(This blog post is a reprint of a piece by Cheryl Holt from July 9th, 2013. Click here for the original post)
"It’s very hard to do integrated
care and still think of mental health and physical health.”
Welcome to the first in the Integrated Care Thought Leader Series. This series
will focus on the forward-thinking individuals who have had the foresight to
envision possibilities in the healthcare industry's future. I'm pleased to
begin the series with a man who has been instrumental in advancing integrated
Alexander Blount, EdD, better known to most as "Sandy," has
played a very important role in bringing the integration of behavioral health
and primary healthcare to its current prominent focus within the healthcare
industry. Dr. Blount is credited with coining the term integrated primary care in his 1994 publication, "Toward a System of Integrated Primary Care," Blount
A, Bayona J. Family Systems Medicine, 1994;12:171-182.
It’s an honor to
talk with Dr. Blount about the integration of behavioral health and primary
care. Yes, he admits that he is optimistic about the direction in which the
field is moving! His enthusiasm is almost palpable, with a freshness that
belies the number of years he has devoted to the advancement of this
revolutionary approach to healthcare. It’s apparent that this enthusiasm easily
holds the attention of the students he teaches at UMASS.
Dr. Blount is a
visionary whose diligent efforts and perseverance have made great strides
toward bringing attention to the widespread failure to address the individual
patient as a whole. He graciously agreed to provide insights for
Behavioral Health Integration Blog:
What do you see as being the greatest barriers for successful
integration of behavioral health and primary care services?
Dr. Blount: I see two things:
First are the
barriers that have always been there: regulatory barriers that are built on the
idea that mental health and medical services have to be kept separate,
financial barriers that only pay fee for service and define services as what is
delivered in specialty mental health, and cultural barriers on the part of both
medical and mental health people that make working together difficult without
some cultural broker who can make the connections and translations necessary.
These have been our problems historically, and happily with the ACA and the PCMH movement, these are reducing.
Also because there is sometimes a faddishness about integration, you get
some administrators who become "true believers” who really don’t know how to do
this. They see a presentation, and they say this is what we are going to
do–and they start it without any depth of understanding. It’s sort of the
administrative version of the clinician that doesn’t work. We need clinicians
who are fully oriented to integrated primary care and leaders who are aware of
the difficulties of making these changes and who can develop the buy-in from
the whole practice. Integrated pilot programs are often funded on three year
cycles. Places like the DIAMOND Project in
Minnesota, where they’ve had some real time to make it work, say that it’s more
like a five year cycle from beginning to fully transformed practice. I
fear that federal and private funders will think it will happen faster than it
does and will turn away.
|We will need a four-fold increase over 2010 levels in behavioral health
area is the barriers caused by our own success. Because integrated
care is becoming more possible and is proving itself, there is pressure to start
programs in settings where there is little understanding of what it entails and
little time and resources to prepare for the change. People are getting
put into integrated programs or co-located, who aren’t trained for it and
didn’t pick it. They don’t know what to do. They go in and do specialty mental
health. They do what they’ve been trained to do…and it doesn’t work. Then
administrators, who may have been skeptical initially, thought this was a fad,
see this failure and think "oh yeah, I was right,” it was more inconvenient
than useful. We felt we had to develop a training program at UMass Medical
School available to these folks to prevent just this form of failure.|
barrier to our success is the workforce crisis we are facing. All of
the government projections of what will be needed for behavioral health
workforce, when compared to the number of people who are being trained, say we
will have a terrible deficit, and those projections were made without any
calculation of the workforce that has proved to be needed in mature integrated
settings. When word gets out that we will need a four-fold increase over
2010 levels in behavioral health clinicians in Federally Qualified Health Centers alone, not to mention the rest of the health system, the
true magnitude of the problem will become clearer.
What excites you about the field today?
Dr. Blount: One, is absolutely the transition in payment
models that may make a great leap forward happen. Essentially those models let
us implement the clinical routines of integrated care. Up to now the payment
models have dictated routines that weren’t very integrated. Paying for
health, rather than for services allows us to deliver evidence based care by
the clinician best able to do it at the point that it is most sensible and
acceptable to the patient. Having it actually knitted into the flow
of care makes a big difference.
So I think, at
least in the places that are more developed, the places that integrated care
gets to be mature, you begin to see different forms of conceptualization and
hopefully we’ll be documenting those, writing about those, helping to pull
others along. There aren’t many places where integrated care is really mature.
The places that are mature are very different in numerous ways that don’t
initially seem to be connected to integration. The question of "isn’t
integration interesting, how do we work on it?” just goes away and the
questions are about new ways of helping patients, new groups of patients we can
understand better, and new ways of involving patients on their care
teams. How we involve people in their own care, how we get past the
doctor as leader and authority to doctor and the team as teachers and
facilitators, that’s really the next piece. And when that is going well, I
think that integrated care will sort of already be there.Will you look into your crystal ball
for us and tell us what you foresee in the future for integration?
|And the other thing
that I see happening is a transformation in how we conceptualize mind and body,
illness and health. It’s very hard to do integrated care and still
think of "mental health” and "physical health”. The categories just begin to
break down because they don’t describe the way people present. They don’t
describe how problems form over the years. We’ve had science now for a good
while on the plasticity of brain and the way that experience changes the brain
and the brain changes experience. The current science even describes the way
that experience changes what genes are expressed at various points in a
person’s development. In other words, the science of the brain has been
there but the way of thinking in our day-to-day clinical lives has not because
we have been enacting models build on conceptions of separate domains. As
we enact integrated clinical routines, we will begin to think
differently. We create the likelihood that the science of the brain will
be mirrored in the unity of our conceptions about people and how we try to help
them.||As we enact integrated clinical routines, we will begin to think
Dr. Blount: Let’s imagine that we get it right in terms of
mature programming, mature routines of integration as far as our workforce
allows. Then we begin to be able to think about health and illness
differently, and the whole set of concepts, the models that we have of
understanding health and illness and how to influence those begin to move. I
foresee the time when there’s a foundation of mature integrated care that we
will be looking at great leaps forward in theory or great research leaps
forward with greater understanding of what and how we should be researching.
That’s one optimistic thing.
And when I look in
my crystal ball I think we are going to have states that begin to have
whole-state programs that are starting to be implemented and organized so that
we can begin to look at the impact of integration on a really big scale.
Thanks so much to Dr. Blount for sharing his insights in the premiere of
the Integrated Care Thought Leader series!
Check back soon for
a conversation on integrated care with Benjamin Druss, MD, MPH, Rosalynn Carter
Mental Health Chair and Department of Health Policy and Management
Professor at Emory University.
|Cheryl Holt, MA, CEO of Behavioral Health Integration Consulting, LLC, is an advocate for the integration of behavioral and primary healthcare for whole-person health and assists organizations in adopting a whole-health focus. She is active in social media promoting integrated care, behavioral health policy, and global mental health. She blogs regularly via the Behavioral Health Integration blog and manages LinkedIn's Behavioral Health Integration group and the Behavioral Health Integration page on Facebook. You can follow her on Twitter: @cherylholt, @BHPCIntegration, and @WorldMentalHlth|