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Practical steps toward integration

March 1, 2011
by Lindsay Barba
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Behavioral healthcare providers should start small and retain their recovery focus throughout integration with primary care

Last fall, the Substance Abuse and Mental Health Services Administration (SAMHSA) provided 53 behavioral healthcare organizations with $20.9 million in grants to encourage one of healthcare's fastest-emerging trends: the integration of primary and behavioral healthcare services. This push for integrated care follows the “medical home” model emphasized in the Patient Protection and Affordable Care Act, where clients can access a one-stop shop for all of their person-centered healthcare needs.

For the behavioral healthcare industry this is, at first glance, great news. Individuals with severe mental illness (SMI) suffer a 25-year disparity in life expectancy, due largely to under- or untreated chronic medical conditions. The effort to bring treatments for these ailments onsite with behavioral healthcare services is essential to closing the life expectancy gap and ensuring parity.

But at what cost to behavioral healthcare as an industry? As organizations from the historically-siloed healthcare sectors come together, could behavioral health's recovery-oriented care be forgotten?

A new model for traditional philosophies

If Suzanne Clifford, consultant and former director of the Indiana Division of Mental Health and Addiction, has anything to do with integration, the answer to that question is a firm “no.”

“Identity changes when you get involved in any type of integrated care, but not necessarily in a bad way,” Clifford says. “The system I'd like to see is one that's very collaborative and leverages deep expertise in both primary care and behavioral health, so that we're really focused on what a client needs and how we can come together as a team of organizations to serve that person.”

Clifford, co-author of the Implementation Guide for Integrating Behavioral Health and Primary Care in Ohio (published by the BeST Center, see “A step-by-step guide for integration projects of every size”), has helped behavioral health providers across the U.S. integrate various levels of primary care into their existing services through her work with Inspiring Transformations, a consulting group she founded in 2005. While she encourages the behavioral health organizations she works with to integrate care for the benefit of those they serve, she emphasizes the need to keep recovery-oriented services intact.

“That's one of the cautions I have for people looking at integrated care,” Clifford says. “You have to understand the medical model of primary care, but integrate that into a recovery-oriented approach.”

Step 1: Take inventory, then action

Clifford is quick to point out that though the push for integration is widely supported, its final destination is not one-size-fits-all. “There are a lot of different approaches,” she says. “One model is not better than another; it depends on the specific situation, the needs of the clients, and the needs of the communities.”

To determine the right approach for a given organization, Clifford recommends assessing the needs of the population served and the availability and scope of primary care resources in the community. Start by studying a representative sample population as a reliable way to project the needs and behaviors of clients relative to primary care.

“Determine, for that sample, are they being connected to primary care? How are their health outcomes?” Clifford says. “If people are doing well, which unfortunately is not the norm right now, there may be smaller changes to the system. But if we see that there are significant health challenges, then a much bigger intervention is needed.”

Then, consider access. Take an inventory of accessible community primary care providers-in terms of both distance and reimbursement. Understand the type and extent of services they offer to your clients, as well as those they lack.

Example: Centerstone Research Institute (CRI) of Bloomington, Ind. had trouble identifying a single community resource that could accommodate all of its clients due to clients' varying levels of reimbursement. The local Volunteers in Medicine clinic-a CRI community partner-could only accept clients without insurance, leaving those with Medicare, Medicaid, and private insurance to find another option.

After surveying its patient population to determine if clients were, in fact, seeking other options, CRI realized that “28 percent of clients with SMI did not have a primary care provider at all,” says Bethany Murray, CRI's project director. “Even those with insurance were not accessing healthcare and getting treated.”

To make up for this disparity, CRI developed the Building Exceptional Wellness (BE Well) program, a primary care clinic within CRI's Bloomington behavioral health clinic, which received a $2 million grant from SAMHSA this fall. The clinic will provide primary care services to 250 of CRI's current clients beginning in late 2010 or early 2011.

Step 2: Establish referral partnerships

Suzanne clifford
Suzanne Clifford

For those organizations who find that primary care options in their communities are prevalent, Clifford suggests forging collaborative referral partnerships, rather than building out costly, duplicate services.