174226 Mental Healthcare Improvement Project: A Case Study of Implementation Science in Primary Care

Wednesday, October 29, 2008: 11:30 AM

David Brown, MD , University of Miami Miller School of Medicine, Miami, FL
Nicole Alexandra Eull, PsyD , Family Medicine, University of Miami Miller School of Medicine, Miami, FL
Ray Ownby, MD, PhD, MBA , Department of Family Medicine, The University of Miami Miller School of Medicine, Miami, FL
Barry Nierenberg, PhD , Department of Family Medicine, The University of Miami Miller School of Medicine, Miami, FL
Kenneth Obiaja, MD, MPH , Department of Family Medicine and Community Health, University of Miami/Jackson Memorial Hospital, Miami, FL
J. Bryan Page, PhD , Anthropology, University of Miami, Coral Gables, FL
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.

Learning Objectives:
Describe the principles of action research and implementation science and how they were applied in an effort to change a system of care for depression in a public primary care clinic. Discuss how the initial plans were modified in response to interim findings. Analyze the implications for mental health care delivery systems.

Keywords: Mental Health Care, Primary Care

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I am principal investigator and primary author.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.