behavioral health integration

Integrated Care Thought Leader Series: Dale Klatzker, PhD

The Times, They Are a-Changin’

When Bob Dylan wrote this iconic song, many felt that it captured the spirit of social and political upheaval of the 1960s, much in the same way that we view mental health as “a-changin’.”  And these changes require mental/behavioral health providers to change the manner in which they deliver services.

Reports over the past decade have brought attention to the current mental health crisis:

In addition, over the past few years far too many catastrophic events have brought attention to this mental health crisis, resulting in a public outcry, demanding that changes are made to prevent future tragedies.

But change isn’t easy.

The relatively brief history of community mental health services has been a challenging one. Just a few months ago, as we celebrated the 50th anniversary of President John F. Kennedy’s signing the Community Mental Health Bill into law, the conversations quickly progressed to the subject that is on the minds of virtually all behavioral health providers—and an unusually large number of the general public and policy makers, given the historical lackluster interest in the topic—mental health is in dire need of change.

The economic downturn in the US in 2008 resulted in massive budget cuts in all but a few states. The March 2011 NAMI report, State Mental Health Cuts: A National Crisis, demonstrated the cumulative cut to mental health services in the U.S. during that time was nearly $1.6 billion. Community mental health services plummeted from being barely adequate to the critical point in many states. Safety-net providers were forced to close programs due to the slashed budgets. Many of those affected ended up on the streets or in jail.

The recent announcement on the anniversary of the Sandy Hook tragedy, of the planned infusion of dollars into help repair our broken mental health system, is encouraging. However, the entire mental health system is in dire need of an overhaul. One that looks at the broader healthcare picture and strategically plans for mental health and substance use disorder treatment to be included. A person-centered, whole health approach to treatment is necessary for improving the patient experience of care; improving the health of populations; and reducing the per capita cost of health care: the Triple Aim.

Dale Klatzker, PhD
Dale Klatzker, PhD

Dr. Dale Klatzker knows that, although it isn’t easy, change is vital for community behavioral health providers.

It’s exciting to be able to offer a look at integrated care from the perspective of a provider, particularly a provider who has demonstrated leadership excellence in integrating behavioral health and primary care services. Dr. Klatzker currently serves as the Chief Executive Officer of The Providence Center in Providence, Rhode Island. He has been a leader in behavioral healthcare for more than 35 years. Since becoming president/CEO of The Providence Center in 2004, Dr. Klatzker, a visionary, has transformed the system of care, quality of service delivery, and social policy decision making at The Providence Center and the state of Rhode Island.  Click here for Dr. Dale Klatzker’s bio.

The Providence Center and the Providence Community Health Centers have created a successful partnership to meet the whole-health needs of the people they serve within their community; a need that is clearly outlined in the literature. According to the Robert Wood Foundation’s Mental Disorders and Medical Comorbidity authored by Dr. Benjamin Druss and Elizabeth Walker, comorbidity between medical and mental conditions is the rule rather than the exception:

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

What advice do you have for healthcare leaders?

Dr. Klatzker:  Change is a good thing. Most CMHCs haven’t changed a lot. They haven’t prepared themselves to change a lot and have marginalized themselves and the people that they serve by not being more a part of the mainstream. We have sets of skills that are integral to wellness and to health across a wide spectrum. We need to be proud of what we do, but also to expand it and extend it because this is the perfect time for this. We have a lot of things to offer that others are trying to replicate.

Things don’t stay static. You have to look though the windshield but also through the rear-view mirror. You have to know where you are but you also have to know where you’re going.

As executive director/CEO of a behavioral health organization, you have the obligation to push yourself, and that will push your organization, to do what is necessary so that your mission is reinforced but also to serve the needs of the community. It’s hard to do that if you’re doing the same thing you did 20 years ago. We do our consumers a disservice if we do that.

Person-centered approach to care

Dr. Klatzker: What we’ve embraced here – what’s part of the DNA of the organization at The Providence Center – we  believe in a person-centered approach to care. No two people are exactly the same. The people that we work for deserve as much access to a wide array of both health and social supports as anyone. That’s how you have to guide yourself. When you’re thinking of those things, primary care integration, working much more toward the mainstream of traditional healthcare is imperative for us.(7:14)

What we’ve found is, if you can build those relationships and find the right connections, then others will embrace you and value you for what you bring to the table. In fact, we bring a lot. Partnership is always the first choice, the default.

We don’t chase dollars, we don’t create programs because it’s the idea du jour from some funder somewhere, we consciously look on our mission as our touchstone and build upon that to provide as much choice to the people we serve. We can be very person-centered because there aren’t many gaps in what we’re providing. (They provide a wider array of services than the average CMHC) We’ve consciously built out a wide array because we think it’s the right thing to do. Rather than to take a “no,” if we can’t partner, we build.

Example of a successful integrated care partnership

Dr. Klatzker: The Providence Center is closely connected to one the largest federally qualified health center in the state of Rhode Island, the Providence Community Health Center. We have become the largest community mental health center. Neither had a desire to replicate the services that the other provided. Over the years we’ve built this into a “no wrong door” integrated collaborative effort so that in the mental health center, the FQHC runs a full-service practice with 1100-1200 patients. In the FQHC, we are integrated in their physician practices building and we also have a separate section of their building where we provide longer term care and some other types of specialty care. We’ve integrated our records with each other. We meet frequently to process and to try to figure out how to make our care efficient and effective. We are working closely with them now on adopting our health home model to integrate a modified health home into the FQHC.

Yes, the times they are a-changin’. And so are healthcare providers. (At least the forward-thinking providers like The Providence Center.) They are heeding the findings from the numerous expert reports and research. They are thinking outside the box, adopting a person-centered approach that enables better outcomes for the many who place their trust in them—trusting them to take care of their whole-health needs.

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behavioral health integration

Behavioral Health 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.

behavioral health integration · Integrated Care · mental health

John F. Kennedy’s Community Mental Health Act of 1963: 50th Anniversary

Today marks the 50th anniversary of the date that President John F. Kennedy signed the 1963 Community Mental Health Act into law. It was to be the last before his death on 11/22/63. The Act represents a monumental turning point in the treatment of psychiatric disorders. President Kennedy’s call to action in 1963 was based on a belief that all Americans – including those with mental illnesses, intellectual disabilities, and addictions – have a right to lead dignified lives and to share in the benefits of our society. Patrick Kennedy, nephew of President Kennedy and former U.S. Representative of Rhode Island, is steadfast in his efforts to continue this important work via the Kennedy Forum.

Act of October 31, 1963 “Mental Retardation Facilities and Community Mental Health Centers Construction Act of 1963”, Public Law 88-164, 77 STAT 282, “to provide assistance in combating mental retardation through grants for construction of research centers and grants for facilities for the mentally retarded and assistance in improving mental health through grants for construction of community mental health centers, and for other purposes.”, 10/31/1963 (Figure 1 below)

History of Psychiatric Treatment

Figure 1: Mental Retardation and Community Mental Health Centers Construction Act of 1963

Early attempts to treat mental illness are thought to date back to 5000 B.C. or earlier, based on the discovery of trephine skulls. A series of barbaric practices followed for millennia. It is suspected that the first asylums were established around the sixteenth century. These early facilities offered no real treatment despite their primitive attempts at cures, consisting of the use of leeches, purges, barbaric contraptions, and the use of chains and other restraints. Conditions gradually began to improve by the mid 1800s thanks to efforts led by humanitarians such as Dorothea Dix. Treatment reform in the asylums offered a more humane approach to the care of people with mental illness.

New treatment options followed in the early twentieth century, including psychoanalysis, introduced by Austrian neurologist, Sigmund Freud, and electroconvulsive therapy, introduced by Italian neuropsychiatrists, Ugo Cerletti and Lucio Bini. Psychopharmacology followed, arguably providing the single most significant change in treatment to date. A former colleague, psychiatrist, Dr. John Wolaver, remarked that when Thorazine was introduced in the psychiatric hospitals, the facilities were suddenly calm and quiet for the first time. It seemed to be a miracle cure. Psychopharmacology provided the next necessary step that led to deinstitutionalization.

The introduction of the Mental Retardation and Community Mental Health Centers Construction Act of 1963, Public Law 88-164, a bold new effort,  forever changed the face of mental health treatment. Prior to this, it was not uncommon for individuals with behavioral health conditions to be hospitalized for many years; hundreds of thousands lived their lives in institutions and were buried on the grounds. Unfortunately, this deinstitutionalization effort fell short of its goal. The USA Today report, Kennedy’s Vision for Mental Health Never Realized, takes a candid look at this.

Figure 2 below illustrates the decrease in inpatient treatment between 1950 and 1995. As the psychiatric hospitals decreased in size, the homeless population grew. The jails and prisons began to fill with the individuals with behavioral health conditions. According to the 10/24/13 article, Why Are The Three Largest Mental Health Care Providers Jails? published by NewsOne:  The three largest mental health providers in the nation are the following jails: Cook County in Illinois, Los Angeles County and Rikers Island in New York. 

Figure 2: Deinstitutionalization

Integrated Care

Many thought-leaders believe that we have embarked upon another pivotal point in mental health (or more broadly, behavioral health) treatment. Mental Health: A Report of the Surgeon General published in 1999 called for the integration of behavioral health and primary care. And the 2006 NASMHPD report, Morbidity and Mortality in People with Serious Mental Illness has prompted the movement toward a whole health approach to treatment that integrates behavioral health and primary healthcare. This promising trend offers hope for improved access for individuals who live with mental health and/or substance use disorders, improved health outcomes, and controlling healthcare spending.

Let us work together to address health conditions wherever the individual presents for treatment. Healthcare must be redefined to include behavioral health. By removing the healthcare silos, providers will begin to recognize and treat the comorbid conditions in their patients. Mind-body integration improves patient outcomes and reduces costs.

Integrated care is necessary for improving the lives of of those who might have spent his or her life chained in a dungeon centuries ago. It is a key element in our efforts to achieve the Triple Aim.

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

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.

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

Making the Behavioral Health – Primary Care Marriage Work

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.

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

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.

behavioral health primary care integration

The Behavioral Health and Primary Care Marriage

We have ascertained in previous posts the value of the integrated behavioral health and primary care partnership. With shrinking healthcare funding and the unmet healthcare needs of people who have serious behavioral health disorders, there are numerous benefits of collaborative care. The blending of resources, expertise, and passion combine to create a synergy that is not possible with one organization alone.

Healthcare Integration Timeline

  • In 430 BC Hippocrates declared:
    “The Body must be treated as a whole and not just a series of parts” 
  • Literature by Dr. Benjamin Maltzberg dating back more than 75 years on studies at the New York State Hospital in Utica has reported “excess mortality due to medical causes in persons with mental disorders”
  • 1999 Surgeon General’s Report on Mental Health
    ◊ First major emphasis on integrated care
    ◊ Dr. David Satcher declared:
       “There is no Health without Mental Health”
  • 2006 NASMHPD Report, Morbidity and Mortality in People with Serious Mental Illness:
    ◊ People with serious mental illness are dying 25 years earlier than the general population
    ◊ 60% of premature deaths are due to modifiable and preventable medical conditions

The Primary and Behavioral Healthcare Partnership

  • Allow for individual choice in determining the healthcare home
  • Ideal for treatment of the whole person
  • Address the health disparities of people who live with serious behavioral health conditions
  • Bi-directional integration allows for individual choice in determining the healthcare home
  • More efficient and effective use of healthcare dollars
  • CNN Report: Companies merge for a variety of reasons
    ◊ Expansion of market share
    ◊ Acquisition of new lines of distribution or technology
    ◊ Reduction of operating costs
    ◊ Corporate mergers fail (up to 80%!) for some of the same reasons that marriages do –
       A clash of personalities and priorities

Four Key Components of a Successful Behavioral Health and Primary Care Marriage

Like all marriages, the behavioral health and primary care marriage requires nurturing. There are four key components that occur at integral stages within the relationship that must be addressed for successful outcomes, aka living happily ever after.

  1. VISION
    > DATING: Partner Selection
        • Mutual attraction
        • Determining potential
        • Wooing and courting
        • Proposal

    > The WEDDING: Formalizing the Partnership
    • Merging of goals
    • Co-location
    • Finances

  2. COMMUNICATION
    > Early Phase: The HONEYMOON
    • Identify a common language
        • Sharing decision-making
        • Synergy
    > Problems within the Partnership (AKA The HONEYMOON is OVER!)
        • Addressing internal conflicts
        • The use of candor
        • Temper expectations
  3. COMPROMISE: Making it Work
    >MARITAL COUNSELING
       • Developing shared solutions
       • Delegate trust
       • Create empowerment
       • Determine expectations
  4. OUTCOMES
    >The MATURE PARTNERSHIP: Growing Old Together
       • Enhanced outcomes through blending of resources
       • The whole is greater than the sum of its parts
       • Accountability

In the next post we will explore the early phase in the relationship, the  first key component, Vision.