Integrating behavioral and physical care
By Rebecca A. Clay
April 11, 2013—With health care reform encouraging greater consolidation among health service professionals and organizations, the trend is toward integrating mental health, behavioral health and substance use services in all kinds of treatment settings. Of particular interest to psychologists are emerging opportunities in new types of settings, such as patient-centered medical homes and accountable care organizations (ACOs). But whether integration takes place in primary care or at the health system level, the “triple aim” goals are the same: enhancing the experience of care, improving the health of populations and reducing costs.
Why integration matters
More than half of adults in the United States – 57 percent – will meet the diagnostic criteria for a behavioral health condition at some point, says Rebecca B. Chickey, MPH, director of the American Hospital Association's Section for Psychiatric and Substance Abuse Services. Sixty-eight percent of adults with mental health conditions also have medical conditions, which results in people with severe and persistent mental illness dying eight to 25 years earlier than their counterparts without mental illness. And 29 percent of adults with medical conditions have co-occurring behavioral health conditions.
These statistics underscore the case for integrating behavioral and physical health care, says Chickey. And psychologists should be working to make that case.
Integrating primary care
Primary care as traditionally practiced can't achieve that triple aim of enhancing care, improving health populations and reducing costs, says Frank V. deGruy, MD, who chairs the department of family medicine at the University of Colorado School of Medicine. That's because traditional primary care is problem-focused, not patient-centered, he says.
"Primary care practices are built on the assumption that the basic problems we're set up to deal with are acute care problems," says deGruy, citing as examples cystitis and ear infections. Yet 80 percent of health care dollars are spent on chronic conditions, he says, which can't be handled the same way acute problems can. "You can't wait until diabetic people can't see or need their foot amputated," he says. "You have to get people into a program of care before they're physically or psychologically symptomatic."
Enter the patient-centered medical home, which offers care that goes beyond what's offered in what deGruy calls the traditional "reactive" form of primary care. Focusing on chronic disease, patient-centered medical homes at their most basic feature care managers who coordinate services, quality improvement initiatives and disease registries that help clinicians keep track of patients with specific diseases and identify gaps in care.
In addition to joining patient-centered medical homes in primary-care settings, psychologists can help in other ways. "The patient-centered medical home is no more than a small island in a sea of health care resources," says deGruy. "I invite you to be in our patient-centered medical homes, but you also need to be in a lot of other places." Psychologists and other specialists in the community can help patients implement personal care plans, for example. They can use the same integration model that works in primary care in more specialized settings such as neurology practices and pain clinics.
Integrating health systems
New financing mechanisms, such as bundled payments, capitation and shared savings programs, in which hospitals and health systems are beginning to assume some risk, are going to be required in order for reform to be sustainable.
"How are we going to get paid in the future?" asks Robin Henderson, PsyD, director of government affairs at St. Charles Health System in Bend, Ore. "For the outcomes we produce." With these new financing models, hospitals and health systems do better when their patients get better.
That's the case for St. Charles, which is part of Oregon's coordinated care organization. Overseen by the Central Oregon Health Council, which Henderson directs, the coordinated care organization has launched several initiatives that show that integrating physical and behavioral health care improves patients' outcomes and reduces Medicaid costs. Thanks to a shared savings agreement with Medicaid, the health system gets to keep some of the money saved. As a result, says Henderson, the incentive is now to provide better care rather than to drive admissions.
Behavioral health integration is even beginning to happen outside the formal health care system. The coordinated care organization's next initiative is to put mental health professionals in school-based health centers. Doing so will not only benefit children, says Henderson, but also parents and everyone else in the neighborhood. "We want to bring mental health to where people are," she says.
Opportunities for psychologists
How can psychologists take advantage of the opportunities health care reform is bringing? The first step should be to apply for medical staff privileges at your local hospital, says Henderson. "That's where you build relationships," she says, encouraging psychologists to join physicians on grand rounds and invite medical colleagues out for coffee. Together, she says, you can start brainstorming about ways to integrate services and thus improve care.
And you can start small, Henderson adds. Even an experiment with a handful of patients can become the basis for improvements on a larger scale, she says, urging psychologists to launch pilot projects. "All of our transformation initiatives were small ideas someone had that we took and turned into big action and big cash," she says. "That's how we're going to change health care."