Suicide Prevention and the Reorganization of Primary Care: The Role of Communication and Role Differentiation in the Era of Team-Based Collaborative Care

Introduction: Primary care is a critical venue for addressing mental health concerns, as it may be the only contact patients at risk for suicide have with the health care system. Indeed, less than a third of patients who died by suicide had contact with mental health services in the year before their deaths while almost three quarters were seen in primary care. Health care providers working in primary care settings thus play a vital role in suicide prevention. To address the increasingly prevalent scope of mental health needs, many primary care practices have begun to co-locate collaborative mental health services. Simultaneously, in response to the increased quantity and complexity of tasks required, primary care practices are increasingly moving towards team-based care, emphasizing new roles for nurses and physicians. The Veterans Health Administration rapidly and systematically adopted both team-based and collaborative mental health in 2010 by launching primary care based Patient Aligned Care Teams (PACTs). The aim of this study is to utilize stakeholder perspectives to ascertain how suicide prevention processes were conceptualized and implemented in the context of PACTs and collaborative care.

Methods:We conducted eight focus groups with nurses and integrated behavioral health providers and in-depth interviews with eight primary care providers from six regions located within one Veterans Administration catchment area in the northeastern US. Transcripts were analyzed using simultaneous deductive and inductive content analysis.

Results: An important theme that emerged from the data was that nurses, primary care providers and integrated behavioral health providers each play critical role in helping to further assess risk and communicate effectively with patients. On the other hand, the clinicians also brought up several barriers, most notably, poor communication about role differentiation, duplication of efforts and challenges that were related to the use of the electronic medical record.

Conclusions: We illustrate how current trends in primary care reorganization, including team-based and collaborative care, may facilitate suicide prevention efforts. In addition, we will discuss several potential communication pitfalls that can result from such reorganization and provide suggestions for mitigating the effects.