The case for integrated care

A concept whose time has come or the right thing to do and the price is right.

By Mary Helen Davis, MD, DFAPA

Our healthcare delivery system has been broken for quite some time. The rising cost of healthcare has driven policy and decision makers to come up with a fix. This fix has generated new buzz words: “collaborative care,”’ “integrated care,” “ACOs,” “medical homes,” “patient and family centered care,” “population based care,” “quality driven care,” and the list goes on.  The expectations of the “fix” is to rework our healthcare system to achieve what has been referred to as the triple aim; “better care, better health and lower costs.”

Behavioral and mental health issues have come front and center stage. Why? Cost! The United States spends more on healthcare costs than any industrialized country but scores below most in delivering quality healthcare. The increasing prevalence of chronic illness has driven healthcare spending. The top five health problems based on economic cost are drug abuse, mental illness, heart disease, alcohol use disorders and nicotine use. A case can be made that at least four of these belong in the domain of the mental health provider.

Given workforce and access to care issues we know that primary care physicians are the foot soldiers in treating mental illness. It has been estimated that up to 50 percent of visits to primary care physicians involve issues related to depression, anxiety or chronic pain. Primary care physicians could benefit from our assistance just as our patients in psychiatry or community mental health centers could benefit from collaboration with primary care MDs.

We know that people with mental illness have significant reduction in lifespan and that their comorbid medical conditions frequently go undiagnosed and untreated. Integrated care is a concept whose time has come, forced by expectations of quality and the need for cost containment. Across the country there are multiple model programs that have ventured into integrated care with compelling data related to obtaining the triple aim.

Goodbye Separate Silos
A successful, integrated care programs must be interdisciplinary utilizing a team approach that incorporates the use of mid-level providers including nurses, physician assistants, mental health workers, social workers and case workers. Unfortunately, physical health (PH) and behavioral health (BH) have traditionally been in separate silos. New models of care are emerging that include everything from co-located PH/BH services to fully imbedded and integrated services.

The provision of psychosocial services has found its way into standards of care in chronic medical conditions. As an example, the Commission on Cancer (COC) has incorporated the standard that programs “develop and implement a process to integrate and monitor on-site psychosocial distress screening and referral for the provision of psychosocial care.”

Attending to a patient’s emotional needs and distress can impact treatment adherence, quality of life and potentially cost of care. All chronic disease states can benefit from integrative care that provides the range of supportive care services. Supportive care aims to optimize the comfort, functioning and social support of the patient across the illness spectrum.  These supportive services should be bidirectional with mental health services coordinated in primary care clinics and primary care services integrated into mental health clinics.

How Integrated Services Work
The provision of integrated services in a primary care clinic would generally involve a screening process, which might include screenings for depression, anxiety or substance use and abuse. If a patient screens positive there would be a protocol for further assessment and a plan for initiating a treatment protocol when appropriate.

A psychiatrist might serve a group of busy primary care physicians a half-day a week. The psychiatrist would also provide case-based consultation to both the primary care MD and their midlevel providers on treatment and provide direct patient consultation only on patients that fail to respond to treatment.

Conversely, in a mental health clinic the screening might be conducted for glucose or metabolic monitoring, hypertension or other chronic disease state.  Multiple models of integrated care are emerging from around the country with very promising results in terms of outcome, cost and patient satisfaction.

Medical Schools Reflect Change
Medical school curriculums are beginning to change and place emphasis on interdisciplinary team care. These paradigm shifts represent a culture change that is vastly different from how care has been traditionally provided and will require reconsideration of reimbursement as well. Healthcare reform is likely to bring concepts of bundles payment, or reimbursement for illness episode compared to the current fee-for-service model.

Current practitioners interested in exploring ways to learn more about this emerging delivery system should consider one of the many courses available on integrative care models that are available at the annual meeting of the American Psychiatric Association, and at other professional conferences.

For more information…

Center of Excellence for Integrated Care, North Carolina
DIAMOND, Minnesota
IMPACT Implementation Center: Jurgen Unutzer, MD
Integrated Behavioral Health Project, California
Mental Health Integration Program, Washington State

Mary Helen Davis, MD, DFAPA works in behavioral oncology at the Norton Cancer Institute.



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