Integrating Physical Health Care and Behavioral Health Care: A Report to the Dorothy Rider Pool Health Care Trust

Introduction: Inventing the neck

This report is intended to be a comprehensive outline of the multiple issues and challenges faced in establishing a system of health care that treats both the physical as well as the behavioral aspects of Pennsylvanians, especially those in the Lehigh Valley. It recognizes that interconnectedness is the key operating principle, in that as we all live in communities, the actions of all the health care providers affect an individual's treatment, and that the actions and policies of government and payers likewise play a major role in meeting the challenges of truly integrated care.We recognize that there are indeed providers that are moving quickly toward integrated care, both in the Lehigh Valley and elsewhere. However, this is the exception rather than the rule, and, there are significant obstacles to be overcome, even by those at the head of the class. This includes working outside with other providers and stakeholders, workforce development and addressing those regulatory, clinical, and, especially, cultural issues that prevent real integrated care.

Integrated health care is, in our opinion inevitable. Poor health outcomes, inadequate quality of care and the unsustainable growth of cost are challenging everyone using, paying for, or working in the America’s health care industry. The pursuit of better quality care, better outcomes, and less cost (the so - called “triple aim”) has led to efforts to improve the design of health care services to reduce inefficiencies and ineffectiveness in their delivery. One key target for redesign has been the long standing clinical, conceptual, financial and organizational splits separating physical and behavioral health care. The primary drivers of current efforts to unify physical and behavioral health are the simple facts that there is a high prevalence of clinically significant psychiatric challenges occurring in people with medical disorders and that these challenges and disorders interact with each other in both the body and the mind.

The divorce of behavioral and physical care began centuries ago with the creation of separate psychiatric and medical hospitals and then continued with separate clinics and practices - each with corresponding financial, organizational and cultural practices evolving alongside. 

This historic “siloization” of physical and behavioral health services has previously precluded any significant efforts to address these co-morbidities comprehensively. Of course, the creation of silos did not stop psychiatric and medical challenges from showing up in practices not designed to address them. Far from it. In very general terms, when they did present together, primary medical care providers, true to their generalist approach, often tried to address the issues of psychiatric challenges, though they could only do this in a limited fashion. What they could not attend to they did their best to ignore. Behavioral health care providers, on the other hand, true to being specialists, seldom even considered the physical health issues of their patients and rarely addressed them at all. Care was and in most places is still being delivered as though the body and the head were not thought to be directly connected.

There were, of course scattered exceptions to this state of affairs (consultation liaison psychiatry and the medical departments in state psychiatric hospitals come to mind), but they were not sufficient to challenge it. Each silo propelled itself forward on its own, effectively keeping the providers and consumers in each silo from seeing and sharing what was happening outside their own silos, and even in some ways engendering a state of competition between them. Without the crisis in cost and poor outcomes, perhaps nothing would have ever challenged this status quo. But the growing crisis has refocused thinking on how things have been arranged. It is now commonly believed that the people and the nation have paid a substantial price for the lack of connection and integration between behavioral health and physical health care in terms of poorer health care outcomes and ever greater expense.

This understanding has generated a nationwide effort to redesign and mutually integrate the care of body and mind. We are inventing the neck. While mind and body are different qualities, they are essential intimates and, at the risk of being obvious, always travel together.

Historical background: the rise and rise again of primary care

This is not the first time efforts to put bodies and minds together has occurred. As noted previously, there is a long standing niche practice of consultation - liaison psychiatry, which, for a variety of reasons, has remained located in inpatient medical units. There is an extensive literature on managing psychiatric conditions in these medical facilities but it is entirely focused on acute care hospitals. Similarly, there is a long history of integrating psychiatric care with medical care in some particular populations, notably older adults, people with cancer and people with HIV. Some of what has been learned in these efforts, such as the critical importance of team based care, has been useful to integration efforts, but they have not focused on the key issue confronting both primary care and behavioral health services - how to, at scale, permeate health services with useful medical and psychiatric help for people with long term conditions living in the community.

The concepts of primary care, community health clinics and family practice arose almost simultaneously with the birth of community psychiatry and the community mental health center. It would be fair to say that the move to community health centers and community mental health centers in the 1960s were part of an overall move to “primary care”. Both were born out of the belief that it was important to provide people with easy access to generalist care (medical or psychiatric) in their own communities. While initially split between physical and mental health, there were initiatives across the country to combine the two movements. These attempts withered by the mid 1980’s.   By then the health care industry had resumed its focus on specialization and acute care and turned away from community based care for both body and mind. The bloom quickly went off the rose for both primary care and community mental health care, taking with it any hope for integration. It wilted dramatically for generalist “primary care” community mental health due to federal and state budget constraints and the politics of stigma. These politics spurred in part by advocates for people with mental illness who saw a continued reduction in funding for community services for those with a serious and persistent mental illness, include contempt for the so called “worried well” (people with non-disabling psychiatric disorders), fear of people with disruptive psychiatric symptoms and a desire to limit spending on mental health. This led to the demise of generalist community mental health services in favor of specialized community mental health services available only for people with disabling psychiatric disorders. Of course, while all this was taking place specialist services for addiction also grew dramatically.

By the 1990’s the nation had a silozed health care industry largely build around specialty care. Even primary care and community mental health care were specialized. Primary care medicine specialized in providing generalist physical health care, community mental health care specialized in providing mental health care to people with disabling psychiatric challenges and substance abuse treatment providers specialized in providing substance abuse treatment.

While it’s a cautionary tale to us all, the failure to integrate in the 1970s and 80s illustrates an important point about what is happening today and why the need to integrate has reoccurred. Specifically, the major driver in both instances has been the perceived need to grow community based whole person primary care capacity that improves health outcomes and reduces expenditures. This refocus away from specialist services and acute hospital care reflects the changing epidemiology of health and illness, with long standing co-morbid conditions that are not presently curable - including psychiatric challenges - now predominating in an aging population that lives in the community.

There is no real mystery as to why our health care outcomes are so bad, our quality of care so poor and our costs so high - we have not been focused on improving care in the community. That is where care must happen if we want to reduce costs and increase health. We can’t avoid the fact that the development of a comprehensive primary care capacity has been the cornerstone of every other developed country’s efforts to improve the health of their populations at much less cost than our own. The efforts to integrate primary medical care and behavioral health care services are an important piece of this realignment. For it to happen, we must reinvent the idea of generalist community based primary behavioral health care and integrate it with generalist community based primary medical care. What will hopefully emerge is “enhanced whole person primary care” in a health care system that works hard to keep people healthy, rather than waits to heal them when they are extremely ill. In short, if we want a healthy nation, we must have excellent primary health care capacity.

The New Putting Place, Person, Body and Mind together in Health and Health Care

The “realignment” of health care services to include the integration of behavioral health has even deeper roots and more implications then just a renewed focus on primary care, critical as this is. These deeper roots are again found in the dramatic shift in the epidemiology of illness and disease from acute illness to persistent ones and in the astonishing escalation of the costs of care provision, the ongoing growth of technological solutions to health related problems and, perhaps most important, certainly from a psychiatric perspective, in the much greater appreciation and reconceptualization of the critically interacting roles of place, person, body, brain and mind in health, disease and health care - both mental and physical.   Mind and brain are the essential elements of personhood and can no longer be ignored in health, illness or health care. This emerging health landscape is creating the forces behind the wide range of efforts to pull body and mind together across all forms of health care - from clinical care to public health and public policy - to create what might be referred to as “population focused, family aware, person centered, recovery oriented” health care. This is the final destination for the journey of integration.

What Is The Full Extent of Integration?
As noted, there are multiple directions for integration to occur:

1. We have yet to achieve the full integration of behavioral health in particular, the integration of substance use treatment with other psychiatric services. This is also true of services for people with developmental disabilities and psychiatric challenges. 

2. Integration of behavioral health capacity into primary health care settings/programs.Integration of primary capacity into behavioral health care settings/programs (so called reverse integration).

3. Integration of behavioral health care capacity into some specialty medical settings (HIV care, dialysis, plastic surgery, etc.).

4. Integration of psychiatric crisis response capacity into emergency care system - while reducing use of medical ER as site of psychiatric crisis care.

5. Integration of behavioral health populations into wellness/health promotion and into population/public health concerns.

6. Integration of behavioral health and primary health with human services (children and youth, aging etc.) in connection with the social determinants of health and public policy (housing, education, income, vocational opportunities).

Item 1, the integration of substance use with other psychiatric services, has been given much less attention that it deserves. From a treatment perspective, addressing both issues concurrently is critical to successful outcomes. From a cost perspective, not doing so assures a continued increase in criminal justice costs. This is a particular problem in Pennsylvania, since the state bureaucracy has gone even farther in splitting out substance abuse services from psychiatric care and medical care by creating a new Department of Drug and Alcohol Programs (even though the current Secretary has shown himself to be both a leader and team member) that is outside the Department of Human Services, where developmental disabilities and mental health reside.

Items 4-7 have generally not been discussed in the current conversation about integration of behavioral health and health though over the long haul, they are critical to the success of putting mind and body together. It is also important to realize that each of the dimensions of integration plays out differently according to the segment of the population being considered.

A) Each of the above directions of integration implicates different populations

1 By age - infants and children, adolescents and young adults, adults, older people

2 By gender and sexuality

3 By race/ethnicity

4 By social class

5 By disability

6 By urban/suburban/rural

The burden of psychiatric and medical concerns ALWAYS falls most heavily on the populations that are excluded, marginalized and disempowered.

B) Pennsylvania, and the Lehigh Valley, have their own issues in promoting, implementing and sustaining integration at any of the levels mentioned above by. In addition to looking at population and demographic issues, a number of other entities will have a direct or strong indirect effect on the ability to integration in the Lehigh Valley. These entities include:

1 State leaders
2 State policies
3 State agencies
4 State regulations
5 State licensing
6 Credentialing agencies
7 Managed care organizations and their operations
8 Provider organizations
9 Professional organizations
10 Foundations and corporate funders.
11 Local leadership
12 Local policy
13 Local resources
14 Local epidemiology
15 Local context and relationships

The Fundamental Elements in the Redesign of Health Care Services

Perhaps a better term for integrated care is “whole person primary health care” meaning neither medical nor behavioral, but both. The framework for the creation of “whole person primary health care” consists of four essential elements critical to the redesign of health care. The first is referred to by psychiatry as “recovery oriented care” while primary care medicine refers to it as “person centered care”. The other three concepts are the medical/health care home (although there are differences in the connotations of the terms, they are essentially interchangeable in usage), the medical/health care neighborhood and the accountable care organization.   They each will require some elaboration, though discussing them in any detail would require separate papers.

The First Steps toward Integration: Recovery oriented care and person centered care Recovery oriented care and person centered care are close to being the same thing, though each emerged out of the separate cultures and histories of behavioral health care and primary health care. The fundamental concept linking the two terms is the idea that people have capabilities and capacities that they can use to manage and even improve their own health if they are engaged to do so. This insight has evolved as the implications of the epidemiologic shift to long standing conditions and related disabilities have become clear. The work of pursuing health cannot be left to the health care professional alone. The person whose health is in question must be actively involved. They must feel that their role in their own health is encouraged and supported and that their input into the process is seen as being central and essential. They must be seen and treated as person in their totality, containing the inherent possibility to shape their own lives and their own health. This is a long way from the paternalism of prior medical practice. It requires the sharing of knowledge and mutual respect in partnership. For some primary care and psychiatric physicians it is a change in roles that has been hard to accept, given that they believe that their power and authority is being stripped away. Other physicians have found the change to be liberating, because it allows them for the first time to engage their patients as people in their own right, capable of working with the physician rather than being subject to him or her. Putting the principles of recovery and person centered care into practice requires learning new approaches to working with patients and, with each person, coming to understand and work with their personal desires and goals. Because the focus is on the person and their capabilities and capacities, these approaches necessarily touch on psychiatric issues, further demonstrating the necessity of integrating care.

Putting Recovery Oriented Care and Person Centered Care into Actual Practice:

The Medical/Health Care Home The concept of the medical/health care home (the terms too are essentially interchangeable) has its roots in American pediatrics in the late 1960’s when pediatricians were first coming to grips with caring for children with multiple disabilities. They needed an organizing framework for the complex coordinated care that was required and the idea of a “medical home” filled the bill. At that point though, the idea did not generalize. It wasn’t till the late 1990s that family practitioners, realizing that the provision of primary medical care as a series of acute care interventions was falling far off the needs of people who mostly had long standing chronic conditions, seized on the term to describe the kind of easily accessed, community oriented, organized, proactive, team and relationship based generalist care they believed was necessary, especially for persons with multiple chronic illnesses. The galvanizing idea behind the medical/health home is that everyone should have one and that it should be about maximizing health as much as it is about treating illness. In this context, it has caught on and is now fast becoming an essential part of the conceptual, clinical, organizational, financial and regulatory framework of American medicine. Ultimately, integrating behavioral health into primary health care means creating a medical home that embraces behavioral health care as one of its core functions.

The Link between Primary Care and Specialty Care:

The Medical/Health Care Home in the Medical/Health Care Neighborhood Once the idea of a medical/health care home was established, it took a little while to reconceive the role of specialty care providers. Eventually the medical/health care neighborhood was built around the medical/health care home. The implication is that specialty services - secondary, tertiary and even quaternary care providers - would be easily accessible from the medical/health care home and that there would be an ongoing relationship between the two. Another metaphor that captures this would be to see the primary care medical/health home as the hub and specialty services, including specialty psychiatric services, as the spokes. In this conception, people always have a medical home that they can attend, but if they need specialty services, those services are intimately connected to the medical/health care home services, and, if and when they are no longer needed the person returns to their primary care medical/health care home. In truth, they don’t have to return because they never actually leave their medical/health care home. It stays with them wherever they go. In this case, the primary care providers are not “gate keepers” but rather “connectors and flow facilitators” who work to keep all the components of a person’s care engaged, coordinated and ongoing, ensuring that people are receiving their care according to their needs, while keeping all the pieces of care connected over space and time. Designing an effective relationship between the medical/health home and the whole panoply of specialty psychiatric services - ranging from crisis intervention to rehabilitation services - is of critical importance.

Putting It All Together:

Accountable Care Organizations and Population Health Organizing and financing the framework of clinical services outlined above falls to “Accountable Care Organizations”. Like the medical home, the ACO concept has a long history, tied to concepts like the Health Maintenance Organizations and Managed Care. An ACO, is, like its name implies, an instrument of accountability. It is also an organization - assembling medical/health homes, medical neighborhoods, hospitals and other services together. Its job is an assure that the care delivered in these medical/health homes and associated neighborhoods, hospitals and services is effective and efficient. Theoretically and perhaps in practice, since these are very new organizations - ACOs will be rewarded financially if they perform well delivering the “triple aim”. What’s critical for the purposes of thinking about integration is the extreme importance the accountable care organization places on “measured care” (what health outcomes are being produced for what effort) and initiatives to promote health and screen, track and proactively organize the care of people receiving services, all with an eye on introducing interventions that will produce better health outcomes at less cost. This means looking populations of patients needing services and designing and constantly improving the services offered to them. Ideally ACOs should be structured so they have the capacity to offer the full range of psychiatric services required by the population they serve, and the behavioral health and medical leadership they will need to be dynamically responsive.

The Likelihood of Future Success is Dependent on What We do Today

Given the stark imperative Pennsylvania faces to improve our health and our health care by, among other things, connecting mind and body, it’s reasonable to assume that efforts to integrate general health care and behavioral health will persist this time and go to scale. This is especially likely, if, as it appears to be, the initial efforts at primary care integration are being done successfully and are producing better outcomes, higher quality services and reduced overall cost. If these early successes persist, it seems unlikely that the effort to integrate will falter again. As for the more extensive effort, reaching beyond primary care integration to a larger integration into medicine and health overall, the same parameters are likely to hold sway - some evidence of early success will foster further growth. Initially, these broader initiatives are likely to be of a lesser extent then the primary care initiative but they are still worth noting and they have been included in this review just to ensure that they remain in mind.

Moving forward in the Lehigh Valley

With the interest of the Dorothy Rider Pool Health Care fund in supporting the development of better health through improved health care services for the people of the Lehigh Valley, what follows is a description of current work to integrate care, as well as an outline of some of the often unrecognized implications of this integration. It focuses on the integration of care in publicly funded programs that make up the “safety net” (or perhaps “recovery net”) of health and human services. The intent is not to be comprehensive, but to spark discussion and creative thinking that may be of use as services in Allentown area are reimagined.

Implementing Change:

Actually Integrating Care The first step in integrating behavioral health care into primary care is to focus on the needs of the patient population and/or the capacity and ecology of the behavioral health and primary medical care providers. Numerous models have been proposed for doing this, including the 4 Quadrant Model, the IMPACT model, the “geographic continuum of services” model and the “hot spotting model”. Each of these highlights different aspects of the clinical processes involved in achieving integration.

Referral and Co-location: the geographic continuum of care

The original approach to integration was to assume that none was needed, beyond the idea of referral. If someone with a psychiatric need was seen and recognized in a primary medical care setting, or any non-psychiatric health setting, the notion was that referral to an appropriate provider would address the issue. The same was presumed to be true for medical needs seen and recognized in psychiatric settings. The simple thing to say about this approach is that it did not work. While it is the process generally used to access specialty medical consults or to engage people in specialty medical care - for example, hematology or neurology or cardiology - it was never successful in either direction for mental health and primary medical care. For a variety of reasons, people often did not follow through on the referral and when they did, there was usually no communication, let along coordination, between the medical and psychiatric providers. This failure has been recognized for some time. A few attempts were made to address this usually relying on the concept of “co-location” - a geographic solution that put mental health services and primary care medical services in the same place. While this did help with ensuring that referrals happened, frequently there was little if any contact between the mental health providers and the primary medical staff, though they might be only down the hall. The barriers to integration are not easily overcome.

Mutually Distinct Cultures

It’s worth digressing here to discuss the different cultures of community mental health and primary care medicine - particularly how they use time. Primary medical care is a large volume business. People are seen quickly by the physician, though there are now usually a team of medical assistants and nurses who assist in collecting information and keeping patients moving through the practice. Unless a person is acutely ill, they are generally seen 1 to 2 times a year, and even when someone is diagnosed with an illness like diabetes, at best they may be seen once a month for a few months. This contrasts with community mental health services, where people are often seen on a weekly or bi-weekly basis in therapy, either individual or group, though generally not so often by a psychiatrist. Some folks who require close monitoring or extra supports or have high acuity are even seen on a daily basis in recovery/rehabilitation programs. While mental health providers, including substance abuse treatment providers, complain about the pressures of throughput and limits on their time with patients (the 15 minute “med check” comes to mind), the time allocated to people with recognized mental health problems, once they get into a service, is luxurious in comparison with “primary care time”. These two versions of clinical time meet head to head in “co-located” care, generating concerns on both sides. From the primary medical care perspective, the mental health and substance abuse treatment providers seemed to be locked away in their offices all the time, while the mental health providers found the medical clinic to be too chaotic and fast paced. It was a marriage that did not work, as long as neither side was willing to give up old ways. One critical aspect of this is for psychiatric and behavioral health services in primary care settings to come to terms with what conditions they can effectively help treat while working in the primary care culture and on its time line. For example, in theory, patients are rarely, if ever, discharged from their primary care setting, since primary care is thought of as a lifelong need. Specialty mental health clinics due not assume this level of obligation, even discharging patients when they are non-adherent with treatment. This is one of the reasons primary care mental health differs from secondary mental health services, even if those services are community based. The presumption is that a primary care practice defines a population of people who get their primary care there, inclusive of primary care mental health services. A specialty service, including mental health and substance abuse treatment services have a defined population too, but it is a population that gets their specialty service there - when that service need ends, the person leaves the population. In primary care, the only way this happens is if the person dies, or moves permanently to a higher level of institutionalized medical care, such as a nursing home. All of this raises the issue of the use of secondary specialist services outside the primary care purview, a topic to which we will return.

The Need for Combined Care
The inability of referral and co-location to solve the problem of ensuring needed care and coordinating it sent everyone back to the drawing board. A couple of ideas emerged out of the Pacific Northwest. First among them was the concept of the 4 Quadrant Model. Its strength is that it looks at a patient population and defines it by it need for medical and psychiatric care. Four populations are described: 1) Low psychiatric/medical need, 2) high medical/low psychiatric need, 3) low medical/high psychiatric and 4) high medical/high psychiatric need. The needs of the population then drives what services are required and the degree to which they need to coordinated. While this model was useful in getting people to think about different populations with varying degrees of need, it was no so helpful in actually describing the populations. In fact, it’s not so clear that there is a population with high medical and low psychiatric needs, or the reverse, a population with high psychiatric and low medical needs. So, while schematically elegant, the four quadrant model is better at capturing an imagined idea rather than a real one. It did, however at least capture the notion that there is a population that carries high psychiatric and medical needs. Now, most folks would likely suggest that there is a population with a middle range of psychiatric and medical need and another with a low range of both. In short, the new insight is that medical and psychiatric need correlate with each other (and with social distress). The challenge is how to provide the right care in a system that is organized to ensure that the person is in the right place to address their need.

Toward Collaborative, Integrated Care

Meanwhile, at the University of Washington, Jurgen Unutzer was busy trying to find a way to bring mental health care into primary medical care clinics across the state of Washington. He focused on depression as the most common psychiatric challenge found in these settings and developed a highly elaborate, though relatively straight forward process of getting primary care physicians to identify people with depression, initiate and track their care and, when needed, seek psychiatric consultation (generally telephonic consultation) when people do not improve with usual care. Called the IMPACT model, it has been adopted in a number of states and provider organizations around the country. It is, without a doubt, the most researched and documented process of primary medical care/behavioral health integration that we have. Its value lies in its effectiveness, in its evidence and in its relative ease of implementation. It is a great place for a primary medical care practice to start the process of integration. It does have a few drawbacks. One of them is that it was designed to treat depression, and depression alone - and not the raft of other psychiatric challenges that daily walk in to primary medical care settings. Another is an almost exclusive focus on the use of medication as the sole method of treatment. Interestingly, in the UK, concerns about the reliance on medication as the only method to treat depression and other psychiatric conditions in primary medical care led to the creation of the Increased Access to Psychological Therapies (IAPT program), which attached number of brief therapists to each primary care practice. In the IAPT program, primary medical care practitioners can easily refer people to brief psychotherapy, often contained within the practice. This has been particularly effective. Interestingly enough, the IAPT program mirrors a program addressing substance abuse in medical settings called the Screening, Brief Intervention, Referral and Treatment (SBIRT) program. Like the IAPT, the primary medical provider is helped by screening to pick up people with substance abuse, then to make a brief intervention with referral and treatment outside the primary care setting if necessary. The IMPACT model, often combined with SBIRT, has had significant uptake in Pennsylvania, with key elements of its approach being used in many of the FQHCs of Philadelphia and a number of FQHCs across the rest of the state. A variant of the IMPACT model, developed for pediatric practices by David Kolko PhD at Pitt, is also beginning to be used in several pediatric and family practice settings across the state.

The Embedded Mental Health Team in Primary Care

As the extent of psychiatric need in primary care settings is becoming clearer, a number of other models have evolved to address the full range of psychiatric challenges. One example of this can be found in the Cherokee Health System model in Tennessee. There, each primary care team has an embedded subsidiary mental health team that is always available in the clinic. Incorporating an on-site psychiatrist and other mental health professionals, the team can handle - at the primary care level - the vast array of psychiatric challenges that present. One recent innovation has been the development of patient registries and treatment pathways to help the mental health team working in a primary care team, along with the primary medical care providers to keep track of patients and their outcomes in a disciplined way. Built around the concept of “measured care” (using outcome measurement tools to assess progress), these teams work with the idea that the care of each person is a project that needs to be managed - with the person driving decisions about which outcomes and available treatment processes are preferable to them. In the Cherokee model, the behavioral health providers are essentially on call all day to see patients coming into see their primary care providers so that assessments and interventions are timely. For those folks whose needs cannot be fully addressed in the primary care setting, there is a specialty mental health care team available that coordinates very closely with the primary care team. Ken Thompson, M.D., the primary author of this paper, works at the Squirrel Hill Health Center in Pittsburgh. The model evolving there builds on the IMPACT and Cherokee models and on his prior work with the McKeesport Family Health Center and before that, the Jacobi Hospital Primary Care Clinic.   A psychiatrist is available a day a week and a halftime social worker available to see people for brief therapy. With new Health Resource Service Administration funding for behavioral health services in FQHCs, they are expanding to a half time psychiatrist, a full time social worker therapist, a mental health coordinator and two or three part time peer recovery workers. There are two reasons they have had to expand on previous models, rather than just copy them. The first is that the FQHC - serving a population of people without health insurance and refugees - has an extremely high rate of psychiatric need. Sadly, the second reason is that there is very limited capacity for this population to obtain specialty psychiatric care. So, if the SHHC is going to attend to the health needs of the people we see, it has to find a way to provide care for people with significant ongoing psychiatric need without actually having to transfer their psychiatric care in its entirety to a specialty service. The way they do this is to provide ongoing psychiatric care, with easy access to brief therapy, with primary medical care and care management, while connecting people to mental health resources in the community. These can range from psychiatric recovery services, like Clubhouses, to substance abuse treatment programs, to private psychotherapy in the community. They also include the full array of social services - income, housing, vocational and educational opportunities. This is where the notion of the interrelationship between whole person primary care and specialty services becomes crucial. Primary health care is the hub and the specialty services radiate out from it. Primary care mental health needs to assume as much of the psychiatric care as it can without taking on too much and gumming up its capacity to be rapidly responsive. This can only be done if there are clear arrangements made with secondary specialty services to facilitate ingress and egress from these services. Organizing this system, along with finding the best financial mechanism to support embedded mental health services in primary care, is proving to be a difficult task - the world of secondary community based psychiatric services is extremely complex and fragmented.

The Integrated Team for Persons with Complex, High Need Health Conditions

There is one further model to consider that has been attracting a lot of attention. The work of Jeff Brenner, a family practitioner in Camden NJ, has garnered a great deal of attention across the country. Building directly on the psychiatric concept of the Assertive Community Treatment team, he has developed community based medical and psychiatric teams to attend to the needs of people living in the community with complex medical, psychiatric and related social needs who, without such care are likely to spend a great deal of time in ERs and hospital beds. While not exactly primary care it’s really a version of quaternary care in the community - it does require primary care skills and the creation of a community based team that fully incorporates mental health, including substance abuse. There are similar teams for persons with specific medical problems, such as HIV, or certain high risk populations, such as geriatric clinics - though these don’t usually have quite the community focus that Brenner’s teams do. It’s certainly possible that such teams could operate out a population focused primary care practice if that practice had a sufficient volume of people with complex, high need conditions. For now, most of Brenner’s teams appear to be free standing.

The Social Determinants of Health, Community Psychiatry and Whole Person Care

A critical aspect of Brenner’s work is the concept of “hot spotting” - he found that most of the people he was serving lived in the same poor neighborhoods and that a good deal of the problem that these people faced was not only the absence of community resources to sustain their health but actual the presence of threats to their health. He realized that these “social determinants of health” had a profound impact on the health and health service utilization of his patients and has made a concerted effort to find ways to mitigate the problems and enhance the social resources available to people. In this, he is rediscovering some of the principles of community psychiatry - using care managers, advocating for housing and other resources. In many ways Brenner’s work is a vindication of community psychiatric practice - but he has finally moved it to being whole person care.

“Reverse Integration”- Putting Primary Medical Care in Behavioral Health Services

Bringing primary care services to specialty behavioral health services is sometimes called “reverse integration.” With government support from SAMHSA, this effort has been the major focus of the community mental health care system - though less so of the substance abuse treatment system.   The goal has been to ensure that people who are using specialty mental health care continue to have access to primary care medical services. The fact that people with disabling psychiatric challenges tend to carry a significant burden of illness, die young and have very spotty histories of medical attention has been the compelling force behind this. It has not been driven so much by the need to restructure primary health care as by the need to address the medical problems of the people using community based psychiatric specialty services. This difference in motivation has impacted on how “reverse integration” has evolved. It is a process that has been driven by specialty mental health services and not by primary medical care providers. The results have been mixed. In some instances, such as Philadelphia, individual with diabetes and a mental health claim with the city behavioral health managed care company receive better care than those without a mental health claim. Other managed care companies report success in rural Pennsylvania, as the local behavioral programs are seen as the familiar treatment home to people. In other areas the primary medical care obtained has often been watered down, often to having a visiting medical clinician who does screenings and treatment of only some common medical problems such as uncomplicated diabetes, hypertension etc. While there is talk of creating a “behavioral health care home”, the concept of having access to a whole person health home that follows a person through life is a stretch too far if the primary medical care resources made available are insufficient to provide such care.

Existing Practices Associated with Successful Integration:

The use of Navigators to assist the Person in Recovery from Behavioral Health problems has been shown to increase success in following up on Physical Health appointments for testing, specialists, and other referrals which are unfamiliar to the patient. These Navigators can be educationally prepared at very high levels or other persons with lived experience, such as Certified Peer Specialists.

At State level administration, the ongoing discussion of Carve Out must be affirmatively addressed. While it is clear, at least to most practitioners in service to the publicly funded individual with Serious Mental Illness, that the specialty insurer with high levels of clinical capacity within their own ranks of claims assessing and authorization of services has had a very positive, beneficial effect on services to that population; it remains to be seen as to whether these services can be truly integrated with the Physical Health insurer. The maintaining of the positive effects of the “Carve Out” cannot be risked in an overzealous attempt to integrate without using the learning of prior experience to guide that effort. Barriers to Integration in Pennsylvania The programs cited above have emerged despite significant obstacles. Examining Pennsylvania practices and policies elicits the following barriers:

Behavioral Health Outpatient Providers

The provision of Outpatient Behavioral Health Services has been established as a very effective, cost - saving alternative to far more expensive treatment options of inpatient or partial day treatment programs. However, these services have been painfully underfunded and increasingly regulated over the past two decades. If this important treatment option is expected to continue, these trends must reverse.The current requirements for the licensure of Behavioral Health Outpatient settings, both for Mental Health and Substance Abuse, need to be re-visited and modified to allow for the most effective and efficient provision of care within those settings and, more so, to allow for the provision of those services to individuals in the Physical Health/Behavioral Health integrated setting. The current practice in Mental Health actually licenses a site at which Outpatient services may be offered, in order to qualify for Medicaid reimbursement for services. Both the physical site and the treatment program established and staffed by the Provider must be surveyed on a yearly basis and conform to staffing, treatment, and case review standards which can be onerous for the sole provision of the Mental Health Outpatient provider and are flatly impossible to achieve and maintain for the integrated provider to offer the occasional or “as needed” provision of the services in the integrated setting. Currently, both within the PA Department of Human Services, Office of Mental Health and Substance Abuse Services (OMHSAS) and the PA Department of Drug and Alcohol Programs (DDAP), there have been Work Groups convened and charged with seeking methods of addressing these regulations for the primary providers of Mental Health and Drug and Alcohol Outpatient services. These efforts must be supported and extended to effect changes which will apply to the provision of these services on the site of the integrated Physical Health/Behavioral Health provider.    Regulatory Licensure requirements for Mental Health Outpatient services have onerous staffing requirements, specifically related to the number of hours per week of Psychiatric time provided “on site.” This serves as a disincentive to the establishment of co-located MH Outpatient Clinics on the same site as a Physical Health Clinic.

Confidentiality

Maintaining the confidentiality of clinical records in Behavioral Health, especially in Drug & Alcohol treatment settings, has long been a priority, well before the passage of the Health Insurance Portability and Accountability Act (HIPAA) in 1996. While this enacted legislation effected numerous changes in the provision of physical health care services and record keeping/sharing, it had far less of an effect on the providers of Behavioral Health services. These confidentiality standards are, in many ways, more restrictive than those imposed by HIPAA and, perhaps, even contemplated in the writing and intended implementation of services encouraged by the Affordable Care Act (ACA) of 2010. Offering advanced care Mental Health and Substance Abuse Services in a coordinated fashion continues to be a challenge. Current D&A confidentiality regulates result in lower standards of care for those with serious mental illness who need higher and more intensive levels of care.For example: In treating an individual for a recent back injury, the Physical Health practitioner has to make a choice among medications which can address the muscular and pain issues that affect the patient and prevent him/her from returning to function and work. There is a myriad of choices for these medications from simple, over-the-counter preparations to the more effective, yet highly addictive, narcotic formulations currently available. If the prescribing physician has ready access to records indicating that the patient is, or has recently been, in treatment for a Substance Use issue, his/her decision is likely to be better informed and less likely to lead to patient to further Substance Use issues.While the restrictions surrounding the sharing of clinical records for persons with Mental Illness for the purposes of continuity of care might be considered consistent with HIPAA and the ACA, the restrictions regarding the sharing of clinical records of those who receive services for substance use and addictions cannot. In our opinion, the higher standards for the confidential maintenance of clinical records for Substance Abuse and Addictions must be altered both at the federal and state levels in order to effectively provide physical health treating professionals with access to those records in order to provide a fully –Informed treatment environment. This will require legislative and standards changes to allow for the sharing of this information for the purposes of continuity of care among the various treating professionals and within the integrated Physical Health and Behavioral Health team. We strongly encourage the treating providers to strongly advocate for these changes in order to offer the most effective and safe treatment in the integrated setting.

Documentation
The understanding and appreciation for the significant differences in documentation between the Physical and Behavioral Health practitioners must be taught/learned. The brief, data/value - laced notes used in the Physical Health arena provides a stark contrast to the well written documentation of an interview with a Behavioral Health consumer and her/his significant persons, noting relationship issues and other relevant information which will provide considerable bases for the development of a treatment plan which will offer sufficient support and be worthy of cooperation on the part of the Person in Recovery for whom it is designed.

Billing
Current billing limitations within Medicaid and Medicare will automatically disallow payment of the billing of two reimbursable services within the same “billing day,” which is usually defined as a calendar day. If the integrated Physical Health and Behavioral Health treatment setting is properly executing its mission, there will be individuals who are evaluated by the Physical Health treating professional and referred for evaluation and treatment by a Behavioral Health treating professional and the reverse as well. Both of these services should be eligible for reimbursement in order to provide the integrated care and to allow for the organization to afford the services. While the Commonwealth is proposing reimbursement on a “Case Payment” method in its State Innovations Model (SIM) proposal submitted to the Centers for Medicaid and Medicare Innovations (CMMI) by the Department of Health, it has not been approved and is a long way from being engineered and finalized. Therefore the reimbursement for services for the foreseeable future will continue on a payment for submitted claims, or Fee – For – Service method.We fully recognize that the above list is not inclusive of all needs reforms.

Finally, in the Lehigh Valley

Establishing a public service integrated approach to whole person health in the Lehigh Valley will require the construction of:

1 A specific Lehigh Valley "Safety Net Health Care Home" - perhaps modeled on the national Commonwealth Fund program of the "Safety Net Medical Home”.

2 A specific Lehigh Valley  "Safety Net Accountable Care Organization" that is build out of the Safety Net Health Care Home and its relationship with specialty medical and psychiatric services and community resources.

3 A specific Lehigh Valley program to promote health and wellbeing from a population/public health perspective that incorporates human services and the social determinants of health and deploys its effort in part through the Safety Net Health Home and Accountable Care Organizations.  

4 A workforce development plan that is associated with an active Learning Collaborative or similar group, which, in turn, is associated with medical and other schools to ensure that the competencies in providing whole person primary care are realized. Much of this may be accomplished if the state’s application for funds from the Center for Medicare and Medicaid Innovation (CMMI) State Innovation Model Initiative is accepted. Perhaps the final point of this paper is that truly integrating care is a complex adventure, with many moving parts, and demands the cooperation of a diverse group of people and organizations. For some, it will be seen as an opportunity to truly save lives and dramatically improve the health of a much greater number of people than ever before. For others, it will be seen as an attack on the status quo, and, on how they have worked and practiced for decades. The PPLC offers thanks and recognition to the Board and staff of the Dorothy Rider Pool Trust for not only recognizing this, but for realizing that communication that is as open as possible is perhaps the best way to maximize the potential of this revolution in health care, and to minimize the fear of those concerned with being lost in the process. The PPLC stands ready to work with you on the next steps.

The Pennsylvania Psychiatric Leadership Council,Kenneth Thompson, M.D., Chief Psychiatric Officer, David A. Dinich, Administrator, Lloyd Wertz, Policy Director & Robert Haigh, Consultant