The anatomy of primary care and mental health clinician communication: a quality improvement case study

Abstract

Background: The high prevalence of comorbid physical and mental illnesses among veterans is well known. Therefore, ensuring effective communication between primary care (PC) and mental health (MH) clinicians in the Veterans Affairs (VA) health care system is essential. The VA's Patient Aligned Care Teams (PACT) initiative has further raised awareness of the need for communication between PC and MH. Improving such communication, however, has proven challenging.

Objective: To qualitatively understand barriers to PC-MH communication in an academic community-based clinic by using continuous quality improvement (CQI) tools and then initiate a change strategy.

Design, participants, and approach: An interdisciplinary quality improvement (QI) work group composed of 11 on-site PC and MH providers, administrators, and researchers identified communication barriers and facilitators using fishbone diagrams and process flow maps. The work group then verified and provided context for the diagram and flow maps through medical record review (32 patients who received both PC and MH care), interviews (6 stakeholders), and reports from four previously completed focus groups. Based on these findings and a previous systematic review of interventions to improve interspecialty communication, the team initiated plans for improvement.

Key results: Key communication barriers included lack of effective standardized communication processes, practice style differences, and inadequate PC training in MH. Clinicians often accessed advice or formal consultation based on pre-existing across-discipline personal relationships. The work group identified collocated collaborative care, joint care planning, and joint case conferences as feasible, evidence-based interventions for improving communication.

Conclusions: CQI tools enabled providers to systematically assess local communication barriers and facilitators and engaged stakeholders in developing possible solutions. A locally tailored CQI process focusing on communication helped initiate change strategies and ongoing improvement efforts.

Figure 1

Fishbone diagram for contributors to poor communication between primary care providers (PCP) and mental health providers (MHP). MH mental health, MHP mental health provider, PC primary care; PCP primary care provider.

Figure 2

Flow chart of how primary care providers (PCPs) contact psychiatrists. ER emergency room, VAMC VA medical center.

Figure 3

Flow chart of how psychiatrists contact primary care providers (PCPs). EMR electronic medical record, PCP primary care provider.