The very first time I ever thought about physical and behavioral healthcare together was when I heard of a psychiatrist who wanted to do complete blood chemistry before prescribing medication to new patients within a mental health clinic, a unique situation some 20 years ago. Clearly, this psychiatrist was a visionary and if her insight had translated into public policy, who knows how many incipient chronic medical conditions would have been diagnosed. Instead, Medicaid denied the claim for the blood work because it could not be used as a “…diagnostic criteria for schizophrenia,” sadly missing the point and an important opportunity.
We may be at a similar crossroads in our discussion of integrated health being too narrowly focused on where care is delivered. It seems that the current focus on integrating healthcare as “placed- based,” rather than “context- based” may well become another opportunity lost. While integrating health care into behavioral health locations (and vice versa) may in fact improve medical monitoring and adherence, that level of integration remains at the patient-practice level and fails to elevate the discussion to the social context. Put more directly, healthcare generally is about a person’s health status and the treatment that can be offered to improve a presenting problem, rather than how the person managed to develop the disorder and what secondary and tertiary interventions can be applied to mitigate the effects of the disease.
There is a common thread that ties the domains of health care and public health together. There are nine preventable diseases that account for 50% of all deaths in the United States. Evidence indicates that prevention targeting the root causes of these diseases account for an 80% reduction in mortality, while direct treatment accounts for less than 20%, (Hardcastle, Record, Jacobson, & Gostin, 2011). This fact alone argues for the development of an integrated healthcare system that gives equal importance to the development of the science of prevention, as well as continued development to improvements in treatment and service delivery.
The Changing Landscape
The Affordable Care Act (ACA) came into being for three simple, but interconnected reasons. These were: (1) the country had over 35 million people without health insurance, 16 million of whom were poor, but did not qualify for Medicaid; (2) while America spent more than any other industrialized nation for health care, our healthcare outcomes placed us at a dismal 37% ranking; and (3) over 18% of the nation’s gross national product (GNP) was being spent on healthcare with an upward trajectory being projected for the future. Put simply, the situation was not economically sustainable, nor was it acceptable from a quality outcome perspective. While the United States has built an exceptional healthcare system for the acute treatment of complex disorders, pioneering innovative developments in pharmacology and surgical procedures, on the one hand, the country has spent enormous resources on unnecessary, inefficient, and expensive interventions, often ignoring improvements in care and efficiencies in cost that could be gained by a more community-based prevention focus. It is estimated that approximately 60-75% of the cost on chronic care could be saved if a full prevention agenda were to be implemented.
Nowhere is this truer than among people who are challenged by serious mental illness (SMI) and complex chronic physical diseases. Indeed, over 50% of people with SMI have at least one, indeed many have multiple, chronic diseases such as repertory, metabolic, and cardiovascular conditions which complicate their care. Added to this level of complexity is the fact that these individuals frequently lack access to specialty care required by these conditions and likewise, lacked the self-care knowledge they need to help self-manage these conditions.
Health Care Through the Lens of the Social Context
In 1979, Surgeon General Julius Richmond established the first national prevention agenda. His ambitious report led to the creation of the Healthy People National Vision, a strategic framework for health promotion and disease prevention using data driven outcomes to motivate, guide and focus action. While the Healthy People framework has accomplished a great deal with regard to population health, it has not focused on the social determinants of health, which are generally defined as social context variables that can lead to negative health outcomes including: (1) health care access/literacy; (2) stable housing; (3) poverty/financial stability; (4) education; and, perhaps most importantly, (5) avoidance and resilience to trauma.
The first iteration of integrated health care placed emphasis on co-location of primary care into behavioral health and behavioral health into primary care utilizing an acuity index predicated on the four-quadrant model of acuity. The second iteration has shifted, while keeping co-location as a core principle, to understanding the social context which results in negative healthcare outcomes. Examples of this shift include NYS Performing Provider Systems (PPS) being asked to incorporate social determinants in care planning/delivery; the immediate past NYS Commissioner of Health not only publishing an article stating that “…housing is healthcare,”( Doran, Misa, & Shah, 2013), but also funding supported housing with Medicaid dollars; and the Immediate past HHS secretary Kathleen Sibelius stating that “…the most lasting legacy of the ACA is its focus on prevention as a national priority” ( Koh & Sebilius, 2010). Further, New York State Health Foundation (NYSHF) President James Knickman titled one of his blogs, “It’s time we get serious about Social Determinants [of Health]”. Today, there is a confluence of professional opinion on the importance of social determinants in population health and the need for strong, targeted prevention initiatives.
What is not well known is how health care and social systems can intervene strategically around social determinants in order to positively impact healthcare outcomes. We lack assessment strategies and prevention applications for social determinants that can be marshaled in the prevention arena in concert with evidenced based practices (EBPs) for disease management and a compendium of self-help skills to promote “healthy behaviors” all designed to improve population health.
Epigenetics, Social Determinants and the Role of Prevention
The Adverse Child Experiences (ACE) study (Felitti, Anda, Nordenberg, Williamson, Spitz, Edwards, Koss, & Marks, 1998) was an early glimpse into the devastating impact that child abuse and neglect has on child development and later adult life. A retrospective application of the ACE scale not only tied the experience of adverse and traumatic events to negative healthcare outcomes, but it was suggested that there was a dose response relationship between trauma frequency and negative outcomes. Subsequent research done in Texas (Dube, Cook, & Edwards, 2002) found that found that people with childhood adversities were more likely to be adults who were poor, less educated, and have difficulties maintaining employment. Moreover, these adults were more likely to be burdened with health problems such as smoking, obesity, substance and alcohol abuse. The emerging science of epigenetics (Lester, Marsit, Conradit, Bromer, & Padbury, 2012) , the study of changes in organisms caused by modification of gene expression, rather than alteration of the genetic code itself, is beginning to suggest that exposure to adverse life experiences not only has an inter-generational expression, but may indeed have a trans-generational expression as well.
These new developments have important implications for the development of the science of prevention. First, Hardcastle (2011) suggests that when we think about integrated health, we consider the development of a Health Care System consisting of appropriately co-located services coordinated by patient care navigators for complex cases where evidenced based treatment, as well as trauma informed care and social determinant intervention and assessment are available. Secondly, the clinical science of prevention requires considerable developmental work in order to produce targeted assessment and intervention strategies that promote resilience for the mental, emotional, and behavioral health (M-E-B) of children and young adults (Yoshikawa, Aber, & Beardslee, 2012). Thirdly, difficult decisions concerning re-allocation of resources to the various priorities of a reconfigured Health Care System will need to be made that keeps the focus on improved healthcare outcomes for the population. Finally, a renewed interest in community development by community-based organizations (CBOs) helping communities become places that foster rehabilitation and support for community members. There is a natural synergy that should exist between CBOs and their host communities.
Preparing the Workforce
Admittedly, this is a hugely complicated, multi-component transformational shift. The ACA has offered a number of tools that can be used to help in the transformation. These include expanded insurance coverage, care navigation, expanded community-based health care through federally qualified health centers and medical homes, and an emphasis on prevention; research resources to promote rapid system transformation; and the development of accountable care organizations to oversee system and payment transformation. System transformation will only succeed to the extent that we develop innovative strategies to fully engage and re-train the workforce. Creating an integrated healthcare system will involve the development and learning of complicated new concepts and implementation strategies. Success will be totally dependent on engaging and re-tooling the workforce to not only adapt, but to also help shape these changes. Experience in workforce re-tooling, thus far, clearly indicates the workforce understands the importance and wants to be engaged. A colleague once remarked that re-tooling the work force for the requirements of the ACA will be a bit like trying to fix the transmission of an automobile as it is going down the road at 60 MPH. Everyone in the car realizes how important it is that we be successful and that failure is not an option.
Peter C. Campanelli, PsyD is a clinical psychologist who serves as an Adjunct Faculty Member; Senior Research Scientist and Senior Scholar in Organizational and Community Services at the McSilver Institute for Poverty Policy and Research, Silver School of Social Work (SSSW), New York University (NYU). He also co-Directs the Advanced Certificate Program in Integrated Primary and Behavioral Health at SSSW.
Doran, K.M., Misa, E.J. & Shah, N.R. (2013). Housing as Healthcare—New York’s Boundary Crossing Experiment. New England Journal of Medicine, 369(25), 2374-2377. doi:10.1056/NEJMp1310121
Dube, S.R., Cook, M.L. & Edwards V.J. (2010). Health-Related Outcomes of Adverse Childhood Experiences in Texas, 2002. Preventing Chronic Disease, Public Health Research Practice & Policy, 09, 7(3), 1-9.
Felitti, V.J., Anda, R.A., Nordenberg, D., Williamson, D.F., Spitz, A.M., Edwards, V., Koss, M., & Marks, J.S. (1998). Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults:The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14(4), 245-258. doi:10.1016/S0749(98)00017-8
Hardcastle, L.E., Record K.L., Jacobson, P.D., & Gostin, L.O. (2011). Improving the Population’s Health: The Affordable Care Act and the Importance of Integration. Journal of Law, Medicine, & Ethics. 39(3), 317-327. doi:10.1111/j.1748-720X.2011.00602.x
Koh, H.K. and Sebelius, K.G. (2010). Promoting Prevention through the Affordable Care Act. The New England Journal of Medicine, 363 (14), 1296-1299. doi:10.1056/NEJMp1008560
Lester, B.M., Marsit, C.J., Conradit, E., Bromer, C., & Padbury, J.F. (2012). Behavioral Epigenetics and the Developmental Origins of Child Mental Disorders. Journal of the Developmental Origins of Health and Disease, 3 (6), 395-408. doi:10.1017/S2040174412000426
Yoshikawa, H., Aber, L.J., & Beardslee, W.R. (2012). The Effects of Poverty on the Mental, Emotional, and Behavioral Health of Children and Youth: Implications for Prevention. American Psychologist, 67 (4), 272-284. doi:1037/a0028015