Integrated Behavioral and Medical Services
Associated with Decreased Use of Primary
Care Among College Students with Mental
Health Conditions
James C. Turner, MD
Professor of Internal Medicine
Executive Director, National Social Norms Institute
Department of Student Health
University of Virginia
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Funding Sources
UVa Department of Student Health and the National
Social Norms Institute
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Federal:
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State:
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CDC
National Institute on Alcohol Abuse and
Alcoholism
U.S. Department of Education
Virginia Alcoholic Beverage Control Board
Virginia Department of Health
UVA:
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Private/Non-profit
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Anheuser-Busch Foundation
Foxfield Racing Association
National Center for Drug Free Sport
National Collegiate Athletics Association
National Organization for Youth Safety
(NOYS)
– The BACCHUS Network
– The Gordie Foundation
– The Network: Addressing Collegiate
Alcohol and Other Drug Issues
Office of the Vice President for Student
Affairs
Student Health fee paid by all UVa
students to Department of Student Health
Laboratory and pharmacy revenues shared
with UVa Health System.
U.Va. Parents Committee
Youth-Nex Grant
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Case Presentation
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20 y.o. female.
Spontaneous bruising.
In counseling, but denied access to records.
Coagulopathy work-up.
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Mental Health Conditions Among
College Students
• 26% of Americans 18 years and older suffer from a
diagnosable mental disorder over 1 yr.
• Half of lifetime cases begin by age 14, three quarters
begin by age 24.
• Prevalence among college students similar to same-aged
non-college population but may be increasing in
frequency and/or severity.
• Rates of suicide and vehicular accidents are equivalent
and leading causes of mortality.
• Rare mass murders linked to mental health issues.
• Common behavioral disruptions on campuses.
• Impact on academic and extracurricular success.
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Counseling and Medical Services on
College Campuses
• Immense commitment of resources to health services
(~1500 college health services; ~800 counseling centers
with directors in AUCCCD listserve).
• Lack of clear consensus on best practices for provision
of counseling and medical services (ACHA 2010).
• Majority of counseling and medical services are
separate entities (AUCCCD 2013).
– 25% are administratively integrated
– 30% collaborate extensively among providers
– 22% share medical records (13% all providers, 8.4%
psychiatry only).
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Counseling and Medical Services on
College Campuses
• National consensus that mental health (MH)
patients cared for in integrated behavioral and
medical services:
– Better treatment outcomes
– Utilize primary care resources less
– More likely to be compliant
• ACA has established incentives and guidelines
for providing patient centered comprehensive
approaches including integrated care.
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Features of Integrated Behavioral and
Medical Services
• Routine exchange of clinical information
across all treatment settings as well as robust
interdisciplinary referral relationships and
clinical collaboration.
• Not co-location or administrative alignment.
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Integration of services on campuses?
• National consensus that mental health (MH)
patients cared for in integrated behavioral and
medical services:
– Better treatment outcomes
– Utilize primary care resources less
– More likely to be compliant
• Establish evidence-based data for higher
education.
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Analysis of the Mental Health
Disorders on College Campuses
• Explore the frequency of these disorders.
• Determine factors that influence rates of
utilization of primary care resources.
– Demographics of patients.
– Mental health conditions.
– Service integration.
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Study Sample
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College Health Surveillance Network
(CHSN)
• Funded by CDC grant and UVa.
• Unique 22 school network using EMR uploads
of depersonalized data to central database.
• Each school has IRB approval or data sharing
agreement.
• Some schools include counseling center data in
the uploads.
• Affords an opportunity to study mental health
frequencies and primary care utilization.
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College Health Surveillance Network
(CHSN)
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702,000 currently enrolled students 2012/13
22 four-year public and private not-for-profits
21 of 22 are Research Universities Very High
Census region representation:
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Northeast:
South:
Midwest:
West:
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• Demographics representative of 108 RU/VHs
• One school dropped from analyses because
using non-standard clinical codes.
• Data analyzed 1/1/11-5/31/13 (29 mo.)
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Demographics of CHSN Enrollment Compared to the 108 RU/VH:
Gender and Academic Standing
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80
70
70
60
60
50
50
40
CHSN
40
CHSN
30
RU/VH
30
RU/VH
20
20
10
10
0
0
Females
Males
Undergrad
Graduate
Demographics of CHSN Enrollment Compared to the 108 RU/VH:
Age and Race/Ethnicity
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70
60
50
40
30
20
10
0
30
25
20
15
10
5
0
Under 18-19 20-21 22-24 25-29 Over
18
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CHSN
RU/VH
CHSN
RU/VH
Clinical Integration Categories
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Categories of integration among
college counseling and health services
• AUCCCD Survey 2012 (completed by CHSN
schools) categorizes integration:
• Enhanced integration
– Accessibility of EMR data for all providers
– Fair amount or extensive patient collaboration
among providers
• Standard integration (one or none of features)
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Assigning Integration Category and
Impact on Study Populations
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Comparison of Standard and Enhanced Service
Models on Key Characteristics
Characteristic
Standard
Enhanced
Total
No. of Schools
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10
21
352,911
320,122
673,033
52.4%
47.6%
100%
263,478
269,193
532,671
49.7%
50.3%
100%
No. of patients with a
mental health diagnosis
23,839
38,861
62,700
38%
62%
100%
No. with counseling
center data
0
0
9
80%
9
43%
School enrollment
No. patients served
Demographic Comparison of Patients
Served in Standard and Enhanced
Integration Models
Gender
Standard
Females
Males
Enhanced
Females
Males
Demographic Comparison of Patients
Served in Standard and Enhanced
Service Models
Age Categories
Standard
Enhanced
Under 18
18-20
21-23
Under 18
18-20
21-23
24-26
27-29
Over 29
24-26
27-29
Over 29
Demographic Comparison of Enrolled
Students Served in Standard and
Enhanced Service Models
Race/Ethnicity (50% missing data)
Standard
Enhanced
White
Asian
Hispanic
Black
NA/NH/PI
White
Asian
Hispanic
Black
NA/NH/PI
Results of Assignment of Integration
Category
• Observe expected increase in mental health
visits among enhanced integration services.
• Otherwise similar characteristics for both
enrolled and patient populations for both
integration models.
• Ethnicity not in EMR for ~50% patients so
cannot analyze variable.
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Diagnostic Categories of Patients
Served
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Percent of Individual Patients* in Top 10
Diagnostic Categories (N=532,700)
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35
30
25
20
15
10
5
0
CHSN
*Patients can have more than one diagnosis.
Percent of Individual Mental Health Patients* in Nine
Diagnostic Categories (N=62,700)
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50
40
30
20
10
CHSN
0
*Patients can have more than one diagnosis.
Analysis of Primary Care
Utilization
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Primary Care Utilization
• Statistical analysis to determine factors that
influence rates and complexity of primary care
visits:
– Demography
• age and gender
– Mental health conditions
• patient with any mental health ICD-9 code during 29
month study
– Health service integration
• enhanced vs. standard
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Primary Care Utilization
• Statistical analysis
– General linear regression using a Poisson model to
derive statistics for rates of primary care and
somatization-related visits.
– A simple analysis of variance to derive the
statistics for complexity of visit scales.
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Primary Care Utilization
Two Categories of Visits
• Primary care visit includes all visits for which
there is a primary care evaluation and
management (E+M) code.
• Somatization-related primary care visits: a
primary care visit for somatic complaints (e.g.
fatigue, dizziness, shortness of breath, weight
loss, insomnia) for which there is usually no
organic cause and potential for psycho-social
etiology.
– See Appendix A slide 46.
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Significant Factors Impacting
Utilization
• Gender and age.
• Mental health conditions.
• Clinical integration.
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Primary Care Utilization by Gender
and Age
• All Primary Care Visits (includes contraceptive
management, other gynecologic visits; travel and sports
physicals; screenings for lipid disorders, STI, HTN)
 Females 16% higher.
 23-29 yrs. 9% higher than 18-22 yrs.
 >29 yrs. 15% higher than 18-22 yrs.
• Somatization-related Visits (Appendix A. Slide 46)
 Males 21% higher.
 23-29 yrs. lower than 18-22 yrs.
 >29 yrs. lower than 18-22 yrs.
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Primary Care Utilization
Mental Health vs. Non-Mental Health
• Rates of utilization per month mental health
patients vs. non-mental health patients:
– all primary care (+10%)
– somatization-related primary care (+18%) visits
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Mental Health Patient Utilization by
Integration Model
• Total of 62,700 mental health patients in CHSN
 38,900 enhanced model
 23,800 standard model
• Total of 18,700 mental health patients with
somatization-related visits
 10,980 enhanced model
 7,730 standard model
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Decline in Rates by Mental Health
Diagnosis: Enhanced vs. Standard
• All primary care visits
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Depression
Anxiety
Alcohol
ADHD
(-32%)
(-42%)
(-23%)
(-28%)
(-23% )
• Somatization-related primary care visits
– Depression
(-32%)
– Anxiety
(-25%)
– Adjustment Dis.
(-41%)
– ADHD
(-14%)
– Drug Abuse
(-55%)
(-28%)
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Complexity Ratings of MH Patients
• Complexity of patients (e.g. time with patient)
can be more significant than the number of visits
for primary care.
 500 minutes of provider time
 50
 10
10 minute appointments (fifty patients)
50 minute appointments (ten patients)
• Important to consider both frequency and
complexity of visits when assessing trends in
utilization.
• Evaluation and Management Codes reflect level
of complexity.
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Complexity Ratings of MH Patients
• All primary care visits
– Complexity for MH patients significantly lower in the
enhanced model for all primary care visits including
most categories (anxiety, depression, ADHD, drug
abuse, and bipolar conditions).
• Somatization-related visits
– Complexity for MH patients was significantly lower in
the enhanced model for all somatization-related visits,
and categories (anxiety, depression, ADHD, and males
with bipolar and psychotic disorders).
• Enhanced integration associated with decreased
use of primary care resources.
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Administrative Affiliation
• Do co-location and administrative alignment
make a difference irrespective of clinical
integration?
• Inconsistent evidence for decreased utilization
of primary care.
• Enhanced clinical integration (shared records
and high levels of collaboration) is statistically
powerful and consistent.
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Conclusions
• Mental health diagnosis in 11.8% of patients,
ranking as the fourth most common diagnostic
category seen.
– Anxiety (49%) and depression (39%) most
frequent disorders.
• Students with mental health disorders use
primary care significantly more frequently.
– When these students are cared for in an
integrated health system they use 30% less
primary care.
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Conclusions
• The two features critical to integration were:
– Sharing medical record information across
disciplines.
– Fair amount or extensive collaboration among
providers in all disciplines.
• Administrative alignment and co-location
were not independently associated with a
decrease in primary care utilization.
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Limitations
• In clinics from the standard integration models, mental
health diagnoses are only provided by the patients
when asked, or if a referral note is sent by a provider
outside Student Health.
• Students cared for at separate counseling centers are
not readily identified and absence of information about
underlying mental health conditions could bias results.
• Controlling for age and gender, analyzed matched
diagnostic cohorts in each integration model and
findings were confirmed.
• Additional studies of primary care use among
counseling center clients?
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Why lower use of primary care?
• Clinicians have more accurate and complete
information about the patient.
– Underlying conditions.
– Informed diagnostic and therapeutic decisions.
– Rapid referrals and ease of discussion -particularly
for amorphous somatic complaints.
– Not necessarily related to availability of
psychotherapy notes: patient summary sheets.
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Why lower use of primary care?
• Students seen in integrated systems more
compliant with mental health appointments.
• More appropriate care for students.
• Endure fewer somatic complaints and use
general medical care less.
• Insight into somatic symptoms being due to
mental health condition and seeks targeted
care.
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Counseling and Medical Services on
College Campuses
• Majority of counseling and medical services are
separate entities (AUCCCD 2013).
– 25% administratively integrated
– 30% collaborate extensively among providers
– 22% share medical records.
• NASPA Mental Health 2014 Program
“Since mental health issues affect not just the individual student but the campus as a
whole, successful approaches require collaboration between campus departments…..”
• There is no more critical collaboration than
between counseling and medical services.
• Can the stakeholders take down the barriers?
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The Upside for Higher Education
• Integration may not require more resources,
improved collaboration.
• Better care for students with mental health
disorders.
• Frees up medical resources for students
without mental health conditions.
• Enhanced integration of behavioral and
medical care is consistent with national
direction.
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Thank you
Questions
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Appendix A.
Somatization-related ICD-9 Codes
38,592 diagnoses among 18,709 individual patients.
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Abdominal Pain – 789, 789.0, 789.00
Abdominal Pain Epigastric - 789.06
Abnormal loss of weight and underweight – 783.2
Back disorders, other unspecified - 724.9
Back symptoms, other - 724.8
Backache, unspecified - 724.5
Chest Pain - 786.5, 785.50
Chronic fatigue syndrome - 780.71
Constipation – 564, 564.0, 564.00
Constipation, Other - 564.09
Constipation, slow transit - 564.01
Dizziness - 780.4
Dyspnea and respiratory abnormalities, other - 786.09
Gastrointestinal malfunction arising from mental factors –
306.4
Headache – 784, 784.0, 784.00
Hiccough - 786.8
Hypersomnia, unspecified - 780.54
Hyperventilation - 786.01
Insomnia, unspecified - 780.52
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Irritable Bowel Syndrome (IBS) - 564.1
Loss of weight – 783.21
Malaise and fatigue - 780.7
Malaise, fatigue, Other - 780.79
Migraine, unspecified w/o Intractable Migraine - 346.90
Neck Pain - 723.1
Other specified psychophysiological malfunction – 306.8
Primary Insomnia - 307.42
Psychogenic vaginismus – 306.51
Psychosexual dysfunction - 302.72
Respiratory & other chest sx, other (Chest discomfort,
pressure, tightness or other sx) - 786.59
Respiratory abnormality, unspecified – 786, 786.0, 786.00
Respiratory malfunction arising from mental factors – 306.1
Respiratory system and chest symptoms, other (breathholding spell) - 786.9
Shortness of breath - 786.05
Sleep disturbance, other - 780.59
Sleep disturbance, unspecified - 780.50
Sleep disturbances - 780.5
Syncope (vasovagal) - 780.2
Tachypnea - 786.06
Underweight – 783.22
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