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Integration of mental health and substance use services with primary healthcare: So much to gain, what not to lose (Charles Curie)

June 23, 2008
by ccurie
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As the title suggests, I would like this first blog to be a consideration of the issue of integrating mental health and substance use services with primary healthcare. This has been a primary topic in recent years at conferences, workshops and in articles. In 2005, the Institute of Medicine issued a report after reviewing a range of documents and research, including the 1999Surgeon General’s Report on Mental Health and continuing with the 2003
President’s New Freedom Commission on Mental Health Report, and cited the importance of integrating mental health and substance use care with general healthcare. A common theme of all these documents is the importance of recognizing that “mental health is essential to overall health” and that if mental illnesses and/or substance use disorders are identified earlier, interventions can be more effective in alleviating the adverse impact of these debilitating conditions. Research has also indicated how depression and substance use can be a complicating factor in other physical diseases, exacerbating or causing those conditions. The case for integrating behavioral health evaluation and intervention into general health and primary healthcare settings was reinforced when the National Association for State Mental Health Directors (NASMHPD) released its data, in 2006, indicating that people with serious mental illnesses lived, on the average, a quarter of a century less when compared to the general population. Clearly, people will benefit by receiving better healthcare if they are treated in a holistic manner and obtain the right evaluation and treatment as early as possible.

However, what do we mean by integration of behavioral health services with general healthcare? There seems to be agreement that the integration of services needs to take place at the point of the individual receiving care. The person should be screened appropriately for mental illnesses and substance use disorders and a pathway to treatment needs to be clearly defined. People with serious mental illnesses should be consistently evaluated and treated for physical conditions that threaten their quality of life and life span. Some good news is that there are several models of effective service integration that are demonstrating positive outcomes. For example, Screening and Brief Intervention (SBI) has been showing good results in identifying substance use disorders and emerging dependence problems. A major challenge is how to bring these models of services integration and practices to the level of “common practice”. This challenge has been a primary focus of many of the forums mentioned earlier.

As we all consider how to realize the integration of behavioral health services with general healthcare, I think we need to be careful not to rush to integrated care without carefully considering what we want to gain and clearly identifying what we do not want to lose. The plusses of integration have been articulated by many experts and are partially considered in the above comments. However, consumers and families have gained influence in shaping policy and programs by voicing what they need to see in a service delivery system. The concept of recovery has had a profound impact on policy and program development and has been shaping outcome measures. We need to make sure we do not lose the ground that has been gained and the momentum to gain further ground in establishing a recovery orientation that is consumer and family-driven in service delivery and financing.

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Dear Charlie:

You raise several important considerations concerning the integration of behvaioral healthcare with all other healthcare. Integration has an intuitive appeal for many who imagine earlier detection and treatment of mental and substance use conditions in primary care settings or improved treatement of co-occurring chronic diseases. Similarly, there is a financial appeal for those who imagine economies from pooling dollars or allocation of behavioral dollars to other medical specialties they may consider more important.

Merging of the dollars is touted as essential to effecting integration of care. However, as the Beatles once crooned "money can't buy you love", and as you correctly cite with the Pennsylvania Health Choices example, without the right safeguards, it also can't buy you behavioral heatlh services. "Integrate" is defined by Roget as "to make into a whole by joining a system of parts". Joining togehter the practices, professionals and infrastructures that comprise care delivery systems is essential to preserving the gains and achieving the advances to which we aspire in the behavioral health community. Moreover, we need to recognize that there are significant gaps (or missing parts) impacting the behavioral health field that integration alone will not solve, most prominently: limited investment in behavioral health promotion and coverage of prevention of mental and substance use conditions and lack of parity in insurance benefits covering behavioral heatlh conditions. Without adequate coverage, the best intentioned primary care practitioners and medical specialists will not embrace fully providing care to persons who are at risk for or have behavioral health and/or co-occurring conditons.

Best, Danna

What a great discussion on this topic of integration of mental health and substance use services with primary healthcare! Danna (6/24 posting) nicely summarized several reasons to continue the movement to integration while at the same time recognized that "adequate coverage" and funding for behavioral health services is essential for primary care physicians to be able to provide integrated care. She is also correct in her second posting (6/25) that the issue I raised on the purpose of carve-outs was to stress the importance of assuring there will be enough dollars specifically "allocated to behavioral health services to meet the continuing needs of individuals who receive care".

In his thoughtful posting earlier this week (7/2), Dave indicated that it is necessary to focus on the "component elements" of services as the approach and framework for moving integration forward. I very much agree with this point. There are several models of integrated care, how care is integrated effectively depends upon many factors that can vary from place to place. If we consider the six aspects Dave outlines, it is clear that such a framework can guide the development of approaches that are best suited to particular and unique practice situations.

Neftali (6/24 posting) makes the point that in his experience financial carve-outs have been an obstacle to providing integrated care. I am confident he is accurate, as there are examples where separate funding streams make providing integrated care or concurrent treatment next to impossible. A key to addressing this is pointed out in Dave's posting where he discusses the Texas example where the "contract content and how it was managed" made the difference in assuring the right incentives were in place. Much attention needs to be paid to assuring that contracts for behavioral health services and physical health services have clear standards and expectations about assuring integrated care. Clear consumer outcomes and what the contract standards include should be central considerations trying to move any system of care towards integration of service delivery.

Thank you to all who have made such great contributions of thought on this important topic. Let's keep this conversation going!

You've certainly selected a hot-button issue for your first blog. Great insight on carve-outs particularly. One of our Editorial Board members recently reminded me that integration doesn't have to be rigid, but rather should be flexible. The field will need this flexibility as it works closer with primary care.

Sorry to be commenting again under anonymous. My signature is below. I though another point interesting regarding the issue raised by Mr. Curie regarding gains made by consumers that could be lost if funding was integrated. From a pragmatic perspective consumers have not really had a voice on all the possible options, only the options available to them, as far as healthcare delivery. Since I work in primary care behavioral health most consumers are surprised when they learn they can see a psychologist and physician at the same visit. 99% of them are pleasantly surprised and come to prefer the flexibility and accessibility of the service versus the commitment often required by specialty mental health practice. The point is that until consumers are exposed to the options, they can't really express a choice and up until now integrated care has not been a reality. So, again, I don't think the merging of the financial stream will be a problem for consumers - especially since I have a hard time seeing folks in primary care who are inundated with mental health needs, not allocating dollars to what most say they need most. In any case, this is a great topic and great Mr. Curie brought it up. We need more of this kind of discussion. great comments by all.

Integration Deconstructed

Integration is one of those words like patriotism or religion that can mean a great many different things depending on one's perspective. In the discussion of integration of behavioral health with general healthcare we all bring something to the table, whether a sense of what could be accomplished, risks, preferred structural or financial models, consumer perspectives or other personal experiences. It is important that all these different perspectives be discussed and it is very gratifying that Charlie has invited us into the conversation.

The ending point of Charlie's post is a great starting point for carrying on the discussion: "Integration of services should take place at the point of the individual coming to the door of care". This statement points us in the direction of understanding the notion of whole health from the viewpoint of the person - absent a label for the person or the door they're entering. To envision this in reality will require many things to be different from where we are today. Frankly, I don't think that focusing on ‘”models of service integration" is as useful as developing a shared understanding of the component elements necessary to impact health outcomes. That's not to say that particular interventions aren't worthy of replication, but to recognize that a holistic view of health requires a holistic framework of interrelated variables that are contributory. Being healthy is more than diet, recovering from mental illness is more than taking medication. Health, broadly stated, is multifaceted.

I would suggest that there are at least 6 distinct but interrelated aspects that deserve attention, efforts to gain consensus and the development of incentives for expansion:
· An organizing conceptual framework
· Identified competencies
· Improvements in service delivery and interventions
· Seeing technology as essential to health outcomes
· Purchasing processes
· Financing models

The most compelling argument for a holistic view of health can be found in the Adverse Childhood Experience Study. This is one of the few examples of the seamless interface between physical and behavioral health and helps frame the notion of integrated health from the person outward to the family, to the community in which they live and the range of services or supports they may find helpful throughout the lifespan. It is the sad state of higher education and clinical training that there is an absence of such organizing frameworks and, by extension, the teaching of competencies that transcend compartmentalized views of a person. There are also competencies needed for leaders who endeavor to change programs, systems or governmental approaches to healthcare.

Imagine what would happen if overnight we all had an "ah ha" moment and found an organizing conceptual framework that brought the needed actions into clear relief. And imagine a holistically trained and competent workforce. For the most part they would find themselves in organizations that have evolved over the past 40 years and have rarely been designed to ensure efficient and effective care delivery. The beauty of the NIATx effort is that it starts with the notion that if program managers walk through their own programs, they will find why things don't work. Having spent more time than I want to with family members in hospitals over the past year, the sad reality is that one requires a full time advocate to force the system to do what it's supposed to be doing in the first place. Staff may be competent, but how services are delivered and the lack of congruence between interventions seriously reduces the odds for success.

The generation that will be taking care of us baby boomers as our health care needs increase will have been raised in a world where technology is second nature. It will be inconceivable that health data isn't shared, that interventions are not delivered over the internet and that instant linkage with content addressing every conceivable question won't be commonplace and expected. What are we doing in our graduate programs, mental health centers, and public health programs to prepare for a technologically savvy workforce? Think about the oft cited example of integrated physical and behavioral healthcare related to a primary care and psychiatric physician consulting on a patient's needs. The deterrent to doing this is that most physicians in primary care settings don't have the time or incentives to do so. Would the potential for consultation be improved if the question, along with a synopsis of the assessment data could be texted via a handheld device and an immediate response received? I think it would.

How we buy things and how we pay for things influences behavior. I fully agree with Charlie's point about carve-outs and the money previously spent on behavioral health disappearing. In Texas a carve-out trumped so called "integrated" managed care models in almost every respect from better access, better coordination, better data and better satisfaction. It wasn't the carve-out model, per se, that made the difference. It was the contract content and how it was managed that was the key. We commit serious errors by assuming that having the ability to reimburse for a service is all there is to it. Developing and managing clinically sound, accountable and performance oriented contracts has not been given significant attention by most state or county purchasers and makes it much more challenging to institute change as quickly as needed.

Finally, we tend to be our own worst enemy. If we are to contribute to the integration of physical and behavioral healthcare we need to accept we're part of it and not continue to wring our hands about not being special enough. We need to be able to adapt to new environments and settings for service delivery. We need to do many things differently, including getting over the notion that we or "our" population is so different as not to be able to change what we do. I had the opportunity to visit a fully integrated community clinic in Oregon a couple of weeks ago and it was eye-opening to see a mature integrated environment where physical and behavioral health clinicians were able to enhance how they approached providing care — and the outcomes for their patients.



To Add to the discussion is the fact that we currently see two different funding streams and systems of oversight for mental health and substance abuse. This division creates extra administrative costs and establishes a pattern payment denials when co-occuring diagnosis are noted. Studies show that between 60 - 75% of the population suffering from a mental health problem have co-occurring chemical dependence issues (and vice versa). This Division of funding streams makes for poorly reimbursed services or clinicians 'choosing' a MH or CD diagnosis rather then noting existence of both. We do not get to 'see' the true problem because the mechanisms for gaining reimbursement actually negatively reinforces accurate diaganosis. We also do not see the growth and development of co-occurring treatment programs because it is impossible to be a hybrid program and get fully reimbursed by two separate systems.

Portland, Oregon

The peoples, who totally facing a challenge of mentally problem.Because they are also like us but their life is always full of painful. So guys we need to do some help and cooperate with them.There are more people in jails and prisons afflicted with mental health illness than in our mental hospitals.

dorkey
Addiction Recovery Rhode Island

I agree with the writer from Portland, that individuals who are consumers of services will not have a problem, per se, with the merging of funding streams. The point that I was making in my earlier note, and that I believe Charlie was making, is that we want to ensure that once merged, the funds will continue to be allocated to behavioral health services to meet the continuing needs of the individuals who receive care.

Your point about engaging individuals who are consumers in this dialogue is well taken and I sent an e-mail about this blog to a few persons.

Finally, as one who hails from Massachusetts where our Health Care Reform initiative to implement universal health insurance is proceeding at a good pace, I would note that we are already running into access challenges. Many of the individuals who are now insured are unable to access primary care physicians (PCPs), due to a shortage of these professionals who are often the gatekeepers of care. The national picture on PCP shortages is not any better and those Medical Schools considered to have the best primary care and family practice training programs report that applications are far fewer than in earlier years for those programs. The large insurers are aware of this development and looking at solutions, but these are not yet defined. This is the reason that I emphasized in my comments yesterday that we need to focus on integrating the "practices, professionals and infrastructures" - to ensure that we have sufficient "hands on deck" in the integrated systems to respond timely and effectively to complex individual needs.

As a professional concerned with integration that will succeed in improving access to holistic care for individuals whose health care needs are, like all of ours, more complex than any one specialty can address, I look forward to the comments of those who are consumers and professionals and are involved now in integrated delivery systems.

I could not disagree more. As a practitioner in primary care and consultant to clinics seeking to integrate care across the country (see: primarycareshrink.com for the model of care I work in) I have seen the struggles that clinics have had in funding integrated care precisely because of carve-outs. By contrast, in states where carve-outs do not exist or exist to lesser degrees (such as WI where I work) the degree of flexibility to implement such programs results in truly integrated care. I also disagree with the assumption that carve-outs have resulted in "provided for an opportunity to develop quality standards, contract requirements and outcome measures that were specific to behavioral health and influenced by consumers and families." I see little evidence of any of this in the cities I have visited. What I do see are distinct, non-communicative systems with different incentives leaving patients, especially those with Medicaid and Medicare with few options for behavioral health. It is true that abolishing carve-outs will not guarantee integration, but a singular funding system would be a welcome improvement. The reality is that mental health services will likely never be well funded - I have found the opposite to be true in primary care. The funds are there because it is much easier to make primary care a national priority than mental health, thus why I have never had to struggle with funding integrated programs at Federally Qualified Health Centers. Good topic.

Neftali Serrano, PsyD (primarycareshrink.com)

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Charles G. Curie is the Principal and founder of The...