(This blog post is a reprint of a piece in the CFHA Blog from January 15th, 2015. Click here for the original post. Reprinted with permission.)
In primary care, more than half of the office visits are for somatic complaints, which are often associated with depression and anxiety. These conditions often go undetected and can have a significant impact on health outcomes. As providers adopt a collaborative approach to care, many have incorporated the use of assessments for screening and early detection of symptoms of mental health and substance use conditions.
With an abundance of assessments, measures, and tools available for use, many collaborative care practices are challenged with determining which are most effective for use in the limited time available during a routine office visit. Screenings are important for all age groups. Below is a list of the top ten tools for use in practices. These ten were selected based on a number of factors, including reliability, validity, sensitivity, efficiency, and cost. In most cases, the tools are available for use at no cost. Most are also available in multiple languages as well.
PHQ-9: The Patient Health Questionnaire (9) is widely used among primary care providers to identify depression. With only nine questions, this tool is easy to use and has been validated for early detection.
AUDIT: The Alcohol Use Disorders Identification Test is a 10-item questionnaire developed by the World Health Organization and is found to be very effective in primary care settings.
GAD-7: The seven-item General Anxiety Disorder screening identifies whether a more complete assessment is needed.
DAST-10: The Drug Abuse Screen Test is a brief 10-item self-report tool that is effect for screening adults and adolescents for drug abuse.
PC-PTSD: This four-item screen is effective for detecting post-traumatic stress disorder in primary care settings.
Pediatric Symptoms Checklist: The 17-item version is easy to use in family practices for detecting developmental and behavioral problems.
SBQ-R: The Suicide Behaviors Questionnaire is a four-question scale for assessing suicide-related thoughts and behaviors.
Brief Pain Inventory: The tool is widely used in medical settings for assessing pain, and is available in 23 languages.
Insomnia Severity Scale: This seven-question screening assessment is effective in identifying problems with sleeping.
MDQ: The Mood Disorder Questionnaire (MDQ) is a 13-item questionnaire used to screen for bipolar disorder symptoms.
In order to limit the list to ten, there are many excellent tools that did not make this list. For example, some providers prefer the CAGE-AID to the AUDIT-7 for alcohol screening. In addition, many will find it very useful to have additional tools on hang to screen for additional conditions, such as:
Geriatric depression
Eating disorders
Postpartum depression
Intimate partner violence
ADHD
Autism
Integrating these tools into your electronic health record, including them in patient kiosks, and/or instructing support staff to make select tools available for completion while in the reception area are ways in which these cools have been included in practices. With routine use of many of these screening tools, collaborative care practices will efficiently and effectively detect signs and symptoms of behavioral health conditions. This enables earlier intervention, resulting in better health outcomes.
When Bob Dylan wrote this iconic song, many felt that it captured the spirit of social and political upheaval of the 1960s, much in the same way that we view mental health as “a-changin’.” And these changes require mental/behavioral health providers to change the manner in which they deliver services.
Reports over the past decade have brought attention to the current mental health crisis:
In addition, over the past few years far too many catastrophic events have brought attention to this mental health crisis, resulting in a public outcry, demanding that changes are made to prevent future tragedies.
But change isn’t easy.
The relatively brief history of community mental health services has been a challenging one. Just a few months ago, as we celebrated the 50th anniversary of President John F. Kennedy’s signing the Community Mental Health Bill into law, the conversations quickly progressed to the subject that is on the minds of virtually all behavioral health providers—and an unusually large number of the general public and policy makers, given the historical lackluster interest in the topic—mental health is in dire need of change.
The economic downturn in the US in 2008 resulted in massive budget cuts in all but a few states. The March 2011 NAMI report, State Mental Health Cuts: A National Crisis, demonstrated the cumulative cut to mental health services in the U.S. during that time was nearly $1.6 billion. Community mental health services plummeted from being barely adequate to the critical point in many states. Safety-net providers were forced to close programs due to the slashed budgets. Many of those affected ended up on the streets or in jail.
The recent announcement on the anniversary of the Sandy Hook tragedy, of the planned infusion of dollars into help repair our broken mental health system, is encouraging. However, the entire mental health system is in dire need of an overhaul. One that looks at the broader healthcare picture and strategically plans for mental health and substance use disorder treatment to be included. A person-centered, whole health approach to treatment is necessary for improving the patient experience of care; improving the health of populations; and reducing the per capita cost of health care: the Triple Aim.
Dale Klatzker, PhD
Dr. Dale Klatzker knows that, although it isn’t easy, change is vital for community behavioral health providers.
It’s exciting to be able to offer a look at integrated care from the perspective of a provider, particularly a provider who has demonstrated leadership excellence in integrating behavioral health and primary care services. Dr. Klatzker currently serves as the Chief Executive Officer of The Providence Center in Providence, Rhode Island. He has been a leader in behavioral healthcare for more than 35 years. Since becoming president/CEO of The Providence Center in 2004, Dr. Klatzker, a visionary, has transformed the system of care, quality of service delivery, and social policy decision making at The Providence Center and the state of Rhode Island. Click here for Dr. Dale Klatzker’s bio.
The Providence Center and the Providence Community Health Centers have created a successful partnership to meet the whole-health needs of the people they serve within their community; a need that is clearly outlined in the literature. According to the Robert Wood Foundation’s Mental Disorders and Medical Comorbidity authored by Dr. Benjamin Druss and Elizabeth Walker, comorbidity between medical and mental conditions is the rule rather than the exception:
Dr. Klatzker:Change is a good thing. Most CMHCs haven’t changed a lot. They haven’t prepared themselves to change a lot and have marginalized themselves and the people that they serve by not being more a part of the mainstream. We have sets of skills that are integral to wellness and to health across a wide spectrum. We need to be proud of what we do, but also to expand it and extend it because this is the perfect time for this. We have a lot of things to offer that others are trying to replicate.
Things don’t stay static. You have to look though the windshield but also through the rear-view mirror. You have to know where you are but you also have to know where you’re going.
As executive director/CEO of a behavioral health organization, you have the obligation to push yourself, and that will push your organization, to do what is necessary so that your mission is reinforced but also to serve the needs of the community. It’s hard to do that if you’re doing the same thing you did 20 years ago. We do our consumers a disservice if we do that.
Person-centered approach to care
Dr. Klatzker: What we’ve embraced here – what’s part of the DNA of the organization at The Providence Center – we believe in a person-centered approach to care. No two people are exactly the same. The people that we work for deserve as much access to a wide array of both health and social supports as anyone. That’s how you have to guide yourself. When you’re thinking of those things, primary care integration, working much more toward the mainstream of traditional healthcare is imperative for us.(7:14)
What we’ve found is, if you can build those relationships and find the right connections, then others will embrace you and value you for what you bring to the table. In fact, we bring a lot. Partnership is always the first choice, the default.
We don’t chase dollars, we don’t create programs because it’s the idea du jour from some funder somewhere, we consciously look on our mission as our touchstone and build upon that to provide as much choice to the people we serve. We can be very person-centered because there aren’t many gaps in what we’re providing. (They provide a wider array of services than the average CMHC) We’ve consciously built out a wide array because we think it’s the right thing to do. Rather than to take a “no,” if we can’t partner, we build.
Example of a successful integrated care partnership
Dr. Klatzker: The Providence Center is closely connected to one the largest federally qualified health center in the state of Rhode Island, the Providence Community Health Center. We have become the largest community mental health center. Neither had a desire to replicate the services that the other provided. Over the years we’ve built this into a “no wrong door” integrated collaborative effort so that in the mental health center, the FQHC runs a full-service practice with 1100-1200 patients. In the FQHC, we are integrated in their physician practices building and we also have a separate section of their building where we provide longer term care and some other types of specialty care. We’ve integrated our records with each other. We meet frequently to process and to try to figure out how to make our care efficient and effective. We are working closely with them now on adopting our health home model to integrate a modified health home into the FQHC.
Yes, the times they are a-changin’. And so are healthcare providers. (At least the forward-thinking providers like The Providence Center.) They are heeding the findings from the numerous expert reports and research. They are thinking outside the box, adopting a person-centered approach that enables better outcomes for the many who place their trust in them—trusting them to take care of their whole-health needs.
In 2008, Congress passed the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act, marking an important step forward in efforts to end discrimination in insurance coverage for mental health and substance use disorder treatment. While the act closed several loopholes left by the 1996 Mental Health Parity Act, it has taken five years to finalize the law. The 2008 act lacked clarity on how parity is to be achieved, particularly when treatment involves intensive care at physician offices or long-term hospital stays.
Today’s ruling provides clarification on how parity applies to residential treatments and outpatient care. It also ensures that copayments, deductibles, and limits on mental health benefits are not more restrictive or provide less coverage than those for medical and surgical benefits, including geographic or facility limitations. These have been tremendous barriers to treatment thus far and represent a significant triumph for the behavioral health community.
“This is the largest expansion of behavioral health coverage in a generation,” declared Secretary Sebelius. Addressing the need for adequate care for mental health has been a goal for more than 50 years, when President John F. Kennedy signed the Community Mental Health Center Act of 1963 into law.
At long last, treatment for behavioral health disorders is regarded as equal to other types of healthcare. This represents a significant achievement in behavioral health and should contribute to the ongoing effort to reduce the stigma. Millions fail to follow up with needed treatment because of stigma. With this final ruling and with movement toward integrated care, we will finally be able to improve access.
What will the world be like when people begin to actually receive that needed treatment?
“If we really think about how to change healthcare to make it more accommodating for integration, we must have comprehensive payment reform that pays for the whole, and not the part. We must recognize that administrative structures in health policy entities often perpetuate fragmentation inadvertently. And we must have a way to collect data that can inform not only the clinical case for why integration is good, but the business case for why integration is inevitable.”
Dr. Benjamin Miller
Healthcare policy plays a crucial role in integrated care. Our current healthcare system contains barriers that prevent successful implementation of behavioral health and primary care integration. We will not be able to effectively adopt whole-health approaches to healthcare until critical changes are made in existing health policy. Thankfully, we can be grateful for those who are out there, tirelessly advocating for changes daily.
Dr. Benjamin Miller has graciously agreed to offer his insights on this important topic for the Integrated Care Thought Leader Series. He has made significant contributions to the healthcare industry and health policy, and continues to collaborate with a number of organizations focused on driving the necessary change for creating a more effective healthcare system. Dr. Miller has been the source of considerable inspiration to many (including me). It seems very appropriate, somehow, that I first met him through Twitter. His many tweets on healthcare, policy, and integration, with excellent links to current resources, provide me and many others with an education like no other. I have learned the value of Live Tweeting and Tweet Chats through his example (see Figure 1 below). Thank you, @miller7!
Having long been a firm believer in the need to provide healthcare in a unified manner, Dr. Miller has determined that three barriers prevent integrated care from becoming more widespread: Financing, policy, and data.
Finance
Dr. Miller: If you ask people why integration is or is not making a larger stand in healthcare, it usually comes out that they aren’t able to sustain their clinical innovation. So practices try to figure out ways that they can sustain themselves through all kinds of workarounds. Here in Colorado about three years ago we did a survey of integrated practices and found that 77% of those we surveyed were solely funding their integrated efforts through grants. I don’t think that’s uncommon. Actually, I think it’s very common across the country. A lot of practices that are doing this got funding from foundations, federal government, etc., to make it work. They’re only able to keep their doors open for the program while they’ve got those dollars. I wanted to figure out, why is that such a big deal? Why can’t we just pay for health? We proposed a project to test out a global payer model for primary care that includes the cost of mental health, just to see if we were to pay primary care a lump-sum of money that includes the cost of that primary care provider, could they sustain themselves? That’s where the Sustaining Healthcare Across Integrated Primary Care Efforts or SHAPE came from. We wanted to see if paying for primary care differently with mental health, behavioral health, substance abuse providers, working in that integrated context could be sustained. We’re about a year into that and the answer is going to be unanimously, yes.
Large Scale Policy Issues and History
Dr. Miller: If you look at how healthcare is set up, it’s set up to continue to perpetuate fragmentation. It’s set up so that administratively, it’s easier to manage pieces rather than a whole. Our states, communities, and government have done something, in an attempt to manage multiple systems, which has really hurt our attempts to integrate. I’ll give you a very high-level example of that: If you just look at most states, they usually have a different department or division for mental health. We decided to take all the dollars that were going into institutions for folks that had mental health issues and put it back into the community in established community mental health centers. The dollars didn’t really follow the patients in that experiment. Community mental health centers actually didn’t get a whole lot of money to do the job that they were intended to do. And so you have entire systems at state levels that manage mental health. When you want to try and integrate, whether it be in primary care or in the community mental health center with primary care, there are multiple administrative structures that you have to figure out how to align. And often, from a policy perspective, it doesn’t make sense fiscally as to how to align these and what to do with the administrative entities. There are a lot of policy issues. Mainly, how we’ve set up our systems to deliver care at the policy level.
Data, Research, and Infrastructure
Dr. Miller: The other reason I think integration hasn’t been taken to scale nationally as much as we would like, is that practices are relatively immature in their ability to collect data, especially as it relates to collecting that informs the outcome around the whole person and not just a physical health outcome or mental health outcome. If you go into a primary care practice and want to determine how effective a behavioral health provider is, often the electronic medical record and how they are tracking the data are in forms that don’t allow you to extract those data. They’re in free-text notes, or they’re in something that just makes it difficult to get at the data to show what they did and how effective it was. In the same vein, if you look at community mental health centers, it’s even worse. With vast amounts of EHRs, if they even have an EHR, are built around this old-fashioned, almost antiquated, “I need to tell the whole story for the patient” model. That’s good on the clinical level. However, if you’re looking at making a case for something, you need to be able to extract data from those electronic medical records and then tell a story with your data. Many of the community mental health centers simply are not there. They have an opportunity here to advance themselves by collecting better data at the practice level.
Though many in the healthcare industry see policy as something beyond their responsibility and concern, the reality is that it has an impact on each of us. Unless we collectively express our concerns, voice our professional opinions, demand the necessary changes, legislators will continue to make uninformed decisions that have significant impact on healthcare delivery.
While there remains a long way to go before the needed changes outlined by Dr. Miller are in place, the industry as a whole is making significant strides in the right direction. Policies are slowly beginning to change.
Perhaps the perfect storm is approaching for healthcare.
Figure 1: Ben Miller live tweeting at the 2010 CFHA Conference in Louisville, Ky.
Today marks the 50th anniversary of the date that President John F. Kennedy signed the 1963 Community Mental Health Act into law. It was to be the last before his death on 11/22/63. The Act represents a monumental turning point in the treatment of psychiatric disorders. President Kennedy’s call to action in 1963 was based on a belief that all Americans – including those with mental illnesses, intellectual disabilities, and addictions – have a right to lead dignified lives and to share in the benefits of our society. Patrick Kennedy, nephew of President Kennedy and former U.S. Representative of Rhode Island, is steadfast in his efforts to continue this important work via the Kennedy Forum.
Act of October 31, 1963 “Mental Retardation Facilities and Community Mental Health Centers Construction Act of 1963”, Public Law 88-164, 77 STAT 282, “to provide assistance in combating mental retardation through grants for construction of research centers and grants for facilities for the mentally retarded and assistance in improving mental health through grants for construction of community mental health centers, and for other purposes.”, 10/31/1963 (Figure 1 below)
History of Psychiatric Treatment
Figure 1: Mental Retardation and Community Mental Health Centers Construction Act of 1963
Early attempts to treat mental illness are thought to date back to 5000 B.C. or earlier, based on the discovery of trephine skulls. A series of barbaric practices followed for millennia. It is suspected that the first asylums were established around the sixteenth century. These early facilities offered no real treatment despite their primitive attempts at cures, consisting of the use of leeches, purges, barbaric contraptions, and the use of chains and other restraints. Conditions gradually began to improve by the mid 1800s thanks to efforts led by humanitarians such as Dorothea Dix. Treatment reform in the asylums offered a more humane approach to the care of people with mental illness.
New treatment options followed in the early twentieth century, including psychoanalysis, introduced by Austrian neurologist, Sigmund Freud, and electroconvulsive therapy, introduced by Italian neuropsychiatrists, Ugo Cerletti and Lucio Bini. Psychopharmacology followed, arguably providing the single most significant change in treatment to date. A former colleague, psychiatrist, Dr. John Wolaver, remarked that when Thorazine was introduced in the psychiatric hospitals, the facilities were suddenly calm and quiet for the first time. It seemed to be a miracle cure. Psychopharmacology provided the next necessary step that led to deinstitutionalization.
The introduction of the Mental Retardation and Community Mental Health Centers Construction Act of 1963, Public Law 88-164, a bold new effort, forever changed the face of mental health treatment. Prior to this, it was not uncommon for individuals with behavioral health conditions to be hospitalized for many years; hundreds of thousands lived their lives in institutions and were buried on the grounds. Unfortunately, this deinstitutionalization effort fell short of its goal. The USA Today report, Kennedy’s Vision for Mental Health Never Realized, takes a candid look at this.
Figure 2 below illustrates the decrease in inpatient treatment between 1950 and 1995. As the psychiatric hospitals decreased in size, the homeless population grew. The jails and prisons began to fill with the individuals with behavioral health conditions. According to the 10/24/13 article, Why Are The Three Largest Mental Health Care Providers Jails? published by NewsOne: The three largest mental health providers in the nation are the following jails: Cook County in Illinois, Los Angeles County and Rikers Island in New York.
Figure 2: Deinstitutionalization
Integrated Care
Many thought-leaders believe that we have embarked upon another pivotal point in mental health (or more broadly, behavioral health) treatment. Mental Health: A Report of the Surgeon General published in 1999 called for the integration of behavioral health and primary care. And the 2006 NASMHPD report, Morbidity and Mortality in People with Serious Mental Illness has prompted the movement toward a whole health approach to treatment that integrates behavioral health and primary healthcare. This promising trend offers hope for improved access for individuals who live with mental health and/or substance use disorders, improved health outcomes, and controlling healthcare spending.
Let us work together to address health conditions wherever the individual presents for treatment. Healthcare must be redefined to include behavioral health. By removing the healthcare silos, providers will begin to recognize and treat the comorbid conditions in their patients. Mind-body integration improves patient outcomes and reduces costs.
Integrated care is necessary for improving the lives of of those who might have spent his or her life chained in a dungeon centuries ago. It is a key element in our efforts to achieve the Triple Aim.
This is Mental Illness Awareness Week and today has been designated as both World Mental Health Day and National Depression Screening Day. Social media has numerous posts this week promoting mental health awareness and related topics as we try to educate the general public. We strive for increased awareness of the importance of good mental health as well as the challenges related to the stigma surrounding mental illness.
Integrating mental health and substance use disorder treatment with primary healthcare provides the opportunity to both increase awareness and decrease the stigma associated with behavioral health issues. Integrated care helps to improve access, reduce costs, and improve outcomes. Integrated care is better care!
In 1990, the U.S. Congress established the first full week of October as Mental Illness Awareness Week (MIAW) in recognition of the National Alliance on Mental Illness’s (NAMI) efforts to raise mental illness awareness. Since then, mental health advocates across the country have joined with others in their communities to sponsor activities, large or small, for public education about mental illness.
Today, 10/10/13, is designated as World Mental Health Day. This year’s theme is “Mental Health and Older Adults.” The day is celebrated at the initiative of the World Federation of Mental Health (WFMH) and the World Health Organization (WHO) supports this initiative through raising awareness on mental health issues using its strong relationships with the Ministries of Health and civil society organizations across the globe.
Today is also National Depression Screening Day. National Depression Screening Day raises awareness and screens people for depression and anxiety disorders. NDSD is the nation’s oldest voluntary, community-based screening program that gives access to a validated screening questionnaire and provides referral information for treatment. More than half a million people each year have been screened for depression since 1991.
Let us work together to promote good mental health locally and around the world.
“When you look at people holistically and start valuing their mind-body resiliency, I think there is a level of excitement, and better outcomes.”
Larry Fricks
September is Recovery Month. This year’s theme is Join the Voices for Recovery: Together on Pathways to Wellness. It is very fitting that Larry Fricks is our featured Integrated Care Thought Leader this month, as he is one of the nation’s greatest leaders in peer-led services, wellness, and recovery. An amazing individual who has devoted his life to helping others, Mr. Fricks was gracious enough to his insights into the importance of whole health wellness and resiliency and the vital role of engaging with people who have the lived-experience to provide support through the process. He offered insight into the role that a whole health approach plays in improving health outcomes and managing wellness. Drawing from his own experiences, Mr. Fricks identified many factors that contribute to a person’s recovery process. Acknowledging that factors such as race, socioeconomic status, and personal support system play a crucial role: “I don’t think you can underestimate what social determinants do to break somebody down.”
I first met Mr. Fricks in 2000 in Rockford, Illinois. He was the keynote speaker at the Consumer Family Forum, addressing a group who receive behavioral health services, their families, and behavioral health professionals from across the state. His passion resonated among the 300+ attendees as he shared his personal recovery story, urging others to believe that recovery is possible. I vividly recall (and have frequently shared with others) a very moving story that he shared about an initiative that has grown to be The Gardens at Saint Elizabeths: A National Memorial of Recovered Dignity, honoring the hundreds of thousands of people who died and were buried in unmarked graves on the grounds of psychiatric hospitals…and were forgotten:
Larry Fricks:Their graves were decimated and desecrated and they have no markers and people didn’t care about maintaining their graves. They walked the Earth and they had a life. Mothers, husbands and wives, children. They had wonderful things happen, and they saw miracles, and they had heartbreak, and you’re just honoring that experience. I just really believe that the Memorial is drawing people that I never expected to draw…very inspiring.
Through the years, Mr. Fricks has traveled from state to state, providing inspiration to so many, sharing his vision, and leading the way to transforming the way behavioral health organizations provide services. He led the national initiative to include peer-led services as a core feature, and is now working with states to embed Peer Support Specialists and Family Peer Specialists in integrated healthcare efforts as well. He currently divides his time between his work with the Appalachian Consulting Group based in Georgia, and his work in Washington, DC, as Deputy Director with the SAMHSA-HRSA Center for Integrated Health Solutions which has included testifying at Congressional Hearings on Mental Health.
Larry Fricks: We now know that things like a social network and service to others are huge health and resiliency factors. People who are in service to others tend to be healthier and they tend to live longer. Also they tend to be more resilient toward relapse or illness. So my life striving to be in service to others to strengthen their health and maybe strengthen their skills in recovery has had the benefit of strengthening my own recovery.
While his earlier work has focused on the role of Peer Support in the recovery process, Mr. Fricks’s work has broadened the focus to include a whole health approach. With startling reports that people with serious behavioral health conditions are dying decades earlier on average than the general population, he led a team at the SAMHSA-HRSA Center for Integrated Health Solutions to create a training called Whole Health Action Management (WHAM) that is designed to address this disparity though self-management supported by peers. Mr. Fricks has great praise for the effort in Georgia to develop Peer Support, Wellness, and Respite Centers that are reducing hospitalizations.
Larry Fricks:Let me tell you about what excites me. Georgia has three of these Peer Support, Wellness, and Respite Centers and they’re going to open two more. I’m very excited about what’s going on in those centers. Basically, if you feel early warning signs of your illness, or your addiction, you can go to one of these peer respite centers where you have your own bedroom and you can stay up to seven nights, chill out, and you’re surrounded by peers trained holistically to support your wellness. I think it’s really cutting the need for more intense crisis services and hospitalizations. So I had a chance to actually pull a shift in one of them, I answered the warm line and experienced what it was like to provide healing support by simply listening, or maybe just ask a few quetions for deeper reflection like we are trained to do. These peer support wellness centers are returning us to whole health. Removing some of the stigma, giving us a sense of owning our recovery and being proactive, and really engaging peer support to be successful. Georgia is leading the nation. With three we had more than any state, and with five we’ll really be out in front.
What’s next on the horizon?
Larry Fricks: I’m really excited about epigenetics. On April 2 of this year, Time magazine had a cover story on curing cancer, and this whole science on epigenetics basically says DNA does not have the last say. There are mind-body resiliency factors and there’s more and more research on epigenetics. “Epi” means over and the epi is the cell structure over your genome, over the DNA. And what they’re saying here is: Things that you do, like what you eat and managing stress to stay well, it determine which genes switch on and switch off. And so being aware of this thing, if you look at the WHAM training, we include ten health and resiliency factors which we got from Dr. Greg Fricchione who used to run Mrs. Carter’s Mental Health Program [at the Carter Center], and now he’s director of the Benson-Henry Institute for Mind Body Medicine. These prevention doctors are big on something called the Relaxation Response, and so we’re looking at the things you can do to switch on and switch off gene markers; and they can impact the next generation.
And in parting:
I’m aware that there are just people and things that happen in your life that, if you’re open to it, you work on staying connected and having faith, your life can experience great meaning and purpose.
Dr. Martin Luther King, Jr. said “We’re all bound in a mutual destiny and I’m not all I can be until you’re all you can be, and you’re not all you can be until I’m all I can be.” We should be about connection. We should be about cooperation, and there’s a spiritual power to that, and when you’re open to it, positive things just seem to happen. And you’re inspired by it.
Sometimes you want to shake your head and say, “Oh my gosh, why don’t I have more faith?”
“That’s the next direction that [organizations] need to go, bringing substance abuse back into the discussion. We need to go past just the integration of primary care and mental health care to a more Whole Person Care.”
Benjamin Druss, MD, MHP
It has been my pleasure to talk with Dr. Benjamin Druss for this edition of the Integrated Care Thought Leader Series. Having had the privilege to work with Dr. Druss on various integrated care projects over the past few years, I have come to respect not only his keen insight into what’s needed beyond the horizon for the care of people with behavioral health disorders, but the compassion and dedication he brings. His humility and brilliance are evident upon introduction; he’s a true visionary. Dr. Druss, my mentor and my friend, has provided inspiration to me in my work and outlook on the world of healthcare, integration, and beyond.
Dr. Druss, Dr. Silke von Esenwein, and their colleagues at Emory University are currently conducting an exciting NIMH research trial, The Health Outcomes Management and Evaluation (HOME) Study. As described on the website clinicaltrials.gov: There is an urgent need to develop practical, sustainable approaches to improving medical care for persons treated in community mental health settings, this study will test a novel approach for improving mental health consumers based on a partnership model between a Community Mental Health Center and a Community Health Center. When this study is completed, it will provide a model for a medical home for persons with severe mental illness that is clinically robust, and organizationally and financially sustainable.
Dr. Druss received his bachelor’s degree from Swarthmore College in 1985, earned his medical degree from New York University in 1989 and later his master’s in public health from Yale University in 1995.He is also board certified in psychiatry. He trained as a resident in general internal medicine at Rhode Island Hospital and in psychiatry at Yale University School of Medicine. Click here for more information about Dr. Benjamin Druss
Advancement in integrated care through the years
Dr. Druss was one of the first to address the physical health concerns among people with serious mental illness and substance use disorders, particularly among the public sector populations in urban regions. During our discussion on integrated care, he addressed areas of change over the past 18 years that has had the greatest impact on the advancement of healthcare for people with serious mental illness. He described the world of Health Information Technology as a frontier that, over the past 10 years, has resulted in changing policies and procedures in healthcare. These changes have had significant impact on the ability for healthcare organizations to share information, resulting in improved care for patients.
Dr. Druss advises that the next stage needed for healthcare is to begin “broadly looking at other social determinants of health.” The focus should be on an approach to healthcare that is person-centered. The concept of addressing population health and creating a system of care will be a more effective approach to improving health outcomes moving forward. He recommends that substance abuse must be brought back into the discussion, and to go past just the concept of integration of physical health and mental health, toward a more “whole person care” approach.
What do you foresee for the field as we move forward?
Dr. Druss: Clearly there’s going to be major changes in how care is delivered. I think there’s a lot of opportunity moving forward with new public sector models, Medicaid, patients with medical homes, and also the promise of new technologies moving forward as well.
I’m very optimistic; I think things will certainly be very different five years from now. We’re in a period where things are evolving very quickly and we don’t know exactly what the world will look like, but I think we can say that things will look different—and that things will look better.
Research has to change as well. I’m mostly a researcher and lot of what we’ve been doing is slow-paced. The slow-paced process by which we develop a model, and then test it over a five year period. You apply for a grant and then you test it for five years, then it’s another two years before it’s published. So we’re going to have to be looking for more ways for understanding data and evaluating programs. I think the new technologies will help, their more wide-spread availability will help. Just as the health system needs to change—and is changing—health research is going to need to change as well.
The funding agencies still are gradually coming to that point. NIMH has a new program that they are looking to fund that looks at natural experiments out in the community. So I think that’s the sort of research that we’re going to need to see more of in the coming years—good, careful, thoughtful evaluations of some of the demonstration projects going on out in the community.
What barriers to integration to you currently see?
Dr. Druss: I’d say that a lot of community mental health centers are still on this part of the learning curve in terms of learning about integration, such as how potential partner organizations work, [such as] Federally Qualified Health Centers. [CMHC’s] often lack information technology infrastructure that makes it easier to do the work. There are some places, some community clinics, and other organizations that are out in front on these issues, that are early adopters, and there’s some that are trying to figure it out and hopefully will learn from the experience of those organizations that are further ahead.
Thank you, Dr. Druss, for your dedication to improving the health and quality of life of so many who live with serious behavioral health conditions.
Be sure to check back soon for our next Thought Leader, Larry Fricks, pioneer in the Peer Support movement.
A sampling of Dr. Druss’s cutting-edge research and other publications are listed below:
Co-Principal Investigator, Robert Wood Johnson Foundation; Funding Period 9/1/96-1/31/98
“Chronic Illness, Disability, and Managed Care”
Principal Investigator, National Association for Research in Schizophrenia and Affective Disorders (NARSAD); Funding period July 1, 1996 – June 30, 1998
“Work and Health Care Costs associated with Depression Compared with Chronic General Medical Illnesses”
Principal Investigator, Donaghue Medical Research Foundation; Funding period July 1, 1996-Decmeber 31, 1999
“Costs of Depression for an Employed Population”
Principal Investigator, NARSAD; Funding Period July 1999-June 2001
“Treatment of Depression and Medical Illness Under Managed Care: Understanding the Differences”
Principal Investigator, NIMH K08 Mentored Clinical Scientist Award; Funding Period January 1999-December 2004
“Impact of Depressive Disorders in Health and Work Settings”
Principal Investigator, Robert Wood Johnson Foundation; Funding Period October 1, 2004-September 30, 2006
“Evidence-Based Management of Depression in Public-Sector Primary Care”
Principal Investigator: R34MH78583; Funding Period September 1, 2006-August 1, 2010
“Adapting a Medical Self-Management Program for a Community Mental Health Center”
Principal Investigator: K24MH075867; Funding period July 2006-June 2011
“Mending the Safety Net: Improving Linkages between CHCs and CMHCs”
Principal Investigator, AHRQ R18; Funding Period September 2008-September 2012
“An Electronic Personal Health Record for Mental Health Consumers”
Principal Investigator R21HS017649; Funding Period August 1st 2008-April 2010
“Mental Comorbidity and Chronic Illness in the National Medicaid System”
Principal Investigator, NIMH R01; Funding period August 2004-April 2014
“Improving Primary Care for Patients with Mental Disorders”
Principal Investigator NIMH MH090584-01A1; Funding Period 06/15/2011- 03/31/16
“A peer-led, medical disease self-management program for mental health consumers”
“It’s very hard to do integrated care and still think of mental health and physical health.”
Welcome to the first in the Integrated Care Thought Leader Series. This series will focus on the forward-thinking individuals who have had the foresight to envision possibilities in the healthcare industry’s future. I’m pleased to begin the series with a man who has been instrumental in advancing integrated healthcare.
Alexander Blount, EdD
Alexander Blount, EdD, better known to most as “Sandy,” has played a very important role in bringing the integration of behavioral health and primary healthcare to its current prominent focus within the healthcare industry. Dr. Blount is credited with coining the term integrated primary care in his 1994 publication, “Toward a System of Integrated Primary Care,” Blount A, Bayona J. Family Systems Medicine, 1994;12:171-182.
He currently serves as Professor of Clinical Family Medicine and Psychiatry at the University of Massachusetts Medical School in Worcester, MA and Director of Behavioral Science in the Department of Family Medicine and Community Health. He teaches resident physicians the psychosocial skills of primary care practice and founded the post-doctoral Fellowship in Clinical Health Psychology in Primary Care. He was previously Director of the Family Center of the Berkshires in Pittsfield, MA and a faculty member at the Ackerman Institute for the Family in New York. He has more than thirty-seven years experience as a therapist, teacher of physicians and therapists, administrator and lecturer in the US and abroad. He is a member of the National Integration Academy Council and has had a leadership role in state and national efforts developing healthcare policy. His books include Integrated Primary Care: The Future of Medical and Mental Health Collaboration published by W. W. Norton and Knowledge Acquisition, written with James Brule’, published by McGraw-Hill. Click here for more information about Dr. Blount.
It’s an honor to talk with Dr. Blount about the integration of behavioral health and primary care. Yes, he admits that he is optimistic about the direction in which the field is moving! His enthusiasm is almost palpable, with a freshness that belies the number of years he has devoted to the advancement of this revolutionary approach to healthcare. It’s apparent that this enthusiasm easily holds the attention of the students he teaches at UMASS.
Dr. Blount is a visionary whose diligent efforts and perseverance have made great strides toward bringing attention to the widespread failure to address the individual patient as a whole. He graciously agreed to provide insights for Behavioral Health Integration Blog:
What do you see as being the greatest barriers for successful integration of behavioral health and primary care services?
Dr. Blount: I see two things:
First are the barriers that have always been there: regulatory barriers that are built on the idea that mental health and medical services have to be kept separate, financial barriers that only pay fee for service and define services as what is delivered in specialty mental health, and cultural barriers on the part of both medical and mental health people that make working together difficult without some cultural broker who can make the connections and translations necessary. These have been our problems historically, and happily with the ACA and the PCMH movement, these are reducing.
The second area is the barriers caused by our own success. Because integrated care is becoming more possible and is proving itself, there is pressure to start programs in settings where there is little understanding of what it entails and little time and resources to prepare for the change. People are getting put into integrated programs or co-located, who aren’t trained for it and didn’t pick it. They don’t know what to do. They go in and do specialty mental health. They do what they’ve been trained to do…and it doesn’t work. Then administrators, who may have been skeptical initially, thought this was a fad, see this failure and think “oh yeah, I was right,” it was more inconvenient than useful. We felt we had to develop a training program at UMass Medical School available to these folks to prevent just this form of failure.
Also because there is sometimes a faddishness about integration, you get some administrators who become “true believers” who really don’t know how to do this. They see a presentation, and they say this is what we are going to do–and they start it without any depth of understanding. It’s sort of the administrative version of the clinician that doesn’t work. We need clinicians who are fully oriented to integrated primary care and leaders who are aware of the difficulties of making these changes and who can develop the buy-in from the whole practice. Integrated pilot programs are often funded on three year cycles. Places like the DIAMOND Project in Minnesota, where they’ve had some real time to make it work, say that it’s more like a five year cycle from beginning to fully transformed practice. I fear that federal and private funders will think it will happen faster than it does and will turn away.
Another barrier to our success is the workforce crisis we are facing. All of the government projections of what will be needed for behavioral health workforce, when compared to the number of people who are being trained, say we will have a terrible deficit, and those projections were made without any calculation of the workforce that has proved to be needed in mature integrated settings. When word gets out that we will need a four-fold increase over 2010 levels in behavioral health clinicians in Federally Qualified Health Centers alone, not to mention the rest of the health system, the true magnitude of the problem will become clearer.
What excites you about the field today?
Dr. Blount:One, is absolutely the transition in payment models that may make a great leap forward happen. Essentially those models let us implement the clinical routines of integrated care. Up to now the payment models have dictated routines that weren’t very integrated. Paying for health, rather than for services allows us to deliver evidence based care by the clinician best able to do it at the point that it is most sensible and acceptable to the patient. Having it actually knitted into the flow of care makes a big difference.
And the other thing that I see happening is a transformation in how we conceptualize mind and body, illness and health. It’s very hard to do integrated care and still think of “mental health” and “physical health”. The categories just begin to break down because they don’t describe the way people present. They don’t describe how problems form over the years. We’ve had science now for a good while on the plasticity of brain and the way that experience changes the brain and the brain changes experience. The current science even describes the way that experience changes what genes are expressed at various points in a person’s development. In other words, the science of the brain has been there but the way of thinking in our day-to-day clinical lives has not because we have been enacting models build on conceptions of separate domains. As we enact integrated clinical routines, we will begin to think differently. We create the likelihood that the science of the brain will be mirrored in the unity of our conceptions about people and how we try to help them.
So I think, at least in the places that are more developed, the places that integrated care gets to be mature, you begin to see different forms of conceptualization and hopefully we’ll be documenting those, writing about those, helping to pull others along. There aren’t many places where integrated care is really mature. The places that are mature are very different in numerous ways that don’t initially seem to be connected to integration. The question of “isn’t integration interesting, how do we work on it?” just goes away and the questions are about new ways of helping patients, new groups of patients we can understand better, and new ways of involving patients on their care teams. How we involve people in their own care, how we get past the doctor as leader and authority to doctor and the team as teachers and facilitators, that’s really the next piece. And when that is going well, I think that integrated care will sort of already be there.
Will you look into your crystal ball for us and tell us what you foresee in the future for integration?
Dr. Blount: Let’s imagine that we get it right in terms of mature programming, mature routines of integration as far as our workforce allows. Then we begin to be able to think about health and illness differently, and the whole set of concepts, the models that we have of understanding health and illness and how to influence those begin to move. I foresee the time when there’s a foundation of mature integrated care that we will be looking at great leaps forward in theory or great research leaps forward with greater understanding of what and how we should be researching. That’s one optimistic thing.
And when I look in my crystal ball I think we are going to have states that begin to have whole-state programs that are starting to be implemented and organized so that we can begin to look at the impact of integration on a really big scale.
Thanks so much to Dr. Blount for sharing his insights in the premiere of the Integrated Care Thought Leader series!
Check back soon for a conversation on integrated care with Benjamin Druss, MD, MPH, Rosalynn Carter Mental Health Chair and Department of Health Policy and Management Professor at Emory University.
The poll generated a tremendous amount of interest, both in voting on the poll and in comments. Much has happened in the healthcare industry in the past twelve months, changes that have an impact on the way behavioral health and primary care will be delivered in the future.
The greatest impact has come from the Patient Protection and Affordable Care Act (ACA) that was upheld by the Supreme Court of the United States on June 28, 2012. Though passed in 2010, the flurry of activity toward implementing began after the Supreme Court ruling. As states prepare for the 2014 implementation of the new health laws, more and more are agreeing to participation in the Medicaid Health Home plan.
Poll Results
As we near the end of the first quarter 2013, time is running out quickly for implementation. With integrated care playing a crucial role in health reform, the challenges for integrating healthcare services are more and more apparent. Revisiting the below results of the poll conducted one year ago, one has to wonder whether the perceived challenges remain the same among healthcare providers.
Poll results from LinkedIn group, Behavioral Health Integration 3/5/2012 – 3/5/2013
Finance and Billing
Poll responses indicated that sustainability issues related to finance and billing were the greatest challenge for integration efforts. While many providers have successfully overcome this barrier, it is no easy feat to develop a financially sustainable integrated services delivery system. Fortunately, the ACA created an optional Medicaid State Plan benefit for states to establish Health Homes to coordinate care for people with chronic conditions who receive Medicaid benefits. While only a handful signed on initially, there are currently 24 states and the District of Columbia who have elected to participate in the Medicaid Expansion. Fourteen states have elected not to participate; and 12 states remain undecided. (Click here for more information on where each state stands on ACA’s Medicaid expansion.)
States that are moving forward with Medicaid Health Homes are in the process of making adjustments to policies, billing, and service delivery to enable service providers to integrate behavioral health and primary care services, a requirement of Health Homes:
Regular visitors to this blog know that much has been published here about the partnership between behavioral health and primary care providers. This was ranked as second most challenging in the poll.
Why do so many people find partnership issues as challenging? It’s counterintuitive. Most providers approach the integration of behavioral health and primary care with a blind eye to the process of partnership development. It is assumed that the interpersonal aspects will fall into place. Unfortunately, it is far more likely that an integration effort will fail due to partnership issues than financial ones. They are not unlike other partnerships, requiring attention to building a strong foundation from the onset.
All healthcare administrators acknowledge the importance of operations for successful service delivery. That’s why 15% of respondents to the poll indicated that this area is the greatest challenge. Once a smooth-running clinic takes on an entirely new service-line, a degree of disruption is inevitable. The workflow will likely be drastically different than the service providers and support staff have grown accustomed to. Of course, taking on a new service also means addressing the organization’s policies, regulatory requirements, physical space requirements, etc.
With a little careful planning and a LOT of patience, your new integrated clinic will be operating smoothly in no time. Click here for a useful integration planning checklist.
Workforce Issues
Seven percent of the respondents indicated that workforce is the greatest challenge. With the current shortage of primary care providers, nurses, and psychiatrists, it’s no wonder that this is of concern. Fortunately, programs for training about integrated care delivery are available, such as the University of Massachusetts Medical School’s Center for Integrated Primary Care, which offers three programs aimed at training healthcare providers for providing integrated services:
Despite concerns over the dilemma of sharing health records for integrating behavioral health and primary care, health information technology garnered 5% of the responses. Fortunately vendors of electronic health records are working earnestly to develop products that allow for the seamless sharing of behavioral health and primary care records. (Click here for more information on the role of HIT in integrated healthcare.)
One Year Later
What are the greatest challenges to integrating behavioral health and primary care in 2013? What will be the challenges next year? Dare we suggest that in the near future there will no longer be challenges?
Behavioral Health Integration 