Health Care Decisions among Mental Health Services ...

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Health & Social Work Advance Access published December 15, 2016

Health Care Decisions among Mental Health Services Consumers in San Diego County: Implications for Integrated Care Elizabeth Siantz, Benjamin Henwood, Zhun Xu, Andrew Sarkin, and Todd Gilmer People living with serious mental illness are at elevated risk for chronic diseases compared with those in the general population. Whether integrated care for this population would be most accessible in primary care or mental health settings is unclear. The cross-sectional study described in this article used descriptive analyses and multinomial logistic regression to assess factors associated with using physical health services from primary or mental health providers. Data were drawn from a large-scale assessment of client-reported use of primary care services in a large and ethnically diverse public mental health system. Most people (80.4 percent) reported accessing primary care services from one or more service settings. Having chronic conditions was associated with accessing physical health care from multiple service settings, whereas having poor self-rated emotional health decreased health services use from any setting. It was concluded that mental health services consumers access health care from various service settings. Social workers can play a critical role in enhancing care coordination across the mental health and primary care systems. KEY WORDS: care management; chronic diseases; mental health services; primary care

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eople living with serious mental illness (SMI) in the United States have shortened life expectancies compared with those among the general population, primarily due to unhealthy lifestyle characteristics and poorly managed chronic health conditions (Miller, Paschall, & Svendsen, 2006). With the prevalence of diabetes mellitus and cardiovascular disease being two to three times higher than among the general population, having an SMI increases risk for having a chronic condition (De Hert et al., 2011). Although there is evidence that monitoring from a primary care provider can facilitate prevention and selfmanagement of these illnesses, people with SMI are less likely than the general population to access these services (DeCoux, 2005). Fragmentation of primary and mental health systems because of geographic distance between clinics, poor care coordination, and separate billing procedures are sources of this disparity (Bazelon Center for Mental Health Law, 2004). Health homes have been proposed as a patientcentered option for people with mental illness as they integrate physical and mental health care and create financing mechanisms for delivering integrated services (Center for Integrated Health Solutions, 2012). The Patient Protection and Affordable Care

doi: 10.1093/hsw/hlw060

© 2016 National Association of Social Workers

Act of 2010 (ACA) (P.L. 111–148) is increasing accessibility of primary care services for people with SMI by supporting health homes through pilot programs and by allowing states to permit Medicaid beneficiaries with chronic conditions and serious mental health conditions to designate a provider as a health home (Croft & Parish, 2013). However, it remains unclear whether health homes for this population would be more accessible if located in primary care or mental health settings. The four-quadrant clinical integration model (Mauer, 2006) provides a conceptual framework for planning integrated care and recommends that health home locales for individuals with co-occurring disorders be based on the severity of each disorder. This model suggests that physical health care for individuals with greater physical health needs and mild to moderate mental illness be delivered in primary care settings, and that physical health care be delivered in mental health settings for people with greater mental health needs, because it is often where people with SMI enter the health system (Druss et al., 2008). Although previous studies have shown that professional boundaries have precluded physical health from being within the scope of practice of many mental health practitioners

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(Kilbourne, Greenwald, Bauer, Charns, & Yano, 2012), the American Psychiatric Association (APA) also agrees that psychiatrists can play a valuable role in delivering these services within specialty mental health settings (Moran, 2015). Whether these suggestions reflect the service-seeking preferences of mental health services consumers in need of general medical care is unclear. The objectives of this study were to describe where mental health services consumers access their physical health care and to assess factors associated with accessing nonemergency physical health care in various locales. The four-quadrant model guided our three study hypotheses: (1) Having one or more chronic care conditions will be associated with accessing physical health care from a primary care provider. (2) Lowrated perceived emotional health will be associated with accessing physical health care from a mental health provider. (3) Low-rated perceived emotional health and having one or more chronic care conditions will be associated with accessing care from both physical and mental health providers. METHOD

Study Setting

San Diego County is the fifth most populous county in the United States, with more than 3 million people (U.S. Census Bureau, 2009), and is one of the most racially and ethnically diverse regions in North America. San Diego County’s mental health services treat approximately 40,000 to 45,000 adults with mental illness per year (County of San Diego Health and Human Services Agency, 2014). Data Collection

Data were drawn from a large-scale assessment of client-reported outcomes regarding San Diego County’s adult and older adult mental health services. Adults age 18 or older who received public mental health services completed an anonymous self-report questionnaire in the presence of a clinician at their provider site during a weeklong data collection period in the summer of 2013. All individuals who received outpatient, case management, or full-service partnership (Gilmer, Stefancic, Ettner, Manning, & Tsemberis, 2010) services from 54 programs in San Diego County were asked to complete the survey. Thus, the sample included people who visited a clinic during the survey period. Upon receipt, program staff members asked their English-speaking clientele to complete the survey. Clients who completed the surveys independently

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placed completed questionnaires in a sealed envelope. Nonclinical staff members provided assistance as needed. Mental health clinic administrators then returned completed surveys for processing. Demographic data and insurance status were drawn from a systemwide patientrecord-holding database. Study Sample

This study analyzed data collected from a supplemental questionnaire that assessed physical health conditions and patterns of physical health services use among mental health services consumers. Mental health programs returned 2,234 surveys. Of these individuals, 1,416 had completed the physical health supplement. After a process of excluding duplications and cleaning the data, 1,262 respondents were merged with the demographic results. Of these cases, 469 cases were excluded from the analysis due to missing data. The data were cleaned further to create an outcome variable with four mutually exclusive categories indicating where respondents seek health care for nonemergency physical health needs. Specifically, the survey asked, “Who do you contact when you have a non-emergency physical health problem?” The supplemental questionnaire allowed respondents to select one or more of seven options: “nobody,” “nobody, I go straight to the ER [emergency room] or urgent care,” “nobody, I don’t know,” “the MediCal line” (a resource hotline for individuals insured through California’s Medicaid program), “the Internet,” “my regular doctor where I usually get care,” or “my psychiatrist or other mental health provider.” To ensure interpretability of the dependent variable, respondents who reported they would seek services from “nobody” or “nobody, I don’t know” in addition to a physical or mental health provider were excluded from the analysis (n = 81). Individuals who selected the “Medi-Cal line” or “the Internet” in addition to a physical or mental health provider were retained, because these sources of information are not considered service use locales. These data-cleaning steps left a study sample size of 712 (see Figure 1). Dependent Variable

Our dependent variable had four categories. The first three categories included respondents who selected (1) regular doctor, (2) psychiatrist or other mental health provider, or (3) psychiatrist or other mental health provider and regular doctor. The fourth category included respondents who reported that they do not access care from either option (the

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Figure 1: Case Selection 2,234 surveys returned from outpatient, case management, and fullservice partnerships 818 surveys excluded

Did not complete physical health supplement

154 surveys excluded

Data cleaning: missing client identifier, duplicate surveys

469 cases excluded

Missing data in physical health supplement

81 cases excluded

Selected “nobody” in addition to health care provider

1,416 returned surveys included physical health supplement

1,262 surveys merged with state survey

793 surveys with complete data

712 included in final sample

reference category). Individuals who reported that they would use the Medi-Cal line or the Internet in addition to one of these service options were coded based on the service option. For example, if a respondent indicated using the Medi-Cal line in addition to a psychiatrist, the physical health services option was coded as category 2. Independent Variables

Andersen’s behavioral model for health services use (Andersen, 1968, 1995) provided our conceptual framework. Predisposing variables were age, gender, and race and ethnicity (Asian, black, Hispanic, white, and other). Enabling factors were health insurance status, use of ER services, and self-rated mental health, which was included as an indicator of functioning or impairment. To assess self-rated mental health, survey respondents were asked to rate their emotional health on a sevenpoint scale ranging from 1 = delighted to 7 = terrible. For ease of interpretability, we converted this variable into a dichotomous scale in which 1 indicated a response of terrible, poor, mostly dissatisfied, or mixed, and 0 indicated mostly satisfied, pleased, or delighted. We dichotomized this variable for

ease of interpretability. A response of “nobody, I go straight to the ER or urgent care” for nonemergency physical health needs was also included as an enabling variable. We classified it as such because it demonstrates that a respondent had a medical concern that required professional attention, but had limited access to other sources of care (Berren, Santiago, Zent, & Carbone, 1999). Three medical need factors were also included. To assess the effects of having multiple chronic conditions, we included a dichotomous variable representing whether a respondent has diabetes, hypertension, or high cholesterol. Because epidemiological studies have indicated that most individuals with chronic conditions usually have more than one such condition (Paez, Zhao, & Hwang, 2009) and the possibility that individuals in this sample had more chronic conditions than diagnosed, the variable indicated whether participants reported having one or more chronic conditions. This was established with three survey questions: (1) “Has your health provider ever told you that you have diabetes?” (2) “Has your health provider ever told you that you have high cholesterol?” and (3) “Has your health provider ever told you that you have high blood pressure?” To control

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for the role of other chronic conditions in an individual’s decision to use health services, a variable reflecting the presence or absence of other chronic conditions requiring regular care was also included. This information was assessed with the question “Has your health provider ever told you that you have any other chronic condition requiring regular care?” Due to the potential for respondents to feel unwell yet be unaware of having chronic health conditions, an assessment of self-rated physical health was also included. Respondents were asked to rate their general physical condition using the sevenpoint scale ranging from 1 = terrible to 7 = delighted. We dichotomized this scale into a dummy variable, with 1 indicating responses of terrible, very poor, mostly dissatisfied, or mixed, and 0 indicating mostly satisfied, pleased, or delighted. Statistical Analysis

Descriptive statistics characterized the study population. Analysis of variance (ANOVA) and chi-square tests were conducted to evaluate the association between independent variables and service use categories. To assess the associations of each independent variable on the outcome, we used a multinomial logit regression model. Analyses were conducted with SPSS (version 21.0) (2012). The University of California, San Diego, Human Research Protections Program approved the use of these data for the purpose of this study in accordance with the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (P.L. 104–191). RESULTS

Descriptive Statistics

As shown in Table 1, this analysis included 712 participants. Participants ranged in age from 18 to 76 (M = 42.4, SD = 13.1). The racial and ethnic composition of the sample was predominately white (n = 388, 54.4 percent), Hispanic (n = 137, 19.2 percent), and black (n = 110, 15.4 percent). Approximately half of the sample were female (n = 352, 49.4 percent). Half of the sample reported having at least one chronic general medical condition such as diabetes, hypertension, or high cholesterol (n = 366, 51.0 percent), and a majority of the sample reported low self-rated physical health (n = 400, 56.2 percent). Nearly 30.0 percent (n = 204) reported that they would contact nobody and go right to the ER for nonemergency physical health needs.

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Regarding whom participants would contact for nonemergency physical health concerns, 33.7 percent (n = 240) indicated both physical and mental health providers; 31.6 percent (n = 225) indicated their regular physical health provider; 14.0 percent (n = 100) indicated their mental health provider, and 20.6 percent (n = 147) indicated neither their physical nor their mental health providers. Chi-square analyses and an ANOVA revealed significant differences in predisposing factors across service use categories. Individuals who indicated they would access only their regular doctor were older than those in the other groups (M = 45.2, SD = 12.09), whereas individuals selecting neither physical nor mental health provider were younger (M = 36.7, SD = 13.3). Gender composition also differed across outcomes; those reporting accessing both mental and physical health providers had the highest proportion of female respondents (57.1 percent) and those accessing only a mental health provider had the lowest (38.0 percent). There were also significant differences in enabling factors. Insurance status differed across outcome categories, with 79.2 percent of those selecting both physical and mental health providers indicating they had insurance, compared with 58.5 percent of individuals selecting neither physical nor mental health providers. Rates of poor self-rated emotional health also differed, with 69.4 percent of those selecting neither physical nor mental health providers having low satisfaction with emotional health, compared with 50.4 percent of those selecting both physical and mental health providers. The proportion of individuals who indicated that they would contact nobody and go straight to the ER or urgent care for nonemergency physical health concerns also differed across categories, with those who accessed health care from their mental health provider having the highest proportion (40.0 percent), compared with 37.4 percent of individuals who selected neither physical nor mental health providers. The proportion of respondents with chronic care conditions also differed significantly across categories; 61.3 percent of individuals selecting a physical health provider had one or more of conditions, compared with 30.0 percent of those selecting neither physical nor mental health providers. Having other chronic conditions requiring regular care also differed significantly, with 39.6 percent reporting that they would access physical health care from their mental health provider having other chronic conditions, compared

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Siantz et al. / Health Care Decisions among Mental Health Services Consumers in San Diego County

Table 1: Participant Characteristics (N = 712) Accessing Physical Health Care Total Sample Variable

Agea Female Race and ethnicity White Hispanic Black Asian Other Has health insuranceb Uses emergency room One or more chronic conditions Other chronic condition Poor self-rated physical health Poor self-rated emotional health a

(n = 225)

(n = 100)

Accessing Both (n = 240)

Accessing Neither (n = 147)

M

SD

M

SD

M

SD

M

SD

M

SD

F

42.4 n 352

13.1 % 49.4

45.2 n 112

12.1 % 49.8

39.1 n 38

13.2 % 38.0

44.7 n 137

12.3 % 57.1

36.7 n 65

13.3 % 44.2

18.8 χ2 12.5 12.67

3 12

.006 .390

388 137 110 36 41 501 204 366 246 400 396

54.4 19.2 15.4 5.1 5.8 70.4 28.7 51.0 34.6 56.2 55.6

131 33 31 16 14 165 41 138 89 119 119

58.2 14.7 13.8 7.1 6.2 73.3 18.2 61.3 39.6 52.9 52.9

53 16 21 5 5 60 40 37 23 59 54

53.0 16.0 21.0 5.0 5.0 60.0 40.0 37.0 23.0 59.0 54.0

126 57 36 8 13 190 68 146 108 137 121

52.5 23.8 15.0 3.3 5.4 79.2 28.3 60.8 45. 57.1 50.4

24.9 23.8 51.2 38.5 1.6 17.1

3 3 3 3 3 3

< .001 < .001 < .001 < .001 .670 .002

M, SD, F statistic, and p value derived from analysis of variance test. Any type of health insurance.

b

Accessing Mental Health Care

78 31 22 7 9 86 55 45 26 85 102

53.1 21.1 15.0 4.8 6.1 58.5 37.4 30.1 17.7 57.8 69.4

df

p

< .001

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with 17.7 percent of those who selected neither physical nor mental health providers. Multinomial Logit Analysis

Table 2 details our multivariate results. The odds ratios (ORs) are relative to individuals who reported accessing services from neither their mental health nor regular primary care providers. An increase in age was associated with increased odds of accessing care from a primary health provider (OR = 1.04; 95% confidence interval [CI] = 1.02, 1.06) and from both physical and mental health providers (OR = 1.04; 95% CI = 1.02, 1.06). Having insurance was associated with increased likelihood of accessing physical health services from a primary provider (OR = 1.92; 95% CI = 1.17, 3.12) and from both physical and mental health providers (OR = 2.57; 95% CI = 1.56, 4.23). Having low or mixed satisfaction with emotional health was associated with decreased odds of using all service options: primary health provider (OR = 0.42; 95% CI = 0.24, 0.73), mental health provider (OR = 0.36; 95% CI = 0.19, 0.69), and both physical and mental health providers (OR = 0.32; 95% CI = 0.19, 0.56). Contacting nobody and instead going to ER was also associated with decreased likelihood of accessing care from a primary health provider (OR = 0.28; 95% CI = 0.16, 0.46), or from both primary and mental health providers (OR = 0.49; 95% CI = 0.30, 0.79). Having one or more chronic care conditions such as diabetes, high cholesterol, and hypertension was

associated with an increased likelihood of accessing services from a primary health provider (OR = 2.61; 95% CI = 1.36, 4.97) and from both primary and mental health providers (OR = 2.00; 95% CI = 1.04, 3.87). Awareness of having another chronic condition that requires regular care was associated with accessing care from primary and mental health care providers (OR = 2.14; 95% CI = 1.02, 4.47). DISCUSSION

This study used the four-quadrant clinical integration model (Mauer, 2006) to understand factors associated with health services use among mental health services consumers in San Diego County. We hypothesized that those with chronic conditions would access care from a primary care provider; that those with poorly rated emotional health would access care from a mental health setting; and that those with both poorly rated emotional health and chronic care conditions would access care from both physical and mental health providers. We received partial support for our hypotheses. Having chronic care conditions such as diabetes, high cholesterol, or high blood pressure was associated with increased odds of accessing care from a primary health provider. This suggests the importance of training primary care professionals in the health needs of mental health services consumers and could indicate a consumer preference for primary care setting as a locale for detecting and managing chronic conditions. To ensure that consumers are managing their cardiovascular risk, some public

Table 2: Factors Associated with Physical Health Services Use Accessing Physical Health Care

Accessing Mental Health Care

Accessing Both

Variable

OR

95% CI

OR

95% CI

OR

95% CI

Age Female Race and ethnicity Asian Black Hispanic Other Has health insurance Uses emergency room One or more chronic diseases Other chronic condition Poor self-rated physical health Poor self-rated emotional health

1.04 1.05

[1.02, 1.06] [0.66, 1.63]

1.03 0.73

[0.91, 1.03] [0.43, 1.23]

1.04 1.38

[1.02, 1.06] [0.88, 2.16]

1.34 1.02 0.93 1.08 1.92 0.28 2.61 1.56 1.08 0.42

[0.49, 3.62] [0.52, 2.02] [0.50, 1.73] [0.42, 2.81] [1.17, 3.12] [0.16, 0.46] [1.36, 4.97] [0.75, 3.23] [0.63, 1.86] [0.24, 0.73]

0.84 1.49 0.83 0.92 0.92 0.99 1.10 1.29 1.66 0.36

[0.25, 2.91] [0.72, 3.08] [0.41, 1.71] [0.29, 2.94] [0.53, 1.59] [0.57, 1.72] [0.51, 2.03] [0.52, 3.22] [0.88, 3.11] [0.19, 0.69]

0.66 1.12 1.57 1.05 2.57 0.49 2.00 2.14 1.45 0.32

[0.22, 1.99] [0.57, 2.17] [0.87, 2.81] [0.39, 2.88] [1.56, 4.23] [0.30, 0.79] [1.04, 3.87] [1.02, 4.47] [0.84, 2.50] [0.19, 0.56]

Notes: Results relative to respondents who reported they would access neither physical nor mental health providers for nonemergency physical health concerns. OR = odds ratio; CI = confidence interval.

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mental health systems are in the process of implementing “reverse” integrated primary and mental health care (Maragakis, Siddharthan, RachBeisel, & Snipes, 2016) by integrating primary care professionals into mental health care teams. For example, the Los Angeles County Department of Mental Health has recently implemented integrated primary care professionals in mental health care teams, and has demonstrated that this is a potentially effective approach to improving client physical health (Gilmer, Henwood, Goode, Sarkin, & Innes-Gomberg, 2016). However, the data did not support our second hypothesis that individuals with poor self-rated emotional health would access physical health services through their mental health provider. This finding is congruent with some previous studies, which have reported that individuals with more SMI severity are less likely to seek medical services (Cradock-O’Leary, Young, Yano, Wang, & Lee, 2014). To ensure that consumers with higher levels of mental health need receive physical health services, mental health and care management professionals should initiate conversations related to physical health during mental health appointments. Because APA now recognizes the role of psychiatry in the delivery of primary care services for people with mental illness receiving care in specialty mental health settings (Moran, 2015), mental health services consumers and other members of the mental health team should be made aware that psychiatrists can be used as a primary care resource. Previous studies have reported that mental health clinicians report both limited training and professional boundaries (Kilbourne et al., 2012), which can inhibit discussion related to physical health. To remedy this, training in primary care must occur in psychiatry residencies, and should continue throughout the psychiatrists’ careers. Additional roles mental health professionals can have in the delivery of primary care are discussed in the following section on the implications of these findings for social work practice. We found partial support for our third hypothesis that those with poor self-rated emotional health and with one or more chronic care conditions would access physical health care from both types of providers. Although having chronic care conditions such as diabetes and other chronic conditions were each associated with accessing care from both primary and mental health providers, this study found that poorly rated emotional health decreased the likelihood of accessing care from both types of providers.

Our analyses also revealed that age, insurance status, and use of ER services care were also associated with consumer access of health care. Older individuals were more likely to access health services from a primary care provider and from a combination of primary care and mental health care providers. This is likely explained by the fact that medical needs in general tend to increase with age, particularly among older individuals with SMI. Insurance was associated with accessing care from a primary health provider and from both physical and mental health providers. This suggests that insurance enables consumers to access care for physical health concerns from their primary provider and other sources of care. Analysis also revealed that accessing ER services for nonemergency health care needs decreased odds of accessing care from a primary health provider. Previous studies have suggested that individuals with SMI have increased use of emergency care (Berren et al., 1999), and studies have demonstrated an inverse relationship between engagement with primary care services and use of emergency services (Hackman et al., 2006). Interventions are needed to ensure that insured individuals can access primary care to reduce ER use. Finally, because having insurance and chronic care conditions were associated with receiving services from multiple care sources, it is essential that health care providers effectively communicate with one another to facilitate medication reconciliation, care coordination, and follow-up with results of screenings and tests. Limitations

Study findings should be considered in light of several limitations. Service use scenarios were hypothetical, and the cross-sectional nature of these data prevented determination of causal relationships. Secondary use of an administrative database also limited the variables we could investigate. Furthermore, medical conditions were self-reported and could be underestimated in these data because respondents could have conditions about which they were unaware. Clients also may have been burdened by the physical health section supplement, and were not required to complete it at all clinics. Finally, our results might not generalize to other mental health systems. Although the racial and ethnic composition of our study sample generally reflects that of the mental health services consumer population of San Diego County (County

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of San Diego Health and Human Services Agency, 2014), study participants represent a small proportion of the county’s consumer population and selection bias might have occurred. Future studies should conduct this survey in different mental health authorities to gain a deeper understanding of the health care decisions of mental health services users, and to determine whether these study results vary by geographic area. Qualitative interviewing mental health services consumers would also enhance researcher and provider understanding of the health care decision-making process among members of this population. Implications for Social Work Practice

There are several opportunities for social workers to improve access to health care for people with SMI under the ACA. According to the National Association of Social Workers (n.d.), social workers provide the majority of the mental health services in the United States. Social workers have traditionally fulfilled the role of case manager, but are ideal to fulfill the newer role of care manager. Under the ACA, care managers have an important role in the delivery of integrated care by relaying information between agencies and ensuring that multiple providers are aware of treatment plans (Stanhope, Videka, Thorning, & McKay, 2015). Patient navigators also help individuals apply for and establish insurance eligibility and ensure that health care needs are met (Stanhope et al., 2015), whereas disease managers ensure that individuals with a chronic disease or combination of chronic diseases receive high-quality, cost-effective care (Stanhope et al., 2015). Disease managers can also deliver chronic disease self-management education (Lorig, Sobel, Ritter, Laurent, & Hobbs, 2000) in the form of behavioral interventions that alleviate the consequences of chronic care conditions through medical management, maintenance or creation of new meaningful life roles, and management of emotional reactions. The social work profession must be represented at the policy level to influence decisions related to the implementation of these roles. To prepare the social work workforce to participate in the delivery of integrated health care, social work students should be educated from an interdisciplinary perspective. Schools of social work should teach integrated care, instead of having separate mental and physical health care concentrations. Students should take courses alongside other professions and

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be taught by faculty from different professional schools. This would prepare social work students for work on interdisciplinary health teams, while training other professions on the value of social workers (Andrews et al., 2015). Conclusion

Our study’s findings suggested that mental health services consumers in San Diego County access health care for nonemergency physical health concerns from various service settings, suggesting that there is not a one-size-fits-all health care setting for this population. Social workers are uniquely positioned to assist with medical management of consumers with complex needs and can work to enhance interdisciplinary communication among and between providers. However, considerable efforts from all members of the multidisciplinary health care teams will be required to accommodate the health care needs of people with SMI. Enhanced training with an interprofessional perspective could help providers from varying disciplinary orientations engage this population within the health care system. HSW REFERENCES Andersen, R. (1968). A behavioral model of families’ use of health services. (Research Series, 25). Chicago: University of Chicago, Center for Health Administration Studies. Andersen, R. M. (1995). Revisiting the behavioral model and access to medical care: Does it matter? Journal of Health and Social Behavior, 36(1), 1–10. doi:10.2307/ 2137284 Andrews, C., Browne, T., Allen, H., Coffey, D. S., Gehlert, S., Golden, R., et al. (2015). Social work and the Affordable Care Act: Maximizing the profession’s role in health reform [White paper]. Retrieved from http:// works.bepress.com/teri_browne/10/ Bazelon Center for Mental Health Law. (2004). Get it together: How to integrate physical and mental health care for people with serious mental disorders. Retrieved from http://www.bazelon.org/LinkClick.aspx?fileticket= 5tCrFDlgyGc%3D&tabid=104 Berren, M. R., Santiago, J. M., Zent, M. R., & Carbone, C. P. (1999). Health care utilization by persons with severe and persistent mental illness. Psychiatric Services, 50, 559–561. doi:10.1176/ps.50.4.559 Center for Integrated Health Solutions. (2012). Behavioral health homes for people with mental health & substance use conditions: The core clinical features. Retrieved from http://www.integration.samhsa.gov/clinical-practice/ cihs_health_homes_core_clinical_features.pdf County of San Diego Health and Human Services Agency. (2014). Adult/older adult behavioral health services: Systemwide annual report fiscal year 2012–2013. Retrieved from http://www.sandiegocounty.gov/content/ dam/sdc/hhsa/programs/bhs/TRL/ AOABHSAnnRepFY1213.pdf Cradock-O’Leary, J., Young, A. S., Yano, E. M., Wang, M., & Lee, M. L. (2014). Use of general medical services

Health & Social Work

by VA patients with psychiatric disorders. Psychiatric Services, 53, 874–878. doi:10.1176/appi.ps.53.7.874 Croft, B., & Parish, S. L. (2013). Care integration in the Patient Protection and Affordable Care Act: Implications for behavioral health. Administration and Policy in Mental Health and Mental Health Services Research, 40, 258–263. doi:10.1007/s10488-012-0405-0 De Hert, M., Correll, C. U., Bobes, J., CetkovichBakmas, M., Cohen, D., Asai, I., et al. (2011). Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care. World Psychiatry, 10(1), 52–77. DeCoux, M. (2005). Acute versus primary care: The health care decision making process for individuals with severe mental illness. Issues in Mental Health Nursing, 26, 935–951. doi:10.1080/01612840500248221 Druss, B. G., Marcus, S. C., Campbell, J., Cuffel, B., Harnett, J., Ingoglia, C., & Mauer, B. (2008). Medical services for clients in community mental health centers: Results from a national survey. Psychiatric Services, 59, 917–920. doi:10.1176/appi.ps.59.8.917 Gilmer, T. P., Henwood, B. F., Goode, M., Sarkin, A. J., & Innes-Gomberg, D. (2016). Implementation of integrated health homes and health outcomes for persons with serious mental illness in Los Angeles County. Psychiatric Services, 67, 1062–1067. doi:10.1176/appi .ps.201500092 Gilmer, T. P., Stefancic, A., Ettner, S. L., Manning, W. G., & Tsemberis, S. (2010). Effect of full-service partnerships on homelessness, use and costs of mental health services, and quality of life among adults with serious mental illness. Archives of General Psychiatry, 67, 645–652. doi:10.1001/archgenpsychiatry.2010.56 Hackman, A. L., Goldberg, R. W., Brown, C. H., Fang, L. J., Dickerson, F. B., Wohlheiter, K., et al. (2006). Use of emergency department services for somatic reasons by people with serious mental illness [Brief Reports]. Psychiatric Services, 57, 563–566. doi:10.1176/ps.2006.57.4.563 Health Insurance Portability and Accountability Act of 1996, P.L. 104-191, 110 Stat. 1936 (August 21, 1996). Kilbourne, A. M., Greenwald, D. E., Bauer, M. S., Charns, M. P., & Yano, E. M. (2012). Mental health provider perspectives regarding integrated medical care for patients with serious mental illness. Administration and Policy in Mental Health and Mental Health Services Research, 39, 448–457. doi:10.1007/s10488-0110365-9 Lorig, K. R., Sobel, D. S., Ritter, P. L., Laurent, D., & Hobbs, M. (2000). Effect of a self-management program on patients with chronic disease. Effective Clinical Practice, 4(6), 256–262. Maragakis, A., Siddharthan, R., RachBeisel, J., & Snipes, C. (2016). Creating a ‘reverse’ integrated primary and mental healthcare clinic for those with serious mental illness. Primary Health Care Research & Development, 17, 421–427. Mauer, B. J. (2006). Behavioral health/primary care integration: Finance, policy and integration of services. Rockville, MD: National Council for Community Behavioral Healthcare. Miller, B. J., Paschall, C. B., III, & Svendsen, D. P. (2006). Mortality and medical comorbidity among patients with serious mental illness. Psychiatric Services, 57, 1482–1487. doi:10.1176/foc.6.2.foc239 Moran, M. (2015). Board approves statement in role in reducing physical health disparities. Psychiatric News, 50(18), 5. National Association of Social Workers. (n.d.). Mental health. Retrieved from https://www.socialworkers.org/ pressroom/features/issue/mental.asp

Paez, K. A., Zhao, L., & Hwang, W. (2009). Rising out-ofpocket spending for chronic conditions: A ten-year trend. Health Affairs, 28(1), 15–25. doi:10.1377/ hlthaff.28.1.15 Patient Protection and Affordable Care Act of 2010, P.L. 111-148, 124 Stat. 782 (March 23, 2010). SPSS Statistics for Windows, (Version 21.0) [Computer software]. (2012). Armonk, NY: IBM Corp. Stanhope, V., Videka, L., Thorning, H., & McKay, M. (2015). Moving toward integrated health: An opportunity for social work. Social Work in Health Care, 54, 383–440. U.S. Census Bureau. (2009). Resident population estimates for the 100 largest U.S. counties based on July 1, 2009 population estimates: April 1, 2000 to July 1, 2009. Retrieved from https://www.census.gov/popest/data/counties/ totals/2009

Elizabeth Siantz, PhD, MSW, is a postdoctoral scholar, Department of Family Medicine and Public Health, University of California, San Diego, 9500 Gilman Drive #0622, La Jolla, CA, 92093; e-mail: [email protected]. Benjamin Henwood, PhD, MSW, is assistant professor, School of Social Work, University of Southern California, Los Angeles. Zhun Xu, PhD, is programmer and analyst, Health Services Research Center, University of California, San Diego. Andrew Sarkin, PhD, is director of evaluation research, Health Services Research Center, University of California, San Diego. Todd Gilmer, PhD, is professor and chief, Division of Health Policy, Department of Family Medicine and Public Health, University of California, San Diego. Original manuscript received November 13, 2015 Final revision received March 31, 2016 Editorial decision April 14, 2016 Accepted April 15, 2016

Siantz et al. / Health Care Decisions among Mental Health Services Consumers in San Diego County

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