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.
“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.”
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, 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:
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”
In the US the first week of October has been recognized as Mental Illness Awareness Week since 1990 when it was established by Congress in recognition of the National Alliance for Mental Illness’s efforts to increase public awareness about mental illness. Mental Illness Awareness Week also coincides with similar organizational campaigns:
There is no doubt that this campaign has been a successful one, raising awareness, encouraging people to screen for depression, and chipping away at the negativity surrounding mental illness. This theme is aligned with the philosophy of behavioral health integration. Therefore, perhaps a day can be designated for recognizing the importance of integrating behavioral health and primary care services. When physical health and behavioral health are addressed concurrently, people have better health outcomes and are better satisfied with their healthcare services. Integrated healthcare also offers improved access to services and reduces healthcare costs.
Of the many challenges in integrating behavioral health and primary care services, the one that garners the most apprehension and concern is sustainability. It is also the most frequent reason for hesitation in moving forward. Healthcare is not set up to address this. Primary care and behavioral health have different billing codes with no easily decipherable means of venturing outside the confines to include payment for integrated services. The mere thought of the process required to begin to tear down the barriers separating the two worlds strikes fear in the hearts of the most courageous administrators.
Healthcare administrators are presented with conflicting demands and are struggling to reconcile the next step. They can:
Ignore the ever increasing focus on healthcare integration and hope it is just another passing fad; or
Place even more burden on the ever-shrinking budgets and hope for the best.
Let’s take a closer look at the options:
Ignoring healthcare integration seems like the easiest solution. Administrators can align themselves with like-minded peers creating a support group who reinforces the notion that it will all just fade away if they merely wait it out. This group gets considerable pleasure in observing the early adopters from a distance, filled with certainty that they are all making huge mistakes. They pat themselves on the back encouragingly as they watch their naïve peers make the occasional fumble, while attributing any successes to sheer (unsustainable) luck.
Over-burdening the current budget seems to be irresponsible. Behavioral health administrators have been faced with budget cuts in unprecedented amounts over the past few years. While they have either become masters at doing more with less or have chosen to leave the field entirely, taking on a new business-line during the increasing uncertainty of their organizations’ financial states seems to be overly risky and counterintuitive.
Yet the pressure is on.
Nationally, more and more behavioral health conferences are featuring healthcare integration tracks. The same is becoming true of primary care conferences and conventions as well. With more and more research and reports being released that provide the necessary data to support the need for integration, it’s becoming more and more difficult to write it off as a passing fad. The recent report from the SAMHSA-sponsored, National Survey on Drug Use and Health, Physical Health Conditions among Adults with Mental Illnesses provides further evidence supporting earlier reports demonstrating the need for integration.
The current model of providing behavioral healthcare may be on its way to becoming obsolete. Now is the time for behavioral healthcare administrators to begin the discussion of how to address the whole-health needs of the people they serve. Whether through collaborative partnership agreements, bi-directional integration, or full integration, this issue can no longer be ignored. There are many changes that can be implemented right away (focusing on billing codes and maximizing billing opportunities) while others will require advocating changes at the state and federal level. (Click here for helpful billing tools created by the SAMHSA-HRSA Center for Integrated Health Solutions.) Daunting though this may seem, the climate is right for these discussions with your state Medicaid and behavioral health offices. They are faced with the task of making the necessary changes to move into the new era of healthcare integration. Strategically, it’s far better to be a part of discussions on creating this new structure than to have it imposed on your organizations. The Georgia Association of Community Services Boards has partnered with the Carter Center to create a forum for change in Georgia via their Integrative Healthcare Learning Collaborative. Not only have they included the public behavioral health providers and their primary care partners, they also have representation from the Georgia Primary Care Association and area medical schools. They recognize that in order to develop sustainable programs everyone must be at the table.
What are your strategies for sustaining healthcare integration? I’d love to hear from you. Please enter your comments/suggestions/ideas below or email: firstname.lastname@example.org.
Let’s not lose sight of the goal: we must work together to make a difference in improving health outcomes of the people we serve. We CAN ensure that the margin is there to continue the mission. Be a part of the solution!
There are several model programs for behavioral health and primary care integration in the United States that are currently demonstrating outstanding results, such as Cherokee Health Systems, Intermountain Healthcare, and Washtenaw Community Health Organization. However, to quote Dale Jarvis, of Dale Jarvis and Associates, a national consultant specializing in payment and reimbursement system redesign, financial modeling, and business systems design for healthcare purchasers and providers: “All healthcare is local.” Behavioral health – primary care partnerships can learn much from the model programs but will need modification to meet the unique needs of their communities. A model that is successful in a rural community may not be effective in an urban setting. State regulations greatly impact the success of various models as well, especially if the model relies heavily on funding sources that may have significant differences from state to state.