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Redirecting Our Care Integration Efforts

November 15, 2019
Ron Manderscheid
By Ron Manderscheid, Executive Director, NACBHDD and NARMH
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The opinions expressed by Psychiatry & Behavioral Health Learning Network bloggers and those providing comments are theirs alone and are not meant to reflect the opinions of the publication.

Care integration remains a superordinate concern of the behavioral health field today. Yet, the exact nature of how we approach care integration continues to shift, in some ways dramatically beyond what we envisioned just a few short years ago. The purpose of this commentary is to help redirect our efforts into these new venues.

First, it is important to review briefly our major care integration foci of the past—change in policy and change in practice.

Change in policy. In the modern era, our effort to change policy in the direction of care integration dates to the mid-1980s. It was at that time we rediscovered that persons with mental illness develop chronic physical illnesses earlier and more severely than do other people. This realization led us to undertake a long series of actions to change policy. They were reflected in the 1998 Surgeon General’s Report on Mental Health (care integration is the task of the next decade), the 2003 President’s New Freedom Commission on Mental Health (there can be no good health without mental health), the 2005 Institute of Medicine report on care integration strategies, the 2008 federal parity legislation, and, ultimately, the 2010 Affordable Care Act (ACA), which codified care integration as national policy. The latter two developments were given impetus by our 2006 mortality study, which shocked everyone, including members of Congress, with the sad and stark finding that public mental health clients die 25 years younger than other Americans.

The ACA made several important changes to promote care integration. Resources were provided to develop medical and health homes; new organizational arrangements, such as accountable care organizations, were codified to house these homes; and person-centeredness became the recommended approach to care.

Change in practice. Viewed in retrospect, it is quite obvious that practice did not change in accord with the evolution of policy. In fact, care integration practice in the behavioral health field still lags considerably today.

Several factors have undoubtedly played a role in slowing actual care integration practice. Primary concerns include fear, complexity and loss of funds.

Although often unstated, fear of care integration is quite pervasive. This fear centers around the perception that one will lose one’s job or that one’s organization will cease operation, or both. It seems unlikely that one will lose his or her job, since behavioral health conditions are so pervasive and our current care capacity is so limited relative to need. Also, the likelihood of an organization ceasing operation probably is less than the likelihood of becoming incorporated into a broader healthcare entity. However, these fears persist and continue to plague our practitioners.

Complexity is another issue. Care integration is not equivalent to adopting a clinical best practice that one learns in graduate school. It can require major organizational change, and it can precipitate culture conflict when different cultures are brought together in the same organization. Careful thought is required to anticipate these issues and address them in any organizational redesign.

Loss of funding when care systems are integrated is a third concern. It is often assumed, rightly or wrongly, that health entities will not provide funding for behavioral healthcare under integrated financing arrangements. As more examples of integrated funding are initiated, we actually will be able to test this assumption. Right now, the issue serves as a presumed impediment to care integration.

Thus, actual care integration has lagged far behind national policy to the detriment of many peers with co-occurring behavioral and physical health conditions.

What can be done?

Recent developments. A number of recent developments are changing the nature of the care integration picture I just have painted. These not only have the potential to address some of the impediments, but actually to alter the face of care integration in ways we did not even envision a decade ago.

Virtuality. The introduction of virtuality into care can have a significant impact on the delivery of integrated care. One provider can be personally present, and one or more others, including peers, can be virtually present through modern communication technology, such as video conferencing. This approach can remove distance and time barriers, and it also can be deployed to avoid some of the organizational and financial impediments noted above.

Cross training. Without joint cross training, behavioral health and primary care providers literally have no joint culture that defines appropriate roles at the point of an integrated care encounter. Recently developed cross training for psychiatrists and primary care physicians conducted in a practice environment is beginning to overcome this chasm. Huge need and opportunity exists to extend this training to other behavioral health and primary care disciplines.

Integration of social services. The need to coordinate behavioral healthcare with social services has been recognized for decades. For example, in the 1980s and 1990s, the federal Community Support Program specifically addressed this need through a care coordinator who sought to assemble a customized array of services for each peer. The modern variant of this procedure is to incorporate social services into care integration arrangements. I call this the “integration of everything.” Better social services can make healthcare services much more effective, both in terms of outcomes and in terms of cost, and they can improve our prevention efforts.

Coordination with public health. Our developing understanding of the role of community health determinants in the genesis of trauma and illness has set the stage for much closer collaboration between the public health and behavioral health fields. To address these issues in the community before they cause health or behavioral health conditions will require the use of public health interventions, and it will require behavioral health practitioners to become adept at these practices. We actually can and should prevent co-occurring conditions before care integration is needed.

Establishing person-centered care. Establishment of person-centered care as the norm can foster a cultural context that promotes care integration. The two are very compatible. Behavioral health has an advantage in this regard, as our concept of recovery already embodies the essential features of person-centered care.

Thus, as we implement care integration, new tools and approaches are available to help smooth the transition. Please consider how they may facilitate your own care integration efforts.

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