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Why Integrate Behavioral Healthcare into Primary Care?: The Neglected Role of Systematic Quality Improvement

Posted By William O’Donohue, Ph.D, Thursday, September 22, 2011
In 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?

I 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.

Behavioral 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 quality parameters:
  • Safe—avoiding injuries to patients from the care that is intended to help them.
  • Effective—providing 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).
  • Patient-centered—providing 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.
  • Equitable—providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.

When 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 quality "care”?

We 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.

Our 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?

First 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.

Integrated 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 continually innovate.

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 ( He has published 70 books and over 150 journal articles.

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Randall Reitz says...
Posted Sunday, October 2, 2011
Dr O'Donohue, this is a great call to action. Thanks for your contribution to the CFHA blog. I would offer a small tweak to your main thesis. As integrated care has come (or is coming) of age during the era of quality improvement, I would suggest that clinic-level QI is actually a hallmark of integrated care. It seems that the majority of clinics that add an integrated team do so as part of a grant-funded learning community. These programs, with their PDSA cycles and change coaches, will instill a good sense of the need to record data and to follow the data toward clinical improvements.

That being said, the kind of QI for which our field has a dire need is a leap forward in system-wide QI that requires top-tier research. While projects like IMPACT and DIAMOND are doing this for care management driven integrated care, we haven't yet seen a flowering of research around integration using mental health professionals. I think we have the right vehicle to get this done, through CCRN, but we now need to move the dial.
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