Policy developments within federal, state and local governments are compelling providers to pursue the “Triple Aim” of healthcare reform and to continually reevaluate their systems and services to this end. Notwithstanding the complexities of the Affordable Care Act (ACA), Delivery System Reform Incentive Payment (DSRIP) program, universal Managed Care and other industry forces, the successful integration of primary (physical) and behavioral healthcare across service domains and its provision in non-institutional, community-based settings is a denominator common to all initiatives and a key metric by which providers’ success will be measured.
The conceptualization of integration is anything but integrated, however. It has been differentially defined in both the research literature and clinical practice, and new models of integration continue to evolve in accordance with available technologies, resources and stakeholder demands. The Agency for Healthcare Research and Quality (AHRQ) offers no fewer than nine definitions of integration, some of which include both quantitative and qualitative dimensions (Agency for Healthcare Research and Quality, 2008). For instance, one definition refers to “any mechanism by which treatment interventions for co-occurring disorders are combined within the context of a primary treatment relationship or service setting” (Institute of Medicine, 2006) whereas another suggests integrated approaches must “have medical and behavioral health components within one treatment plan for a specific patient or population of patients” (Blount, 2003). Integration may be achieved among service settings, populations, treatment interventions, diagnostic classifications and innumerable other dimensions, but the overarching goal of integration remains largely consistent across disparate approaches. Each endeavors to apply increasingly holistic methods to the management of comorbid health conditions in order to enhance the quality and coordination of care, reduce expenditures associated with inefficient and duplicative services and improve healthcare outcomes.
To this end the Westchester County Department of Community Mental Health (DCMH) has secured support from the New York State Office of Mental Health (OMH) for the implementation of a novel approach to service integration for members of an especially vulnerable target population. The DCMH has funded three community-based organizations to deliver mobile outreach, peer support and respite services to recipients with histories of treatment at state-operated psychiatric facilities and others at risk of admission to them. This approach is expected to reduce the incidence of emergency department visits and inpatient hospitalization among service recipients and to effect measurable improvements their overall health status.
The mobile outreach component of this project includes two care managers and a Licensed Practical Nurse (LPN), and they maintain modest caseloads in order to maximize their capacity to deliver intensive support services for recipients with complex and comorbid health conditions. Although the Mobile Outreach Team (MOT) does not retain as comprehensive an array of clinical supports and credentials as an Assertive Community Treatment (ACT) Team, it nevertheless employs a multidisciplinary approach in its attention to both behavioral and primary (physical) health conditions. It also leverages existing community support services in order to achieve integration across various clinical and service domains and to address the innumerable social determinants of health for its target population. Peer support services are delivered by two agencies with proven expertise in this modality, and these services are provided in concert with mobile outreach as needed in order to ensure recipients may benefit from the support of others with lived experience in the recovery process. Care managers, peer support providers and an LPN routinely conduct “inreach” activities in a state-operated psychiatric center in order to cultivate relationships with prospective recipients and to develop individualized support plans. Principles consistent with a Critical Time Intervention (CTI) approach are applied in order to promote recipients’ resilience during precarious periods of transition. In addition, respite services are available to individuals who have been discharged and secured housing in the community but require more intensive support than is available to them in their permanent living arrangements. The flexible and coordinated provision of mobile outreach, peer support and respite services, individually or in combination, is designed to address the myriad clinical, medical, psychosocial and emotional support needs of individuals for whom unmet needs have often been precipitants of relapse.
Inasmuch as these and similarly holistic approaches address both clinical and social determinants of health they constitute meaningful steps toward a fully integrated approach to health management. Conventional definitions of integration, such as those described above, refer to the coordination of primary and behavioral healthcare services but they seldom address other influencing factors of nutrition, stable housing, and social and emotional support resources. This is hardly surprising in view of the nation’s myopic management of its healthcare resources. The United States ranks first in healthcare spending among industrialized nations and 25th in social service spending (Harris, 2015), and this disparity is tragic in view of the relatively modest role healthcare delivery plays in overall population health. By some estimates only 10% of our health status should be attributed to healthcare interventions. Individual behavior, genetics and social circumstances are significantly greater determinative factors (McGinnis, Williams-Russo, & Knickman, 2002).
Although it is premature to assess the efficacy of our mobile outreach, peer support or respite initiatives in reducing preventable hospital readmissions or emergency department visits, an emerging body of research suggests truly effective approaches to integrated care must attend to the medical, behavioral and social determinants of health. Approaches that achieve only partial integration are unlikely to fulfill the Triple Aim of healthcare reform. We applaud the DCMH and OMH for their vision and abiding commitment to complete integration and we thank our partners for their support in the implementation of this promising project.
You may reach Mr. Brody by phone at (914) 428-5600 (x8228) or by email at abrody@searchforchange.org.
