Patient-centered medical homes for patients with severe mental illness: utilization and quality of care variation in rural and urban areas

In rural areas, people with severe mental illness (SMI) often have more difficulties accessing mental health services. As a result, the responsibility for addressing both physical and mental needs is likely to fall to the primary care provider. The patient-centered medical home (PCMH) has been proposed as a model for prevention, care coordination, and management of chronic disease. There is a growing body of literature on adults in the PCMH. However, there is very little on people with SMI in the PCMH and the performance of the model in rural versus urban areas remains unknown. The objective of this dissertation was to examine the performance of the PCMH for Medicaid beneficiaries with SMI living in urban and rural areas based on a set of health services utilization and quality of care outcomes. First, it examined if there were differences for Medicaid patients with SMI between urban, non-metropolitan urban and rural PCMHs. Next, it focused on the impact of the PCMH in rural areas by examining primary care provider experience with SMI and, then, the interaction between the mental health workforce supply with primary care provider experience with SMI. North Carolina Medicaid administrative paid claims data from 2004-2007 was used to analyze the outcomes in this dissertation. There were differences between urban, non-metropolitan urban, and rural PCMHs for some, but not all outcomes among people with SMI and there was some variation by SMI diagnoses. Within rural PCMHs, the impact of experience with SMI showed higher primary care and specialty mental health use, but also emergency department use. There was no impact of the interaction between primary care experience with SMI and mental health workforce shortages across all of the outcomes studied. Findings from this dissertation suggests that rural and non-metropolitan urban PCMHs may benefit from targeted resources to help close the remaining gaps in health services utilization and medication adherence for people with SMI. Several areas for future research exist that can advance our understanding of effective coordinated care models in order to inform future policy decisions regarding programs aimed at improving care for people in rural areas with SMI.Doctor of Philosoph