Delivering Integrated Care for Individuals with Serious Mental Illness and Chronic Disease: Examining the Potential of FQHCs

Background: Individuals with serious mental illness (SMI) often suffer from co-occurring chronic medical conditions, such as diabetes and hypertension. Access to high quality, integrated behavioral health (IBH), which facilitates systematic coordination between health and behavioral health providers, is critical for this population. Federally qualified health centers (FQHCs) are a core component of our nation’s safety net system and a primary source of health and behavioral health care for those with SMI. Federal funding greatly expanded IBH within FQHCs, however, there is significant variation in how these clinics structure and deliver integrated services. Little is known about how individuals with SMI access IBH within safety net clinics, and how such variation impacts health outcomes among individuals with SMI and chronic diseases. This study utilized administrative data from a national network of FQHCs to examine patterns of IBH utilization among individuals with SMI, and examine the impact of IBH utilization on clinical outcomes.

Methods: This study utilized data from the OCHIN ADVANCE network, which merges client-level service utilization data from over 100 FQHC networks across the United States. Our primary sample included individuals with SMI who receive primary care and mental health services at an OCHIN network FQHC (N=86,565). To describe patterns of IBH we examined whether individuals in our sample received their primary care and mental health services within the same physical location (eg, colocated care), or from separate clinics within the same FQHC network (eg, coordinated care), reflecting higher to lower levels of IBH, respectively. Logistic regression models estimated the impact of individual-level characteristics on the receipt of colocated and coordinated IBH. Using logistic regression, we then examined whether colocated IBH predicted differences in clinical outcomes and care quality measured among a subsample of individuals with an SMI and diabetes and/or hypertension.

Results: The majority of individuals (N=61,590, 71%) received colocated mental health and primary care. SMI diagnosis did not robustly predict how IBH was received. Black (AOR=1.70, p<.001) and Latinx (AOR=1.20, p<.001) individuals were more likely to receive colocated IBH than white counterparts. On average, individuals receiving colocated and coordinated care had similar annual utilization of physical health visits (M=5.51(SD=9.27 vs M=5.04 (SD=10.46)) and mental health visits (M= 7.53 (SD=17.42) vs ( M=8.17 (SD=18.40)). Among individuals with co-occurring SMI and diabetes, those receiving colocated IBH were more likely to have controlled A1c levels compared to engaged in coordinated IBH (AOR, 1.2, p<.001). Differences in hypertension-related outcomes were not statistically significant.

Discussion: Within FQHCs, the majority of individuals with SMI receive colocated behavioral health and primary care. Social workers increasingly function as the primary behavioral health providers within these settings, and therefore must be trained to meet the unique needs of the SMI population. Consistent with established literature suggesting improved outcomes with higher levels of integration, individuals with co-occurring SMI and diabetes were more likely to have controlled blood sugar levels when their mental health and primary care were colocated, offering preliminary support for the effectives of these IBH models for the SMI population.