The Affordable Care Act (ACA) can be expected to foster a dramatic transformation in health service delivery systems operated and supported by counties, including mental health, substance use, and intellectual development/developmental disability (ID/DD) programs. A primary feature of this transformation will be the creation of integrated service systems that combine these separate services into medical homes operated by primary care entities or health homes operated by behavioral health entities. Here, we discuss these developments and how counties can prepare for them.
We have known for more than a decade that separation of primary and behavioral care can lead to very significant adverse consequences. Clients with severe mental illness and substance use conditions who are served by public systems die 25 years earlier than other people. Although lifestyle factors and the adverse effects of second-generation psychotropic medications can contribute to early mortality, lack of needed primary care services clearly is a key factor. At the same time, persons with serious medical conditions, like heart conditions or diabetes, also have worse prognoses and die earlier when they suffer from untreated or poorly treated mental and substance use conditions, such as depression. Hence, service integration is not only advisable, it is absolutely essential for personal longevity and wellbeing.
Stages of Service Integration
Services integration has gone through several stages of development during the past decade. Early service integration efforts included behavioral treatment for mental or substance use conditions, followed by referral to a unrelated primary care practice. Generally, this approach worked very poorly because most clients never appeared at the site to which they were referred.
To solve the problems of referral, a co-location approach (also called bidirectional integration) has been adopted more recently. Behavioral healthcare service units are placed next to primary care service units, or vice versa. This second approach suffers from two problems: lack of sustainability because funding comes primarily from grants, and ineffective service coordination because primary care and behavioral health service units remain separated and do not constitute actual service teams. Since behavioral healthcare funds are “carved out” or separated from health care funds, payment mechanisms for integrated care are very complex, at best, and ineffective, at worst. Grant funds provide a very unstable foundation for this work. Also, co-location does not assure close teamwork on complex cases, and primary care services are not likely to learn about whole health, recovery, trauma informed care, resilience, or peer support services.
Because of the problems of treat-refer and co-location, a new approach to care integration is beginning to be implemented. Called simply full integration, this approach is based on an integrated service delivery team and integrated funding. Full integration can be implemented in either a primary care or behavioral health setting.