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Integration: Time for action, not talk

March 1, 2009
by Larry A. Green, MD
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Integrated care must be a priority

The redesign of primary care practice into modern, person-centered medical homes presents a propitious, if not unprecedented, opportunity to make a leap forward in the care of people with emotional and behavioral problems. A number of developments are coalescing to make now the right time to vigorously launch further practical experiments to derive exportable knowledge for widespread application.

From recent neuroscience research we know that usually no single factor, genetic or environmental, is sufficient to lead to a psychiatric disorder. Our brains' architecture is neither fixed nor static but is reshaped throughout our development by genetics, experience, the external world, and interactions between genes and experience. This capacity to change enables us to learn throughout our lives and enables compensation and recovery from psychiatric illness and, indeed, any illness. It appears that we are on solid ground to conclude that we are complex, adaptive creatures changing throughout our lives in response to what we think, do, and perceive-to become the whole, special person we each are.

Since the early 1990s, there have been stable estimates of why we die before our time and suffer needlessly. About 40% is assignable to behavior, 30% to genetics, 15% to socioeconomic circumstances, 10% to shortfalls in medical care, and 5% to environment. Choices about addictive substances like nicotine and dietary and exercise patterns powerfully influence the development of chronic conditions that wreak havoc on our hearts, lungs, kidneys, vessels, and brains, leading to unsustainably high levels of clinical care expenditures.

We also know that a person with a serious “mental health” problem in the public system dies on average 25 years sooner than other persons, at least in part because of a lack of clinical care. We've known for decades that a large portion of care for persons with mental health or substance use problems occurs in primary care settings, or not at all.

Yet for the first time in decades, the design of primary care practice is unfrozen. The structures and processes of this, the nation's largest platform of formal healthcare delivery, are in active experimentation and redesign (See http://www.transformed.com). New roles are being created, and old ones are being revised. Technologies sufficient to enable evidence-based acute care, chronic care, and preventive services are being adopted and tailored for local implementation in practices all across the country. New connections among clinical providers and public health are being invented. This redesign is still in relatively early phases, presently somewhat like liquid Jell-O in the refrigerator trying to firm up.
We are rich. There are hundreds of thousands of primary care clinicians and behavioral clinicians licensed and at work today. In 2008, we spent on average just a bit less than $8,000 for each person in the United States for healthcare. If U.S. healthcare were a nation, it would be the planet's fifth largest economy by itself.

We have well-researched and carefully articulated guidance from reputable national bodies to guide movement toward integrated care. A 2005 Institute of Medicine report announced the relevance to mental health of the six aims and ten rules proposed to cross the healthcare quality chasm. The IOM called for making care collaboration and coordination for people with emotional and behavioral problems the norm, instead of the exception. It proposed transitioning from isolation or only formal agreements among sectors to clinically integrated practices. Other prestigious bodies have made similar recommendations, such as the President's New Freedom Commission and the World Health Organization.

The 2008 WHO report on why integrating mental health into primary care is so important stated the case in a straightforward manner: The burden of mental disorders is great. Mental and physical health problems are interwoven. The treatment gap for mental disorders is enormous. Primary care for mental health enhances access, human rights, affordability, and effectiveness. Primary care for mental health generates good outcomes.

What holds us back? Many would say perverse payment systems and interprofessional rivalries, and others would say the current economic disaster means hunkering down and getting by with what we have. However, we created the payment systems and, therefore, we can change them. And many look back through history and notice that the United States makes significant changes usually in times of economic distress.

Perhaps those who yearn to close the gap between what we know to do and what we actually do for people with emotional and behavioral problems actually have the rest of the world “right where we want them,” as the current mess begs for practical, sustainable, new solutions. And making room for so-called “mental health” in so-called “primary care” via the emerging person-centered medical home is the chance not of a lifetime, but of a century.

A proven approach to innovations will be required to create integrated care for people with emotional and behavioral problems. We need to perturb the existing systems with promising ideas, grounded in evidence to date; see what happens; and then adapt and reperturb the systems. The cycles that follow will be laden with learning and eventually can result in sustainable innovations.

Behavioral health providers might fit into and inspire “perturbations of business as usual” by initiating contact with local leaders of primary care enterprises committed to modernizing primary care into the patient-centered medical home.

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