behavioral health integration

Integrated Care Thought Leader Series: Dale Klatzker, PhD

The Times, They Are a-Changin’

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
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:

In 2002, more than half of disabled Medicaid enrollees with psychiatric conditions also had claims for diabetes, cardiovascular disease (CVD), or pulmonary disease, substantially higher than rates of these illnesses among persons without psychiatric conditions. The authors conclude that the high prevalence of psychiatric diagnoses among people with chronic medical conditions should be an impetus for prioritizing the improved integration of behavioral and medical care.

What advice do you have for healthcare leaders?

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.

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

Integrated Care Thought Leader Series: Benjamin Druss, MD, MHP

“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
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, world-renown researcher in health policy, has made a significant contribution to healthcare and the integration of behavioral health and physical health. He has impacted the lives of many individuals as a result. As the first Rosalynn Carter Chair in Mental Health, Dr. Druss is working to build linkages between mental health, general medical health, and public health. He works closely with Carter Center Mental Health Program, where he is a member of the Mental Health Task Force and Journalism Task Force. He has been a member of two Institute of Medicine Committees, and has served as an expert consultant to government agencies including the Substance Abuse and Mental Health Services Administration, the Centers for Disease Control, and the Assistant Secretary for Planning and Evaluation. He serves as professor at Rollins School of Health Policy and Management at Emory University.

Dr. Druss’s research focuses on improving physical health and healthcare among persons with serious mental disorders. He has published more than 100 peer‐reviewed articles on this and related topics, including the first randomized trial of an intervention to improve medical care in this population in 2001. His research is funded by grants from the National Institute of Mental Health and the Agency for Healthcare Quality and Research, and he serves as a standing member of an NIMH study section. He has received a number of national awards for his work.

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:

The Health Recovery Peer (HARP) Program: A Peer-Led Intervention to Improve Medical Self-Management for Persons with Serious Mental Illness
Benjamin G. Druss, Liping Zhao, Silke A. von Esenwein, Larry Fricks, Sherry Jenkins-Tucker, E. Sterling, R. Diclemente, K. Lorig

Behavioral Health Homes for People with Mental Health & Substance Use Conditions: Core Clinical Features
Laurie Alexander, PhD, Alexander Behavioral Healthcare Consulting, and Benjamin Druss, MD, MPH, Rollins School of Public Health, Emory University authored this document for the SAMHSA-HRSA Center For Integrated Health Solutions

A Randomized Trial of Medical Care Management for Community Mental Health Settings: The Primary Care Access, Referral, and Evalution (PCARE) Study
Benjamin G. Druss, M.D., M.P.H.. Silke A. von Esenwein, Ph.D. Michael T. Compton, M.D.,. M.P.H.. Kimberly J. Rask, M.D., Ph.D. Liping Zhao, M.S.P.H.. Ruth M. Parker, MD

Budget Impact and Sustainability of Medical Care Management for Persons With Serious Mental Illnesses
Benjamin G. Druss, M.D., M.P.H., Silke A. von Esenwein, Ph.D., Michael T. Compton, M.D., M.P.H., Liping Zhao, M.S.P.H., Douglas L. Leslie, Ph.D

Understanding excess mortality in persons with mental illness: 17-year follow up of a nationally representative US survey
Druss BG, Zhao L, Von Esenwein S, Morrato EH, Marcus SC.

Mental Disorders and Medical Comorbidity
Goodall S, Druss BG, and Walker ER

Understanding Disability in Mental and General Medical Conditions 2000
Druss BG, Marcus SC, Rosenheck RA, Olfson M, Tanielian T, Pincus, HA

Integrated Medical Care for Patients With Serious Psychiatric Illness 2001
Druss BG, Rohrbaugh RM, Levinson CM, Rosenheck RA

Mind and Body Reunited: Improving Care at the Behavioral and Primary Healthcare Interface publication 2007
Mauer BJ and Druss BG

Mental disorders and medical comorbidity publication 2011
Druss, BG and Walker ER

Research Projects:

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”

Affordable Care Act · behavioral health integration

Behavioral Health Homes

In the midst of talk of healthcare reform, it is apparent that the face of healthcare is undergoing numerous changes from the traditional delivery system. Accountable Care Organizations and other collaborative efforts are proving to be viable solutions for addressing the gaps within healthcare, providing a glimpse of its future structure. Efforts are underway across the nation (and internationally) to integrate behavioral health and primary services within the ACOs as well as between community behavioral health and primary care providers.

The Patient Protection and Affordable Care Act has created a health home option in Medicaid for treatment of chronic conditions. Thus, the concept of the health home was created, with incentives in place for a more holistic approach to healthcare in an attempt to improve quality of care, contain or reduce costs, and improve outcomes. With behavioral health conditions meeting the established criteria for chronic conditions, behavioral health homes are the ideal solution for meeting the needs of people with serious behavioral health disorders who have not traditionally accessed healthcare on an ongoing basis. While the majority of information circulating regarding healthcare integration is related to integrating behavioral health into a primary care setting, it’s a mistake to assume that primary care will absorb all behavioral health services. Specialty behavioral healthcare plays a distinct and important role within healthcare. Individuals with serious mental illnesses historically receive the majority of their services in community behavioral health settings. Many prefer to receive their primary care services within this setting as well for a variety of reasons. Primary care, in its typical current structure, would require significant modifications to take on the added line of business. Many organizations have successfully managed this, with Cherokee Health Systems leading the way for decades. However, primary care clinics that are not prepared nor inclined to follow this model may defer to the Behavioral Health Home.

What is a Behavioral Health Home?

First, let’s talk about what it is not. It is not a group home or nursing home. It is not a physical structure meant to house those in need of behavioral health services. The behavioral health home is a behavioral health organization that serves as a health home for people with mental health and substance use disorders.

Behavioral Health Homes for People with Mental Health and Substance Use Conditions prepared by Dr. Benjamin Druss and Dr. Laurie Alexander for the SAMHSA-HRSA Center for Integrated Health Solutions provides a thorough overview and guidance for establishing the behavioral health home. This document provides practical information for providers in their efforts to provide a more comprehensive delivery system to address the triple aim of healthcare. Behavioral Health Homes for People with Mental Health and Substance Use Conditions is an excellent resource and a must-read for providers in their efforts toward transitioning their organizations into a behavioral health home.