Primary Care Practice Redesign: Challenges in Improving Behavioral Health Care for a Vulnerable Patient Population

Area of Science:

• Public Health
• Family Medicine
• Behavioral Health

Background:

• Economically challenged urban settings present unique barriers to accessing integrated mental health care.
• Family medicine practices are crucial touchpoints for identifying mental health needs in diverse patient populations.

Purpose of the Study:

• To evaluate a program integrating mental health services within an urban family medicine practice.
• To assess the prevalence of mental health conditions and patient engagement with referrals.

Main Methods:

• Screening 202 patients in a family medicine setting using a behavioral health technology platform.
• Implementing a collaborative model with community mental health agencies and a community health worker (CHW).
• Comparing depression diagnoses between screened and control groups; qualitative analysis of patient decision-making.

Main Results:

• High prevalence of anxiety (56%), moderate to severe depression (38%), and PTSD (34%) identified.
• A statistically significant increase in depression diagnoses compared to a control group.
• Low referral follow-through rate (27%) despite CHW navigation and assured access.

Conclusions:

• Integrated mental health programs can identify significant unmet needs in urban primary care.
• Patient-level factors present complex challenges to behavioral health care engagement.
• Further research is needed to improve referral completion rates in vulnerable populations.