Integrated Primary Care & Behavioral Health Services on College Campuses

With finals season upon many of us across the U.S., we thought it would be appropriate to discuss an article that focuses on college students. The article we will be discussing this week is a review of national survey data. The article, “Integrated primary care behavioral health services in college health: Results from a national survey of health center administrators” was written by Readdean, Heuer, Hoban, & Parrott and was published in the Journal of American College Health this past October. The authors of this paper investigate the organization and structure of primary care behavioral health practice within college student centers.

What did they do?

The purpose of this study was to contribute to the already-in-progress benchmarking of available approaches to behavioral health interventions for college students within a primary care setting. Four primary strategies that have emerged in the literature for integrating primary and mental health services for students are discussed. The authors of this study also sought to compare the organizational structures (integrated vs. non-integrated), assess levels of integrated care practice, and investigate different levels of behavioral health staff that are working within primary health care centers on college campuses. Five specific research questions that the authors’ of this study sought to answer are:

1. How do colleges and universities organize their primary care and specialty mental health services?
2. Has the percentage of integrated care centers increased from previous surveys?
3. Is there a relationship between organizational structure and integrated care practices?
4. Is there a relationship between the number of behavioral health staff in an organization and levels of practice that are integrated?
5. To what extent do non-integrated organizations have non-prescribing behavioral health care embedded into a primary care setting?

Why did they do it?

As we have discussed a number of times in previous blog posts, the integration of behavioral health care into primary health care settings is a prominent movement. Currently, there are many health care reforms at state and national levels which encourage such integration by means of structural connections between behavioral and physical health care. As the authors of this article highlight, the growing trend of behavioral health care integration combined with the increasingly large amount of college students in need of mental health care is driving colleges and universities to connect mental and physical health services which have been historically separated.

How did they do it?

The authors of this review style article collaborated with the American College Health Association (ACHA) to develop and distribute an online, 54-item cross sectional survey, the Survey of Primary Care Behavioral Health Services in College Health. The survey is broadly based upon the global state of primary care behavioral health intervention systems on university and college campuses, and included three primary components based on published literature on behavioral health integration:

1. Demographics and organizational structures
2. Behavioral health staffing information
3. Outcome measures

To assess integration, the survey administered to participants included the Practice Integration Profile (PIP). The PIP provides levels of integration that can be used to compare outcomes within and across different integrated care systems.

What did they find?

A total of 233 surveys were collected, and 189 of those were usable for the purposes of this study. Forty-six percent of survey respondents reported that their represented institution used an integrated care model. Of the individuals surveyed, a majority held a “director” title, which represented a wide range of professionals. Almost all of the included institutions were 4-year schools, both private and public, and almost half of the institutions held some sort of accreditation. Total PIP scores (which can range from 0 to 100) across institutions ranged from 1.7 to 84.5, with an average score of 44.8. According to the authors of this study, these results are consistent with previous survey data. There were no statistically significant differences in PIP scores based on the size or type of institution, however, total scores and sub scale scores did vary based on whether or not the institution was integrated or non-integrated, with integrated organizations scoring higher in across all domains compared to non-integrated organizations.

When comparing health care centers with higher numbers of full time behavioral health staff compared to centers with lower numbers of full time behavioral health staff, positive correlations between the number of full time behavioral health staff and PIP scores were consistently found for total PIP scores and many of the PIP sub scale scores. This association was true across a variety of sizes of institutions, but the correlations were strongest in schools with the largest enrollments. The number of behavioral health staff within a healthcare center was also examined as an indicator of a non-integrated organization implementing a primary care behavioral health (PCBH) model.

We encourage everyone to read the full article where all of the statistical analyses and results are outlined in depth.

What does it all mean (our take)?

In 2007, a national survey conducted by the American College Health Association reported that 26% of respondents identified their institution as actively implementing an integrated behavioral healthcare system on campus. The article we discussed today reported that number to have risen to 46%. Data from this survey study also indicates that college health centers that are not administratively integrated with college counseling centers are still identifying patients in need of behavioral health services. These non-integrated centers also report making referrals to specialty mental health care, and coordinating care between departments despite a formal integration. While the steps being taken, even in non-integrated healthcare settings are improvements, there are still lower levels of shared treatment planning, clinical collaboration, and information sharing being reported in nonintegrated centers compared to integrated centers. As described by the authors, the PCHB model is an approach to behavioral health integration where behavioral health professionals are embedded within the primary care setting without a formal, organizational integration. This is one way to increase collaborative care without fully reorganizing the administrative structure of a healthcare center. Overall, it’s great to see that the overall organization of physical and behavioral health services on college and university campuses is considerably integrated and collaborative, and integration is progressing rapidly!