From the biomedical to the biopsychosocial model: the implementation of a stepped and collaborative care model in Swiss general hospitals

Background and objectives
International and national initiatives like the Sustainable Development Goals and the National Strategy on the Prevention of non-communicable diseases aim to reduce the burden of mental health. Early detection of mental health conditions is thus, a major priority of public health. Stepped and Collaborative Care Models (SCCMs) offer an opportunity to early detect and appropriately treat mental health conditions in vulnerable populations, fostering integrated care. This thesis focuses on a SCCM that aims to implement a routine psychosocial distress assessment and offers appropriate treatment to distressed hospital patients. However, integration of mental health services into somatic settings was seen to be challenging in other settings, e.g., primary care. Evidence for patients with mental–somatic multimorbidities in hospital settings is scarce.
Thus, the main objectives of this thesis were to assess the integration of mental health services and to assess implementation of a SCCM into general hospitals in Basel-Stadt, Switzerland (Objectives 1 and 2). The unforeseen coronavirus disease 2019 (COVID-19) pandemic additionally triggered further research questions. We investigated the association between COVID-19 restrictions and mental health of non-COVID-19 hospital patients (Objective 3). Additionally, we explored an alternative method to monitor mental health consequences of the COVID-19 pandemic, the use of Big Data (Objective 4).
Methods
This thesis focuses on a SCCM implemented in four hospitals, three of which were included in the studies presented here: the University Hospital Basel, the University Department of Geriatric Medicine FELIX PLATTER, and the Bethesda Hospital. Including three hospitals differing in structure and focus allowed us to get a broader view of possible facilitators and barriers to the integration of mental health and the implementation of the SCCM. We conducted qualitative interviews with physicians and nurses operating the SCCM at the hospital before (N = 18) and after (N = 18) the implementation of the SCCM. Additionally, we used quantitative data of 873 patients on COVID-19 distress, mental health consequences, and social support collected during periods with different COVID-19 restriction levels, using multiple regression models. The last objective was presented as an opinion paper, highlighting advantages and disadvantages of Big Data based on literature.
Results
Before the SCCM was implemented in hospital settings in Basel, Switzerland, healthcare professionals perceived mental–somatic multimorbidities to be relevant due to their high perceived frequency (Objective 1). Mental health dimensions had, however, a low priority due to suboptimal environments, suboptimal interprofessional collaboration, existing stigma among healthcare professionals and patients, lack of mental health knowledge, and the strong emphasis on somatic diseases. Particularly physicians reported the low priority of mental health, also due to historical views focusing on biomedical aspects and time constraints.
Afterwards, we assessed facilitators and barriers of implementing the first step of the SCCM (Objective 2). The first step of the SCCM is a psychosocial distress assessment of patients through healthcare professionals. Healthcare professionals highlighted the importance of integrating the assessment into preexisting hospital workflows and IT systems. Being able to adapt certain workflows to the needs of the different wards and hospitals was key to adherence and thus, to the sustainability of the SCCM.
Still, structural and social barriers to the implementation of the psychosocial distress assessment were emphasized. Hospitals are characterized by a strong focus on somatic diseases with tight working routines. Adding additional tasks like the mental health assessment constituted a challenge. Besides the strong emphasis on somatic diseases and the time constraints, lack of knowledge, awareness, and familiarity and subjectivity of the mental health assessment were impeding the efforts towards integrated care. This, partially, is also caused by the high turnover rate of physicians.
The implementation of the SCCM described herewas accompanied by the COVID-19 pandemic. The Swiss government set different COVID-19 restrictions depending on COVID-19 case numbers, hospitalizations, and deaths. Thus, we investigated the association between the COVID-19 restrictions and the COVID-19-related distress, mental health consequences, and social support (Objective 3). Multiple regression analyses of non-COVID-19 patients during different levels of COVID-19 restrictions indicated that hospital patients were more distressed related to leisure time and loneliness when stronger COVID-19 restrictions were in place. Surprisingly, this did not result in increased mental health consequences or changes in social support.
Another approach to monitor mental health of the general population or subgroups like hospital patients could be Big Data, such as social media or routine hospital data (Objective 4). These may help to tailor appropriate interventions to populations at risk of mental health consequences. Applying Big Data should always consider ethical and legal concerns to protect privacy and data. Particularly, transparency regarding data analysis may prevent these concerns.
Conclusion
This thesis adds evidence to the integration of mental health and implementation of a SCCM to hospital settings in Switzerland. Structural and social challenges, such as missing knowledge and awareness, strong emphasis on somatic diseases, time constraints, suboptimal environment, suboptimal interprofessional collaboration, and stigma were emphasized by healthcare professionals. To overcome these challenges, hospitals and policy makers need to think about changes in the healthcare system. For instance, task shifts, new roles, and new processes are needed in the hospital setting to better achieve integrated care.
Hospitals are built to care for patients in acute medical situations. Patients with mental–somatic multimorbidities, however, need continuous and long-term care. Certain patient groups (e.g., cancer patients, transplantation patients) receive this care within hospitals. Other patient groups rely on treatment outside hospital. Strong networks between services within and outside hospitals are, thus, essential to guarantee continuity of care.
Overall, the current healthcare system with its strong biomedical focus needs to adapt to the increasing number of patients with chronic diseases, including mental–somatic multimorbidities. This system change could be achieved through learning health systems, where interprofessional and interdisciplinary work is a high priority. Continuously collected data supports the adaptation of the healthcare system to the current needs and evidence base. Thus, the change from the biomedical to the biopsychosocial model may be strengthened.