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A ROOM IN THE MEDICAL HOME

October 1, 2007
by RONALD W. MANDERSCHEID, PHD
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Consumers deserve “first-floor” access to mental and substance use care in collaborative care systems

A house has different rooms but is still one home. Likewise, a medical home has different specialties but is still a single source of care. The primary care disciplines developed the medical home concept as a simple way to communicate the idea and importance of collaborative care, whether or not the care is physically colocated. For several key reasons, the medical home model is important to the mental health and substance use care fields.

The medical home model will allow our fields to retain their own identities yet be fully collaborative with primary healthcare services. It will permit any entry point to be the “right” door to care. In addition, it will address the needs of mental health and substance use care clients for a full range of primary healthcare services, and it will encourage our fields to effectively address the care needs of consumers with co-occurring mental and substance use conditions.

As we develop our dialogue with colleagues from the primary care and family practice fields, we are going to encounter the medical home model a lot. Like mental health and substance use care, primary care disciplines are in a period of rapid ferment. Also like us, they are trying to overcome their fragmentation and address staffing problems.

The Robert Graham Center, the think tank and research arm of the American Academy of Family Physicians, has been evolving the medical home model, and its staff has reached out to leaders of the mental health and substance use care fields to collaborate on implementing the Institute of Medicine's report on quality improvement for mental and substance use conditions. You will recall that this report calls for the close coordination of mental health, substance use, and primary care services. The Center's staff believes family and primary care practition-ers are primed for change, including close coordination with mental health and substance use care. In a word, these fields are at a “tipping point” much as we are. Our fields' leaders should continue to work with the Graham Center to evolve the medical home model.

As noted above, a major benefit of the medical home model is that it will permit close integration while preserving identity. Clearly, the primary care disciplines have some of the same fears that we do about losing the identities of their disciplines as they work more closely together. The question I want to pose is how can we develop a medical home model that includes the mental health and substance use care specialties. If we are to achieve the vision set forth in the IOM report, then we need to find ways to collaborate closely with our primary care colleagues.

The medical home model could help the government achieve care integration goals. A recent congressional initiative to reform mental health coverage under Medicare would provide coverage for collaborative care among mental health, substance use, and primary care, with coordination achieved through a care manager. This effort would have a much greater chance of success if mental health and substance use care have rooms in the medical home.

Many in our fields already have concluded that we can no longer “go it alone”; in other words, mental health and substance use care can no longer remain separated from general healthcare. The need for working together is underlined by the fact that public mental healthcare consumers die 25 years younger than other Americans, primarily because they do not receive badly needed primary healthcare.

We need to enhance the dialogue with our family and primary care colleagues as a first step in developing a place in the medical home for mental health and substance use care. This dialogue will help us develop a much clearer mutual understanding of our respective fields. I suspect that we will have the pleasant surprise of discovering that we share many of the same problems.

Once we are communicating in an open manner, it will be possible to develop actual on-the-ground demonstrations of collaborative care in the medical home. Current demonstration work usually gives primacy to one field over the other. New demonstrations ought to include work on rooms in the medical home for mental health and substance use care, as well as the reverse: rooms in the “specialty home” for the primary care disciplines. Learnings from these demonstrations can be used to improve our implementation of collaborative care in the future.

We also need to remove impediments that would prevent us from implementing the medical home model. Medicaid audit barriers that prevent payment for primary care and specialty encounters on the same day need to be removed. Federal initiatives always should require, as a condition of award, clearly defined efforts to promote needed collaborative care. Policy initiatives that have collaborative care and service integration as their sole focus are required.

We will want to avoid some things, as well. We do not want to be placed in a FEMA trailer on the back lot of the medical home. We want mental health and substance use care to be treated the same way as any family or primary care discipline. We also don't want an upstairs room in the medical home that is difficult to access through a long, dark, narrow staircase. Mental health and substance use care must be as accessible as primary care.

You get the idea. The medical home model holds a lot of promise for the mental health and substance use care fields.

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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