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Our need for ‘general contractors’

February 1, 2007
by RONALD W. MANDERSCHEID, PHD
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The foundation of proper behavioral healthcare depends on care continuity

Consider the following: You have just completed work with an architect to design a wonderful new house for your family. After you purchase the site, one team comes to dig and pour the foundation, and another comes to construct the walls. However, the team needed to install the roof never arrives. The walls and foundation are ruined by ice and snow. Unlikely? Not if you neglect to engage a general contractor to organize and mobilize the construction teams in an appropriate sequence. You say, “I would never let this happen to my new house.” Why, then, do we allow it to happen to behavioral healthcare services?

Continuity of care has emerged as the crux of a major problem because it has great potential to fail. Many consumers either do not successfully span the chasm between inpatient and community behavioral healthcare services or do not become engaged in community care once they arrive there. (Similarly, many consumers do not successfully negotiate the chasm between behavioral and primary care services.) The negative consequences of such failures can be devastating. They may include becoming homeless, running out of needed meds, not receiving needed peer support, reentering the hospital after just a short period, or even death. Consumers and family members do have a very strong vested interest in successful care continuity.

Recently, two key meetings on care continuity were held in Washington, D.C. One focused on implementation of a study on how behavioral healthcare continuity currently operates; the other, on major steps that need to be taken to improve continuity. Here, I would like to discuss some of the factors that cause continuity to fail and some of the actions we can take to rectify this situation.

Continuity fails frequently because there is no “general contractor.” The inpatient provider may attempt only a perfunctory effort at coordination, i.e., simply fax the care record to a community provider; the community organization may not engage in outreach to facilitate continuity; system managers may not permit resources to be expended on this function; accreditation standards may not address the topic; and no integrated care record (either electronic or paper) may be available. The net effect is that the consumer leaves inpatient care with a less than evenhanded chance of receiving community care in a reasonable period.

What is needed to improve behavioral healthcare continuity? The following strategies should be considered as we begin to address this important problem:

Revising policies and procedures.At the most fundamental level, we need policies and procedures that encourage both the sending and receiving programs to coordinate care transfer effectively. Accrediting entities should examine current practices and insist through appropriate standards that effective continuity actually becomes part of the treatment regimen, and that periodic reviews be conducted for potential improvements.

Creating integrated recovery plans.As we continue to implement the recommendations of the President's New Freedom Commission on Mental Health and the Institute of Medicine's strategy for care coordination, much greater attention will need to be given to consumer recovery plans. Every consumer should have a recovery plan, and every consumer should have an opportunity to have significant input into the plan's design and content. Clearly, this plan should address continuity of care, and it should specify the major functions of a care coordinator, as described below.

Designating care coordinators.The implementation of a care coordinator system in community facilities, with clear responsibility for specific consumers irrespective of program placement, would go a long way to ensure much better continuity of care. The care coordinator's role should be designed carefully, and the care coordinator's functions should be specified in each consumer's recovery plan. Care coordinators are the “general contractors” we need.

Implementing integrated electronic health records.Although we are still several years away from widespread use of EHRs for behavioral healthcare consumers, these tools hold considerable promise to improve care continuity. Witness the use of the VA EHR system in the post-Katrina context of New Orleans (for details, see http://www.californiahealthline.org/index.cfm?action=dspItem&itemid=114675). Hence, as EHRs are developed, we need to ensure that they contain appropriate content to promote continuity and the sharing of necessary behavioral healthcare information.

Designing payment systems that incorporate continuity.Paying for behavioral healthcare continuity can save money in the longer term. Consumers who lack employment, become homeless, or are incarcerated cost society a lot of money. Behavioral healthcare payment systems need to pay for needed consultation and record transfer, as well as using care coordinators, to ensure successful continuity.

None of us wants the behavioral healthcare house to not have a roof. To achieve this goal, we need “general contractors” to ensure care continuity, as well as policies and systems to support them. Leaders in the field need to form a public-private coalition to advocate for and ensure the adoption of steps to dramatically improve behavioral healthcare continuity in the short-term future.

Ronald W. Manderscheid, PhD, currently Director of Mental Health and Substance Use Programs at the consulting firm Constella Group, LLC, worked for more than 30 years in the federal government on behavioral health research and policy. He is a member of

Behavioral Healthcare's Editorial Board.

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