the past decade there has been a notable increase in the amount of
interest of redesigning healthcare service delivery so that
"fractionated” care is changed into "integrated care”. The quotations
marks are meant to indicate that it is none to clear exactly what these
terms mean. How do we understand the reasoning behind this interest in
integrated care? Is it simply a fad—perhaps even a passing one? Is
the reason because some sort of change in an expensive, inefficient
healthcare system is needed and integrated care seems as good as any?
Is part of the reason rhetorical—"fractionated” sounds bad and
"integrated” sounds much better? Ought integrated care be pursued for
its own sake—is there something about it that is an unalloyed good—like
kindness or a goodwill?
propose that the fundamental reason for integrating care is that it—if
done correctly—is that it can improve the quality of healthcare
services. That is, integrated care needs to be understood in terms of
an overall context of quality improvement. If not understood in this
context, a much weakened, and perhaps even unsuccessful, integrated care
system will be instituted. An implication of this is that integrated
care is not good in and of itself—it is only as good as the QI process
it represents.The Neglected QI Agenda in Behavioral Health.
health has and has had a serious quality problem. This problem is
poorly recognized, harms patients and wastes money. Physical medicine
received its wake up call around a decade ago with the Institute of
Medicine’s 2001 Crossing the Quality Chasm
(which should be required reading for anyone in this area). This
report found that physical health care was dangerous, deadly,
inefficient, and did not have the needs of the consumer in mind. It
called for a radically new healthcare system around the following
- Safe—avoiding injuries to patients from the care that is intended to help them.
services based on scientific knowledge to all who could benefit and
refraining from providing services to those not likely to benefit
(avoiding underuse and overuse, respectively).
care that is respectful of and responsive to individual patient
preferences, needs, and values and ensuring that patient values guide
all clinical decisions.
- Timely—reducing waits and sometimes harmful delays for both those who receive and those who give care.
- Efficient—avoiding waste, including waste of equipment, supplies, ideas, and energy.
care that does not vary in quality because of personal characteristics
such as gender, ethnicity, geographic location, and socioeconomic
we examine standard contemporary behavioral healthcare, what evidence
exists that it meets the criteria above? How often do patients receive
care that is based on clinician’s irrational beliefs about
effectiveness instead of evidence based treatments? How often are
patients misdiagnosed? How often are patients given less safe and less
effective medication regimens instead of safer more effective
psychological treatments. How often do patients die because of the poor
quality of behavioral healthcare? How much money is wasted on poor
as a profession have been poor at recognizing the quality problem in
behavioral health and taking systematic responses to it. Integrated
care can be a step in the right direction, but if done without
sufficient attention to systematic QI, can suffer from most of the
quality problems found in specialty behavioral health care. The
integrated clinician can prescribe interventions that have no evidence
base. Diagnoses can be missed or false positives can be made. There
can be an over-reliance on medications, etc.
professional organizations are largely part of the problem—not part of
the solution. They have done little to lead on this issue, but instead
trumpeted guild issues such as increasing payment to practitioners for
the same old problematic services—instead of trying to raise salaries by
improving the value proposition we offer. There has been little to no
leadership on taking quality seriously. It is a good sign that
President Obama has appointed Donald Berwick as head of the Centers for
Medicare and Medicaid Services as Dr. Berwick has been one of the
leading thinkers on bringing systematic QI into healthcare. What Can be Done?
and foremost our profession needs to be educated in the philosophy and
technology of systematic quality improvement. QI is not a slogan and
most importantly it is not a rhetorical phrase meant to impress or
persuade. Rather it is a systematic approach to understanding what
consumers need, the extent to which data can be continuously collected
to see the extent to which these needs are being met; and continually
innovating to meet or exceed these needs all the while driving price
down. QI never ends. Honda has a saying "The reason why our customers
are satisfied is because we never are”. We can look at the innovations
in physical medicine and adopt some of these training programs and
innovations—they are ahead of us and making some excellent progress. We
need to get on board as soon as possible.
care can be an important step in QI. Many customers want one stop
shopping. By identifying the behavioral health pathways impacting
medical presentations, patients can become healthier and costs can go
down. Integrated care can increase diagnostic accuracy and the
treatments offered can be evidence based. Or integrated can be the same
sloppy, non-consumer oriented, set of services in a different setting.
We must make sure it is the former not the latter. We must learn
quality improvement, collect quality data, establish benchmarks, have a
deep understanding of the processes that produce key outcomes, and
William O'Donohue, Ph.D. received his doctorate in clinical psychology from the State University of New York at Stony Brook. He is currently Professor of Psychology at the University of Nevada, Reno and the CEO of OneCare Health Solutions, LLC (myonecare.com). He has published 70 books and over 150 journal articles.