Category: primary care behavioral health integration

Integrated Care Thought Leader Series: Benjamin Miller, PsyD
behavioral health integration · collaborative care · healthcare integration · Integrated Care · mental health · primary care behavioral health integration

Integrated Care Thought Leader Series: Benjamin Miller, PsyD

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“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
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!

Dr. Miller is an Assistant Professor in the Department of Family Medicine at the University of Colorado Denver School of Medicine where he is the Director of the Office of Integrated Healthcare Research and Policy. Dr. Miller is a principal investigator on several federal grants, foundation grants, and state contracts related to comprehensive primary care and mental health, behavioral health, and substance use integration. He leads the Agency for Healthcare Research and Quality’s Academy for Integrating Behavioral and Primary Care project as well as the highly touted Sustaining Healthcare Across Integrated Primary Care Efforts (SHAPE) project in Colorado and Oregon.

He received his doctorate degree in clinical psychology from Spalding University in Louisville, Kentucky. He completed his predoctoral internship at the University of Colorado Health Sciences Center, where he trained in primary care psychology. In addition, Miller worked as a postdoctoral fellow in primary care psychology at the University of Massachusetts Medical School in the Department of Family Medicine and Community Health.

He is the co-creator of the National Research Network’s Collaborative Care Research Network, and has written and published on enhancing the evidentiary support for integrated care models, increasing the training and education of mental health providers in primary care, and the need to address specific healthcare policy and payment barriers for successful integration. He is the section editor for Health and Policy for Families, Systems and Health and reviews for several academic journals. Dr. Miller is a technical expert panelist on the Agency for Healthcare Research and Quality Innovations Exchange and on the International Advisory Board of the British Journal of General Practice. Miller is the past President of the Collaborative Family Healthcare Association, a national not-for-profit organization pushing for patient-centered integrated healthcare.

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.

Ben Miller live tweeting at the 2010 CFHA Conference
Figure 1: Ben Miller live tweeting at the 2010 CFHA Conference in Louisville, Ky.
Integrated Care Thought Leader Series: Alexander “Sandy” Blount, EdD
behavioral health integration · behavioral health primary care integration · collaborative care · primary care behavioral health integration

Integrated Care Thought Leader Series: Alexander “Sandy” Blount, EdD

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“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.

behavioral health integration · behavioral health primary care integration · collaborative care · healthcare integration · primary care behavioral health integration

The Partnership: Choosing the Right Model for Your Integrated Healthcare Services

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Determining the Model

How do partnering Community Behavioral Health Centers (CBHC) and  Community Health Centers (CHC) determine the ideal model for their foray into integration? There are many factors to consider such as:

  • What are the needs of the individuals served by the partnering organizations?
  • What are the needs of the community?
  • What resources do the organizations bring to the partnership?

Now that the partners have a solid foundation and clear vision for their collaboration, it is time for the careful planning that is necessary to make it a reality.  There are effective tools available to assist organizations in working through this very important process. (Please note that these suggestions and resources are not limited to community providers.) 

The MH/Primary Care Integration Options scale  is available on the SAMHSA-HRSA Center for Integrated Health Solution website. This is very helpful for leading the discussion among the members of the implementation team. The scale assists the partners not only in determining the current reality but also mutually deciding on the desired level of integration: Minimal Collaboration, Basic Collaboration from a Distance, Basic Collaboration On-Site, Close Collaboration/Partly Integrated, and Fully Integrated/Merged in each of these key functional areas:

  1. Access: How do individuals access services?
  2. Services: Are the services separate and distinct or are the primary care and behavioral health services seamless? Or perhaps somewhere in between.
  3. Funding: Do the partners share resources or are they separate?
  4. Governance: Are there separate boards of directors for each organization?
  5. Evidence-based Practices: Do the organizations administer the PHQ-9 or disease registries, for example, and share the results?
  6. Data: Do the partners share information? Do the providers have access to the partner’s EHR?

This assessment process is most effective when stakeholders from each organization are included. Ideally, representatives are included from clinical, management, and administrative departments, as well as a few individuals who use the services. It’s very helpful to have frontline staff and board members to take part as well.  Call center and reception staff offer a unique perspective that leadership frequently finds enlightening.

Other useful tools available include the National Council’s Success in the New Healthcare Ecosystem: Mental Health & Substance Use Provider Readiness Assessment prepared by Dale Jarvis.   This allows provider organization management teams to assess their organization’s readiness for engaging in the changing healthcare system.

Another tool to consider is the COMPASS-PH/BH  created by Zia Partners.  This self-assessment tool is used for primary care/behavioral health integration for implementation of a Comprehensive Continuous Integrated System of Care.

Making the Vision into a Reality

Once the ideal model of integration has been determined, the journey begins to make it a reality. Be sure to stop by for the next installment in the series.

What tools or methods have you found to be helpful when selecting a model for your healthcare integration endeavor?

I would love to hear from you! Please email your suggestions to me at behavioralhealthintegration@gmail.com for inclusion in a future post.

 

behavioral health integration · healthcare integration · primary care behavioral health integration

The Partnership: Creating a Solid Foundation for Successful Healthcare Integration

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Consider this scenario:

The CEO of the local Community Behavioral Health Center (CBHC) and the CEO of the local Community Health Center (CHC) bump into each other at a local community function. The conversation turns to a deliberation about healthcare integration. They plan to meet for lunch next week to discuss it further.

At lunch, they examine the latest healthcare trend: providers from behavioral health and primary care joining forces to form integrated healthcare partnerships to improve health outcomes. Both agree that theirs’ is a match made in heaven. Over dessert they decide to become partners, sealed with a firm handshake.

What happens next?

For a successful partnership, it is crucial to start with a solid foundation that includes flexibility in the core structure to weather the inevitable storms ahead. This must be accomplished before beginning to build. Failure to adequately address this will result in a partnership that appears to be healthy on the outside but with a weak core. Remember that it’s easy to have a good relationship during the good times. When troubles arise, the solid core serves as an anchor to enable perseverance.  To accomplish this, there are key areas that must be discussed thoroughly before moving on to formalizing the partnership.

Why is this important?

Consider this version of the next chapter in the aforementioned scenario:

Over a series of phone calls, the two CEOs discuss the details of their lunchtime plan for partnering to to provide integrated healthcare. Topics discussed include creating a Memorandum of Understanding; financial arrangements (who pays for what); which services will be provided; and who bills for which services; becoming a health home. Separately, the CEOs meet with their management teams to plan logistics. At that point the leaders, thinking their work was done, withdrew from the planning. The management teams put together the clinical teams for providing the services. The various teams finally meet for a face-to-face planning session, roughly two weeks prior to the scheduled kickoff. The CEOs make a final appearance to give it their blessings.

The teams are thrust into the arranged marriage, virtual strangers. They never had the opportunity to establish a relationship before the partnership was finalized.

Shortly after the two year anniversary, the partnership is dissolved. The two CEOs think back to the dessert agreement with the “happily ever after” partnership they envisioned and, scratching their heads, wonder what happened.

Unfortunately too many partnerships follow the course outlined above. Once the relationship is dissolved, the organizations return to business as usual. However, it is the people who received the integrated services who are hurt as a result; once again left without services.

Some important things to consider for a successfully integrating behavioral health and primary care include the following:

Identifying the Vision and Mission

Locating a partner is an important first step. Before the partnership is formalized, however, it’s essential to carefully clarify the vision and mission to ensure that they are in alignment with the expectations of each of the organizations. Each partner must become very familiar with the other’s mission and vision. These questions will help to drive that discussion:

    • Are the potential partners prepared for taking on a new business venture?
    • Are the stated missions of the organizations in sync?
    • Can the long-term plans of each organization be adjusted to include this partnership?

Over the next few weeks we will examine critical steps to ensure that your partnership avoids the pitfalls that the organizations in the scenario encountered: A partnership that has the solid and flexible foundation that is necessary for a lasting partnership.

Next week we will take a look at the process of determining the level of integration that will best fit with your vision for the partnership.

Healthcare Integration Partnerships: Understanding Specialty Behavioral Health
behavioral health integration · healthcare integration · primary care behavioral health integration

Healthcare Integration Partnerships: Understanding Specialty Behavioral Health

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The integration of behavioral health and primary care services allows for a holistic approach for the treatment of people with serious behavioral health disorders. As the disparate healthcare providers join together to provide treatment, the obvious differences between them must be addressed for success.

There are misconceptions that behavioral health providers want to address with their primary care partners for maximizing their integration efforts.

Understanding the Community Behavioral Health Core Mission

Community Behavioral Health Centers (CBHCs) are specialty behavioral healthcare providers and serve a vital role in the healthcare industry.  The community behavioral health system provides treatment for individuals who have serious mental illnesses, substance use disorders, co-occurring SMI/SUD, and children and adolescents with serious emotional disturbances. These organizations are not a repository for the worried well. Their role is to address complex disorders that are generally beyond the scope of practice of primary care providers. In addition to providing psychiatric oversight, they also possess an expertise in rehabilitation and recovery that is not available in primary care. These services include psychosocial rehabilitation, peer support, case management, supported employment, and supportive housing. Treatment is provided through a team approach that begins with a thorough biopsychosocial assessment to identify life stressors, level of functioning, and clinical symptomology. Services are directed by the psychiatrist or psychiatric-extender who serves as prescriber.  Counseling, rehabilitation, recovery, and support services are carried out by other members of the team.  CBHCs can work collaboratively with CHCs to effectively meet the whole health needs of people with behavioral health concerns.

Differing Pace and Workflow 

The CBHC pace is very unlike that of the primary care clinic. Long waits for appointments are the norm rather than the exception. CBHC office visits with the prescriber frequently exceed the standard 15 minute allotment in the CHC. This is due to the complexity of symptoms of many of the individuals served. While some CBHCs are beginning to use an open access approach, most are still using the standard scheduled appointment model that may result in a several week wait to see a prescriber. This has been a barrier to working collaboratively in the past. CHCs have opted to avoid making referrals because of the excessive wait and lack of status updates.

A side note: behavioral health can assist with the flow in the primary care setting. The flow of busy primary care clinics can be side-railed by patients with behavioral health disorders in addition to their other health concerns. Adding a behavioral health specialist to the team to address the behavioral health issues improves the flow, patient satisfaction, and clinical outcomes.

Lack of Regulation Uniformity

Reimbursement for CBHC services varies greatly from primary care. Block grants for mental health and substance use disorder treatment are regulated at the state level, resulting in a lack of consistency. Each state has created its own system for determining how the funds are allocated and how outcomes are measured. The process of billing for and receiving reimbursement for services is tedious. Some states have opted for capitation; others have a fee for service system. Other states have outsourced this to managed care companies.  Historically private insurance has not provided equitable coverage for behavioral health disorders, creating a gap between coverage for behavioral health and physical health conditions. A mental health law, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act, ensures that individuals with mental health and substance use disorders receive healthcare services equal to those for physical health conditions without larger co-pays.

Unique Needs of Specialty Care

The National Association of State Mental Health Program Directors (NASMHPD) 2006, Morbidity and Mortality for People with Serious Mental Illness, reports that people with serious mental illness are dying on average 25 years earlier than the general population. In addition, according to Substance Use Disorders and the Person-Centered Healthcare Home a 2010 report by Barbara Mauer, people with co-occurring mental illness and substance use disorders were at greatest risk with their average age of death 45 years of age. The people we serve are dying prematurely in part due to poor quality of medical care. This population fails to get adequate healthcare for a variety of reasons. Integrating primary care services in the behavioral health setting is a viable solution for improving health outcomes.

  • Specialty behavioral health services for individuals who have a serious mental illness and one or more comorbid health condition requires coordinated care. Ideally the care is delivered via the behavioral health home. The team is led by the psychiatrist working closely with the entire treatment team, including the primary care provider.
  • Stigma is a barrier to accessing services for people with behavioral health disorders. Historically preconceived notions associated with behavioral health disorders have limited effective access to healthcare by many individuals.
  • Due to the pervasive lack of support systems for people with serious behavioral health conditions, the role of case manager is extremely important for supporting identified functional needs. Case managers frequently assist clients with preparing for visits with their primary care provider and often accompany them as well to ensure coordinated care.

Solution for Information Sharing

Historically CBHCs have not freely communicated with primary care about their shared patients. This originated because of a common misperception that has persisted in behavioral health that sharing mental health and substance use information with primary care providers is prohibited without going through an elaborate process. CBHCs realize that this has created a barrier for collaboration and are actively working at developing a solution; addressing HIPAA/confidentiality and 42 CFR Part 2 to develop a process for effectively sharing information.

It is through increased understanding of the differences between the healthcare partners that true success will occur, evidenced by improved health outcomes.

behavioral health integration · behavioral health primary care integration · primary care behavioral health integration

No Margin No Mission: Sustainability in Behavioral Health – Primary Care Integration

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Of the many challenges in integrating behavioral health and primary care services, the one that garners the most apprehension and concern is sustainability. It is also the most frequent reason for hesitation in moving forward. Healthcare is not set up to address this. Primary care and behavioral health have different billing codes with no easily decipherable means of venturing outside the confines to include payment for integrated services. The mere thought of the process required to begin to tear down the barriers separating the two worlds strikes fear in the hearts of the most courageous administrators.

Healthcare administrators are presented with conflicting demands and are struggling to reconcile the next step. They can:

  1. Ignore the ever increasing focus on healthcare integration and hope it is just another passing fad; or
  2. Place even more burden on the ever-shrinking budgets and hope for the best.

Let’s take a closer look at the options:

Ignoring healthcare integration seems like the easiest solution. Administrators can align themselves with like-minded peers creating a support group who reinforces the notion that it will all just fade away if they merely wait it out. This group gets considerable pleasure in observing the early adopters from a distance, filled with certainty that they are all making huge mistakes. They pat themselves on the back encouragingly as they watch their naïve peers make the occasional fumble, while attributing any successes to sheer (unsustainable) luck.

Over-burdening the current budget seems to be irresponsible. Behavioral health administrators have been faced with budget cuts in unprecedented amounts over the past few years. While they have either become masters at doing more with less or have chosen to leave the field entirely, taking on a new business-line during the increasing uncertainty of their organizations’ financial states seems to be overly risky and counterintuitive.

Yet the pressure is on.

Nationally, more and more behavioral health conferences are featuring healthcare integration tracks. The same is becoming true of primary care conferences and conventions as well. With more and more research and reports being released that provide the necessary data to support the need for integration, it’s becoming more and more difficult to write it off as a passing fad. The recent report from the SAMHSA-sponsored, National Survey on Drug Use and Health, Physical Health Conditions among Adults with Mental Illnesses provides further evidence supporting earlier reports demonstrating the need for integration.

The current model of providing behavioral healthcare may be on its way to becoming obsolete. Now is the time for behavioral healthcare administrators to begin the discussion of how to address the whole-health needs of the people they serve. Whether through collaborative partnership agreements, bi-directional integration, or full integration, this issue can no longer be ignored. There are many changes that can be implemented right away (focusing on billing codes and maximizing billing opportunities) while others will require advocating changes at the state and federal level. (Click here for helpful billing tools created by the SAMHSA-HRSA Center for Integrated Health Solutions.) Daunting though this may seem, the climate is right for these discussions with your state Medicaid and behavioral health offices. They are faced with the task of making the necessary changes to move into the new era of healthcare integration. Strategically, it’s far better to be a part of discussions on creating this new structure than to have it imposed on your organizations. The Georgia Association of Community Services Boards has partnered with the Carter Center to create a forum for change in Georgia via their Integrative Healthcare Learning Collaborative. Not only have they included the public behavioral health providers and their primary care partners, they also have representation from the Georgia Primary Care Association and area medical schools.  They recognize that in order to develop sustainable programs everyone must be at the table.

What are your strategies for sustaining healthcare integration?
I’d love to hear from you. Please enter your comments/suggestions/ideas below or email: behavioralhealthintegration@gmail.com.

Let’s not lose sight of the goal: we must work together to make a difference in improving health outcomes of the people we serve. We CAN ensure that the margin is there to continue the mission. Be a part of the solution!

behavioral health integration · behavioral health primary care integration · collaborative care · healthcare integration · primary care behavioral health integration

UPDATE: The Greatest Challenges for Integrating Behavioral Health and Primary Care Services

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The recent poll conducted via the LinkedIn group, Behavioral Health Integration, continued to generate thought-provoking comments following the last post. (Click here to see the initial results.) Thought-leaders, behavioral health, and primary care professionals have offered their perspectives on the pressing question:

WHAT IS THE GREATEST CHALLENGE FOR INTEGRATING BEHAVIORAL HEALTH AND PRIMARY CARE SERVICES?* 

Mark L:  Community health records (CHR) that follows the patient and not the provider or payer source will create the sustainability –finance and billing that aid Partnerships to create better operations/workflow that in turn solve workforce issues.
I think the solution for integration of health care is an IT solution that allows for communication not in any “one” silo but in a cloud, it is the premise of the question about integration that it will be in a silo that leads to obsolescence or a least does not address systemic issues of communion about the actual needs of the patient first.

  1. Providers at all levels of care need to exchange information both horizontally and vertically, such as a transfer of care to another provider at a higher or lower level of care. Also community integration of available resources for discharges from one provider to the next or transitions to the public systems from private system or vice versa.
  2. The public and private sectors need to work together to “speak the same IT Language” the health record should follow the person in any system.
  3. Acute care and mental health care systems need the same ability to communicate, whether or not you call the person a client or patient. Mental health and acute care providers can then communicate and bill on a “continuity of care” coordinating treatment for a patient as a team and not in silos.
    The export of data from one CHR to the next is where standardization needs to be the focus. I am excited to see future of blending of Regional Health Information Organizations (RHIOs), Health Information Exchange (HIE). RHIOs and HIE are changing the discussion from silos to clouds.

Leslie B: This may be one of my favorite topics. Yes, I agree that IT can play a part of it, but that is not the only part of the system that needs to change. Like one of the members of discussion, the providers and their ability to talk to each other is one. Program Development requires system and staff changes, changes in thinking, and the ability to assess each site. Each Primary care setting has its own challenges, so one can say provider insight at one location and Behavioral Health provider readiness at another location and yet another location might have the inability to see each other’s records or there may be a staffing problem. I think the biggest challenge can be who is going to pay for it, once everybody in the system figures out what it is anyway. It may require more behavioral health providers and more medical providers. Will there really be a return on that investment. The patient would probably get more holistic care, but it isn’t going to cost any less money.

Bob H:  I believe that one of the greatest challenges is that we need to stop talking about behavioral health and primary care and begin focusing on the needs of the individuals receiving our services and how our systems can best serve their needs. We need to include clear measures of ‘behavioral economics’ and understand that we all act and react to rewards and benefits. We need to structure our systems and our interventions to incentivize overall health improvements, whether behavioral or medical.
We will only have truely intregrated care when we are patient centered and stop distinguishing between behavioral health and primary care. That does not mean that we will not have specialists; whether they be psychiatric, medical, communication, design, or information and technology. It is all about the focus on the patient’s needs and building workflows to address those needs appropriately to assist them in reaching productive and effective outcomes as a result of our services and interventions.

Nelson B: In short, the greatest challenge of healthcare integration is getting paid for effective services. Coleman Professional Services will look at the best outcome of our customer; their health, their ability to have stable living conditions, volunteering or employed and their ability to appropriate socialize in their community. Let’s look at the outcome for our customer and get paid for this outcome.

Michael J: Reading this thread shows that there is a great deal of thought being put into this topic. I think that some of this boils down to a chicken and an egg. And Nelson is right on target about the pay systems. We in our industry have not truly integrated mental healthcare and addictions treatment. Now I know there are pockets of good co-occurring treatment programs here and there, but as an industry they continue to be separate. And the biggest reason is following the money. The money for these services are not braided, and so they stay separate.
I’m currently working on a perinatal mental health integration project. We know what to do clinically (we are using the IMPACT model) and we have OBs who want to participate. We have Medicaid insured women we have identified as needing care. But since the Medicaid is carved-out, the physical health Medicaid plan will not pay for the service as they don’t pay for MH services, and the MH plan won’t pay because they don’t purchase physician services from non-psychiatrists unless they are credentialed as a part of a licensed agency with a MH contract. If the insurance companies and the government wanted to have integrated healthcare, they would have it. If there was a requirement that integrated care was insisted upon for reimbursement we would be all over it. In fact, we do all sorts of odd things now to respond to external requirements that have absolutely nothing to do with the delivery of care. So I have to believe that once the system starts demanding integration it will have it. The system gets what the market commands. The reason there are no solid IT solutions that can incorporate MH and PC is because the market doesn’t demand it. But vendors will respond when that’s required or they will be out of business, just like we would be if the demands were levied upon us and we didn’t respond.

Bob F: This has been a great discussion Cheryl – thanks for posting it. I read the responses from the other groups where you posted this question as well. It seems there isn’t necessarily an individual “biggest” challenge that organizations face versus as much as a varying number or group of issues that organizations face depending on a variety of factors: state environment, organizational structure, readiness to change, internal infrastructure, willing partners, etc. One of the keystones of integrated care is that our patients come to us fully assembled, and our treatment/wellness/prevention response to them has to be, in turn, as fully assembled in order to be effective. And efficient. Clearly the challenge we face in just about every region of the country is that the obstacles are likewise effectively assembled. At Cherokee Health Systems here in TN – even after running an integrated system for over 30 years new challenges surface all the time, chief among them payers who shift priorities from contract to contract, workforce (less primary care docs and psychiatrists all the time), finding time to be innovative in the development of such practices as telehealth, telepsychiatry and telepharmacy, etc. When we do our training academies we focus on all of these issues – administrative, operations, financing, workforce, PC-BH collaborations, model development – because we understand that it is almost never a single obstacle. Anyway – great to follow along and see the efforts being undertaken out there!

David R: New EMR processes are forcing medical case management accountability. Behavioral health case management processes are a generation behind medical and will require a sizable accountability shift for clinical participants.

*The question was also posted in these LinkedIn groups: Behavioral Healthcare Magazine Group, Mental Health Networking, The Friends of SAMHSA.

The poll results demonstrated a shift: with 44 total votes, Partnership has demonstrated a considerable increase, closing the gap on Sustainability.

POLL RESULTS:

Sustainability — finance and billing           38%

Partnership issues                                           31%

Workforce issues                                              7%

HIT issues                                                         5%

Operations/workflow issues                         18%

Without a doubt, each of the five factors is very important for successful integration. The next blog post will take a look at overcoming these challenges.

What do YOU think is the greatest challenge for integrating behavioral health and primary care services? Please send your comments to BehavioralHealthIntegration@gmail.com or visit Behavioral Health Integration

behavioral health integration · behavioral health primary care integration · collaborative care · healthcare integration · primary care behavioral health integration

The Greatest Challenges for Integrating Behavioral Health and Primary Care Services

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In a recent poll conducted via the LinkedIn group, Behavioral Health Integration, this question was posted*:

What is the greatest challenge for integrating behavioral health and primary care services? 

POLL RESULTS:

Sustainability — finance and billing           50%

Partnership issues                                          23%

Workforce issues                                             11%

HIT issues                                                          3%

Operations/workflow issues                        11%

The question produced a number of excellent comments that are listed below. Obviously there are differing opinions about the greatest challenge for integration. The most important factor is that the healthcare community is actively thinking about this very important topic! There is no easy solution. However, as long as we continue to move forward we will establish the path to success. It’s a challenge that is worthy of our efforts. We WILL make a difference.

What do YOU think is the greatest challenge for integrating behavioral health and primary care services? Please send your comments to BehavioralHealthIntegration@gmail.com or visit Behavioral Health Integration

Peggy H:  Hmmmm. And possibly beneath it all is the issue that both systems are needing to care for an overwhelming number of people, with increasingly complex needs, in the first place. I have only recently joined, but am eager to learn more about how policy, the priorities it sets and the direction it gives to financing, is shaping critical features of integration efforts.

Joseph B:   In my mind, until the silo mentality for benefit and payment is integrated, there can not be true clinical integration. In settings where integrated payment has been settled (VA, Kaiser, ACOs), all other issues solve themselves.

I believe that carved-in, risk sharing financial models are the solution to integration

Bob F:  I think Dr. B is directly on target. Risk sharing models – capitated systems, shared savings models – can encourage better integration between modalities. Fee for service and carve outs fail to capture the true essence of integration – the vital “almost billable” services like warm handoffs, hallway consults, follow up phone calls, and the treatment team meeting; not to mention the varied allowable services among the states pertaining to same-day billing, discipline/credential requirements, etc. Trying to pound the traditional mental health square peg (with all of its burdensome documentation requirements) into the primary care round hole is not the answer – and just pounding harder with a bigger hammer is definitely not the answer.

Lena Z:  I work for a pediatric health care system in Texas and we have only been able to deliver this type of service under grant funding…which was recently stripped away prematurely by the state of TX.

Bob F:  It’s frustrating, isn’t it Lena? What we’ve found in TN is that it’s all about what you negotiate in your contract; the payers have latitude to “turn on” certain codes, allow for different funding arrangements/systems – but the provider has to be able to have the data and show the outcomes. The payer can also do some cost comparisons of your services versus your neighboring providers/competitors – that is the key. If you can get them to share their data in comparison with yours and can show those savings and improved outcomes – you have better leverage. We also learned that we were never going to be in a position to negotiate until we had a big enough member panel. It’s a battle well worth fighting – and one that is never truly won. Or lost.

Cheryl H:  Each of the issues can and often does create barriers for behavioral health and primary care integration. Sustainability is the area in which most providers tend to focus for obvious reasons: No margin no mission. However, too often concern over sustainability becomes the primary focus, diverting attention from the other issues causing them to be neglected:

  • Partnership issues have brought about the demise of many promising partnerships. For long-term success, behavioral health and primary care partners must address establishing the mission for the partnership; identify a common language; maintaining pacing, flexibility, and capacity; develop shared solutions; determine expectations; delegate trust; create empowerment; and measure outcomes.
  • Workforce issues can create significant barriers to successful integration. Service provision in the integrated environment varies greatly from services provided in traditional behavioral health and primary care organizations. Training programs for current and future workforce is necessary for long-term success.
  • Health information technology issues create significant challenges for healthcare integration. Challenges created when partners have incompatible electronic records and other issues with record sharing inhibit successful integration.
  • Operational issues such as workflow can impact productivity, creating further challenges to sustainability.

With commitment among all stakeholders, successful integration of behavioral health and primary care can be accomplished. The resulting improvement of health outcomes for people with behavioral health disorders makes it worth all the effort.

Cindy M: As I think about this and read all your comments, I’m now thinking that the biggest challenge depends a lot on the people who are facing that challenge. I voted “workforce” because I’ve thusfar been able to find ways to deal with the silos in the back office so that they are transparent — or CAN be, at least — to the clients and possibly even the service delivery staff.

The biggest problems I’ve had are in teaching my fiscal dept. staff to think “integration” on the front line while complying with the silo mandates in the back office. Then there are the issues with some — not all, by any means — clinical and service staff who either are flummoxed a bit by the concepts and practices they have to integrate OR are stuck in “we don’t do that” gear.

The finance structure and silos are what I lose my religion over, but (apart from the unlucky fiscal staff) don’t need to interfere with anyone else. In dealing with THAT, I still find the main determinant to success or frustration being the persons I have to deal with at the governmental offices with whom we’re contracting. Some are very creative in helping create ways to make it work and others just AREN’T. Those ones do not help me find ways to create an “integration effect” without having an actual integration on the finance side. Which, again, is a work force issue.

Long story short: in my experience, integration has been as good as the people in charge of making it happen.

Stephen W: Great question. From an information system perspective, the greatest challenge is finding a software vendor that handles both BH and PC effectively. CCHIT has certification standards that address both BH and Ambulatory Care. These standards are more stringent than MU certification. I would start there and only look at those vendors that are certified in both.

Joseph P:  I see a legacy of “carving out” behavioral health from medical benefits as segregating the two. Now that the value of treating diseases with high levels of psychological cormobidity is well established there will be a need to embed behavioral health with primary care much in the manner demonstrated by bariatric and transplant programs. Behavioral health specialists will need to provide brief cogent consults to PCPs and brief strategic interventions to patients focusing on patient education, compliance and stress/pain management in addition to more traditional psychological care. Insurance reimbursement can target shared risk/rewards for health care homes that provide this multidisciplinary approach.

Bill H:  I don’t see it as a greatest single challenge as much as a multitude of challenges that require coordination, planning and leadership. I generally recommend starting small and building on successes. Once you effectively implement integration in one area, you will create a demand for similar services in other areas. Finding the right location to pilot a program that has a clinical need and a physician champion provides a great place to start an integration program. Would be happy to discuss integration in more detail.

I am currently working on developing a behavioral health model for accountable care organizations. Thoughts on that topic??

Karen M: The largest challenge I had dealing with both was a very direct problem but I do not think their is a simple and straightforward way to handle it. I found when working with Behavioral Health and also co-morbid medical cases I had a lack of communication between providers. This communication was the single item that told me whether a case would be successful or not. The willingness of providers to communicate is paramount to success and I know that isa complicated issue due to the fact physicians
and other professionals do not get paid for consultation but that leads me to believe some changes need to be made.

Joseph P: I am currently director of a multi-facility, multi-state program that offers integrated outpatient medical and behavioral health care to members of a Medicare Advantage program. We provide urgent ED level and ongoing complex care in conjunction with hospitalist service. This allows members a continuum of care that augments that provided by their PCP. PCPs have their HEDIS metrics improved (with higher level of reimbursement), patients receive excellent care that reduces inappropriate ED and hospital admissions and the insurance company reduces unnecessary costs. Behavioral medicine in these advanced care center focus on compliance and psychological factors that affect physical conditions. This type of program is likely to become a model of how care will be provided in the future as the carriers invest more dollars in better integrated healthcare as a wy of controlling inappropriate costs related to inappropriate higher level of care

Jim H:  Possibly not the greatest challenge, but still a significant one is to provide an environment that is safe for patients who may have self-harm or suicidal tendencies. According to studies by the American Psychiatric Association we were averaging 1,500 inpatient suicides per year in 2003 and that number has increased to 1,800 by 2008. That averages just under 5 inpatient suicides per day. The typical med/surg hospital unit provides many opportunities for suicide and access to items that may be used by patients to harm themselves or others.

The American Society for Healthcare Engineering (ASHE) published a monograph last year that addresses this issue titled “Converting Medical/Surgical Units for Safe Use by Psychiatric Patients”. This is available for purchase on their website at http://www.ashe.org.

Also the National Association of Psychiatric Health Systems (NAPHS) publishes the “Design Guide for the Built Environment of Behavioral Health Facilities” that is available free of charge at either their website (www.naphs.org) or mine (www.bhfcllc.com). I am the co-author of both publications and I also offer free 30 minute phone consultations on patient and staff safety in behavioral health facilities.

Jay O:  I’ve built several counseling centers and consulted for a lot of physicians. From my perspective, there are a number of issues that make it difficult, but could be overcome. Therapists in general are used to working in isolation. They typically do not communicate well with physicians and many are frankly afraid to do so. This can be overcome through training therapists how to adapt to a faster paced primary care setting.

I’ve embedded counselors in several primary care offices with some success. Patients feel less stigmatized going to a primary care office. There still needs to be strong referral patterns developed internally. Even with a therapist present, physicians still need to develop the habit of having a referral conversation with their patients and make a referral for an assessment. Alerts could be set up in EHR to remind the physician to do this when they prescribe psychotropic medications.

On the business side, a lot needs to be worked out to integrate with a practice. Medical space is often more expensive than a therapist can afford. The ROI on this space may be very low for the therapist, but high for the physician. If the space is unused, then it can be subleased at a reduced rate, otherwise it would not make financial sense for either party.

In general, therapists are not as good at creating business relationships and resolving operation issues that would need to be worked out to integrate with physician offices. These trends can be overcome with some training and coaching of the counselors.

Denise S:  My position as a Behavioral Health Specialist was created to do just that to work as a link between Behavioral Health and the Medical Case Management Teams.

Bill H:  A resource on the topic is: Understanding the Behavioral Healthcare Crisis: The Promise of Integrated Care and Diagnostic Reform. The book was edited by Cummings and O’ Donohue and published in 2011.

Scott W:  A major challenge is the same challenge that exists in integrating primary health with any specialty area. Healthcare providers are largely oriented to focusing on the problem at hand, and do not necessarily feel able or equipped to take the time to understand the relationship between the various health problems a patient may have, including behavioral health. I believe to successfully integrate a patient’s different healthcare needs, there may need to be a professional (nurse) or paraprofessional (trained technician) who can serve as a care manager. Obviously, adding this expense would need to have some criteria and parameters to be cost effective.

Anyone who has an older family member or friend who has multiple health problems and a variety of medications knows that there can often be medical and/or psychiatric complications from the interactions of those medications. To me, and perhaps using an overly simple definition and context, integration means care management.

Ally L:  The medical field has not experienced peer/family/youth/young adult involvement to the same extent that mental health has. They don’t yet understand the value or that we as peers and family members can understand the complexity of integration. We have made great strides in this area within mental health (always more work to be done) but it feels like we’re starting at square one with medical professionals in the development of statewide integration, Coordinated Care Organizations and Health Homes that is occurring here in Oregon.

The other challenge is the medical model. Mental health has operated under the medical model for many years as far as billing (Medicaid and private insurance); however, there are other elements of the medical model that do not translate well when it comes to practice. For example, the measuring of outcomes. Recovery is more easily measured when we are looking at physical illness or injury. Recovery in mental health and/or addiction is more subjective. The person in recovery determines what recovery looks like for them, not whether the rash is gone or the broken bone has healed. A mental health professional or family member’s definition of recovery for their “patient” or loved one may be very different than for the person working toward their self-defined recovery.

Cindy L:  Reimbursement? I will be graduating in a year with my Psych Nurse Practitioner finding my place will be challenging

*The question was also posted in these groups: Behavioral Healthcare Magazine Group, Mental Health Networking, The Friends of SAMHSA. Several of the comments came from these groups.

behavioral health integration · behavioral health primary care integration · collaborative care · healthcare integration · mental health · primary care behavioral health integration

Integrating Primary Care into the Behavioral Health Clinic

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Innovative, forward-thinking behavioral health leaders are quickly moving forward to bring primary care services into their clinics. They are committed to improving the health outcomes of the individuals who receive their services. This blog post focuses on practical how-tos for optimizing service delivery.

PREPARING FOR INTEGRATED SERVICE DELIVERY

When co-locating primary care in a community behavioral health center, take care in planning the physical location of the primary care staff offices and exam rooms. Most behavioral health centers find space to be a premium. Bringing primary care services into the behavioral health clinic begins a flurry of activity of planning. An empty office or an office that is the obvious choice for doubling up employees is the typical starting point in planning. The easy solution is not the ideal solution. In order to prevent problems once the services are established, it is worth the effort to consider the following points:

Start with a Customer Service Perspective

Initial planning must be based on providing the best service for individuals who will be accessing services. This includes consideration of the ideal customer experience will be. Through starting with the end-goal in sight, you can effectively work backward to create the ideal. Providing a pleasant environment with a customer-centric flow that effectively integrates service delivery results in satisfied customers and providers.

Strategic Planning 

Integration of services will not occur unless primary care and behavioral health staff are located so that they can interact regularly. Passing each other in the hall promotes a sense of teamwork and allows for brief hallway consults. Physical distance prevents interaction and reduces the likelihood of true integration. When primary care services are segregated into a separate hallway, wing, or even a different floor, integration of services is hindered to the point of being essentially impossible. This model promotes a siloed model that discourages interaction between providers. A little disruption on the front end will prevent problems in the long run. Take the time to carefully plan the workflow. By relocating a few offices, chances for successful integration of services is maximized. Perhaps you may want to be really daring and have behavioral health and primary care professionals’ desks located in a central office near the exam rooms. Togetherness breeds camaraderie.

Encourage Warm Handoffs

This vote of confidence from one professional to another greatly increases the likelihood of follow through by the client. When the behavioral health and primary care professionals are in close proximity, even the busiest providers are able to take a moment to make this brief but invaluable introduction.

The Value of Flexibility 

Flexibility can be a challenge for behavioral health clinics. As a result, many rely on a rigid method of scheduling that is based on convenience of the clinic rather than the customer. This method has historically been a challenge for clinics and the people who seek services there. No show rates soar while unyielding (or is it naive?) administrators continue to expect people with cognitive impairment to somehow be trained to adhere to rigid methods of receiving services. This is costly for the clinic and frustrating for the client. It is NOT customer-centric.

It behooves community behavioral health clinics to follow the lead of their primary care cousins and opt for more flexible scheduling to meet the demands of the individuals served. This is even more important in an integrated setting that requires greater coordination for meeting the whole health needs of individuals. Open access and same-day scheduling are options.

Engage the Primary Care Staff in Planning the Workflow

Engaging primary care staff in planning workflow not only allows buy-in from everyone, it prevents having to make modifications later on. Workflow in primary care is very different than in the behavioral health setting. Negotiating the flow for integration ensures smooth service delivery and maximizes staff productivity.

Shared Reception is Ideal

One front desk for check in promotes the sense of seamless service delivery. It greatly simplifies the process for clients as well as staff. Having separate locations for checking in is an extra step in the workflow and is not customer-centric.

Plan for Frequent, Regular Case Consultation 

Weekly treatment team meetings that include all behavioral health and primary care providers offers a forum for integrated case discussion to supplement (rather than take the place of) ongoing, daily consultation. This allows providers to discuss difficult cases, building on the expertise of all. It also further promotes the sense of teamwork that is important for integration.

Check back for more practical how-tos for integrated service delivery.

This is by no means an exhaustive list. I encourage readers to send in their ideas of other logistical considerations for successful integration to behavioralhealthintegration@gmail.com to be included in a future post of Behavioral Health Integration. 

behavioral health integration · behavioral health primary care integration · collaborative care · healthcare integration · mental health · primary care behavioral health integration

Making the Behavioral Health – Primary Care Marriage Work

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Every relationship follows a similar pattern. The early phase begins with the selection of a partner. The same holds true for the integrated behavioral health and primary care partnership. It may begin with running into each other at a meeting. Or perhaps while reading the latest report on the emerging trend of healthcare integration, Accountable Care Organizations, health homes, etc…

The VISION begins to form                         

The behavioral health and primary care clinics enter into the dating relationship when the leaders of each, who have mutual admiration for each other, begin to recognize the potential of doing business together. One leader calls the other, suggesting they get together for lunch. It’s only lunch, he rationalizes to himself, it doesn’t mean anything…there’s no harm just in talking…. One thing leads to another during the wooing and courting phase; soon the idea transitions and the outline of a plan begins to emerge. The two leaders have entered the early stages of the partnership. The Vision is being created, becoming a driving force for each. The two organizations soon find themselves having serious discussions about forming a partnership. How did THIS happen?? The proposal is followed with a flurry of planning. There are so many details! Attorneys are kept busy creating a business plan and reviewing financial and regulatory documents, planning for the wedding of two organizations. Decisions must be made of how the assets are to be shared. Finances are sorted, MOUs are signed, and the partnership is official. The marriage of behavioral health and primary care creates a unique entity that is far greater together than either had, or could have been, alone. The early stage of the partnership is filled with excitement as the Vision takes shape and becomes reality. The shared vision is driven by the passion to become what neither can achieve alone. The specialty behavioral health provider and the primary care provider have integrated, raising the bar of healthcare for people with behavioral health disorders.

This marriage of healthcare providers is based on a Vision shared by two of eliminating the health disparities of people who suffer from serious mental illness and substance use disorders.

COMMUNICATION

Early Phase: THE HONEYMOON

In the early days of the partnership, the Honeymoon phase, there is a distinct tendency toward assuming that both partners are speaking the same language and are working toward the same goals. The excitement of the new endeavor and the synergy created initially helps to move things along at a rapid pace. When the behavioral health partner talks about workflow and scheduling appointments, there is little thought given to the fact that these two concepts have VERY different meanings for the primary care provider. It is important to have a thorough review of operations from both perspectives and to find a viable middle-ground that both partners find acceptable. Making open, frequent communication a priority from the onset will prevent problems later on.  This should include a thorough overview of each organization’s regulatory, financial, and operational processes as well as overall mission. Don’t assume that the two partners really understand how each other’s organization functions.

Problems within the Partnership
(AKA THE HONEYMOON IS OVER!)

If the partners neglect to develop an open culture of communication on the front end, it is likely that miscommunication will develop. The Honeymoon phase is in jeopardy. The entrepreneurial partner fails to understand the ongoing delays from the partner with the extensive bureaucratic approval process that prevents a quick turnaround of virtually everything. As misunderstandings develop into disappointments and resentments, the previous harmony is disrupted. The Honeymoon is over. Internal conflicts must be addressed immediately with candor. This is a good time to have an open conversation about all the aforementioned points and develop a plan for ongoing, frequent communication. Concerns about the great divide over productivity targets, outcome measures, and caseloads must be openly discussed, among other important points of contention. By devoting the necessary focus on the importance of Communication, the partnership will successfully transition to the third key component for a successful behavioral health – primary care marriage, Compromise. The shared mission to reduce health disparities for the individuals served who suffer from comorbid behavioral health and medical conditions will persevere. However, failure to make this transition may very well land this promising partnership into divorce court.

COMPROMISE

I shall argue that strong men, conversely, know when to compromise and that all principles can be compromised to serve a greater principle. –Andrew Carnegie

It isn’t easy to bring a behavioral health organization and a primary care organization together for the creation of an integrated partnership, despite the reason–altruistic or otherwise. When partners fail to provide adequate attention to open and effective communication, the excitement of early marriage can wane; the relationship may become troubled, requiring mediation. When misunderstandings occur and tempers flare, it’s time for an intervention to get the partnership back on track.

Marital Counseling

As with any relationship, compromise is a necessary element in the behavioral health – primary care partnership. After the honeymoon phase, the partnership enters a crucial period in which its future is determined by the ability of the partners to negotiate the (sometimes rocky) path ahead. Differences between the two entities become more apparent as pressure mounts via the divergent audits, budgets, various regulatory requirements, etc. Furthermore, what are the partners to do when they encounter conflicting requirements? Marital counseling may be in order at this point. In other words, it’s time for the partners to take a time-out and take an honest and open appraisal. Developing shared solutions are important for strengthening the bond. The partners must approach all dilemmas together as a team. Each has a vested interest; negotiating solutions will strengthen that bond. Wise leaders recognize that trust is not automatically bestowed. Members of the teams need time and patience for trust to develop. By bringing together members from each team who share similar roles and encouraging ongoing, regular interaction, trust begins to develop within the partnership. Remember that trust cannot be rushed but will grow into a strong foundation  throughout the partnering organizations if nurtured. Empowering the team provides the opportunity for everyone to develop a sense of ownership for successful outcomes. Empowered employs who feel that they play an important role in the organization and who feel valued by management have a greater sense of commitment to the organization. Allow team members the ability to make decisions rather than having every movement scripted. When the receptionist is empowered to work-in an emergency patient without having to gain approval for every occurrence, amazing things begin to happen:  The receptionist feels like a valued member of the team, the patient benefits from the responsiveness, and the other members of the team benefit from the smooth workflow. In marriage, each partner has a responsibility for doing his/her part to ensure equilibrium. The same is true between andwithin the partnership.

Determine Expectations

Mentioning expectations at this point might seem unnecessary. After all, the behavioral health and primary care organization have formed the partnership for the distinct purpose of providing healthcare integration. It’s a very clear expectation and doesn’t require discussion. Or does it? Just as a couple contemplating marriage might wrongly assume that each has the same idea of what their marriage will be like (one partner daydreams about a trendy loft in the city while the other longs for a house with a massive lawn in the suburbs), the integrated healthcare partnership can fall into the same trap of flawed thinking. Don’t assume! The chances for happily ever after increase exponentially when time and effort are committed for open discussions about expectations for the partnership. Both partners must be willing to compromise on expectations when they are incongruent. And don’t forget:

People with serious mental illness are dying while we try to figure this out!

OUTCOMES

With individuals who suffer from serious mental illnesses dying 25 years prematurely on average, behavioral health and primary care have been mandated to address this health disparity. More effective protocols are in order and must be initiated immediately. This is a matter of life and death. The Behavioral Health and Primary Care Marriage is a viable solution.

Growing Old Together

Once the marriage has successfully navigated the first three essential components of a behavioral health – primary care marriage, Vision, Communication, and Compromise,  the final component builds and maintains the mature partnership for growing old together.

The Whole is Greater Than the Sum of Its Parts

The Behavioral Health – Primary Care Marriage, at its best, is an entity so much more than just two collaborating organizations. The synergistic effect of the partnering of two organizations has the ability to surpass what either can accomplish alone. The community behavioral health organization has expertise in treating complex behavioral health disorders but does not address the primary care needs of individuals. The primary care organization excels at treating a myriad of health conditions including mild behavioral health disorders but does not have the expertise to address serious mental illness or substance use disorders. The marriage of behavioral health and primary care serves as a means of connecting the head and the body; it may be thought of as the neck of healthcare. The neck allows the best of both worlds to work together in unison, becoming far greater than either can be alone.

Enhanced Outcomes through Blending of Resources

Measuring outcomes provides evidence of the value of the partnership. Through building on the expertise of each, the blended resources result in enhanced outcomes. For example, theUniversity of Washington’s IMPACT Evidence-based Depression Care has impressive results in improved outcomes with significant cost reduction through collaborative care. The marriage thrives with ongoing feedback, allowing for calibration to ensure that services are effective and financially sustainable. To provide a comprehensive overview, it is recommended that individual health outcome indicators, service outcome indicators, and outcomes data for decision making are included in the repertoire of data collected for analysis and sharing. Implement a system of collecting the indicators at the onset of the partnership. The indicators must be meaningful to both partners. The National Association of State Mental Health Program Directors has a very useful report for guiding the process, Measurement of Health Status for People with Serious Mental Illness.

Accountability

Frequent, regular intervals of sharing results with the team establish a sense of accountability that builds the foundation for longevity. Both partners have responsibility to the partnership and to producing positive outcomes. By following the Four Key Components for a Successful Behavioral Health and Primary Care Marriage, the partnership will live happily ever after.