Mental Healthcare Improvement Project: A Case Study of Implementation Science in Primary Care

Our pilot study demonstrated that primary care physicians were not adequately addressing mental illness in a public clinic in a distressed urban Miami community that serves as a family medicine residency training site. The Three-Component Model (3CM) of interdisciplinary depression care management in primary care has been found to be efficacious in prior studies. With grant funding from two foundations, we implemented an adaptation of the 3CM. We adopted an action-research paradigm to implement a complex system of care into an existing public clinic. Patients reported that they appreciated the process of care management and demonstrated improvements in symptoms and self efficacy despite severe symptoms and extremely low self-efficacy at baseline. Institutional inertia, conflicting demands, and disorganized systems of organizing care were formidable obstacles. Patients enrolled in depression care management were found to be facing complex problems of coexisting poverty, mental illness and social isolation. A variety of adaptations to the initial plan were required in order to overcome obstacles. We moved from a consultation model to a coaching model. Quality Improvement methods were required to obtain participation from physicians. We had to focus more narrowly on depression than initially anticipated in order to consolidate gains. We also focused more on those things that could be accomplished by the patients and providers relying less on referral to outside resources. Involvement of a community advisory board highlighted the existing public mental health infrastructure, and inadequate mechanisms for funding mental healthcare for the vast number of uninsured people in Miami.