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 Healthcare Offers Solution to Inadequate Behavioral Health Services

Behavioral health advocacy groups are expressing concern over recent media attention about people who may or may not be suffering from mental illness.

And they should be.

The horrendous acts committed in the recent past in Connecticut, Oregon, Colorado, etc. are tragic acts of violence. However, make no mistake that these atrocities are NOT synonymous with mental illness.

The fear of advocacy groups, such as the National Alliance on Mental Illness, A New PATH, and Mental Health America, is that the association between behavioral health and these violent acts will result in increased stigma. These and other groups have worked diligently for many years to reduce/eliminate the negative stereotypes associated with mental illness and substance use disorders.

However, the grain of truth to be derived is that behavioral health services need to be more accessible. Ongoing cuts to behavioral health budgets by states over the past few years have resulted in inadequate coverage (click here for NAMI’s chart: State Mental Health Budgets FY2009-FY2012).

Community Behavioral Health Safety Net

Community behavioral health providers are mandated to serve more people with funding that is steadily decreasing and with no hope in sight. The safety net is nearly frayed beyond repair.

Health Reform has spawned a wide array of innovative approaches to healthcare delivery. The integration of behavioral health and primary care is one such alternative that holds great promise for mental health and substance use services.

When primary care providers integrate behavioral health services, there is a dramatic increase in access to services. When behavioral health is included in routine screenings, the stigma of seeking behavioral health services is removed and opportunity for early detection is dramatically increased. Depression, anxiety, and substance use screenings are normalized through inclusion with height, weight, and blood pressure.

Research shows that depression impacts such chronic health conditions as heart disease. Concurrent treatment of behavioral health and physical health conditions results in improved health outcomes. In addition, integrated behavioral health and primary care services results in reduced healthcare costs.

Integrating behavioral health and primary care is a win-win for patients and providers.

Healthcare providers across the US and in many other countries are integrating services in order to improve service delivery. As individuals, we can do our part by reporting both behavioral health and physical health symptoms to our healthcare providers. Remember, healthcare is a partnership. You are a vital member of your healthcare team.

Healthcare Integration Partnerships: Understanding Specialty Behavioral Health

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.

The Greatest Challenges for Integrating Behavioral Health and Primary Care Services

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.

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.

OUTCOMES: The Fourth Key Component of a Successful Behavioral Health and Primary Care Marriage

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

To recap, for behavioral health and primary care marriages to be effective, there are four components that are necessary. Vision, Communication, and Compromise have been explored in previous posts. The final component, derived from the first three, is Outcomes. This element 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, the University 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.