Coordination of Services for People With Serious Mental Illness and General Medical Conditions: Perspectives From Rural Northeastern United States

Abstract

Objective

The objective of the study was to investigate providers’ perspectives on how medical, mental health, and social services are coordinated for people with serious mental illnesses and general medical conditions in 2 predominantly rural states.

Method

To achieve multiple perspectives on service coordination, this study includes perspectives from providers employed in community mental health centers, social service agencies, and primary care settings in 2 northern rural New England states with contrasting approaches to financing and organizing services. We conducted 29 individual semistructured interviews and 1 focus group, which included administrative leaders, team leaders, primary care providers, social workers, and case managers who provide services for people with serious mental illness. Data were analyzed using qualitative thematic content analysis.

Results

We identified key themes at 3 levels: (a) provider-level coordination: bridging across services; managing interprofessional communications; and contrasting perspectives on the locus of responsibility for coordination; (b) individual-level coordination: support for self-management and care navigation; trusting and continuous relationships; and the right to individual choice and autonomy; (c) system-level coordination: linking appropriate residential and care provision services, funding, recruiting and retaining staff, policy enablers, and integration solutions.

Conclusions

Three levels of provider-reported coordination themes are described for the 2 states, reflecting efforts to coordinate and integrate service delivery across medical, mental health, and social services.

Implications

Improvements in patient outcomes will need additional actions that target key social determinants of health.

People with serious mental illness (SMI), including schizophrenia-spectrum disorders, bipolar disorder, and persistent major depressive disorder, experience high rates of early mortality predominately caused by comorbid chronic medical conditions such as heart disease, diabetes mellitus, hypertension, asthma, and emphysema (Behan, Doyle, Masterson, Shiers, & Clarke, 2015; De Hert et al., 2011a). These co-occurring chronic health conditions are associated with a shorter life expectancy of approximately 12–20 years compared with the general population (Behan et al., 2015; De Hert et al., 2011a; Druss, Zhao, Von Esenwein, Morrato, & Marcus, 2011; Walker, McGee, & Druss, 2015). This health disparity is likely to be compounded for people with SMI who live in rural areas because they are more likely to experience poverty and have difficulties accessing safe housing, transportation, and health care services (Rural Information Hub, 2019). In addition, rates of age-adjusted mortality, disability, and chronic disease in the general population are known to be higher in rural areas compared with urban settings (Meit et al., 2014).

This disparity in health outcomes for people with SMI indicates the need for a coordinated, multifaceted approach that goes beyond conventional psychiatric care alone. In addition to disparities in health outcomes, people with SMI often have disparities in social determinants and use the mental health care system as their principal setting for access to medical and social care (Bartels, 2003; De Hert et al., 2011a; Kleiman, Hayes, & Churchouse, 2015; Patel et al., 2013). As such, community mental health settings are challenged to address the many demands associated with highly prevalent comorbid chronic medical conditions and related primary and preventive care needs (Bao, Casalino, & Pincus, 2013). A key strategy to reducing these disparities requires effective coordination among these domains and improving care integration.

We consider coordination as a range of bridging activities as identified by the Agency for Health Care Research and Quality (AHRQ; McDonald et al., 2014). These activities include: (a) establishing accountability and negotiating responsibility for patient care; (b) communicating with involved stakeholders (e.g., team members, service users, and families) and transferring information; (c) facilitating transitions; (d) clinical assessment of needs and goals; (e) care planning, care monitoring, and responding to change; (f) support of self-management; and (g) linkage to community resources and alignment of resources to service user and population needs. These AHRQ coordination activities have been categorized into provider-, individual-, and system-level activities by Samal and colleagues (2016) and are presented in Table 1.

Table 1.

Provider-, Individual-, and System-Level Coordination Activities From the AHRQ Measurement Framework Developed by McDonald et al. (2014) and Samal et al. (2016)

Level	Coordination activities
Provider level	Establish accountability or negotiating responsibility for patient care Communicate  Interpersonal  Communication  Information transfer Facilitate transitions
Individual level	Assess needs and goals Create a proactive plan of care Monitor, follow up, and respond to change Support self-management goals
System level	Link to community resources Align resources with patient and population needs

Little is known about how mental health care systems coordinate medical, mental health, and social care for people with SMI. This is particularly important in rural settings in which there are added challenges in accessing housing, transportation, and health care services (Rural Information Hub, 2019) and in which the shortage of mental health and other specialists and geographical distances affects the capacity to provide the necessary services (Godwin, Sonola, Thiel, & Kodner, 2013; Hoeft, Fortney, Patel, & Unützer, 2018). Access to, and coordination of, necessary health care services for people with SMI is further complicated by organizational and structural barriers, such as underresourced primary health care, fragmented community support resources, and minimal supported housing (Bao et al., 2013; Hanrahan, Bressi, Marcus, & Solomon, 2016; Horvitz-Lennon, Kilbourne, & Pincus, 2006). Health care reforms to reshape the delivery of mental health services through insurance reform and the 2010 Affordable Care Act have taken place over the last decade. New models of service delivery to improve coordination and integration of medical and behavioral health have been introduced (Bartels et al. 2014a; Druss & Goldman, 2018) as well as payment reform strategies such as risk-adjusted payment that can account for medical and social risk (e.g., poverty, housing, behavioral health needs, education, etc.) (Ash et al., 2017; Gottlieb, Tobey, Cantor, Hessler, & Adler, 2016). These reforms and strategies are important first steps in transforming services and practices. The overall aim of this study using qualitative interviews with service providers is to investigate how services are coordinated for people with SMI and co-occurring chronic medical conditions across medical, mental health, and social care domains in rural settings, in conjunction with identifying influencers on coordination and potential strategies to improve coordination.

Method

Study Design, Setting, and Participants

Our study design includes individual interviews and a focus group interview with key informants (Marshall, 1996). Participants were employed in community mental health centers, social service agencies, or health care settings with in-depth information and insights and who could provide quality data in a limited amount of time. Individual interviews were conducted with administrative leaders, clinicians (i.e., psychiatrists, psychologists, social workers) and case managers working with people with SMI and co-occurring chronic medical conditions including chronic obstructive pulmonary disease, cancer, diabetes, and heart disease. The focus group interview was conducted with primary care providers (i.e., physicians and registered nurses).

The key informant and focus group interview participants were identified from two rural states in New England [BLINDED]. We intentionally selected two rural states that represented different approaches to financing, organizing, and integrating Medicaid supported community mental health services to enhance the generalizability of our findings.

State 1 has a history of fee-for-service Medicaid and has recently elected to participate in a novel approach to provide more flexible management of services in the context of a federally supported Medicaid 1115 Waiver. This Delivery System Reform Incentive Payment demonstration program includes an emphasis on performance payments intended to enhance the integration of mental health, social, substance use, and primary care services. The intent of this waiver is to enable health care providers and community partners within a region to form regional collaborative relationships to integrate care.

State 2 has converted from fee-for-service Medicaid to an all-payer accountable care organization with risk-based contracting consisting of a capitated per member per month payment allowing flexibility in the type of services provided. A major innovation in State 2 supporting integration is a program called Care Navigator, consisting of a system that supports an electronic shared care plan that can be accessed by different community partners, allowing for real-time electronic information sharing and cross-sector care coordination.

We identified a purposive sample of study sites, which included four community mental health centers and two social service agencies in State 1 and two community mental health centers and two social service agencies in State 2. We aimed to include interview participants that had similar roles and functions across the study sites. We also included a convenience sample of primary care providers attending an annual meeting of a primary care research network that included the two states in this study. The [BLINDED] Primary Care Practice-based Research Network is a voluntary and cooperative network of primary care clinicians and other health professionals. Its mission is to provide clinicians and professionals with opportunities to develop their research skills, perform research studies in partnership with primary care, generate funded research, and facilitate knowledge translation across research and clinical practice.

Ethics and Recruitment

The [BLINDED] College Committee (for the protection of human subjects) Institutional Review Board approved the study. Interview participants were included based on their interest and willingness to participate in the study. The first author contacted the directors of the community mental health centers and the social service agencies via e-mail with information about the project. Upon agreement to include their organization in the study, interview participants were identified in each of the community mental health centers and social service agencies representing four key roles meeting the following inclusion criteria: (a) administrative leader (chief executive officer or chief operations officer); (b) program manager (director of a core community mental health or social service program); (c) clinician (mental health center psychiatrist, psychologist, or social worker); and (d) case manager (individual assigned the role of outreach case management and/or care coordination). Next, potential individual interview participants were contacted via e-mail and were included if they agreed to participate in an interview. Primary care providers were recruited to focus group interviews at the primary care research network meeting. Participants were provided written information about the research project, and details were provided with respect to ensuring confidentiality with respect to the identity of participating in clinical and social service agencies and that names and other identifying information would not be used in any articles, reports, or publications on this project. A gift card of $25 was given to each interviewee upon completion of the interview.

Data Collection

We designed a semistructured interview guide to explore providers’ views on coordinating services for people with SMI and chronic medical conditions in rural areas. Our semistructured interview guide consisted of 10 questions related to the coordination activities as identified by AHRQ (McDonald et al., 2014) and focused on individuals with SMI and chronic medical conditions. Table 2 presents the coordination activities covered in the 10 interview questions.

Table 2.

Coordination Activities Covered in the 10 Interview Questions

Formalized collaboration and coordination across organizations and settings

Information exchange within teams, across service settings and sector (e.g. extent of oral, written and electronic communication and information exchange, issues related confidentiality)

Availability of electronic tools for communication and information exchange (e.g., text messaging, smartphone apps, care management dashboards, electronic care plan)

Assessment of occurrence of SMI and medical comorbidity

Follow-up of mental health and medical care needs (e.g., practices for referrals, care planning and follow-up of tests, treatment, and services)

Involvement of the individual and family members in decision making about medications, treatment, and follow-up (e.g., practices for shared decision making, including family members in team meetings)

Strategies to promote self-management and engagement in preventive care

Rural influence on coordination (e.g., link with needed medical, social, and other services, transportation, housing, availability of specialist services and providers)

Influence from local and state policies on coordination (e.g., workforce resources, funding)

Barriers and solutions to improve coordination in this setting

Note. SMI = serious mental illness.

We conducted 29 individual key informant interviews and one focus group interview, which included 12 participants—for a final sample of 41 participants. The interview participants had between 2 and 30 years of work experience in their current organization. The majority of the sample was female (n = 30). In the community mental health centers, interview participants included three chief executive officers, five chief operating officers, five team leaders (including two Assertive Community Treatment team leaders, two community rehabilitation and support team leaders, and one wellness program manager), four clinical therapists, and six case managers. From the social service agencies, interview participants included two agency directors and four case managers. One focus group that included a total of three nurse practitioners and nine primary care physicians was conducted.

We conducted interviews between January and June 2018 until we reached theme saturation. Qualitative interviews and focus groups were considered to have reached thematic saturation when interviews did not result in more information, commonly occurring for interviews of 20–30 total participants (Seale, Gobo, Gubrium, & Silverman, 2004). Individual interviews took place with the first author and were conducted in person or over the telephone. The individual interviews lasted between 20 min and 60 min (average 30 min). The focus group interview was conducted in person by the first and last authors and lasted 45 min. All interviews were audio-recorded.

Data Analysis

The audiotaped interviews were transcribed to written text and analyzed by three members of the research team to minimize bias and increase transparency (Bradley, Curry, & Devers, 2007). The first author developed an initial code structure including codes derived from the coordination activities from the AHRQ measurement framework (McDonald et al., 2014). For overall understanding, the first author read and coded all the interview transcripts. Two members of the research team independently applied the code structure to the text transcripts through a process of iteratively reading the transcripts, applying the codes to the text, identifying additional codes, and documenting reoccurring themes or concepts in the data material (Bradley et al., 2007). The codes and themes were discussed in two separate meetings. Once it was established that the coders were aligned with one another, the first author independently applied the code structure to a selection of interview text transcripts. Using thematic analysis, the first author summarized themes identified in the data (Braun & Clarke, 2006). The software tool NVivio was used.

Results

Below we describe the study participants’ descriptions of how two state-supported mental, medical, and social services are coordinated for people with SMI and chronic medical conditions at the provider-, individual-, and system-levels. In addition, we provide accounts of influencers on coordination including policy enablers and integration solutions. Illustrative quotes and themes are presented in Table 3.

Table 3.

Quotes and Themes Across the Coordination Levels

Coordination level	Themes	Quotes
Provider-level	Bridging across services	“So there are clients that I actually arrange all their doctors’ appointments and actually bring them to them and sit with them during the appointment time” (case manager, community mental health center). “We have somebody that’s doing cancer treatments; that’s numerous times per week. We have one person right now who’s on dialysis three times a week, which takes a lot of time and coordination” (case manager, community mental health center). “The combination of severe mental and physical illnesses—that was really difficult to manage. So I actually had his case manager from the county mental health agency, who was his, quote, lead care coordinator, I had him come to every single office visit and work with my social worker to do care coordination” (primary care provider).
	Managing interprofessional communications	“We have access to the medical hospital system as long as we have the electronic releases signed. We are able to access records and review medical records, which is great when we find out that they just went to the emergency room or they’ve been admitted or they just recently had an office visit, but that doesn’t go both ways” (program director, community mental health center). “It is very poor communication that we have with the mental facilities. We get almost zero records or recommendations. They very seldom will send us back a care plan” (primary care provider). “So our local hospital here has a behavioral health team and found a handful of people receiving behavioral health services there and at the community mental health center. The big hole was that primary care did not know that their patients had a major mental illness and wherein mental health treatment” (division director, community mental center). “Lack of cell services, lack of internet is definitively an issue” (adult service division director, community mental health center).
	Contrasting perspectives on the locus of responsibility for coordination	“How does coordination get paid in a way that commiserates with the work that’s happening and the time it that it takes? You can’t have the conversation we need to have, and the coordination of care in 15 or 20 minutes, with someone with a serious mental illness” (therapist, community mental health center). “We probably deal with 30–35 different primary care offices for just our adult population” (division director, community mental health center). “Case managers play an active role in getting individuals hooked up with benefits, housing, transportation, primary care” (division director, mental health center). “We’re not considered case managers, although having said that, sometimes it ends up that I do more active case management because of the needs of the person” (support counselor, social service agency). “The handoff of three people, having somebody come in and help them with their medicines or check their blood pressure at home, the amount of visits and phone calls and portal cases that have no longer been directed to my office, is huge” (primary care provider).
Individual level	Support for self-management and care navigation	“Just with the nature of their illness, they might not be aware of their medical condition or might need help really advocating for themselves to get their medical needs met” (ACT team leader, community mental health center). “I do whatever I can in my role to keep them as independent as possible. Often that is working with them to make sure that they make it to medical appointments” (case manager, community mental health center). “Initiating certain antipsychotics, we’re always having a conversation about the risk of weight gain and glucose intolerance” (primary care provider). “We’re not clinical; we’re trying to give the person the tools they need to be able to maintain whatever it is they need to maintain” (support counselor, social service agency).
	Trusting and continuous relationships	“So I just think that folks really need ongoing, continuous, safe, caring, compassionate support sometimes over the lifetime” (ACT team leader, community mental health center). “A lot of my clients have no families and live alone or live in the residences, so after working with some of them for years, they’re very much connected with me and there is a lot of responsibility that goes with that” (clinician, community mental health center). “It was really important for me to have the person that he trusted in the room because he did not have any family members that he trusted. The mental health worker that had been going out to see him on an ongoing basis for years he’d had a trusting relationship with, and that was what really worked for him” (primary care provider).
	The right to individual choice and autonomy	“Just for one reason or another, they don’t prioritize their health” (case manager, community mental health center). “First of all, getting them to accept care is a challenge” (primary care provider). “Sometimes the challenge is getting the person to accept the service in the first place. Whether it is mental health or just basic needs at home, like needing care at home and getting them to the point where they can accept it” (support counselor, social service agency). “When you walk in the door here, you have to sign a release of information. It is very specific on what you want shared, what you do not want shared. They have the right to tell us, I don’t want you talking to XX” (clinical therapist, community mental health center).
System level	Link with appropriate residential and care provision services	“Housing is expensive; it is hard to find and it is hard to keep the persons with comorbid mental health and medical conditions with SMI in housing situations” (support counselor, social service agency). “People have to rely on themselves, friends, or family members or volunteers for transportation. It is a huge challenge the more remote one lives in an area” (support counselor, social service agency). “We can get a CAT scan with a phone call, within 20, 30, 45 seconds, but to get somebody a bath it takes maybe four or five phone calls. Because our system is geared toward making doctors and hospitals money, it’s not geared toward taking care of the basic needs of patients and people” (primary care provider). “We face a lot of discrimination for folks who have mental illness, schizophrenia in particular, around accessing community care homes. People will just say they have schizophrenia. We don’t take folks” (team leader, community rehabilitation treatment, community mental health center).
	Funding and recruiting and retaining staff	“The state reimbursement rate is very old. I think it’s from 2006, and that affects salaries and program development” (clinical therapist, community mental health center). “We are facing challenges here in this area now, not having enough direct workforce. There just are not enough workers, especially for the Medicaid-supported program. The person becomes eligible, but there is no one to provide the service” (support counselor, social service agency). “We have 200 clinical openings between the 10 mental health centers in the state. We have 21 here, right now, at this agency, which means we can’t serve as many people and they can’t get as comprehensive services as needed” (chief clinical officer, community mental health center).
	Policy enablers and integration solutions	“We developed a community care team in the hospital emergency room that does a lot of follow-up in the community for people that are frequently going to the emergency room. We have some representatives from our agency there. We have people for primary care offices that are there. We have people from other social service agencies in town there” (clinical licensed therapies, community mental health center). “We have a formal memorandum of agreement with the hospital and primary care practices where we have embedded staff in the local hospital. We have a contract with them because we’re providing them a staff person and they’re paid for it” (adult service division director. community mental health center). “Our plan is to develop what we’re going to call an intensive transitions team who work with the people identified in emergency room as high risk in terms of medical and psychiatric and substance misuse and that team will do an assessment. We are calling it huddles with primary care teams so that we can discuss these cases and ensure that there is follow-through on any of the areas that have been identified as problematic for the person” (chief executive officer, community mental health center).

Note. CAT = computerized axial tomography; ACT = Assertive Community Treatment.

Provider-Level Coordination

Bridging across services

Service providers, including case managers and team leaders, described bridging across services and acting as important sources of support for individuals with comorbid mental health and medical conditions. Specific support activities from service providers described included scheduling appointments, transporting and accompanying the individual to medical appointments, and acting as a care navigator to help guide and connect the individual to the necessary health care. For example, one community mental health center has an assertive community treatment team responsible for 15 individuals with SMI and medical comorbidity (e.g., chronic obstructive pulmonary disease, cancer, diabetes) that includes case managers or other staff who accompany the individual to their medical treatments. Other examples include accompanying individuals with SMI to receive dental treatment because of pain, to cancer treatments over an extended period of time, or to dialysis treatments several times per week.

Managing interprofessional communication

In addition to supporting individuals in navigating health care settings, staff described routinely engaging in interprofessional communication across teams within one organization or across different organizations and providers to coordinate services. Case managers coordinate by phone, fax, and e-mail, although restrictions exist on information that can be electronically shared because of regulations designed to protect the confidentiality of health information. Mobile phones help to simplify communication within teams when case managers provide services out of the office setting and in the community, although in some rural settings there are difficulties caused by lack of cell service and Internet connection. Enhanced communication across community mental health centers and primary care is more likely to occur in networks of large medical service providers in which shared electronic systems for information exchange are in place. In smaller primary care practices and mental health settings, different electronic medical record systems are often used and generally do not have the capacity to communicate with each other and with their general medical counterparts. An example of poor interprofessional communication between mental health and primary care settings was provided by one interviewee describing a subgroup of individuals receiving duplicate services (e.g., case management and therapy) from both the medical hospital and the community mental health center.

Contrasting perspectives on the locus of responsibility for coordination

Mental health, social service agency, and medical care providers all described coordinating services for individuals with SMI and chronic medical comorbidity but communicated contrasting perspectives on the locus of responsibility for coordination. For example, primary care providers frequently reported that they were relegated to taking responsibility for the majority of care coordination with mental health providers and other types of medical services. In contrast, mental health case managers described being responsible for linking mental health services and primary care as well as coordinating with services provided outside the mental health organization in which they work.

Individual-Level Coordination

Support for self-management and care navigation

All groups of interview participants noted that the common cooccurrence of SMI and medical comorbidity substantially increased the complexity of the person’s needs and frequently created difficulties with self-management, capacity to navigate services, ability to undertake preventive measures, and the likelihood of following-up on treatment recommendations. Mental health and primary care providers emphasized striving to stabilize the person’s symptoms and keeping the individual as independent as possible. Mental health and social service providers described supporting self-management through teaching activities related to daily living, making the person aware of their medical conditions and symptoms, and instructing individuals on how to communicate with primary care providers, family, and friends about needs and preferences in an appropriate and meaningful way. Case managers described working to support individuals in navigating services, including helping to prepare the individual before their appointments with the primary care provider as well as facilitating follow-up appointments to ensure that recommended preventive measures or treatments occur.

Trusting and continuous relationships

Mental health and primary care providers described how they sometimes became highly connected with vulnerable individuals in their practice and experienced feeling especially responsible for the welfare of these individuals in the context of inadequate social support. Several interview participants described the importance of establishing a trusting relationship as critical to the individual being willing to talk about their symptoms because of the stigma associated with living with SMI. It was frequently recognized that family members also played a role in care coordination, but their involvement in the persons’ life varied considerably across individuals. For example, many individuals experienced complicated relationships with family members associated with a lifetime of mental illness and sometimes experienced fractured relationships with their families with no contact with their family members. In these instances, some providers described considering themselves in some ways substituting for family members, including taking on advocacy or basic support roles, typical of functions often associated with family members.

The right to individual choice and autonomy

Providers described how the right to exercise individual choice and the right to autonomy can influence coordination across mental health, social, and medical health care. For example, individuals have the right to choose the types of treatments and services that they are willing to accept. Honoring individual autonomy was noted to include the right to avoid recommended and essential medical care. The choice to not accept medical care altogether was recognized to be complicated by the presence of mental illness as well as potentially reflected deep-seated fear of prejudice and discrimination. Providers also noted that a major challenge to care coordination across medical, mental health, and social service providers occurs when individuals choose to not sign a release for the sharing of information. This can include not signing a release of information of their mental health records to their primary care provider in the event that they elect to keep their mental illness symptoms confidential and to avoid anticipated stigma.

System-Level Coordination

Linking with appropriate residential and care provision services

Interview participants across the different service sectors described how they coordinate across sectors by linking mental health, medical, and social services for individuals with SMI and chronic medical conditions. The availability of affordable and safe housing in rural settings was identified as an uphill battle in care coordination because the need for safe, low-income housing greatly exceeds availability, requiring providers to work closely with public housing providers and private property owners. Similarly, lack of adequate public transportation in both of the rural states was noted to influence coordination at the individual and system levels. Primary care and mental health providers described their coordination effort to link with appropriate mental health and community care services for individuals with SMI and chronic medical conditions. This was noted to be especially difficult when an individual’s medical care needs increase and the individual requires medically necessary services such as palliative and home health care. Interview participants across primary, mental health, and social services reported difficulties in accessing necessary home health and long-term care for middle-aged people with SMI before they reach the age of 65 years and become eligible for Medicare. An especially challenging subgroup of individuals identified by providers consists of those who do not meet eligibility requirements for nursing home–level care but need a higher level of care than independent living. Some interview participants described instances in which they believed that stigma and discrimination were associated with the refusal of a service provider to provide an essential community care service to individuals with SMI.

Funding, recruiting, and retaining staff

The interviewees described statewide difficulties with recruiting and retaining qualified staff. Low salaries in State 1 reflecting low Medicaid rates for state mental health services was reported as a major contributing factor to difficulties in hiring and retaining qualified staff. Providers in the community mental health centers, social agencies, and primary care across the two states described vacant positions and a lack of staff for several Medicaid-supported programs. An additional challenge associated with inadequate funding and staffing reported was the lack of ability to provide continuous and comprehensive services.

Policy enablers and integration solutions

Potential enablers to support care coordination and integration of services were described by mental health, social, and medical care sectors across both states. It was noted that the two rural states in this study had adopted policy reforms aimed at improving service integration and coordination. According to the interviewees in State 1, a shared care plan will be piloted as a tool to allow medical and mental health care providers to work toward the same goals. Primary care team huddles that include both mental health and medical providers will discuss complicated cases and ensure follow-through by coordinating the different psychiatrist and primary care provider care plans and medication prescriptions. In addition, interview participants described the plan for a shared emergency response system to identify frequent emergency department users, to perform medical and psychiatric risk assessments, and to connect individuals with comorbid mental health and medical conditions with services.

Interviewees in State 2 provided specific examples of integration between behavioral and primary care including embedding a mental health worker or community care teams in emergency departments in local hospitals and in primary care settings to ensure follow-up in the community of frequent emergency room users. According to the interviewees in State 2, there had been extensive preparation in the previous year, including staff training and incorporation of the new electronic Care Navigator system into the existing system. Despite the potential of this system to enhance care coordination and communication spanning different service sectors, some participants expressed concern that the new system will be an add-on to the clinical records system. This could potentially lead to duplicating documentation and result in extra administrative work for case managers who already spend much time documenting their contacts with service users for billable services.

Discussion

Our interview study explores providers’ perspectives on the coordination of mental health, medical, and social services in two rural states at the provider level, individual level, and system level. Provider-level coordination includes descriptions of efforts to bridge across services and supports, managing interprofessional communications, and their contrasting perspectives on the locus of responsibility for coordinating care. Provider reports regarding individual-level coordination include support for self-management and care navigation, developing trusting and continuous relationships, and the right to individual choice and autonomy. System-level coordination includes the link with appropriate and accessible services and housing and funding, recruiting, and retaining qualified staff. The two rural states piloted different innovative approaches in Medicaid policy reform with the goal of improving care coordination and better integration of mental health, medical, and social services for people with SMI.

Providers from the different care sectors of mental health, social services, and primary care reported a lack of clearly defined approaches to care coordination and navigation for persons with comorbid mental health and medical conditions. In seeking care, providers view individuals with SMI as routinely experiencing difficulties navigating the health care system. Individuals with SMI often lack adequate information about their health care and opportunities to engage in informed choices in care and shared decision making (Bartels, Mueser, & Miles, 1997; Fortuna et al., 2018; Morden, Mistler, Weeks, & Bartels, 2009). Addressing the many determinants of health of individuals with SMI requires effort, support, and navigation by providers to ensure access to critically needed services and service integration. This sometimes constitutes approaches that consist of substitution for the natural support Baker (1977) provided by family, friends, and informal caregivers outside the boundaries of professional service delivery systems. For example, providers described how they advocate and over time develop trusting and continuous relationships through their frequent contact and assist the individual with tasks that family or friends normally might otherwise provide.

Coordination and information exchange occurs through multiple modalities including phone, fax, and e-mail. Mobile phones simplify intrateam communication, but there are challenges with cellular connectivity in rural areas. However, an optimal approach consisting of shared electronic record systems spanning medical providers and mental health centers could be the exception and limited to networks of large medical service providers that are less likely to provide comprehensive services for people with SMI. Hence, health information-exchange technologies that integrate personal health records, mobile health applications and the electronic health records of multiple health care systems are a potential solution to improve care coordination (Dixon, Embi, & Haggstrom, 2018; Druss et al., 2018; Kilbourne et al., 2018). Providers described that unless the individual with SMI authorizes the sharing of health information across providers and systems, this separation of information systems may continue to contribute to major challenges in the coordination of services and care needs. Federal initiatives such as the Health Information Technology for Economic and Clinical Health Act (U.S. Government, 2009) add assistance to primary care to stimulate adaption of health information technologies, but community mental health centers along with other community providers are excluded from this incentive program. A recent systematic review of technology use in care coordination identified a lack of financial resources, inadequate reimbursements, limited access to technologies, and underperforming electronic health records as barriers in mental health care coordination (Falconer, Kho, & Docherty, 2018). Privacy concerns and lack of formal agreements to securely share behavioral health information with medical providers are also influence information sharing and coordination (Ranallo, Kilbourne, Whatley, & Pincus, 2016).

A future priority in the effort to enhancing outcomes and autonomy of individuals with SMI and chronic medical conditions should include actively supporting integrated self-management of both mental health and medical conditions. Individuals with SMI and medical comorbidity can experience challenges in interpreting physical signs of their medical condition and have difficulties with carrying out recommended lifestyle changes (De Hert et al., 2011b). The many challenges associated with addressing the complex needs of adults with combined psychiatric and medical care needs underscore the importance of developing coordinated and integrated approaches designed to address the needs of the whole person (Bartels, 2004). Group-based skill training combined with nurse health care coordination has been shown to improve independent living skills and receipt of preventive health care (Bartels et al., 2004, 2014b). Integrated psychiatric and medical self-management training has also been effective in improving the capacity and skills of adults with SMI (Bartels et al., 2014b). Finally, automated telehealth has promise in providing in-home self-management support and remote monitoring capacity to help to support adults with SMI and complex health conditions to successfully reside in-home and community-based settings (Pratt et al., 2013).

Providers in the community mental health centers, social service agencies, and primary care described inadequate funding, difficulties with recruiting and maintaining staff, and not having enough staff to provide services as major barriers to coordination and services provision. Difficulties with staff retention in the mental health workforce is a well-known challenge that disrupts continuity of care and increases organizational costs (Paris & Hoge, 2010; Yanchus, Periard, & Osatuke, 2017). A general underresourcing of mental health care (De Hert et al., 2011b; Liu et al., 2017) and an increasing number of adults with SMI living in rural areas (Meit et al., 2014) accentuate the coordination challenges. The results of our study support the need for innovative approaches to financing and coordination of mental health, medical, and social services for people with SMI and chronic health conditions in rural settings. The two northern New England rural states included in this study are engaged in two different potentially informative natural experiments in Medicaid financing and care delivery with the overall goal of improving coordination and better integration of medical and mental health care (Druss et al., 2018). State 1 was engaged in planning efforts to pilot shared care plans and primary care team huddles. The participating mental health centers, social service agencies, and primary care in State 2 were actively engaged in implementing integrated care models including multidisciplinary teams and shared electronic care plans. Both states are trying to implement integration solutions to transform the service system to respond to the complex coordination needs of individuals with SMI and chronic medical conditions described in this study.

Our study has a number of limitations that should be considered in interpreting our findings. First, we used a key informant approach (Marshall, 1996). Study participants were included based on their capacities, interest, and willingness to participate, which could contribute to a potential reporting bias. To ensure multiple perspectives and minimize bias, we included study participants from two states and from several community mental centers, social service agencies, and primary care settings. We also recruited participants that had similar positions across the organizations and settings. However, it should be noted that the two rural states selected for this study are representative of only northern New England and are not necessarily generalizable to other rural states that are more ethnically diverse and have different state Medicaid plans. Our sample of primary care providers was recruited at a primary care research network meeting, which could also represent a potential bias. Although the results are not broadly generalizable, we believe the study results have relevance and can be transferable to similar contexts (Patton, 2006). Second, our study does not include quantitative data that might provide the capacity for complementary and comparative analyses based on measures of key study variables. Finally, we did not conduct interviews with individuals with SMI and chronic health conditions who were seeking or receiving services in the two states, which would have added an important perspective. Our intent in conducting this study was to specifically investigate care coordination experienced by the three provider groups of mental health, social services, and primary care. Although this approach yielded a number of key themes, and potential strategies for improvement, acquiring the added perspective of individuals receiving services could further enhance the implications of our findings.

Conclusions

This study describes the complex coordination of mental, medical, and social services for individuals with SMI and chronic medical conditions in rural areas. The two northern New England states included in our study are currently engaged in implementing innovative approaches such as reforms in Medicaid financing and the use of multidisciplinary teams and shared electronic care plans to improve coordination, service delivery, and better integrate medical and mental health care. Despite these important efforts, actions beyond the mental, social, and primary care systems will be needed to target key social determinants of health that are strongly associated with health outcomes and independent living in the community.

Impact and Implications.

In the context of two rural New England states implementing innovative approaches to improve coordination and integration of services for individuals with serious mental illness and chronic medical conditions, providers described complexities of coordination at multiple levels. Despite substantial efforts, additional actions outside mental, social, and primary care systems are needed to target adverse social determinants of health that impact health outcomes for individuals with serious mental illness and medical comorbidity.