The integration of primary and behavioral health has become a major focus of healthcare restructuring across the country in the past several decades. New partnerships, emerging from a historically siloed system, share the triple aim of improving health status, containing costs and enhancing service delivery to individuals with behavioral health conditions. The growing number of federal, state and local health initiatives, rolling out alongside those of the health insurance and technology industries, highlights the myriad stakeholders committed to achieving integrative care models. Still, the challenges facing providers and systems of care are many and often require new approaches to successful collaboration.
While there is robust evidence supporting the addition of behavioral healthcare services to primary care settings, less exists to support embedding primary care within mental health clinics (L.E. Raney, ed., Integrated Care: Working at the Interface of Primary Care and Behavioral Health, 2015). Data from a community-based sample of adults with serious mental illness (SMI) – whose high rates of medical comorbidities and excess mortality disproportionately drive health care expenditures – show that over 60% of subjects had difficulty taking medication, keeping medical appointments, and identifying symptoms (Skinner et al, Met and unmet needs for assistance and quality of life for people with severe and persistent mental disorders, 1999). In addition, the stark association of SMI and poverty with modifiable risk factors and poorer health outcomes underscores the need for targeted integration efforts in public settings (Vick, Jones, & Mitra, Poverty and severe psychiatric disorder in the U.S.: Evidence from the Medical Expenditure Panel Survey, 2012). Individuals with SMI often identify their behavioral health providers as their primary resource in the community and their mental health clinic as their unofficial health home. It therefore stands to reason that placing physical health services in the behavioral health setting would produce better outcomes.
In 2014, New York State finalized the terms of a waiver from the federal government to allow the State to reinvest $8 billion in federal savings for Medicaid redesign. Over $6 billion was allocated to the Delivery System Reform Incentive Payment (DSRIP) Program to streamline healthcare delivery and reduce avoidable hospitalizations and emergency department visits by 25% over five years. DSRIP promotes community-level collaboration between providers of care into formal, sustainable care networks called Performing Provider Systems (PPS) (Algonquin Studios, NYS DSRIP: An $8 Billion Experiment in Working Together for Better Healthcare, 2014; Schuyler Center for Analysis and Advocacy, Overview of the Delivery System Reform Incentive Payment Program, 2014). PPS are required to streamline the delivery system and make quality health care accessible to Medicaid members as the foundation to achieve the program milestones. The level of funding and coordinated effort involved in DSRIP speaks to the priority given to enhancing services to residents with behavioral healthcare needs.
Under this initiative, NewYork-Presbyterian (NYP) is leading a PPS and collaborating with the Washington Heights Community Service (WHCS) to embed primary care in two state mental health clinics in Upper Manhattan. The collaboration arose from a mutual, long-standing concern and interest in the poor health of the Washington Heights and Inwood communities. NYP and WHCS are separate organizational entities located in Upper Manhattan. NYP is a large private not-for-profit academic medical center, while the WHCS is a state-administered and -operated community mental health service of the New York State Psychiatric Institute. Each organization has its own mission, leadership, governance, and operational structures. The NYP-WHCS team, while excited about this unique opportunity to provide comprehensive care to adults with SMI, has come to understand that systemic integration and physical colocation – a first for both – presents both challenges and opportunities for growth and innovation.
The WHCS has provided psychiatric care to adults with SMI since its inception in the 1970s. It currently serves approximately 1,000 individuals, most of whom are of low socioeconomic status (95%), from racial-ethnic minority groups (82%), primarily Hispanic (62%) and non-Hispanic black (19%), and have a psychotic spectrum disorder (56%) or mood disorder (39%). Its multidisciplinary teams of psychiatrists, social workers, nurses, peer providers, occupational therapists, and trainees of all disciplines work together to provide the range of clinical and recovery services needed to help ameliorate psychiatric symptoms, address psychosocial stressors and rebuild the functional shortfalls commonly seen in this population. Factors such as low health literacy and side-effects of psychotropic medication compound the challenges for these providers in managing and coordinating clients’ physical and behavioral health services.
Prior to DSRIP, the WHCS recognized the need to address the medical problems of their clients and made efforts to integrate behavioral and physical healthcare. The WHCS hired an internist for weekly medical consultation to clients and case consultation to staff managing complicated medical comorbidities. The WHCS participated in the Office of Mental Health PSYCKES pilot project to identify and track cardiovascular risk factors and interventions to reach targeted outcomes. Until now, more comprehensive integration has been stalled by factors that include financial and regulatory constraints, and difficulty providing discipline-specific support and supervision to primary care providers housed in mental health settings.
The NYP-WHCS collaboration provides vital resources to achieve the goal of full integration. DSRIP funding is available to cover start-up costs, including building and equipping primary care space in each of the two clinics and hiring primary care staff. Primary care providers at the clinics will receive support and supervision from the professional community of NYP. Clients will have access to routine primary care and walk-in services. Staff can leverage clients’ engagement with the clinic to increase their utilization of on-site primary care services as an alternative to the emergency room, and to improve modifiable risk factors and physical health outcomes. However, the sustainability of the model has been of primary consideration as the project unfolds. Examining the staffing ratios of other integration models and gathering data on client primary care utilization and need have been key aspects of the project design. As the state moves toward a value-based payment model, a combination of improved health outcomes and lower utilization of high-cost services will be key to programmatic fiscal sustainability.
The merging of the two systems to form a new culture has been greatly facilitated by the framework created by Substance Abuse and Mental Health Service Administration (SAMHSA). The Integrated Practice Assessment Tool (IPAT) is a tool that places practices on the level of collaboration/integration defined by the Standard Framework for Levels of Integrated Healthcare (Waxmonsky, Auxier, Romero, & Heath, Integrated Practice Assessment Tool, 2014; Heath, Romero, & Reynolds, A Review and Proposed Standard Framework for Levels of Integrated Healthcare, 2013). The latter has enabled the team to understand the continuum of collaboration and their future objectives by operationalizing three ways of joining efforts: coordination, colocation and integration. The project aim of primary care integration into the clinics’ existing structures and cultures has entailed discussions around documentation, access to a shared medical record, and primary care participation in team meetings and rounds. In addition, while DSRIP’s focus on innovation and evidence-based, population-based care builds upon the clinic’s existing quality projects, the aim to bridge communication with collaborating agencies accelerates the need for enhanced technological capabilities and will require staff to adjust to new systems and forms of communication and documentation. The SAMHSA tools have helped to mitigate culture clashes and resistance to change through the development of a common language about integration.
Still, the initiative is in its inception, and cross-fertilization of ideas will need to continue within and between the two organizations to meet programmatic and fiscal goals. DSRIP has provided sorely-needed start-up resources and structures to facilitate collaboration and systemic change in the hopes of achieving improved health outcomes for clients with SMI. This NYP-WHCS team is fortunate to have this opportunity to develop a program that will not only improve its clients’ health but contribute to the development of best practice models for integration. The learning curve has been, and will continue to be, steep but the anticipated payoffs are great.
Julie Chipman, LCSW, MPA, is Primary Care-Behavioral Health Integration Program Manager of New-York Presbyterian DSRIP Programs; Jean-Marie Bradford, MD, is Director of Washington Heights Community Service; and M. Goretti Almeida, MBA, is Administrator of Washington Heights Community Service.