Introduction:
Effective and appropriate provision of mental healthcare has long been a struggle globally, resulting in significant disparity between prevalence of mental illness and access to care. One attempt to address such disparity was the Patient Protection and Affordable Care Act (PPACA), 2010, mandate in the United States to integrate physical and mental healthcare in Federally Qualified Health Centers (FQHCs). The notion of integration is attractive, as it has demonstrated the potential to improve both access to mental healthcare and healthcare outcomes. However, while the PPACA mandate set this requirement for FQHCs, no clear process as to how these centers should achieve successful integration was identified.

Methods:
This research employed case study methods to examine the implementation of this policy in two FQHCs in New England. Data were obtained from in-depth interviews with leadership, management, and frontline staff at two case study sites.

Results:
Study findings include multiple definitions of and approaches for integrating physical and mental healthcare, mental healthcare being subsumed into, rather than integrated with, the medical model and multiple facilitators of and barriers to integration.

Conclusion:
This study asked questions about what integration means, how it occurs, and what factors facilitate or pose barriers to integration. Integration is facilitated by co-location of providers within the same department, a warm hand-off, collaborative collegial relationships, strong leadership support, and a shared electronic health record. However, interdisciplinary conflict, power differentials, job insecurity, communication challenges, and the subsumption of mental health into the medical model pose barriers to successful integration.In the United States, approximately 46.4% of all adults will experience mental illness during their lifetime, but a well-documented disparity persists between the numbers of people who are living with a mental illness and those who access services and treatment.1–3 In 2019, 20.6% of US adults were diagnosed with a mental illness, less than half of whom received any mental health service. In the same year, incidence of serious mental illness, that is, those that significantly impair an individual’s ability to carry out regular life activities, was 5.2% of US adults, of whom 65% received mental health services. 4

A significant piece of legislation that sought to address problems of access to services for people with mental illness was the Patient Protection and Affordable Care Act (PPACA), 2010. The Act’s stated intent is to “improve access to and the delivery of healthcare services for all individuals, particularly low income, underserved, uninsured, minority, health disparity, and rural populations.” 5 One goal is to promote the integration of physical and mental healthcare in community-based centers.

This article presents findings that provide a roadmap for Federally Qualified Health Centers (FQHCs) to integrate physical and mental healthcare, discussing both facilitators and barriers to integration. To understand the process of integration, a background on the development of FQHCs and of health center organizational behavior is provided.

The development of community-based care
The development of US mental health policy demonstrates a shift over time from the asylums and self-reliance of the 18th-century mental health ethos to the large inpatient psychiatric facilities of the 19th century to care in the community, first proposed in the mid-20th century.6,7 Numerous policies, including the National Mental Health Act, 1946, the Community Mental Health Centers Act, 1963, and the Mental Health Parity and Addictions Equity Act, 2008, were developed to attempt to address the aforementioned gap between prevalence of mental illness and access to services.

Individuals are more likely to follow up on referrals to mental healthcare if such care is provided in the same location as their physical healthcare and if their providers work in a multidisciplinary team.8,9 Furthermore, by providing physical and mental healthcare in one setting, the idea of accessing mental health services is normalized. 10 Community Health Centers (CHCs) were established in the 1960s to provide healthcare to low-income individuals with limited or no health insurance.11,12 Following the establishment of these centers came FQHCs that provide comprehensive healthcare, including, but not limited to, physical healthcare, mental healthcare, and dental care to low-income individuals in their community. Nationally, the number of FQHCs increased from 545 in 1990 to 1385 in 2019. 13

The PPACA (2010) mandated that FQHCs integrate physical and mental healthcare and provided US$11 billion in new FQHC funds to support this integration. 14 The objective then of the PPACA mandate for FQHCs to integrate physical and mental healthcare was to provide comprehensive care, improve outcomes, and reduce disparities in treatment.5,15–18 Integrated behavioral health can be delivered in a brief, economical format, and research demonstrates positive clinical outcomes, as well as high levels of patient and health provider satisfaction.19–22

Organizational behavior
An organization’s culture, mission, and relationships between different levels of agency workers impact outcomes. Organizational culture and influence are shaped by the agency’s values and beliefs, and organizational culture informs its mission and purpose.23,24 Any one agency can have competing cultures, although one culture may be more prominent than others. This can give rise to problems when tasks that fall outside the purview of the dominant culture do not get the same attention or resource allocation. 25 Thus, decision making about which services receive resources is indicative of the agency’s perception of the value of mental healthcare relative to other priorities, and a commitment to truly integrate care. 26

The dynamic between agency leaders, management, and practitioners and the effect on outcomes Relationships and communication between workers at different levels within an agency have importance in how care is provided and integration policy is implemented. The top-down approach focuses on the role of leadership in policymaking and implementation.27–29 Leadership (the top) establishes agency goals, policies, and practices, and frontline workers (the bottom) carry out their directives and it is how leadership perceives mental illness that shapes service delivery. However, the bottom-up approach suggests that it is frontline workers or street-level bureaucrats who have influence and discretion in implementing and creating policy; thus, their perceptions of mental illness can impact how policies are put into practice. 30 Thus, the top-down approach focuses on goal achievement, whereas the bottom-up approach focuses on problem solving.31–33
The purpose of the research is to understand the facilitators and barriers to integrating physical and mental healthcare in FQHCs. The research questions how organizational policies serve the needs of different actors; therefore, it is important to consider integration from different perspectives within the FQHC.This article analyzes findings from a 6-month qualitative study to understand how physical and mental health integration occurs in FQHCs. The study was conducted by the first author, comparing and contrasting the state of integration in two FQHCs, via two methodologies. 34 First, a case study methodology was utilized to understand the co-location, coordination, and integration of each center from its respective employees. Second, a critical epistemology was utilized, to capture impressions of practical deployment of integration by the degree of equality, empowerment, and voice of the different levels of actors at each site. The rationale for using this approach is that the case study methodology permitted deep analysis of FQHCs’ policies and practices and the critical approach seeks to uncover inequality and disparity in society. The study involved the collection and qualitative analysis of data obtained from in-depth interviews with agency staff at two FQHCs. 35

Sampling strategy and ethical issues
The research took place at FQHCs situated in a large urban center in the New England region (USA). An initial set of 15 potential sites was identified from an analysis of characteristics of local FQHCs; final selection was informed by consideration of a number of criteria (see Table 1). Taking these criteria into account, two FQHCs, Site A and Site B, met all inclusion criteria. Participants were recruited by purposive and by snowball sampling. Prior to beginning the research, a full Institutional Review Board (IRB) application was approved by the University of Massachusetts in December 2013 (Protocol #: 2013227); the study was completed in 2015.