Munazzah Ambreen1
Sihan Zhang1Osnat C. Melamed1,2
Christopher Canning3,4Brian Lo1,5
Sri Mahavir Agarwal1,4
Amer M. Burhan4,6M. Elisabeth Del Giudice2Mary Rose van Kesteren1
Barna Konkolÿ Thege3,4Sanjeev Sockalingam1,4
Terri Rodak1
Tania Tajirian1,2Caroline Walker1
Vicky Stergiopoulos1,4,5*
- 1Centre for Addiction and Mental Health, Toronto, ON, Canada
- 2Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- 3Waypoint Research Institute, Waypoint Centre for Mental Health Care, Penetanguishene, ON, Canada
- 4Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- 5Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- 6Ontario Shores Centre for Mental Health Sciences, Whitby, ON, Canada
Individuals living with serious mental illness (SMI) face significant barriers to accessing appropriate physical health care, poorer associated health outcomes and premature mortality compared to the general population. This scoping review examines service delivery models and clinical practices supporting the integration of physical health care for adults with SMI within mental health settings, and their outcomes. Searches of four academic databases yielded 65 academic articles. Most integrated service delivery models were implemented in community mental health settings in the United States and incorporated elements of Wagner's Chronic Care Model, emphasizing delivery-system redesign, patient self-management support and use of clinical information systems. In most outcome studies, integrated care models were associated with improvements in primary care access and preventative screening rates, while other physical health indicators and emergency and inpatient service use demonstrated promising but mixed results. Implementation challenges of integrated service delivery models included securing financial resources and maintaining effective use of clinical information systems, among others. Successful implementation was facilitated by effective teamwork, care coordination, and administrative and leadership support. Study findings highlight the complexity of integrating physical health care in mental health settings, and the longer timeframes needed to observe changes in some outcomes. The review further underscores the need for ongoing efforts to advance integrated care delivery in mental health settings and the importance of longitudinal data collection to fully assess and optimize the implementation and outcomes of these interventions.
Systematic Review Registration: https://doi.org/10.17605/OSF.IO/3T9VK.
Introduction
Serious mental illnesses (SMIs), such as schizophrenia, bipolar disorder and treatment resistant depression, are chronic health conditions that severely impact the everyday functioning and quality of life of affected individuals (1–7). Adults with SMI between 18 and 49 years of age are 3.2 and 2.5 times more likely to die from cardiovascular disease (CVD) and stroke respectively, and die on average 10–20 years earlier compared to the general population (8, 9). Although findings on the relationship between SMI and cancer mortality remain mixed, adults with SMI 50–75 years of age were 1.32 more likely to die of respiratory cancer compared to the general population in one study (9), while lower cancer screening rates among adults with SMI are well documented (10). Multiple factors contribute to premature mortality among adults living with SMI, including individual level, health system level, and social and community level factors (11–13). Illness-related and behavior specific factors can hinder individuals’ ability to manage their physical health and adhere to treatment regiments (14–18). Additionally, antipsychotic medications commonly used to treat SMI are associated with significant side effects, such as weight gain and metabolic imbalances (19, 20). Furthermore, limited access to comprehensive primary care, poor service design and engagement, and diagnostic overshadowing make screening and timely treatment of common health conditions challenging for this population (3, 21–23). Collectively these barriers result in poor quality and experiences of care and growing health disparities among adults with SMI, further accentuated by poverty, homelessness and social isolation (24–30).
To date, most efforts to integrate physical and mental health service delivery have focused on introducing mental health professionals into primary care settings to address the needs of individuals with mild and moderate mental health conditions (31–34). Generally, these models have demonstrated improved patient outcomes and adaptability to the needs of diverse subpopulations, with implementation costs typically offset by longer term healthcare expenditures (35, 36). Less is known about how best to deliver integrated physical and mental health care within mental health settings, such as psychiatric hospitals and community mental health teams serving adults with SMI, who are less likely to engage in primary care services (33, 37). Recent literature has conceptualized such efforts as “reverse integration”, a term referring to providing collaborative physical and mental health care within behavioral rather than primary care settings (38–40).
Various reverse integration models have been described in the international literature in recent years, along with policy development and targeted initiatives in some countries (38, 39, 41–43). Furthermore, research efforts have examined the impact of peer-led self-management, provider education, electronic reminders, and other patient-centered approaches to promote attention to and treatment of chronic health conditions in this population (44–53). Finally, in Canada and other countries, without specific policy or practice mandates, mental health service organizations have been increasingly introducing hospitalist physicians or nurse practitioners to support the physical health needs of adults with SMI in their setting (54–57). Yet despite growing awareness of the mortality gap and efforts to address these health disparities, in most jurisdictions there is no actionable roadmap to advance physical and mental health care integration and delivery within mental health services, the “health home” of this population (4, 58–61).
To help inform service redesign efforts, we undertook a scoping review of the literature to understand the extent and type of evidence in relation to service delivery models and clinical practices that are used to support the integration and delivery of physical health care to individuals with SMI within mental health settings. Two research questions were addressed: [1] What service delivery models and clinical practices are used to support the delivery of physical health care to individuals with serious mental illness in mental health settings?; and [2] What are the outcomes of these models and practices?
Methods
To effectively capture the extensive scope and depth of this field, we undertook a scoping review of the academic literature. The methodology for this review was based on the framework developed by Arksey and O'Malley (62) and adhered to the reporting guidelines of the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) extension for scoping reviews (63). The scoping review was registered via OSF (https://doi.org/10.17605/OSF.IO/3T9VK). Notably, the study team included clinicians, health service researchers, persons with lived experience of SMI and family members, who jointly framed the research questions, interpreted findings, and co-authored the manuscript.
Inclusion and exclusion criteria
The Substance Abuse and Mental Health Services Administration in the U.S. defines SMI as a diagnosable mental, behavioral, or emotional disorder that substantially interferes with a person's life and ability to function (7). Articles were eligible for this scoping review if: [1] the population of interest included individuals over the age of 18 living with SMI, such as bipolar disorder, treatment refractory depression or schizophrenia, with no other demographic constraints; the age cutoff of 18 was selected to focus on the adult population, as mental health needs and treatment approaches can differ between adults and minors (64); [2] articles focused on the concept of reverse integration, defined as the provision of physical health care services within mental health settings to address physical health needs and prevent physical health decline (40, 65); [3] they were published as peer-reviewed academic journal articles and book chapters; [4] they were published between January 1, 2010 and June 6, 2024, to capture the most recent studies and reflect evolving practices and developments in the field over the past decade; and [5] they were written in English language. There were no methodological restrictions on article eligibility.
Articles were excluded if they: [1] focused on individuals without SMI (e.g., anxiety); [2] did not discuss the provision of physical health services (e.g., focused on psychosocial care); [3] targeted a single health dimension (e.g., smoking, obesity, physical fitness, metabolic health, sexual health, oral health, sleep), lifestyle modifications, or self-management skills training without attention to physical health needs comprehensively; [4] were not or not clearly stated to be set in mental health settings [5] did not describe or evaluate service delivery models or clinical practices; [6] were conference abstracts, dissertations, theses, reviews or study protocols. The decision to exclude articles focused on a single health dimension or lifestyle interventions was made to ensure the study focused on service delivery models and practices supporting the physical health needs of adults with SMI comprehensively, making the findings more relevant for service redesign efforts.
Search strategy
To locate scholarly articles, a medical librarian (TR) developed the core search strategy in MEDLINE in collaboration with the review team, then translated the search for use in other selected databases. Searches were conducted in the following four databases on July 19, 2023, and updated on June 6, 2024, using the same search strategy: MEDLINE (Ovid), Embase (Ovid), APA PsycInfo (Ovid), and CINAHL (EBSCO). The first section of the search strategy combined a robust “physical health care” concept comprised of database-specific subject headings, keywords in natural language, and advanced search operators with natural language strings of “integration” or “co-location” terms appearing within five words of terms related to mental healthcare or mental health conditions. The second section combined a “mental health care” concept with strings of “integration” or “co-location” terms appearing within five words of primary healthcare or physical health terms. The third section used subject headings that capture the programming or implementation aspects of integrated care, as well as “integration” or “co-location” keywords, which were then combined with subject headings from Sections One and Two. The results of all three sections were pooled and limited to publication years 2000 to present. No study type or language limits were applied. The full Medline strategy can be found in Supplementary Table S1.
Evidence selection
Following the search, all identified citations were uploaded into Covidence where duplicate citations were removed. Titles and abstracts were screened by two independent reviewers, SZ and TM, for assessment against the inclusion criteria for the review. The full text of selected citations were assessed in detail against the inclusion criteria by two independent reviewers. At the beginning of these phases, the senior author, VS, reviewed an initial sample of 20 review decisions made by the two reviewers to ensure consistency. Reasons for exclusion of sources of evidence at full text review were recorded and reported in the scoping review. Disagreements between the reviewers at each stage of the selection process were resolved through discussion with the senior author and/or resolved by consensus.
Data charting process and items
A data extraction template was developed by the research team to chart details about the included articles and relevant content. The domains of the data extraction form included: authors, publication year, country, article title, study type, target population/study setting, and key findings for all articles. Descriptions of the model and types of interventions were extracted. One research team member extracted the data from the included articles, which was reviewed by the senior author for accuracy and completeness. Given the nature of scoping reviews and the conceptual focus of this review, critical appraisal of article quality was not performed.
Synthesis of results
Reverse integration initiatives, especially in North America, where most studies originated from, have typically followed the principles outlined by Wagner's Chronic Care Model for the treatment of adults with chronic illness and complex health needs. This model, focused on improving health outcomes through the provision of high quality, patient-centered and evidence-based care, has been central to integrated care delivery initiatives in the US, including collaborative care models in primary care settings. Service delivery models and practices were therefore examined using Wagner's Model as a guide to identify the essential elements that encourage high-quality physical health care and chronic disease management (66, 67). A descriptive process was used to identify and synthesize the most common elements within the service models and related outcomes.
Results
A total of 10,610 records were identified through database searching across the two searches on July 19, 2023 and June 6, 2024 (10,036 records from the first search and 574 records from the second search). After removing duplicates, 7,927 titles and abstracts were screened. Following title and abstract screening, 418 articles were eligible for full-text review. Of these, 57 academic articles were included. Eight additional academic articles were included from forward and backward citation searches of the included articles, for a total of 65 academic articles (Table 1). The study selection process is presented in Figure 1. Most articles were from the United States (n = 54). Others were from Australia (n = 3), the United Kingdom (n = 3), Canada (n = 4), and Malta (n = 1).
Table 1. Overview of included studies.
Figure 1. Study selection and exclusion process (PRISMA flow diagram).
Articles included randomized controlled trials (n = 9), quasi-experimental studies (n = 10), longitudinal cohort studies (n = 4), qualitative studies (n = 12), descriptive studies, inclusive primarily of program descriptions (n = 12), pre-post study designs (n = 3), and case studies (n = 4). Please see Table 1 for description of all studies.
We present below a synthesis of our findings, including a description of the integrated care models identified, individual and system-level outcomes, implementation considerations, and associated costs.
Service delivery models and clinical practices promoting physical health service delivery in mental health settings
The number of articles discussing integrated service delivery models and clinical practices increased over time: 21 articles were published from 2010 to 2016, and 44 were published from 2017 to June 6, 2024. Most of the service delivery models and clinical practices described were implemented in public sector community settings in the United States, such as community mental health centers and community-based behavioral health clinics serving adults with SMI. Commonly, initiatives integrated primary care physicians or nurse practitioners (NP) within outpatient behavioral health settings to establish on-site primary care clinics and support coordination with community-based primary health services (49, 56, 68–71). Efforts to integrate primary care physicians and NPs into Assertive Community Treatment (ACT) teams and inpatient psychiatric units to improve the assessment and treatment of physical health comorbidities in this population were also described (72–75). More recently, studies described a novel pharmacist-led collaborative care model leveraging telehealth and population-based care to support medication management, health screenings, and access to multidisciplinary services and community resources for adults with SMI in northern California (76, 77).
The services and practices discussed in the literature leverage different levels of the healthcare system, from macro-level policy levers and grant supports to deliver integrated care to micro-level direct practice changes. Macro-level initiatives, such as the Primary and Behavioral Health Care Integration (PBHCI) grant program in the US provided funding or financial incentives to integrate services for people living with SMI (78, 79). Meso-level initiatives focused on organizing and managing services at regional or organizational levels (80). These initiatives included optimizing leadership and strategic planning within organizations, regular monitoring and reporting of certain health indicators, and creating patient registries to track patients’ physical health needs (81, 82). These meso-level practices aimed to bridge the gap between broad policy directives and individual patient care and ensure that healthcare services are efficient and well-integrated. At the micro level, initiatives included designated healthcare professionals to support the physical health needs of patients within mental health settings and the development of personalized care plans.
The service delivery models and practices described have generally followed one or more of the elements outlined in Wagner's Chronic Care Model (CCM) for treating individuals with complex chronic health conditions (67). The core components of Wagner's CCM include patient self-management support, delivery system design, decision support, and clinical information systems, in addition to organizational commitment to safe, high quality care, and linkage to community resources. Models varied in their description of these components; seventeen of the 51 (33.3%) distinct models described in this review appeared to include four or more components of Wagner's CCM, whereas 20 (39.2%) appeared to include two or less. Among the six CCM components, the ones most commonly addressed include delivery-system redesign (100%), patient self-management support (52.9%) and use of clinical information systems (45.15%). Access to decision support was the component least likely to be discussed in these models (21.6%), although program descriptions were often limited and components of the model may have been missed.
Delivery-system redesign refers to redefining work roles for clinicians and staff to facilitate preventive care, as well as creating new positions as needed to support the care model (67, 83). The models emphasized screening and referral for the treatment of general medical conditions, designated primary care physicians, NPs, healthcare managers, or peer support specialists to monitor physical health issues regularly, and provided psychoeducation on illness prevention (68, 84–87). Patient self-management support, as part of comprehensive care models, involved empowering individuals to recognize and manage their symptoms (66, 67, 83). The support typically combined education and skills training, often facilitated by healthcare professionals such as nurses, NPs, and care managers. Some programs included care managers and peer providers, as well as wellness specialists offering health education on lifestyle factors such as weight loss, smoking cessation, diabetes management, and heart disease prevention (49, 85, 88).
Furthermore, to provide comprehensive physical and mental health care by a multidisciplinary team or across different teams, communication and information sharing among providers is crucial (66, 67). Some studies implemented and improved processes within electronic health records (EHRs) and reminder systems to ensure efficient documentation, information flow among clinicians, and timely reminders for care coordination. For instance, all PBHCI grantees were required to develop a registry/tracking system for physical health needs and outcomes (89). Other programs have enhanced EHR functionality with features like provider alerts for patient transitions, health status registries, standardized order sets and comprehensive discharge reports (74, 90, 91).
Health indicator outcomes
Common physical health indicators assessed in the articles examined included blood pressure, blood glucose, cholesterol, and other cardiometabolic risk factors. Among the twelve studies that reported on physical health indicators, results were promising. Select findings are presented below, with study details described in Table 2.
Table 2. Description of integrated care delivery models/ clinical practices and associated outcomes.
A randomized controlled trial (RCT) by Druss et al. (92) found that integrated care participants received significantly more preventive services and had significantly lower Framingham cardiovascular risk scores compared to controls at 12 months (6.9% vs. 9.8%, p = 0.02). In a more recent RCT, Errichetti et al. (93) demonstrated that intervention group participants had significantly lower systolic blood pressure (adjusted mean difference −3.86, p = 0.04) and average Hemoglobin A1C (HbA1c; adjusted mean difference −0.36, p = 0.001) compared to controls at 12 months, with no differences found in diastolic blood pressure, body mass index (BMI), or cholesterol. Other RCTs demonstrated that integrated care models can improve processes and quality of care (e.g., screening rates for preventive care) if not health and wellness outcomes (49, 55, 68, 84, 94).
In a quasi-experimental study, Scharf et al. (95) reported that compared to control clinic consumers, PBHCI consumers showed greater mean reductions in total and low-density lipoprotein (LDL) cholesterol (36 mg/dl, p < 0.01 and 35 mg/dl p < 0.001 respectively), and greater mean increases in high-density lipoprotein (HDL) cholesterol (3 mg/dl, p < 0.05), though no significant effects were observed for other health indicators such as BMI and HbA1c.
In a controlled retrospective cohort study, Iturralde et al. (77) showed that participants of a pharmacist-led collaborative care model for adults with SMI, compared to controls, achieved greater glycemic (ARD = 9.3; 95%CI = 5.0–13.7) and lipid screening (ARD = 13.0; 95% CI = 8.1–17.9) and increased EKG evaluations (ARD = 6.8; 95% CI = 2.0–11.5) from pre- to post-enrollment compared to propensity matched control participants.
In other studies, Gilmer et al. (96) found that highly integrated programs, compared to programs with low integration levels, led to greater improvements in physical health status (p < 0.01), higher screening rates for blood pressure, cholesterol and blood glucose (all at p < 0.01), a decline in the number of patients who were identified with hypertension and an increase among those identified with prediabetes or diabetes (both at p = 0.01). Similarly, Johnson et al. (70) found that Behavioral Health Home (BHH) participation, compared to no participation, was associated with 0.29 fewer percentage points for HbA1c (p < 0.05) with no changes noted in LDL cholesterol.
Non-controlled studies also reported on the effects of integrating care on common health indicators. A longitudinal cohort study by Pirraglia et al. (97) found that a primary care clinic co-located in a mental health setting for veterans with SMI had significantly improved goal attainment for blood pressure (adjusted odds ratio [AOR] = 2.16; 95% confidence interval [CI], 1.47–3.18), LDL cholesterol (AOR = 1.60; 95% CI, 1.10–2.34), triglyceride (AOR = 1.64;95% CI, 1.06–2.51), and BMI (AOR = 1.81; 95% CI, 1.29–2.54), though changes in HDL cholesterol and HbA1c were not significant. In a pre-post retrospective chart review, Chambers et al. (69) reported a decrease in the percentage of participants with a blood pressure over ≥120/80 mmHg (27.4% vs. 20.0%, p < 0.05) and ≥200 mg/dl total cholesterol (12.0% vs. 8.3%, p < 0.05) between 2015 and 2019, though worsened outcomes were observed in waist circumference during the same period.
Health service use outcomes
Eleven studies reported on healthcare utilization outcomes, with select findings described below (see Table 2 for study details). Integrating physical health care into mental health settings was found to have generally positive impacts on healthcare utilization. Primary care and general medical outpatient care access showed improvements in most studies, while emergency and inpatient service use demonstrated promising but not uniformly positive results.
Johnson et al. (70) reported that BHH enrollees experienced an immediate increase in primary care visits, with 0.18 more visits per month compared to non-BHH participants (p < 0.01). They also reported an increase in general medical outpatient visits per month compared to non-BHH participants (+0.055, p < 0.01). Similarly, Krupski et al. (85) reported that a higher proportion of PBHCI program enrollees in Washington State used outpatient medical services at two sites following program enrollment, compared to propensity matched controls from the same sites. Specifically, the percentage of PBHCI enrollees using outpatient medical services increased from 80% to 92% in site 1, and from 39% to 76% in site 2, compared to limited changes in the control groups (p < 0.003 and p < 0.001 respectively). In contrast, Breslau, Leckman-Westin, Yu, et al. (98), in a quasi-experimental study using administrative health data observed no differences on the odds of having an outpatient medical visit between PBHCI enrollees and control participants in New York State. Similarly, Iturralde et al. (77) found no differences in primary care visits between participants of a pharmacist led collaborative care model and control participants in northern California.
In non-controlled studies, Pirraglia et al. (97) reported that enrollment in a collocated primary care clinic was associated with a significant increase in primary care visits among veterans with SMI and poor primary care engagement, with the median number of visits increasing from 0 to 2 post-implementation (p < 0.001). More recently, Zatloff et al. (98), using a pre-post retrospective chart review, reported significant improvements in the percentage of primary care appointments attended over a one-year period after integrating primary care services within an outpatient behavioral health clinic [t(136) = 14.50, p < 0.001].
Emergency department (ED) use and hospitalization patterns revealed more complex outcomes across studies. Bartels et al. (68), in a randomized controlled trial, found no change in acute service use at the three-year follow-up of a preventive healthcare intervention for older adults with SMI. Breslau, Leckman-Westin, Han, et al. (99), using Medicaid claims data, found that hospital stays for medical conditions increased significantly in PBHCI clinics in New York City compared to control clinics, possibly due to these programs uncovering previously unidentified physical health needs. The relative odds of hospitalization for a medical diagnosis in PBHCI vs. control clinics was 1.21 (95% CI: 1.10–1.32) in wave 1 and 1.33 (95% CI: 1.07–1.65) in wave 2 of PBHCI grant implementation. Furthermore, there was no significant association between PBHCI enrollment and the likelihood of having an ED visit with a medical diagnosis.
In another PBHCI study, Krupski et al. (85) found that program enrollment was associated with a reduction in the proportion of enrollees with inpatient admissions (from 18% to 12%) at one of two sites, compared to propensity-matched control participants (a reduction from 15% to 17%; p < 0.04) but had no significant impact on emergency department use at either site. Using Medicaid claims data from three States, Breslau et al. (100) found that PBHCI program implementation was associated with a reduction in the proportion of enrollees having four or more ED or inpatient visits compared to control clinics, with statistically significant decreases observed in three of the five PBCHI cohorts examined. The reduction in frequent utilization was specific to health service utilization for physical health conditions.
Bandara et al. (101) on the other hand reported that Maryland's BHH program was associated with a reduction in the odds of having an all-cause ED visit compared to non-enrollment (OR:0.87, p < 0.01), though there was no effect on inpatient admission rates per person in a three-month period. The reduction in ED utilization was driven by a reduction in the predicted probability (PP) of having a physical health ED visit in a 3-month period among BHH enrollees (PP: 0.21 BHH enrollment vs. 0.24 non-enrollment, p < 0.01). Similarly Tepper et al. (91) reported that the total number of ED visits per capita decreased significantly among BHH enrollees compared with control participants (p = 0.014). Total psychiatric hospitalizations per capita similarly declined for BHH patients in that study, but remained stable for control group participants (p = 0.002). There were no differences in either the rate or the number of general medical hospitalizations. Furthermore, Johnson et al. (70) reported that relative to control group participants, BHH enrollees had an immediate decrease in emergency department visits (–0.031 visits/month, p < 0.01). They also reported that while inpatient visits decreased over time for both BHH enrollees and control participants before BHH implementation, they decreased more slowly for BHH patients post-implementation. More recently, Iturralde et al. (77) found no significant differences in ED use and hospitalizations between participants of a pharmacist led collaborative care model for adults with SMI and control participants. Lastly, Goh et al. (75), in a retrospective file audit, analyzed admissions to assess medical comorbidities and interventions, finding that adding a medical resident to an inpatient psychogeriatric unit did not affect emergency medical transfer rates.
Barriers and facilitators of implementation
Seventeen studies discussed barriers and facilitators to implementing integrated care initiatives in mental health settings. Multidisciplinary teams, care coordination, administrative support and organizational cultures emphasizing shared responsibility and collaboration were found to facilitate implementation (47, 82, 90, 102). Furthermore, improved organizational communication and patient engagement were associated with enhanced participant outcomes (102, 103).
Finally, effective teamwork, characterized by clearly defined roles and responsibilities among team members, attention to daily workflows, and connection to community programs were found to be crucial for effective collaboration among providers (79, 82, 88, 89, 104). A clear vision emphasizing integration of physical and mental health care in the organization's mission, and leveraging data systems, were also highlighted as essential, along with strong leadership, aligning efforts and resources (79, 86, 102).
The most frequently identified challenges of implementation include securing adequate financial resources, usability and maintenance of clinical information systems, population health management capacity, lack of care coordination, staff retention, and patient enrollment (47, 79, 81, 82, 89, 90, 103–109). Time-limited funding was identified as an ongoing challenge across different settings (79, 81).
McGinty et al. (108), Daumit et al. (47) and Stone et al. (82) reported that Medicaid Behavioral Health Homes (BHH) in Maryland faced tensions between population health management and direct clinical care, and implementation barriers related to limited staff experience, health information technology usability, difficulty engaging external service providers and state regulations impacting service delivery. Workforce limitations, such as high client-to-staff ratios and frequent staff turnover, further complicated care delivery (47, 82).
Scharf et al. (89) highlighted that across 3 integrated care initiatives in New York State, implementation barriers included licensing requirements, information sharing between providers, infrastructure, and sustainability challenges. In other settings, payment structures and low wages for community mental health work were noted to exacerbate staff retention issues (102, 107).
Engaging primary care providers (PCPs) remained a significant challenge in several settings. Negative attitudes toward patients with SMI and limited incentives contributed to low PCP participation in care coordination (47, 107).
Despite these challenges, programs like PBHCI, and Maryland's BHH demonstrated that with robust funding, strong leadership, and effective communication strategies, integrated care models could reduce costs and improve outcomes when tailored to local needs and supported by multi- disciplinary collaboration (89, 100).
Costs and financing
Six studies explored the costs and savings associated with integrating care in behavioral health settings, focusing on funding and reimbursement strategies, cost-savings and sustainability.
In the initiatives examined, funding was allocated through various mechanisms. Ramanuj et al. (79) reported that the PBHCI program, administered by the Substance Abuse and Mental Health Services Administration (SAMHSA), provided $400,000 per year for four years to enable behavioral health clinics to offer primary care services. The program, initiated in 2009, had awarded 189 grants by 2015, with an average of 250 enrollees per grantee. In 2010, in complementary efforts, the New York State Office of Mental Health introduced regulations designed to promote physical health care in mental health clinics by allowing partial reimbursement for health monitoring and health physicals through Medicaid, although insufficient reimbursement for high-cost services hindered adoption (78). The same year, the Affordable Care Act Medicaid health home waiver allowed states to create Medicaid health homes, including behavioral health homes, to provide care coordination and health promotion services for beneficiaries with complex health needs (101). Regarding sustainability, the temporary nature of PBHCI grants was a noted barrier, as clinics struggled with fragmented funding. Ramanuj et al. (79) further concluded that sustaining integration efforts required investments in infrastructure, such as electronic health records and care quality monitoring.
Integrated care models achieved variable outcomes in terms of cost savings. An assessment of a medical care management intervention in community mental health settings serving adults with SMI found a $932 reduction per patient in total costs by the second year of the intervention, with a 92.3% probability of being associated with lower costs than usual care [95% CI (−1973, 102)] (48). The study also highlighted that community mental health centers would need at least 58% of their patients to have Medicaid or other insurance for the program to break even financially. Since only 40.5% of enrollees had Medicaid at the study site, the program appeared unsustainable in the long term (48).
Krupski et al. (85) comparing PBHCI clients with propensity matched controls at 2 sites, found that PBHCI participation was associated with a trend toward reduced inpatient hospital costs per participant per month at one site (–$217.68, p = .06), although no hospital-related cost savings were observed at a second site. Breslau et al. (101), evaluating PBHCI outcomes across three states, found that PBHCI participation was associated with a reduction in the total costs of care per consumer in three of the five cohorts examined, and no significant cost differences in the remaining two cohorts, compared to control sites. Further, sources of cost reduction varied across cohorts: outpatient costs decreased in two cohorts, while emergency department-related costs showed mixed results, increasing in one cohort and decreasing in another.
Connor et al. (78) examined the financial impact of providing physical health monitoring or physical health monitoring plus health physicals for adults with SMI in specialty mental health clinics in New York State, highlighting significant cost barriers. Health physicals were estimated to cost $153 on average but were reimbursed at lower Medicaid rates ($89.48–$129.28). Similarly, health monitoring sessions cost $51, while reimbursements ranged from $33.79 to $48.82. Additional costs for care coordination, such as referrals and follow-ups, strained clinic budgets, especially for freestanding facilities. The authors highlighted these gaps as barriers to sustainability and widespread adoption and called for policies to address them.
Discussion
With a growing interest in addressing the mortality gap among adults living with SMI internationally, a variety of policy initiatives and integrated care models have been described in the literature in recent years. This scoping review sought to examine integrated service delivery models and clinical practices within mental health settings serving adults with SMI and their outcomes, aiming to capture service delivery and practice innovations in this important area.
Most integrated service delivery models and clinical practices described in this review were implemented in community mental health settings in the United States. The service delivery models examined, although often not described in detail, typically involved collocated or integrated primary care professionals, and generally leveraged several components of Wagner's Chronic Care Model, emphasizing delivery system redesign, patient self-management support, and use of clinical information systems. Funding and leadership support, effective teamwork, care coordination, and leveraging data systems were central to implementation efforts (79, 89, 102). Several implementation challenges were highlighted by stakeholders. These included reimbursement mechanisms, high staff turnover rates, difficulties in engaging primary care providers to treat people with SMI, and communication and coordination between team members (47, 78). Furthermore, challenges with poor health information system usability, were common (108). Overall, integrated care models were noted to require investments in comprehensive workforce training, continuous improvement of clinical information systems, and sustained implementation support. Longitudinal evaluation and dynamic adaptation of these models, informed by implementation science tools, such as the Consolidated Framework for Implementation Research, will be helpful to ensure they meet the evolving needs of both patients and healthcare providers (110).
Physical health indicator and healthcare utilization outcomes showed promising results. Inconsistent improvements across health outcomes are not uncommon in the early stages of implementing service delivery changes (95), and program implementation challenges and limited patient engagement may have reduced program effectiveness in some studies. Although some of the mixed outcomes may reflect the need for service improvements (111), managing complex conditions such as diabetes and obesity necessitates both medical interventions and significant behavioral changes, which can be more challenging to achieve and sustain and generally require longer-term follow up to see improvements (112, 113). Notably, significant improvements were observed in cholesterol and blood pressure in some programs (69, 89, 95–97). As approximately 44% of the decrease of death from coronary heart disease in the general population has been attributed to changes in risk factors, including reductions in total cholesterol and systolic blood pressure (114), these improvements underscore the achievements of the integrated care models, and their potential to improve health outcomes and life expectancy in this population.
While most integrated care models increased primary care visits, there were inconsistent impacts on emergency department visits and hospitalizations, highlighting that additional attention is needed to the complex care needs of this population (70, 85, 98, 99). On the other hand, the observed increases in medical hospitalizations in some programs, particularly during early implementation, may represent a positive outcome by identifying and addressing previously unmet medical needs in this historically underserved population. This understanding emphasizes the importance of considering the complex pathway to improving physical health outcomes among adults living with SMI, and the need for tailored person-centered interventions. Short-term follow-up times may also contribute to the lack of integrated care impact on general medical inpatient utilization, as intervention components may require longer timelines to effect positive change (91).
Strengths of this review include the use of rigorous methods and the assistance of a health librarian. Furthermore, the review examined service delivery models and clinical practices that addressed health needs comprehensively rather than focusing on a single disease or on individual risk factors. This approach renders findings more relevant for service planning and policy development aimed at improving general health. Finally, the review was enriched by input from a diverse study team, inclusive of individuals living with SMI and family members, health services researchers, and clinicians serving this population. The inclusion of these varied perspectives guided our efforts to ensure our work, including our research questions and synthesis and interpretation of key findings, is relevant to key stakeholders. As this scoping review focuses on the breadth of research rather than the quality, it does not include a quality assessment of the included articles. The heterogeneity of the interventions further complicates this issue, making it difficult to apply a standardized quality assessment across all sources. Further, the vast differences in health system structures, organization and funding models across countries and jurisdictions highlights the need for caution in interpreting findings, as interventions that are successful, feasible and acceptable in one context may not be applicable or necessarily yield the same effectiveness or cost outcomes in another. Finally, this scoping review was limited to the academic literature published since 2010, potentially missing models of care or practices captured in the grey literature or earlier academic publications. To address the mortality gap among adults living with SMI, health systems and policy makers need to address all contributing factors, beyond healthcare delivery, including substance use, medication side effects and the social determinants of health affecting this population. Despite its limitations, this review offers important insights into opportunities to advance integrated physical and mental health care delivery for people with SMI within diverse mental health settings, setting the stage for more comprehensive policy interventions.
Future research should continue to examine the effectiveness of integrated care interventions over longer periods of time, to assess long term effectiveness. Further, future studies should offer more detailed program descriptions and include measures of engagement among adults with SMI, as current service delivery models continue to present barriers to engagement (115). This understanding will allow for the refinement and dynamic adaptation of service innovations, and improve their acceptability to service users. There is a notable gap in the literature on aging with SMI. While our review included studies on older adults, the limited research available highlights the need for further exploration in this area, given the challenges of cognitive comorbidities and accelerated aging in this population (116, 117). Finally, no studies addressed the physical health needs of long-term psychiatric inpatients, such as forensic inpatients, which may be difficult to address outside of general hospital settings. These long-term inpatient psychiatric care models require attention to improve the quality and comprehensiveness of care and reduce rates of emergency medical transfers to general hospital settings (75).
In conclusion, this scoping review examined service delivery models and clinical practices aimed at integrating physical health care within mental health settings for adults living with SMI. Although studies of integrated care models demonstrated improvements in some physical health indicators and aspects of health care utilization, further efforts are needed to achieve sustained improvements in a range of health domains and ultimately, reduce health disparities in this population. These findings underscore the necessity of ongoing efforts to address the health needs of this population comprehensively and of evaluating the effectiveness of these interventions over time.
Data availability statement
The original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding author.
Author contributions
MA: Data curation, Writing – original draft, Writing – review & editing. SZ: Data curation, Formal analysis, Methodology, Validation, Writing – original draft, Writing – review & editing. OM: Writing – review & editing. CC: Conceptualization, Formal analysis, Methodology, Supervision, Writing – review & editing. BL: Conceptualization, Formal analysis, Methodology, Writing – review & editing. SA: Writing – review & editing. AB: Writing – review & editing. MD: Writing – review & editing. Mv: Writing – review & editing. BK: Writing – review & editing. SS: Writing – review & editing. TR: Methodology, Writing – review & editing. TT: Writing – review & editing. CW: Writing – review & editing. VS: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing.
Funding
The author(s) declare that financial support was received for the research and/or publication of this article. Financial support was provided by the Canadian Institutes of Health Research (CIHR Foundation Grant Number 492136). The funder did not have any involvement in the preparation of this article.
Acknowledgments
The authors would like to acknowledge Talveer Mandur and Maarya Abdulkarim for their contributions to evidence selection.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Generative AI statement
The author(s) declare that no Generative AI was used in the creation of this manuscript.
Publisher's note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
Supplementary material
The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/frhs.2025.1570100/full#supplementary-material
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Keywords: serious mental illness, integrated care, reverse integration, premature mortality, service delivery
Citation: Ambreen M, Zhang S, Melamed OC, Canning C, Lo B, Agarwal SM, Burhan AM, Del Giudice ME, van Kesteren MR, Konkolÿ Thege B, Sockalingam S, Rodak T, Tajirian T, Walker C and Stergiopoulos V (2025) Strengthening the delivery of integrated physical health care for adults experiencing serious mental illness: a scoping review of interventions in mental health settings. Front. Health Serv. 5:1570100. doi: 10.3389/frhs.2025.1570100
Received: 2 February 2025; Accepted: 30 May 2025;
Published: 20 June 2025.
Edited by:
M. Barton Laws, Brown University, United StatesReviewed by:
Brandon Gaudiano, Brown University, United StatesIsaiah Gitonga, Maynooth University, Ireland
Copyright: © 2025 Ambreen, Zhang, Melamed, Canning, Lo, Agarwal, Burhan, Del Giudice, van Kesteren, Konkolÿ Thege, Sockalingam, Rodak, Tajirian, Walker and Stergiopoulos. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Vicky Stergiopoulos, dmlja3kuc3Rlcmdpb3BvdWxvc0BjYW1oLmNh