We examined the routine practice patterns for a large representative sample of PCCs from the majority of FQHCs in New York and New Jersey. We found that very few of these CHCs had fully integrated health care teams for addressing PTSD and other mental health problems (only 11%) and less than a quarter had fully integrated community linkages/support (22%). These numbers are low in light of the increasing proliferation of team-based practice structures.
Our findings highlight the important role that system factors play for PTSD management in primary care settings. Having mental health specialty care available on-site or accessible for routine consultation and practicing in a clinic with established relationships with social and legal services are independently associated with PCCs’ reports of their experiences with PTSD in their practice. The key finding that mental health integration is associated with individual clinician perceived confidence and barriers is consistent with depression studies [21
] showing that reported attitudes and practices may depend on the extent to which mental health resources are accessible. If no mental health resources are available, PCCs report a proclivity toward treating within their primary care setting whereas those who have access to mental health resources report a proclivity to refer to specialists. This situation is good if it can be assumed that both PCCs and specialists deliver evidence-based care.
While having established linkages with community services including social and legal assistance for patients with PTSD was significantly associated with several reported clinical actions (referral to mental health and scheduling follow-up visits), mental health integration was not. This stronger association between community linkages and reported practices relative to the association between mental health integration and reported practice was surprising given the empirical literature that finds that mental health integration with primary care also affects the proclivity to deliver depression care [26
]. We found that PCCs who reported stronger ties to community services were less likely to report that they would refer to a mental health specialist or schedule a follow-up visit with those patients. One explanation for this finding is that PCCs may be hesitant to discuss, diagnose, or treat PTSD when working with patients who experience chronic interpersonal violence. This is also an issue in other types of chronic conditions (HIV/AIDs and traumatic brain injury) for the same reasons.
For scenario-specific treatment proclivity, we found that variation in the system factors was not associated with an overall tendency to recognize and/or treat patients described as having experienced political or interpersonal violence. However, variations in system factors were associated with this tendency for the community violence scenario. One possible reason for this pattern is the distinctive characteristics of interpersonal and political violence compared to community violence. Interpersonal violence, such as intimate partner violence and child abuse and political violence, such as torture, are frequently prolonged, chronic, and personalized experiences of violence. Both present to PCCs with a recognized web of inter-related mental health, social service, and legal needs [31
]. The well-documented challenges PCCs face addressing interpersonal violence are likely experienced with patients who experienced political violence [33
]. For interpersonal violence, reporting abuse, often involving a family member, combined with survivor safety needs are challenging for medical providers. For political violence, clinicians have limited time to also deal with concerns about immigration and family problems. In both cases, PCCs may frequently suspect a complicated array of problems and may prefer to refer out and to involve community resources no matter how integrated these services are with primary care. Indeed, referral for social services was the most common action reported by the PCCs in our study for patients with interpersonal or political violence, reported by 93% and 95% of PCCs, respectively. Thus, our study would not detect an association with system factors since PCCs are referring out regardless of the system they are in.
In contrast, PCCs are just beginning to incorporate an understanding of the environmental and contextual issues surrounding community violence into their care of these patients [34
]. Though studies are needed to explore this hypothesis further, PCCs may be less likely to refer patients exposed to community violence because their focus on “one-time” injury neglects to account for contributing factors and psychosocial outcomes [35
]. Our results support this explanation as PCCs in our study had a lower proclivity to refer patients described as victims of community violence for social services. PCCs who are less aware of the surrounding issues may exercise greater discretion with referrals to social and mental health services. Referrals may be more influenced by the availability and ease of obtaining social and mental health services. Thus, treatment proclivity for community violence appears more sensitive to variations in these system factors.
While the number of clinicians was not large and limited our power to detect associations, our data systematically sampled the majority of FQHCs in New York and New Jersey. In fact, our sample of 58 CHCs in the CDN network represented 89% of all CHCs and 72% of responders making these data broadly generalizable to FQHCs in these 2 these states. Given the similar sociodemographic profiles of attendees at these FQHCs, findings may lend themselves to other types of primary care settings in low-income urban communities [10
]. In addition, self-report data often runs the risk of biased responding. However, many of the measures were adapted for PTSD from other studies that have been validated in the literature [21
] which minimizes potential for measurement error. Further exploration is needed to explain the non-linear associations between the system measures and some of the dependent measures. Clinicians may have interpreted the descriptions of service integration and community linkages too broadly which could have affected the presumed order of response categories. Additionally, the items on system factors asked about mental health problems generally rather than PTSD specifically which could limit our ability to find associations if interpretations vary. Finally, we cannot assume that findings would be consistent if we had studied this issue in other types of health care settings or in other regions of the country.
Our study suggests that more integration with mental health increases PCC treatment confidence, reduces some barriers, and increases the likelihood that patients will receive treatment for some patients with PTSD. While clinician education may strengthen early detection and rapid initiation of treatment for PTSD [36
], our data suggest that structural interventions may also address system-level barriers. In addition to the survey data, feedback from the expert panel discussion indicates that to address barriers to care for PTSD, strategies that restructure service delivery to better integrate primary and mental health care and to better coordinate with other community-based health services are among the most promising. In particular, PCCs would benefit from established relationships with mental health professionals and with agencies that provide complementary services (such as social and legal aid).
However, structural change alone may be insufficient to change clinician behavior unless combined with other important intervention components in a multi-faceted approach. Other potential components to improve care may include strong leadership support, patient management and tracking systems, and education for patients and clinicians [38
]. In particular, collaborative care interventions [39
] that include regular interaction between PCCs and mental health professionals are needed to improve care. Moreover, interventions that include components and strategies implemented through a specially trained care manager such as the chronic care model for depression (www.improvingchroniccare.org
] may help patients overcome system barriers as well as patient- and clinician-level barriers such as stigma, limited clinician treatment knowledge, clinician time constraints for dealing with psychological issues, and difficulty finding mental health specialists. Such intervention programs have demonstrated success for improving depression care in medical practices [29
] and are worthy of exploration for improving anxiety [49
] and PTSD care [50
]. A promising step forward is to adapt some of these successful approaches to improve access to and quality of care for PTSD.