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1. Discussion: Key Stakeholders in Public Health Issue
Discussion: Key Stakeholders in Public Health IssueORDER HERE FOR ORIGINAL,
PLAGIARISM-FREE PAPERS ON Discussion: Key Stakeholders in Public Health IssueWho are
the possible key stakeholders for the public health issue identified in your problem
statement in DQ 1? What interest would each of these stakeholders have in the public health
issue identified? Why is it important to identify key stakeholders in a policy
analysis?PLEASE:– minimum of 250 words or more– strong academic writing / APA style
7TH ED (please use in-text citing and References at end with hyperlink/ DOI )– used
attached resources or additional ( must be scholarly articles only no older than 5 years )
and reference and in-text cite.– please be original writing and must answer all parts of
question for full credit.Read “Fairness Versus Efficiency of Vaccine Allocation Strategies,” by
Yi and Marathe, from Value in Health (2015).URL:https://www-sciencedirect-
com.lopes.idm.oclc.org/science/article/pii/S1098301514047718?_rdoc=1&_fmt=high&_ori
gin=gateway&_docanchor=&md5=b8429449ccfc9c30159a5f9aeaa92ffbRead “Doing Health
Policy Analysis: Methodological and Conceptual Reflections and Challenges,” by Walt,
Shiffman, Schneider, Murray, Brugha, and Gilson, from Health Policy and
Planning (2008).URL:https://academic.oup.com/heapol/article/23/5/308/617219Explore
the Health Care Policy Analysis page of the RAND Corporation
website.URL:https://www.rand.org/health/key-topics/health-policy/health-policy-
analysis.htmlbarriers_and_enablers_to_integrating_mental_health_into_primary_care__a_poli
cy_analysis.pdfhow_to_write_a_health_policy_brief.pdftoward_effective_water_pipe.docxUnf
ormatted Attachment PreviewBarriers and Enablers to Integrating Mental Health into
Primary Care: A Policy Analysis Anna Durbin, MPH, PhD candidate Janet Durbin, PhD
Jennifer M. Hensel, MD, MSc Raisa Deber, PhD Abstract Integrating care for physical health
and behavioural health (mental health and addictions) has been a longstanding challenge,
although research supports the clinical and cost effectiveness of integrated care for many
clients. In one such model, primary care (PC) physicians work with specialist physicians and
non-physician providers (NPPs) to provide mental health and addictions care in PC settings.
This Ontario, Canada-focused policy analysis draws on research evidence to examine
potential barriers and enablers to this model of integrated care, focusing on mental health.
Funding challenges pertain to incentivizing PC physicians to select patients with mental
illness, include NPPs on the treatment team, and collaborate with specialist providers.
Legal/ regulatory challenges pertain to NPP scopes of practice for prescribing and
counselling.Integrated care also requires revising the role of the physician and distribution

2. of functions among the team. Policy support to integrate addictions treatment in PC may
face similar challenges but requires further exploration. Address correspondence to Anna
Durbin, MPH, PhD candidate, Institute of Health Policy, Management and Evaluation,
University of Toronto, 155 College Street, Suite 425, Toronto, Ontario M5T 3M6, Canada.
Phone: +1-416-8241078; Email: Anna.durbin@gmail.com. Jennifer M. Hensel, MD, MSc,
Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto,
Ontario, Canada. Raisa Deber, PhD, Institute of Health Policy, Management and Evaluation,
University of Toronto, Toronto, Ontario, Canada. Email: raisa.deber@utoronto.ca Janet
Durbin, PhD, Provincial System Support Program, Center for Addiction and Mental Health,
Toronto, Ontario, Canada. Phone: +1-416-5358501; Email: Janet.Durbin@camh.ca Jennifer
M. Hensel, MD, MSc, Center for Addiction and Mental Health, Toronto, Ontario, Canada.
Email: jennifer.hensel@mail.utoronto.ca ) Journal of Behavioral Health Services & Research,
2013. 127–139. c 2013 National Council for Community Behavioral Healthcare. DOI
10.1007/s11414-013-9359-6 Integrating Mental Health into Primary Care DURBIN et al.
127Introduction The integration of care for physical health and behavioural health (mental
health and addictions) has been a longstanding challenge. Although they are likely to have
worse physical health problems than the general population, persons with mental illness—
especially serious mental illness—are less likely to use general, preventive and specialty
healthcare services.1,2 Similarly, substance misuse disorders are now viewed by clinical
experts as chronic diseases, which are often associated with a variety of other side effects
and consequences (e.g. kidney disease, diabetes and major depression).3 One of the topical
subcommittees created in the United States to support the work of the President’s New
Freedom Commission on Mental Health4 in 2002 was charged with addressing the interface
of mental health with general medicine.5 The Institute of Medicine report on Improving the
Quality of Health Care for Mental Health and Substance Use Conditions6 noted the need for
health care delivery to understand and respond to the interactions between mind/brain and
body. Primary care is seen as a focal point for integration, often being the first or only point
of entry to the health care system for individuals with a host of mental and physical health
problems.7 Integration of mental health and addictions services into primary care is
supported internationally 8–12 as a strategy to improve access to person-centred mental
health care, and a number of models have been proposed.The four quadrant clinical
integration model13 is an example. Proposed by the National Council for Community
Behavioral Healthcare, this model locates main responsibility for patient care within the
primary and speciality health care systems, considering the patient’s mental health and
substance use need and risk. In general, it suggests that persons with low mental health and
substance use complexity/ risk be followed in the primary care system with specialty
consultation accessed as needed (quadrant 1), while individuals with high mental health
and substance use and physical health complexity be served in the specialty mental health
and substance use care system, with coordination with primary care. To manage patient
mental health and substance use needs in the primary care setting, the model suggests use
of standardized screening tools and inclusion of a behavioural health provider in the setting
to assist with assessment, treatment and care management. An integrated approach to
behavioural health at the level of primary care is commonly proposed to enhance the

3. capacity of primary care providers to manage patient needs related to mental health and
substance use conditions and comorbid illnesses.5,14 Consistent with quadrant 1 care in
the Four Quadrants model,13 the primary care physician (PCP) and psychiatrist or other
mental health professional are concurrently involved in the patient’s treatment but the PCP
typically remains the ongoing health-care provider.15The PCP may deliver the mental
health care supported by consultation from the mental health specialist (indirect approach)
or may arrange for the mental health specialist to directly provide care, often at the primary
care site (direct approach). Some models combine both approaches.16 Increasingly, other
health professionals on the care team such as social workers, nurses and occupational
therapists are involved. This interdisciplinary team shares information, makes joint
decisions about care, and provides an expanded range of treatments and supports such as
prevention and wellness education, proactive illness management and assistance to
patients to access other services as needed.5,14 Canada, the United States, the United
Kingdom, and Australia are among the locations that have adopted integrated and
collaborative primary care approaches, while acknowledging that many issues still must be
addressed before these models can be implemented on a large scale.8–12 This paper will
focus exclusively on such integrated care approaches for mental health, hereafter referred
to as integrated care (IC).5,14 Benefits of integrated care There are a number of benefits
associated with IC.One is increased population access to mental health care. This is
important because many individuals with mental health needs do not receive mental health
services.17 PCPs are the most commonly contacted providers and often the only providers
contacted for mental health care.17–19 In the United States and Canada, studies have found
that PCPs are responsible for prescribing between 60 and 80 % of 128 The Journal of
Behavioral Health Services & Research 43:1 January 2016 psychotropic medications.20,21
In IC, the same team treats physical and mental health problems, which is an important
advantage since people with mental health issues often receive inadequate physical health
care.22 Studies across a range of health care systems demonstrated that IC models can
achieve clinically meaningful improvements for depression outcomes and public health
benefits in an array of populations, settings and organizations. Specific outcomes that have
been observed are improved symptom outcomes in the short- and long-term, increased
satisfaction with care and greater quality of life.23–30 For patients, receiving services from
PCPs can be less stigmatizing, more coordinated, and more accessible than mental health
specialist services.31,32 Cost effectiveness of IC has also been demonstrated. Dewa et al.33
reported that Ontario employees who received IC had fewer short-term disability days and
returned to work faster. For every 100 individuals this translated into an estimated $50,000
in disability benefit savings (mean of $503 per individual). Similar results were reported by
van Orden et al.24 who noted that IC was associated with significantly shorter referral
delays, reduced time in treatment, fewer appointments, and lower treatment costs. An
additional benefit of IC is the ability to address both mental health and substance use
needs.This is important due to the high rates of mental illness and comorbid substance use
disorders.34 Screening, Brief Intervention and Referral to Treatment (SBIRT)35,36 is an
example of a structured intervention applicable in IC that addresses both conditions. SBIRT
creates an opportunity to engage individuals in care for a problem for which they may not

4. have necessarily sought help. Screening and brief intervention strategies are well-
supported practices to increase recognition and treatment of mental health and addictions
problems in primary care but require willingness, time, and practice changes to
implement.35 Identifying barriers and facilitators to implementing IC is critical, especially
since primary care reform is underway in many jurisdictions internationally and offers
opportunities to support IC. The present study examined the potential impact of primary
care reform on implementation of IC for mental health, using Canada’s largest province
(population: about 13.5 million) Ontario, as an example. The delivery of IC is important for
both mental health and substance misuse management. However, the mental health and
addictions treatment systems are still generally separate and are often addressed in
separate policies and practice literatures. While this policy review focuses on mental health,
a final section addresses some key policy-relevant issues for integrating addictions services
into primary care. Ontario uses a healthcare funding model described by the Organisation
for Economic Cooperation and Development (OECD) as a public contracting model.37
Discussion: Key Stakeholders in Public Health IssueUnder this model, all legal residents
(‘insured persons’) must be covered by the provincially run health insurance system for all
medically necessary care delivered by physicians or in hospitals in order to receive federal
funding under the terms of the Canada Health Act. This legislation is a floor, not a ceiling;
other services may be covered by the provincial plan (and/or by private insurance), but this
is not required. Delivery is largely private; in particular, physicians are private
providers.38,39 Traditionally, primary care in Ontario had been delivered via solo
physicians or small groups of physicians paid through fee for service (FFS) reimbursement.
In recent years, Ontario has introduced several new primary care reimbursement models,
which carry different incentive structures.40,41 While the new models vary in PCP payment
arrangements, all these models link reimbursement at least in part to the number of
patients rostered (or enrolled) in the primary care practice. The main models include:
enhanced (blended) FFS; blended capitation and team-based blended capitation, which are
called Family Health Teams. Salaried physician models are also present in the system but
constitute a very small portion of practices (4 %) and are not considered further in this
analysis.42 In enhanced FFS models, PCP reimbursement is mainly through FFS payments.
In blended capitation models, PCP reimbursement is mainly through a fixed payment based
on the number of patients rostered into the practice (depending on the model, the precise
payments may vary by such factors as age and sex). Team-based blended capitation models
allow Integrating Mental Health into Primary Care DURBIN et al. 129 PCPs to apply for
funding to include non-physician providers (NPPs), such as registered nurses, nurse
practitioners, and social workers, in their practice. In the team-based blended capitation
models only, PCPs may additionally apply to include NPPs (non-physician providers (NPPs),
such as registered nurses, nurse practitioners (NPs) and social workers, in their
practice.43–45 Across all models, these main reimbursement strategies are blended with
other approaches such as incentive payments for delivery of specified services to rostered
patients. Aim With this range of primary care models, Ontario provides an appropriate
setting to conduct a policy analysis of barriers and enablers to IC. Discussion: Key
Stakeholders in Public Health IssueOur analysis focuses on funding arrangements and

5. legislation/regulation related to scope of practice—these have been identified as important
system wide factors that influence delivery of IC.15 For each of these policy areas, the
mental health literature is summarized and then relevance to the Ontario context is
examined. In a final section implications of the findings and strategies for moving forward
are presented. Methods Our search sought information relevant to funding, regulatory/legal
barriers, and enablers to implementation of IC. We conducted an environmental scan of
scholarly literature—Ovid Medline, Embase and Social Work Abstracts and Google
Scholar—using the following key words: mental illness; mental health; collaborative mental
health care; primary mental health care; shared care; integration; legislation; regulation;
legal; funding; reimbursement; remuneration and capitation. We also used Google to search
for relevant legislation, policy reports and position statements by the Ontario government
and by professional colleges and advocacy organizations that pertained to implementation
of IC in Ontario. Feedback from selected Ontario stakeholders helped to clarify retrieved
information and identify additional relevant sources. Results Regarding the impact of
funding, the identified studies addressed patient selection, inclusion of NPPs, and
reimbursement for collaboration. Regarding regulatory/legal issues, the reviewed literature
addressed scope of practice for NPPs related to medication prescription and counselling,
and the role of the physician. The impact of capitation funding models Patient selection
Under capitation, the PCP receives a fixed payment per enrolled patient for delivery of
required care. Thus in theory, capitation encourages care that keeps patients healthy
through prevention, early intervention, and collaboration with other providers.
Comprehensive care can be beneficial for individuals with more complex illness profiles
that include mental and substance use disorders as well as physical illness.46,47 However,
in capitation models, high-needs patients represent a larger financial risk to PCPs, unless
there is adjusted compensation.48 Thus, as has been shown in studies from the United
States, patients with mental illness may be less likely to be rostered by PCPs (cream-
skimming) in capitation models, compared to FFS-based models.49–51 Although more
sophisticated risk adjustment models may theoretically account for the costs of serving
different patient groups, including those with mental illness and addiction issues,52 they
have traditionally been challenging to develop, and often did not sufficiently capture
variability in costs.53 These methods, however, appear to be improving.54 Challenges still
remain due to the wide spectrum of severity of mental illness and substance use disorders,
their varying courses over time, along with unpredictable fluctuations in cost.48,52 This
unpredictability is accentuated because there 130. Discussion: Key Stakeholders in Public
Health IssueThe Journal of Behavioral Health Services & Research 43:1 January 2016 are
often high non-mental health medical costs among persons with chronic mental illness and
substance use issues.54 Recent approaches to risk adjustment may mitigate challenges
associated with this unpredictability. For example, some US states (e.g. Oregon, New York,
and Missouri) have introduced tiered per member per month payment models to allow for
greater payment on behalf of patients who are expected to be high-users based on specific
eligibility criteria, such as having two or more chronic diseases or serious mental illness.55
This approach has been viewed positively by other states and is expected to be adopted in
more widely across the USA. Even if risk adjustment methods are better than they have

6. been, it is questionable if primary care is the most appropriate setting to manage patients
with severe mental illness, as indicated by the Four Quadrants model.13 However, if higher
risk patients prefer to receive care in the primary care setting and/or resist referral to
specialists,32 that preference can be honoured, for example, by developing protocols with
specialist providers to manage care if needs escalate (e.g. when the patient experiences an
acute episode). Inclusion of non-physician providers Reimbursement models can also
influence who delivers care in the primary care setting and, in particular, which NPPs are
included on the care team. Historically in the United States and Canada, health care systems
have emphasized the medical model and physician-delivered care.56,57 The lack of
government funding for non-physician services can be a barrier for widespread adoption of
IC.For example, in Ontario in the 1970s, an effort to introduce NPs into primary care
practices failed largely because the funding model at that time only paid for services
delivered by physicians or in hospitals. Unsurprisingly, PCPs did not find it financially
attractive to pay for NPs without being able to collect payments from the provincial health
insurance plan.58 Sufficient funding is necessary to support recruitment of the right level
and number of NPPs.59,60 Without sufficient funding, quality of care may be compromised
due to shortages of appropriately trained staff and/or heavy caseloads which could be
linked to, for example, employee burnout and high staff turnover.60,61 Application to
Ontario context Ontario’s reforms have resulted in more PCPs operating in blended
capitation, which has the potential to support IC. However, capitation payments to PCPs are
only adjusted for patient age and sex.44 Without these adjustments PCPs incur financial risk
by caring for patients with more severe mental illness—these patients are more likely than
other patients to suffer deteriorations and less likely to comply with treatment
recommendations and follow-up.62 In an effort to address this inherent disincentive to
treat these patients, financial incentives were introduced by the Ontario Ministry of Health
and Long Term Care to encourage PCP enrollment of at least ten patients with bipolar
disorder or schizophrenia. However, there are no policy incentives for PCPs to roster more
than ten patients with these conditions, to roster patients with this diagnosis with more
severe illness or to roster patients with other mental illnesses. Limited Ontario evidence on
inclusion of patients with mental illness into each primary care practice62 indicated that
PCPs in capitation models appear to avoid selecting patients with more severe mental
illness into their practices.This is consistent with an older Ontario study43 that found that
patients in the recently introduced capitation practices in Ontario had lower morbidity and
comorbidity indices than those in the enhanced FFS models. It was not clear if these
patterns were pre-existing or developed after physicians joined capitation-based models,
although ongoing research is addressing these issues.63 Similarly, a qualitative Ontario
study identified low remuneration as an obstacle to rostering homeless patients into an
Ontario primary care practice because of their high rates of mental illness and addiction
issues, and many related social challenges.64 Integrating Mental Health into Primary Care
DURBIN et al. 131 Inclusion of non-physician providers Most funding models in Ontario do
not cover outpatient services by NPPs, thereby requiring patients to pay out-of-pocket or be
covered by private health insurance. However, by 2011, 186 team-based capitation
practices in …Discussion: Key Stakeholders in Public Health Issue