Decision makers' perceptions of integrating genetic counselors into primary care

Changes in medicine domestically and globally are transforming primary care in the United States. Many have suggested that primary care is in crisis or at least at a crossroads in the United States. The Annals of Internal Medicine recently devoted much of one issue to this topic.1 Primary care for children and adolescents, however, was not addressed specifically. This article focuses on pediatrics and identifies potential roles and new models for primary care pediatrics. The Institute of Medicine has defined primary care as “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.”2 Starfield3 has defined 4 attributes of primary care including first-contact care, longitudinality, comprehensiveness, and coordination. September 11, 2001, the anthrax scare, and emerging threats such as severe acute respiratory syndrome (SARS) have brought a new focus on the importance of individual-level contacts in addressing population-level threats. Before these world events, however, primary care pediatrics was already grappling with its identity and responding to significant changes in medical systems, science, and family needs. The pace and scope of these changes are such that primary care pediatricians of the future will not be performing the same role as today. Historically, American medicine has tended to be reactive rather than proactive in defining its roles in society. However, dynamic change demands collective reflection; it is time to be proactive in assessing the needs of patients, exploring potential roles as health care providers, and developing the mechanisms to redefine the primary care pediatrician of the future. Projecting future trends requires reflection on the history of the profession of preventive pediatrics. In the 1800s, few physicians in the United States routinely … Address correspondence to Tina L. Cheng, MD, MPH, Johns Hopkins University Department of Pediatrics, 600 N Wolfe St, Park 392, Baltimore, MD 21287. E-mail: tcheng2{at}jhmi.edu

Building the Genetic Counsellor Profession in the United Kingdom: Two Decades of Growth and Development

Organization of Diabetes Care

2005 APA Gold Award: Improving Treatment Engagement and Integrated Care of Veterans

In three primary health care clinics run by Médecins Sans Frontières in the informal settlement of Kibera, Nairobi, Kenya, we describe the caseload, management and treatment outcomes of patients with hypertension (HT) and/or diabetes mellitus (DM) receiving care from January 2010 to June 2012. Descriptive study using prospectively collected routine programme data. Overall, 1465 patients were registered in three clinics during the study period, of whom 87% were hypertensive only and 13% had DM with or without HT. Patients were predominantly female (71%) and the median age was 48 years. On admission, 24% of the patients were obese, with a body mass index (BMI) > 30 kg/m2. Overall, 55% of non-diabetic hypertensive patients reached their blood pressure (BP) target at 24 months. Only 28% of diabetic patients reached their BP target at 24 months. For non-diabetic patients, there was a significant decrease in BP between first consultation and 3 months of treatment, maintained over the 18-month period. Only 20% of diabetic patients with or without hypertension achieved glycaemic control. By the end of the study period,1003 (68%) patients were alive and in care, one (<1%) had died, eight (0.5%) had transferred out and 453 (31%) were lost to follow-up. Good management of HT and DM can be achieved in a primary care setting within an informal settlement. This model of intervention appears feasible to address the growing burden of non-communicable diseases in developing countries.

Mind the Gap

Opioid use disorder (OUD) is commonly treated in specialized care settings with long-acting opioid agonists, also known as opioid agonist therapy, or OAT. Despite the rise in opioid use globally and evidence for a 50% reduction in mortality when OAT is employed, the proportion of people with OUD receiving OAT remains small. One initiative to improve the access and uptake of OAT could be to offer OAT in a primary care setting; primary care clinics are more numerous, might reduce the visibility and potential stigma of receiving treatment for OUD, and may facilitate the care of other medical conditions that are unrelated to OUD. However, it is unknown how effective treating OUD in primary care would be. To assess the benefits and harms of using opioid agonist therapy (OAT) to treat people with opioid use disorder (OUD) in a primary care setting, as compared to a traditional specialty care setting. We searched the Cochrane Drugs and Alcohol Group Specialized Register, Cochrane Central Register of Controlled Trials, MEDLINE, Embase, three other databases, and two trials registers in March 2025. We did not restrict searches by language or publication date. Eligible studies were parallel randomized controlled trials (RCTs) and cluster-randomized trials comparing OAT for OUD treatment in primary care versus specialty care settings. Participants were community-dwelling adults with OUD, as identified and defined by trial-specific inclusion criteria. We excluded trials if they included only pregnant women, or those who were incarcerated, but accepted all other comorbidity requirements (e.g. being HIV positive). Primary outcomes included treatment retention, abstinence from non-prescribed opioids, major adverse events, and withdrawals due to adverse events. Secondary outcomes were other patient-oriented outcomes, including quality of life, patient satisfaction, all-cause mortality, opioid-related mortality, all-cause hospitalization or emergency room visit, all-cause incarceration, and minor adverse events. Two review authors independently extracted data using a predesigned RCT template in Covidence. We assessed risk of bias using the Cochrane RoB 1 tool, and certainty of evidence using GRADE. We analyzed outcomes using Review Manager and a random-effects model to account for variability in care models and populations. We included seven RCTs involving 1992 participants. The studies were completed in France (1 study), Ukraine (1 study), and the US (5 studies), and enrolled predominantly males (75%) with a mean age of 38 years. Risk of bias in individual trials was typically low or unclear in all domains except for blinding, where it was high, given participants and providers could not realistically be blinded to setting. One trial was at high risk of bias related to random sequence generation and another for incomplete outcome data. The evidence is very uncertain whether there was a difference in treatment retention in a primary care setting (risk ratio (RR) 1.15, 95% confidence interval (CI) 0.98 to 1.34; 7 studies, 1952 participants; very low-certainty evidence). Abstinence from non-prescribed opioids at the end of follow-up may have been higher in participants managed in primary care (RR 1.59, 95% CI 1.03 to 2.46; 5 studies, 428 participants; low-certainty evidence). Major adverse events were infrequently reported. Only one trial reported all-cause death (one in primary care versus four in specialty care), but these numbers were too small to be meaningful (very low-certainty evidence). Although data from three studies regarding patient satisfaction could not be combined, patients in primary care may have had greater satisfaction. We downgraded certainty in the evidence twice for indirectness for all outcomes given the studies excluded high-risk patients (e.g. those who were pregnant, had co-dependence on alcohol or benzodiazepines, had psychiatric illness, or were homeless) and primary care providers were often atypical of primary care in general (with connections to, or proximity with, OUD-specialized clinics). We downgraded treatment retention an additional level for inconsistency due to high heterogeneity (I2 = 69%). For lower-risk people with OUD who were stable on OAT, managing their OAT in primary care, as compared to specialty care, the evidence is very uncertain for treatment retention and may have resulted in better abstinence from non-prescribed opioids and better patient satisfaction. Further trials in primary care clinics that have less experience with, or connection to, OUD specialty clinics is warranted.

Barriers to expanding primary care roles for chiropractors: the role of chiropractic as primary care gatekeeper

This study examined the association between provider specialty and guideline-concordant care after the initiation of antidepressant treatment. Medical and prescription claims were analyzed from adults newly diagnosed as having major depressive disorder who initiated antidepressant treatment. Follow-up visits during the first 90 days after the index prescription were identified, and an indicator for receipt of guideline-concordant care (three or more visits) was created. Logistic regression models were used, and propensity score matching techniques were applied. Sensitivity analyses were conducted to investigate how results differed by varying the approach to identify follow-up visits. The study included 4,102 patients, and only 31% received guideline-concordant follow-up visits. Patients receiving their initial prescription from psychiatrists were nearly five times as likely as patients receiving their initial prescription from primary care providers to receive guideline-concordant follow-up care (odds ratio=4.6, 95% confidence interval=3.9-5.4). Routine care for antidepressant management falls short of guideline recommendations, especially in primary care.

Introduction: Mental health disorders in low and middle income countries contribute to roughly 10% of the global burden of disease. In rural areas especially, lower access to care and lack of health services contributes to failure to get proper care and treatment for conditions such as schizophrenia, depression, anxiety, and even suicidal ideation. In settings where resources are low, mental health services from primary health care settings would allow for better detection and intervention strategies. Thus, this study aims to assess the current level of mental health integration in the primary care setting as a baseline for future improvement. Methods: A cross sectional study design using a literature review was conducted on the current mental health status of Ethiopia as well as previous strategies for integration of mental health in primary care. Next, quantitative data was collected from 2 primary care units in Debre Markos town in order to determine mental health utilization under the current health strategies. Program information was collected from a health professional within each primary health care unit along with observational data and document review. Referral data from the Debre Markos reference hospital was also collected in order to assess referral utilization. Results: Attempts for mental health integration into the primary care system are evident through policies of the Federal Democratic Republic of Ethiopia. However, the implementation is recent and the capacity for training and services is low. Low levels of mental health integration were recorded in the primary care setting. Areas of improvement include education and training for primary health care worker and communication between primary and secondary health care systems. Conclusion and Recommendations: Training for mental health services in primary care units is poor. It is recommended greater education and training for the various disorders including epilepsy, substance abuse, and depression are addressed. In addition, funding is necessary to increase utilization, education, and to reduce stigma among mental health patients.

The integration of genetic counselors (GCs) into primary care represents an opportunity for a transformative shift in healthcare delivery, bridging the gap between the historical medical genetics delivery model and the increasing need for genetic services. This paradigm aligns the holistic ethos of primary care with the specialized expertise of genetic counseling and frontline access to preventive care, addressing critical barriers in genetic services. Current genetic service delivery models, concentrated in tertiary care settings, face limitations, including access disparities, fragmented care, and inefficiencies that disproportionately affect underserved populations. Embedding GCs within primary care leverages GCs' unique skills to enhance personalized healthcare delivery, improve risk assessment, and facilitate the implementation of precision medicine. GCs in primary care can streamline referrals, manage routine genetic concerns, and provide genetic continuity of care across the patient's lifespan. This integration ensures that genetic insights are contextualized within patients' day‐to‐day healthcare, fostering equitable and efficient access to genomic medicine. We explore the potential impact of primary care genetic counselors (PCGCs) on healthcare systems, emphasizing the alignment of their scope of practice with primary care principles such as accessibility, comprehensiveness, and continuity. By addressing evolving patient needs and collaborating with primary care teams, PCGCs can increase patient access, reduce system inefficiencies, alleviate pressures on specialty genetics services, and improve health equity. This paper advocates for a collaborative model where GCs are embedded within primary care, enabling proactive, prevention‐focused interventions and enhancing patient outcomes. By integrating genetics into primary care settings, we reimagine genetic healthcare delivery to maximize the benefits of genomic medicine for all individuals. This paradigm shift underscores the urgency of addressing systemic barriers and advancing the role of GCs in healthcare to improve patient and clinician experiences, better population health, and achieve greater health equity.

Reforming England's National Health Service

Back to table of contents Previous article Next article Professional NewsFull AccessCollaborative-Care Models Prove Cost-EffectiveMark MoranMark MoranSearch for more papers by this authorPublished Online:7 Sep 2012https://doi.org/10.1176/pn.47.17.psychnews_47_17_4-aAbstractModels of “collaborative chronic care” can improve mental and physical outcomes for individuals with psychiatric disorders across a wide variety of care settings, and they provide a robust clinical and policy framework for care integration, according to a meta-analysis published July 12 in AJP in Advance.Investigators performing a literature search found 161 analyses from 57 trials involving care of a mental disorder (depression, n=40; bipolar disorder, n=4; anxiety disorders, n=3; multiple/other disorders, n=10). The meta-analysis indicated significant effects across disorders and care settings for depression as well as for mental and physical quality of life and social-role function.Moreover, total health care costs did not differ between collaborative-care models and comparison models.The report was titled “Comparative Effectiveness of Collaborative Chronic Care Models for Mental Health Conditions Across Primary, Specialty, and Behavioral Health Care Settings: Systematic Review and Meta-Analysis.” The analysis was conducted by Emily Woltman, Ph.D., of the Brown School of Social Work at Washington University, and colleagues.Collaborative care—also known as “integrated care”—is a feature of the delivery-system reforms in the new health care reform law, and policymakers and many clinicians have converged on the idea that the full range of medical services should be brought together in patient-centered locations. Integrated care was the theme of immediate past APA President John Oldham, M.D.’s presidential year. And today, a small but dedicated cadre of psychiatrists is advancing the cause of integrated care and the participation of psychiatrists in collaborative-care models (Psychiatric News, October 21, 2011).Integrated-care models have evolved from the traditional consultative role that consultation-liaison psychiatrists have practiced, to a “co-located” model in which psychiatrists see individual patients in a primary care clinic, to a fully collaborative care model in which a psychiatrist takes responsibility for a caseload of primary care patients and works closely with primary care clinicians and other primary care–based mental health care providers. Though models may differ, the core principles of collaborative care are constant: patient-centered care teams providing evidence-based treatments to a defined population of patients using a measurement-based “treat-to-target” approach. (The latter refers to the use of tested instruments so that symptoms can be measured with numerical targets established for clinical treatment goals.)In the AJP in Advance analysis, randomized, controlled trials comparing collaborative-care models (CCMs) with other care conditions, published or in press by August 15, 2011, were identified in a literature search and through contact with investigators. CCMs were defined as interventions with at least three of the six components of the Improving Chronic Illness Care initiative developed by the Robert Wood Johnson Foundation. Those components include patient self-management support, clinical information systems, delivery-system redesign, decision support, organizational support, and community resource linkages. (Details about the initiative are posed at www.improvingchroniccare.org/.)Articles were included if the CCM effect on mental health symptoms or mental quality of life was reported. Data extraction included analyses of these outcomes plus social-role function, physical and overall quality of life, and costs.An example of a trial of collaborative care that was included in the analysis was a report titled “Collaborative Care Management of Late-Life Depression in the Primary Care Setting: A Randomized, Controlled Trial,” which appeared in the Journal of the American Medical Association (December 11, 2002).In that trial, patients were randomly assigned to a collaborative-care intervention or to usual care. Patients had access for up to 12 months to a depression care manager who was supervised by a psychiatrist and a primary care expert. Services included education, care management, and support of antidepressant management or a brief psychotherapy. The report found that at 12 months, intervention patients had a significantly greater reduction in depressive symptoms from baseline compared with usual-care participants. Intervention patients also experienced greater rates of depression treatment, more satisfaction with depression care, lower depression severity, less functional impairment, and greater quality of life.Woltman and colleagues said that the analysis demonstrates the cost-effectiveness and outcome-enhancing utility of chronic-care models. “CCM effects were robust across populations, settings, and outcome domains, achieving effects at little or no net treatment costs,” they wrote. “Thus, CCMs provide a framework of broad applicability for management of a variety of mental health conditions across a wide range of treatment settings, as they do for chronic medical illnesses.” “Comparative Effectiveness of Collaborative Chronic Care Models for Mental Health Conditions Across Primary, Specialty, and Behavioral Health Care Settings: Systematic Review and Meta-Analysis” is posted at http://ajp.psychiatryonline.org/Article.aspx?ArticleID=1213771. ISSUES NewArchived

Health Care Reform and Care at the Behavioral Health--Primary Care Interface

Back to table of contents Previous article Psychiatry and Integrated CareFull AccessNIMH Fosters ‘Practice-Ready’ Solutions to Integrating Primary, MH CareMark MoranMark MoranSearch for more papers by this authorPublished Online:19 Mar 2014https://doi.org/10.1176/appi.pn.2014.3b11AbstractResearch at the interface of mental health and primary care should focus on generating knowledge that decision makers need and incorporating practice-based evidence.Courtesy NIMHIn any area of clinical practice, what drives innovation is research. The same is true for the new movement toward integrated care. And there has been a history—at the National Institute of Mental Health (NIMH), the Agency for Healthcare Research and Quality, the John A. Hartford Foundation, and the Robert Wood Johnson Foundation—of funding research on best practices for integrating mental health and primary care. The Collaborative Care for Depression Model, as exemplified by the IMPACT program developed by Jürgen Unützer, M.D., M.P.H., and colleagues at the University of Washington, is a prominent example of an innovative model with more than a decade of research behind it (Psychiatric News, August 2, 2013). In an interview with Psychiatric News, Susan Azrin, Ph.D., of the Division of Services and Intervention Research at NIMH, talked about new NIMH initiatives designed to bring “practice-ready” innovations concerning mental health-primary care integration to primary care settings—and to community mental health centers working to integrate primary medical care for patients with serious mental illness.“More than 30 million previously uninsured people will enter the U.S. health care system this year as a result of the Affordable Care Act and its expansion of Medicaid,” Azrin said. “About 6 million of these newly insured people will have untreated mental health problems, and many are likely to have multiple chronic medical conditions due to a lack of prior care, and their overall health may be poor. Primary care will be the likely health care entry point for these complex patients, so there is a new urgency in the mental health-primary care interface.”Because of the unique difficulties of primary care clinicians seeing complex patients amid competing demands, as well as system and reimbursement challenges, bringing research-tested innovations in integrated care to clinicians’ practices has not been without problems. “Previously, integrated care research at NIMH and elsewhere has tended to follow the traditional linear approach to intervention development,” Azrin said. “The linear approach attempts to translate findings conducted under highly controlled conditions to diverse community settings. But bridging the research-to-practice gap for integrated care has been slow with this approach. Interventions shown effective in clinical trials often have only modest traction in the primary care community.” She said what’s often been lacking in this research is an early focus on the intervention’s potential for sustainability and uptake. “Primary care practices need flexible mental health care interventions that are relevant to the majority of their patients and compatible with the realities of primary care practice,” Azrin said. “To meet this practice need, the research field should focus on flexible, integrated care models that target multiple psychiatric and medical comorbidities and are compatible with the reality of the primary care setting.”Specifically, she said, such research should focus on generating knowledge that decision makers need, incorporating practice-based evidence, using efficient methods, and planning for sustainability and broad uptake from the outset.She described three NIMH-funded efforts that hold promise for delivering practice-ready integrated care solutions to the physician’s office.Antidepressant Adherence via Interactive Voice Recognition; primary investigator: Gregory Clarke, Ph.D., of Kaiser Permanente.This study is testing a very-low-cost direct-to-patient antidepressant adherence intervention using automated telephone interactive voice recognition. Study participants are identified using electronic medical records, and recruitment is by mailed brochures, which is inexpensive and similar to how patients might access such an intervention in real-world practice. Participant exclusions are minimal, resulting in a highly generalizable sample, and the intent-to-treat design allows Clarke and colleagues to assess both intervention dropouts and completers to better understand who would participate in the intervention. Additionally, Clarke and colleagues will conduct evaluative qualitative interviews with study participants and other key stakeholders to identify barriers and/or facilitators of intervention implementation, as well as keys for future dissemination.Physician Training to Support Patient Self-Efficacy for Depression Care Behaviors; primary investigator: Anthony Jerant, M.D., of the University of California, Davis. This study will seek to train primary care physicians (PCPs) in the use of self-efficacy enhancing interviewing techniques (SEE IT) with patients who have coexisting depression and diabetes. SEE IT is a low-intensity, low-cost, 15-minute provider-training intervention to increase patients’ ability to effectively manage these co-occurring conditions. Jerant and colleagues are training PCPs at 14 offices to use SEE IT with patients during routine office visits. If effective, Azrin said, SEE IT could easily be used with a broad range of PCP patients to increase self-efficacy for managing many mental and general medical conditions that require self-management strategies.The Mental Health Research Network (MHRN), led by psychiatrist Gregory Simon, M.D., of Group Health Research Institute. This is a practice-based research network of 11 public-domain research centers based in not-for-profit health care systems. Azrin said the network exemplifies the “health care system as lab approach,” where critical practice problems drive the research questions and the data needed to answer them. MHRN is conducting a surveillance study of depression treatments and evaluating their effectiveness using routinely collected scores on the nine-item Patient Health Questionnaire (PHQ-9). The network is also developing capacity for a trial of population-based suicide prevention programs with 15,000 outpatients who, based on the PHQ-9, are at risk of attempting suicide. “Given the diversity of its primary care practices and patient populations, the MHRN offers an ideal infrastructure for rapid and efficient development of practice-ready integrated care solutions,” Azrin told Psychiatric News. What about research focused on bridging the gap between primary care and care of people with severe and persistent mental illness in community mental health centers and public mental health settings? Azrin said that NIMH funds a number of research projects—by Benjamin Druss, M.D., of Emory University, Martha Sajatovic, M.D., of University Hospitals, Cleveland, Stephen Bartels, M.D., of Dartmouth Medical School, and Gail Daumit, M.D., of Johns Hopkins University, among others—to address this problem.For instance, in Daumit’s Randomized Trial of Achieving Health Lifestyles in Psychiatric Rehabilitation (ACHIEVE) nearly 300 people with schizophrenia, bipolar disorder, or major depressive disorder were divided into two groups—half participated in a program focused on improving eating and exercise habits, while the other half received no special training. Weight loss in the intervention group increased progressively over the 18-month study period and differed significantly from the control group at each follow-up visit. At 18 months, the mean between-group difference in weight was −7.0 pounds. The results were published in the New England Journal of Medicine (April 25, 2013). In addition, NIMH recently issued a major funding announcement titled “Improving Health and Reducing Premature Mortality in People With Severe Mental Illness.” Azrin said the initiative supports research to test the effectiveness of service interventions that aim to reduce common modifiable health risk factors that contribute to premature mortality for adults with severe mental illness, as well as for children with serious emotional disturbance. Azrin said that the Affordable Care Act has introduced powerful momentum toward integrated care, and she described a research agenda that is now intensely focused on generating the evidence that clinicians can use and that health care decision makers need. “The evidence most valued by decision makers answers questions such as: Will the intervention work in my setting? For which patients will it work? What staff can deliver the intervention? How much training will they need? And what will it cost?” ■For more on this subject, see Susan Azrin’s article in Psychiatric Services, “High Impact Mental Health–Primary Care Research for Patients With Multiple Comorbidities,” posted at http://ps.psychiatryonline.org/Article.aspx?ArticleID=1831984. An FAQ primer on integrated care is posted at http://psychnews.psychiatryonline.org/newsarticle.aspx?articleid=1742623. ISSUES New Archived