Behavioral Health Integration 2013 in Review

2013 has been a very good year for Behavioral Health Integration Blog! Our popular Integrated Care Thought Leader Series began this year, providing insights into the minds of some of the most prominent thought leaders in integrated care, including Dr. Alexander “Sandy” Blount, Dr. Benjamin Druss, Larry Fricks, and Dr. Benjamin Miller. Stay tuned in 2014! We have several excellent integrated care thought leaders lined up, to provide their expert perspectives on whole health and integrating behavioral health and primary care for enhancing health outcomes, reducing healthcare costs, and improving access to healthcare.

The WordPress.com stats helper monkeys prepared a 2013 annual report for this blog.

Here’s an excerpt:

A New York City subway train holds 1,200 people. This blog was viewed about 4,800 times in 2013. If it were a NYC subway train, it would take about 4 trips to carry that many people.

Click here to see the complete report.

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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”

Challenges to Integrating Behavioral Health and Primary Care Services Revisited

One year ago a poll was published in the LinkedIn group, Behavioral Health Integration:

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

The poll generated a tremendous amount of interest, both in voting on the poll and in comments. Much has happened in the healthcare industry in the past twelve months, changes that have an impact on the way behavioral health and primary care will be delivered in the future.

The greatest impact has come from the Patient Protection and Affordable Care Act (ACA) that was upheld by the Supreme Court of the United States on June 28, 2012. Though passed in 2010, the flurry of activity toward implementing began after the Supreme Court ruling. As states prepare for the 2014 implementation of the new health laws, more and more are agreeing to participation in the Medicaid Health Home plan.

Poll Results

As we near the end of the first quarter 2013, time is running out quickly for implementation. With integrated care playing a crucial role in health reform, the challenges for integrating healthcare services are more and more apparent. Revisiting the below results of the poll conducted one year ago, one has to wonder whether the perceived challenges remain the same among healthcare providers.

Poll results from LinkedIn group, Behavioral Health Integration 3/5/2012 - 3/5/2013

Poll results from LinkedIn group, Behavioral Health Integration
3/5/2012 – 3/5/2013

Finance and Billing

Poll responses indicated that sustainability issues related to finance and billing were the greatest challenge for integration efforts. While many providers have successfully overcome this barrier, it is no easy feat to develop a financially sustainable integrated services delivery system. Fortunately, the ACA created an optional Medicaid State Plan benefit for states to establish Health Homes to coordinate care for people with chronic conditions who receive Medicaid benefits. While only a handful signed on initially, there are currently 24 states and the District of Columbia who have elected to participate in the Medicaid Expansion. Fourteen states have elected not to participate; and 12 states remain undecided. (Click here for more information on where each state stands on ACA’s Medicaid expansion.)

States that are moving forward with Medicaid Health Homes are in the process of making adjustments to policies, billing, and service delivery to enable service providers to integrate behavioral health and primary care services, a requirement of Health Homes:

Health Homes providers will integrate and coordinate all primary, acute, behavioral health, and long-term services and supports to treat the whole person.” – Medicaid.gov

Partnership Issues

Regular visitors to this blog know that much has been published here about the partnership between behavioral health and primary care providers. This was ranked as second most challenging in the poll.

Why do so many people find partnership issues as challenging? It’s counterintuitive. Most providers approach the integration of behavioral health and primary care with a blind eye to the process of partnership development. It is assumed that the interpersonal aspects will fall into place. Unfortunately, it is far more likely that an integration effort will fail due to partnership issues than financial ones. They are not unlike other partnerships, requiring attention to building a strong foundation from the onset.

Here are additional resources:

Operations/Workflow Issues

All healthcare administrators acknowledge the importance of operations for successful service delivery. That’s why 15% of respondents to the poll indicated that this area is the greatest challenge. Once a smooth-running clinic takes on an entirely new service-line, a degree of disruption is inevitable. The workflow will likely be drastically different than the service providers and support staff have grown accustomed to. Of course, taking on a new service also means addressing the organization’s policies, regulatory requirements, physical space requirements, etc.

With a little careful planning and a LOT of patience, your new integrated clinic will be operating smoothly in no time. Click here for a useful integration planning checklist.

Workforce Issues

Seven percent of the respondents indicated that workforce is the greatest challenge. With the current shortage of primary care providers, nurses, and psychiatrists, it’s no wonder that this is of concern. Fortunately, programs for training about integrated care delivery are available, such as the University of Massachusetts Medical School’s Center for Integrated Primary Care, which offers three programs aimed at training healthcare providers for providing integrated services:

Health Information Technology Issues

Despite concerns over the dilemma of sharing health records for integrating behavioral health and primary care, health information technology garnered 5% of the responses. Fortunately vendors of electronic health records are working earnestly to develop products that allow for the seamless sharing of behavioral health and primary care records. (Click here for more information on the role of HIT in integrated healthcare.)

One Year Later

What are the greatest challenges to integrating behavioral health and primary care in 2013? What will be the challenges next year? Dare we suggest that in the near future there will no longer be challenges?

Additional Resources:

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

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

Integrating Primary Care into the Behavioral Health Clinic

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. 

Making the Behavioral Health – Primary Care Marriage Work

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, VisionCommunication, 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.

COMPROMISE: The Third Key Component of a Successful Behavioral Health – Primary Care Marriage

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 and within 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!