) with the integrated behavioral health provider 52 4.0 3.7 0.9 2–5
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were randomly assigned to fill out a mental health questionnaire discussed those issues with their patients more than those providers whose patients were not assigned to fill out the ques- tionnaire. Not only did providers perceive the screening questionnaire as having a high level of utility within their clinical practice, but the patients also reportedly were comfortable with filling out the questionnaire during their ap- pointments.
Our findings highlight the importance of se- lecting an appropriate screening questionnaire that can be completed and scored quickly. A common concern among providers when dis- cussing the implementation of regular screening for mental health issues is the time involved in integrating the screen within the clinical ap- pointment (Thomas, Waxmonsky, McGinnis, & Barry, 2006). Within this study, a majority of the providers and nurses reported responses within the neutral range when asked about whether the screening measure took time away from other clinical duties. This is not surprising as the questionnaire obviously does add time to the patient visit, as noted in prior research (Alschuler et al., 2008). The typical patient ap- pointment at this clinic is only 15 minutes, so allocating 1–2 minutes to review the screen with the patient would reduce the time left to focus on the patient’s presenting complaint. The fact that providers endorsed a modal response within the neutral range suggests that the screening can be incorporated without a signif- icant negative impact. One study on behavioral health screening found that using a measure that includes areas specific to college students (e.g., academic stress, risky sexual behavior) im- proved detection of students struggling with adjustment issues compared to a more general screening measure (Alschuler, Hoodin, & Byrd, 2009). However, the benefit of added sensitivity from a college-specific screening measure may not offset the cost of greater administration and scoring time. As completion time increases, the rate of compliance with screening may de- crease.
Another element that was identified within this study was the importance of not only de- signing the screening questionnaire to be easily comprehended by patients but to make sure it is easily scored and interpreted by providers. Most providers did not indicate difficulty scoring or interpreting the screen. However, anecdotally
there were some problems with patients incor- rectly self-scoring the PHQ-9; this may have led to some confusion or the need for providers to double-check or recalculate scores. The screen- ing tool was later modified to discourage pa- tients from totaling their own scores. To maxi- mize screening coverage and efficiency, it is important to select brief, user-friendly, vali- dated measures that are easy to score and inter- pret (Kirkcaldy & Tynes, 2006).
As university health centers work toward im- proving the identification and treatment of men- tal health issues as well as implementing rec- ommended screening guidelines for depression, suicidal ideation, tobacco use, and alcohol mis- use, this study suggests that an IBHC program may be one way to effectively accomplish this while maintaining provider and patient satisfac- tion. A previous study of behavioral health screening in university health centers found that screening increased discussion of behavioral health issues among patients and PCPs (Alschuler et al., 2008). However, PCPs re- ported that they did not have the time or the expertise to adequately address behavioral health issues with patients, but they were open to collaborating with BHPs. Likewise, our re- sults suggest high willingness to refer patients to BHPs to improve attention to behavioral health issues. Thus, the IBHC program can help PCPs deal with positive screens by providing the integrated BHPs, who are trained to assess mental health issues and provide brief treatment on-site or facilitate a referral to a specialty men- tal health clinic.
Regarding the integrated BHPs component of the IBHC program, PCPs also strongly indi- cated that their patients benefited from the ser- vices provided by the BHPs. The providers felt that having the integrated BHPs helped patients receive treatment faster (compared to referring them to specialty mental health) and that the BHPs functioned as part of the overall care team. All of the providers reported that they would strongly recommend the IBHC to other colleagues working in college health. Taken together, these results indicate satisfaction among the medical providers, which is essential for the success of IBHC. Strong buy-in on the part of PCPs is needed to sustain the implemen- tation of a new clinical program like IBHC, which requires procedural changes and addi- tional effort (i.e., reviewing screens, referring
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patients to BHPs). Acceptability among the nurses is also important, as they were the ones responsible for offering patients the behavioral health screens in our IBHC program.
Similarly, satisfaction and acceptability were high among patients. Patients who were seen by BHPs reported feeling comfortable with the ser- vices received and were willing to be seen again should the service be needed in the future. These results corroborate Westheimer and Steinley-Bumgarner’s (2008) finding that pa- tients were accepting of referrals to BHPs. Pa- tients may like the convenience of being seen quickly by BHPs in health centers. In the case of BHPs having open access schedules, patients can be seen immediately after their PCP visit, which eliminates the need for scheduling an- other appointment or returning to the health center; in contrast, specialty mental health cen- ters may have long (e.g., up to 2–3 weeks) wait times (Mowbray et al., 2006). Also, health cen- ters carry less stigma compared with specialty mental health settings. On average, the patients were comfortable seeking services at the uni- versity health center, but there was a greater level of variability suggesting some individual differences as to the comfort of seeking those services at a specialty mental health clinic.
Limitations
Interpretation of the findings should take into account the limitations of the study. First, al- though slightly higher than that found in other research using similar methodology (Shih & Fan, 2009), our response rate for the patient satisfaction survey was 29%. The response rate may be improved by contacting patients soon after their final IBHC visit instead of at the end of each semester, which is generally a busy time for students. Second, a significant proportion of the patients did not remember completing the screening questionnaire or meeting with a BHP. Patients may not have remembered completing the screening questionnaire because it was a brief (i.e., 2–3 minutes) activity and/or because their health center visit was up to four months before completing the satisfaction survey. It is possible that the students who did not remember meeting with a BHP had a more neutral expe- rience than the students who remembered the program. Thus, the satisfaction ratings could be artificially elevated because of this lack of data.
It is also possible, however, that these students did not remember the meeting with the BHP because they simply considered the components of the IBHC part of standard medical care. Authors have noted that primary care has be- come the “de facto mental health care system” (Kessler & Stafford, 2008, p. 9), so these stu- dents may have expected to discuss behavioral health problems during their visit and may not have perceived the BHP as different from a regular medical provider.
Third, patient data were obtained via anony- mous self-report. Though this method of data collection was necessary because of the scope of this study, it prohibited collection of identi- fying information, including diagnostic infor- mation. The ability to compare satisfaction across diagnostic categories would have pro- vided beneficial information, including whether patients with more severe diagnoses (e.g., major depressive disorder vs. adjustment disorder with depressed mood) had equally positive experi- ences with the program. In addition, the satis- faction ratings are limited to only those patients who were seen by an integrated BHP. Future research should compare satisfaction between patients seen within IBHC and patients seen within standard care (i.e., the PCP provides any treatment for behavioral health concerns or makes a referral to specialty mental health). Fourth, the provider and patient satisfaction measures were created specifically for this study. The limited range of response options (1–5) may contribute to restricted range/ variability and ceiling effects. These limitations should not be ignored when considering the generalizability of the study.
Finally, the scope of this study did not allow us to obtain information on the clinical out- comes associated with the IBHC program. Al- though providers reported that patients benefit- ted from meeting with BHPs, their perceptions were based solely on behavioral observations of and/or self-report from patients, not on clinical outcome data. Future research should evaluate the clinical effectiveness of interventions deliv- ered by integrated BHPs. From an IBHC per- spective, other markers of success that are wor- thy of future study include increased access to mental/behavioral health services, improved identification of mental/behavioral health issues through screening, increased referral uptake (i.e., BHPs referral attendance compared to spe-
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cialty mental health referral attendance) attrib- utable to colocation and “warm hand-offs,” im- proved provider communication (e.g., between BHPs and PCPs), reduced burden on specialty mental health centers from patients with sub- threshold or mild symptoms, and reduced bur- den on PCPs from repeat visits because of psy- chosocial issues.
Conclusions
In summary, providers and patients indicated a high level of satisfaction with this IBHC pro- gram. Accordingly, providers are likely to refer patients to BHPs, and patients are likely to engage in brief treatment within the IBHC pro- gram. Given the increasing demand on univer- sity primary care clinics to address the mental health needs of students, IBHC offers a prom- ising method whereby to address this need. Par- ticularly in light of data that indicate that most college students do not seek needed mental health treatment (Rosenthal & Wilson, 2008), the finding that IBHC patients would feel com- fortable seeing a BHP again in the future is a positive step toward making mental health care more accessible to patients who need treatment.
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Received September 6, 2011 Revision received January 5, 2012
Accepted March 26, 2012 �
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