For Better Health, Why We Need Integration of Care

I was asked recently why I didn’t actively seek out a specialized school setting many years ago in which to educate my son.

My son has a serious mental illness, one which first manifested when he was a child.  I’ve written about this before in Health Affairsand will write about it again in a book scheduled for publication later this year.

The argument is this.  If you put children with a special condition – such as serious mental illness – into a classroom with other children with the same condition, then you can adjust your educational services to meet the needs of those children all at the same time – and you will get better outcomes.

That’s essentially how our health care delivery system has often been built, too.  Through most of the twentieth century, people with mental illnesses were treated in one set of hospitals (usually state hospitals). And people with most physical conditions were treated in a different set of hospitals.

I wrote “most” above because we even segregated regular health care sometimes.  For example, we had specialized TB hospitals through most of the twentieth century, remnants of which still existed in some places as we turned the page to this century.

But segregating services like this did not lead to better outcomes. 

The best data to support this conclusion come from a study of life expectancy of people who were in state psychiatric hospitals in several different states.  The study found that, on average, the life expectancy of people in those hospitals was reduced by up to twenty-five years or more.

To get a sense of how significant this is, consider this.  It is greater than the overall life expectancy reduction attributable to cancer.

The problem with segregating health care services was this.  When you segregate treatment, you often forget about the rest of the person.  The people with mental illness who died young were not usually dying because of their mental illness, they were dying because they had other medical problems that were undertreated, too.

This is the argument against segregating educational services, too.

When we did move my son into a private school for children with emotional disturbances, it focused almost entirely on managing his emotional disturbance, and he received few, if any, educational services.  He arguably didn’t get a better health outcome, nor did he get a better educational outcome.

This is not to say that we should educate or treat everyone “in the mainstream.”  That’s too simplistic, because it too often implies that a “one size fits all” standard should be the norm, when that is not what children (or adults) with serious chronic conditions, like mental illness, need. 

What people need are services tailored to their own needs that take their “whole person” into account.

There is really only one way to do this – by integrating care and services. 

For everyone, this means that the right thing to do is to integrate general health treatment and services with behavioral health treatment and services. 

It means screening for behavioral health in the annual check-up, just as we screen for weight, vision, hearing, blood pressure, heart, and lung function.  It also means connecting the work of behavioral health specialists to primary care providers in the same way that we want obesity care, cancer care, diabetes care, treatment for hypertension, and pain management connected to primary care.  We want good communication, and each treatment strategy considered in the context of all the others.

This gets meaningful results, as reflected in the chart that accompanies this column.

But it also means making the changes necessary to integrate health and behavioral health services with non-health services.

In the case of children, this means integrating them with educational services, and actually making community-based care a part of the overall instructional plan.  The million dollar question (literally) is “who should pay for this – the educational or the health care system?”

In the case of adults, this means integrating health and behavioral healthcare services with housing, employment, and social and peer support services, and recognizing that recovery is only possible through integration, and only meaningful if it can be measured by an increase in life expectancy.

Otherwise we’re just spinning our wheels and repeating our past mistakes.  

Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/