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Where is the frontier in behavioral health integration?

Posted By Mara Laderman, Kedar Mate, Thursday, April 10, 2014

Behavioral health integration is becoming the standard of care; in the not-too-distant future, “non-integrated” primary care practices we predict will become rare or even extinct. So, where is the frontier now? Where are innovators in the field focused at this point in time?   Where is the frontier now?
We believe there are currently four areas of primary innovation. The first is deployment of integration into high-risk specialty clinics which often serve as the health homes for patients living with chronic conditions such as heart failure or spinal injuries. In such settings, while the principles of integration are similar to those employed in primary care, care can be more episodic which can challenge consistent behavioral health service delivery. The second area is around scaling up integration to entire communities, regions, and even states. Solving structural challenges of measurement, interoperability of records, and behavioral health resource availability at scale is an important area where innovation is needed. Current efforts in Colorado, Washington, and New York are leading the way to tackling these state-level challenges. Third, significant innovation work will be needed to understand how much integration costs and what financial models and alternative payment methods will allow integration efforts to thrive.

Finally, as we describe in a recent article, while the majority of integration work has focused on individual clinics, this may overemphasize the clinic environment itself and not the functions of the primary care practice, which include an emphasis on providing continuous supportive care beyond the clinic encounter, navigating community support systems, and engaging family and relationship support systems.  More comprehensive primary care systems are designed to support patients in the many thousands of hours patients spend outside of the clinic, living with behavioral illness and co-morbid medical disease. Much thinking is being done right now about the so-called “5000+ waking hours”1 that patients live with their chronic conditions outside of their clinic visits and face-to-face time with medical providers. We strongly believe that this is where the frontier is in behavioral health integration in primary care.

To guide innovation in this area, we turned to some of the work that is beginning on chronic disease care outside of the clinic visit.2 3 This thinking led us to a conceptual model for full-spectrum integrated care that identified three key components: 1) frequency of the points of interaction, 2) where is the service provided, and 3) who it is provided by. We identify five layers of potential service using these three dimensions. All are needed for a complete care system for patients living with behavioral and physical chronic conditions. In this model, costs are reduced as the service moves closer to patient self-management.

The first layer, Acute Care, applies to patients during a hospitalization. Many hospitalized patients are not evaluated for behavioral health problems as their medical needs supersede other issues. However, the need for intervention remains. There are opportunities for behavioral health interventions to affect both behavioral and physical health outcomes; for example, St. Charles Health System implemented an intervention in which a behavioral health consultant routinely rounds in the NICU to work with parents of premature infants to teach what to expect, how to stimulate neurodevelopment, and how to care for their children. The intervention reduced NICU utilization (measured by earlier discharge) with better outcomes and retention in post-natal care. 

There are opportunities for behavioral health interventions to affect both behavioral and physical health outcomesThe second, the Clinic Visit, is the focus of most integration models. Innovations here might include group visits—a concept that has been employed for substance abuse disorders, in ‘centering pregnancy’ models, and for multiple chronic conditions. Integration innovators in this arena might purposely build patient groupings of individuals living with both depression and diabetes, for example, who would meet together to discuss coping and living strategies. Another innovative model, the Ambulatory Intensive Care Unit, pioneered in California by Arnie Milstein and others, might utilize smaller panel sizes of patients with co-morbid mental illness and employ primary care “specialists” to help manage these patients more intensively in the ambulatory setting.

In the third layer, Community Care, innovators might use Community Health Workers (CHWs), a category of interventions that have long been used in resource-poor environments for supervision of therapy for tuberculosis and HIV. These are being applied by novel programs like PACT and Commonwealth Care Alliance in Boston to target high-risk, high-cost patients to help with their management. Behavioral health issues are often the hardest to solve for these programs, but CHWs with training in behavioral health could assist with co-morbid disease. This layer may also include group visits in community based-settings. Finally, in this layer, alternative service providers such as “community paramedics” like those being deployed by MedStar Ambulance system in Fort Worth, Texas might be mobilized to care for patients living with comorbid physical and mental illness to assist in keeping them healthy at home.

The fourth layer, Family Engagement, has been used for some time to help with the management of infectious diseases and chronic conditions. Training family members to also help with the management of co-morbid behavioral illness would provide a near continuous asset to the integration process.

Finally, Self-Management would put the patient at the center of their care. New technologies to track movement (pedometers), sleep (sensors), mood (SMS technology), weight (scales), blood pressure (BP cuffs) in the home and wirelessly transmit them to providers are allowing patients to see their own data and manage their conditions themselves. These solutions may not be for everyone, but they can often passively collect substantial amounts of data and help patients and providers better characterize contexts that affect both their physical and behavioral ailments. Tools like the Big White Wall, a web-based platform to assist patients in finding community and consultative support in the home, can greatly assist patients with self-management.

We have not encountered, to date, anyone in the field looking at this full spectrum of “complete care integration” for behavioral health and primary care. While many organizations are still in the early stages of implementing integration we believe that those innovators on the frontier are and will be thinking seriously about how to address some of these key issues to achieve the Triple Aim of better health, care, and lower per capita costs for patients with comorbid medical and behavioral health needs.

  1. Asch DA, Muller RW & Volpp KG. Automated Hovering in Health Care – Watching Over the 5000 Hours. New England Journal of Medicine. 2012;367:1-3.
  2. Logan AG et al. Mobile Phone-Based Remote Patient Monitoring System for Management of Hypertension in Diabetic Patients. American Journal of Hypertension. 2007;20(9):942-948.
  3. Koehler F et al. Impact of Remote Telemedical Management on Mortality and Hospitalizations in Ambulatory Patients with Chronic Heart Failure. Circulation. 2011;123:1873-1880.
  4. Jaber R, Braksmajer A & Trilling J. Group visits for chronic illness care: Models, benefits, and challenges. Family Practice Management. 2006;13(1):37-40.
Mara Laderman, MSPH, is a Research Associate at the Institute for Healthcare Improvement (IHI). She leads IHI’s work in behavioral health, developing content and programming to improve behavioral health care in the U.S. and globally. In addition, as a member of IHI’s innovation team, she researches, tests, and disseminates innovative content to inform IHI programs and further IHI’s strategic priorities within the Triple Aim for Populations focus area. Prior to IHI she managed a nationally representative psychiatric epidemiologic study investigating the effect of social and environmental factors on the behavioral health outcomes of vulnerable populations. Ms. Laderman received a Master of Public Health from the Harvard School of Public Health and a Bachelor of Arts in Psychology from Smith College.

Kedar Mate, MD is an Internal Medicine physician and an Assistant Professor of Medicine at Weill Cornell Medical College and a Research Fellow at Harvard Medical School’s Division of Global Health Equity. In addition, he serves as the Vice President for Innovation at the Institute for Healthcare Improvement and the Regional Vice-President for the Middle-East and Asia-Pacific. In addition to his clinical expertise in hospital-based medicine, Dr. Mate has developed broad expertise in health systems improvement and implementation sciences. In his leadership role at IHI, Dr. Mate has overseen the developments of innovative new systems designs to implement high quality, low cost health care both in the US and in international settings. He graduated from Brown University with a degree in American History and from Harvard Medical School with his medical degree. He trained in internal medicine at the Brigham and Women's Hospital in Boston and currently resides in Virginia.

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