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/

New Programs Show Value of Health and Behavioral Health Integration

A Kaiser Health News sampling of the latest headlines about Obamacare reflects our continuing anxiety over the law just months before it is fully implemented.

The most interesting to me was this one.  According to a new CNN poll, only 43 percent of the public favors Obamacare.  But of those who oppose it, only 35 percent do so because it is too liberal.  Sixteen percent say that it is not liberal enough!

No matter how you feel about Obamacare, one of the most significant changes it facilitates will be the integration of health and behavioral health care – meaning that care for both physical and mental illnesses will soon be delivered together.

This only makes sense.  People with cancer, for example, often develop depression or anxiety that complicates their care.  And people with mental illness often develop physical conditions – sometimes as a side effect from the medications they take – that can cut twenty-five years from their lives.

Integrating health and behavioral health care has not been the norm over the past century. 

In a nutshell, this is because regular health care evolved from an acute care model – the idea that we could cure disease with aggressive, short-term interventions.  Mental health care evolved from a chronic care model – that mental illnesses could be managed, but not prevented or cured.

What we have learned in the last 20 to 30 years shows that both models can be useful in treating all diseases.

So we began to manage some diseases that we could not cure using a newer chronic disease model.  HIV/AIDS treatment is an example, but so are today’s treatments for many chronic conditions, including cancers, heart diseases, diabetes, and hypertension.  And we began to use an acute care model to treat mental illness, offering short-term stabilization in addition to longer-term therapies.

With diseases co-occurring and treatments often intersecting, care integration was the logical next step.

In its 2010 document, Evolving Models of Behavioral Health Integration in Primary Care, the Milbank Memorial Fund offered numerous examples of the care integration approaches that have evolved over the past twenty years. 

And while care integration has been slow to gain traction, that is about to change as a result of the Affordable Care Act.

Access to insurance despite pre-existing conditions, prohibitions on rescinding coverage after a person gets a chronic disease, and greater parity in health and behavioral health benefits are three reasons why, from a consumer perspective. 

More billing options and better reimbursement rates for primary care providers offering behavioral health screening and support services are two reasons why, from a provider perspective.

And the call for early intervention to prevent future tragedies is one big reason why, from a purely political perspective.

This week and next, I have the good fortune of being witness to two cutting-edge integration initiatives that reflect our changing environment. 

I serve on the Board of Directors of the Jerome Golden Center for Behavioral Health, and this week attended the grand opening of its new primary care clinic.

For the first time in its forty year existence, this safety net community mental health center will offer formal primary care services in the same location in which it offers behavioral health services.  Patients will benefit from one-stop shopping, and receive monitoring and treatment for health conditions as they are treated for behavioral illnesses. 

Integrating health services into behavioral health services in this way is a far less common approach to integration than doing it the other way around.  HRSA, for example, notes that 70 percent of community health centers offer at least some mental health services.  But some people – especially those with serious mental illnesses – often access only behavioral health providers, because they are reluctant or unable to seek out care in multiple locations.

And in the coming week, I’ll be at the annual meeting of Mental Health America for a presentation by the Mental Health Association of Palm Beach County about its Be Merge initiative.  Through Be Merge and related initiatives, MHAPBC is training primary care and mental health providers to work together in any model to integrate health and behavioral health services.

The initiative has won Mental Health America’s 2013 Innovation in Programming Award, and is clearly ready for prime time.  MHAPBC has made the training and toolkit available online through the University of South Florida, for use by agencies and providers throughout the nation.

As these two initiatives show, integration has finally arrived.  Better late than never.

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