Integrated health care has become the new “buzz word” of an era ushered in by the passage of the Affordable Care Act (ACA) and its associated elements of health care reform. More than a buzz word it signifies an approach to medical care for high risk people faced by multiple life threatening co-morbid conditions that could literally save their lives. The fundamental underlying presumption is that if integrated health care can be achieved then health care costs will decrease and quality health outcomes will increase. Reductions in healthcare costs and improvements in healthcare outcomes are two of the three triple aims of the ACA and arguably important issues for a country that spends more than any other industrialized nation on the health care of its citizens, yet ranks dead last in terms of most health care quality indicators. Although the concept of integrated health care likely could provide considerable improvement for both coast and outcome how does one achieve an approach to integration across multiple disorders and for a diverse group of people all presenting person centered idiosyncrasies. After all, many life threatening chronic medical conditions are linked, for example metabolic disorders like diabetes can lead to cardiovascular disorders and smoking, a personal behavior choice, leads to a vast array of chronic diseases including cancer, repertory ailments, and hypertension to name just a few. So, the challenge is how is integrated health operationally defined for people with much different co-morbidity, all of whom have person centered differences, taking into account different levels of disease progression spanning premorbid disease development through chronic disease development?
Making matters more complex, medication treatment choices made for one issue may have profound iatrogenic effects in other body systems, the most frequently cited example being depression and weight gain secondary to some medications which is especially problematic if the person is also struggling with type II diabetes. The social determinants of health and disease also do undoubtedly exert and influence on health cares’ effort to improve the health and well- being of people particularly if they come from high poverty communities. No one would argue with the fact that most people with SMI are living within the federal definition of poverty.
Behavior is notoriously resistant to change and so nutritional and lifestyle habits that provide immediate gratification like consumption of sugars and carbs as well as sedentary activities like sitting around all day watching TV as well as addictive behaviors like smoking all contribute to the poor health outcomes associated with people with SMI. Stable housing; access to continuous medical care that provides continuity and proper nutrition are among the important social determinants of health that will help to mitigate poor health outcomes.
A safe and stable place to live that provides reasonable geographic access to consistent and continuous community-based health care as well as access to nutritional food sources and the knowledge and skill to prepare meals certainly play an important role in facilitating the goals of integrated health care. Further, each individual’s response patterns to all of these issues is different making a person-centered approach to health care integration essential. These are complicated interactive issues that make the concept of integrated health care difficult to define and elusive to programmatically structure.
However, the public health crisis presented by people with serious mental illness (SMI) and co-morbid medical disorders represents the “perfect storm” that integrated health care can address best if clearly operationally defined and implemented properly within the array of mental health program assets that can be leveraged. Recent population health fiscal analysis of the public burden of this health crises published on the Commonwealth website and in the Journal of Health Affairs suggest that over 80% of the dollars consumed in Medicare and Medicaid combined are spent because of the impact of SMI and comorbid medical disorders including secondary substance use disorder (SUD) by dual eligible clients that are younger than 65 years old. There is both a fiscal and life preservation imperative to the search for a functional programmatic reality that can help structure integrated health care.
The Programmatic Landscape
We have made tremendous strides in the community-based treatment and support of people with SMI. Thirty years ago, deinstitutionalization was in full swing with little more than flop houses, adult homes and a few community based mental health clinics available to support people leaving psychiatric hospitalization. Since then the social and treatment circumstances have changed considerably for people with SMI as a result of the development of a number of innovations in program design. These have included various specialty forms of supported housing, assertive community treatment and supported competitive employment programs. Additionally, many community-based mental health clinics have introduced cognitive behavior therapy, empirically supported family and child therapies and some innovative providers have developed a set of best practices geared toward adaptation to cultural and ethnically diverse populations. Most recently a full understanding of the role of trauma in the development of SMI and a trauma informed care model has emerged. Finally, we have come to the realization that housing is not just housing but may serve multiple important functions such as crisis intervention, admission diversion, and avoidance of re-traumatization.
During this virtual explosion of community-based support program development people with “lived experience” found a voice and used it to communicate the important contributions they could make in the treatment and support of people with SMI. Theirs has been an important force in the development of self-help, advocacy and peer support programs. However, studies focusing upon the health and well- being of people with SMI found significant gaps in the system not addressed by the development of community mental health support programs.
During the decades following deinstitutionalization there was a preoccupation with the development of mental health support systems. So much so that we failed to recognize the importance of health care. So, when it was reported in a research study some years ago that people with SMI were dying 25 years sooner than people who did not have SMI it really came as no surprise to people working in the field. However, what was shocking was that people with SMI were not dying prematurely of psychiatric related causes but rather they were dying from the physical diseases most of us will suffer and die from eventually including hypertension, diabetes, cardio vascular disorder and the like. The dramatic difference was that these premature deaths were avoidable and were the result of very poor continuity and quality of physical healthcare received by people with SMI. As one provider once commented when talking about this state of affairs, it is as though all the advances in community care for people with serious mental illness over the last 30 years were focused on issues “from the neck up and between the ears.”
Toward a Functional Reality
While everyone can agree that integrating health and mental health from a clinical treatment and support perspective is most desirable and the most likely intervention to improve health care outcomes for people with SMI the real challenge is how one best accomplishes this programmatically.
Several different strategies have emerged to accomplish integrated health. These can be categorized into site-based strategies, clinical treatment strategies, and collaborative strategies. Site based strategies have involved co-location of health and mental health treatment access imbedded within a mental health or a health care clinic. Integrated clinical treatment strategies typically involve imbedding treatment capacity within ether the medical or mental health specialty thereby insuring that medical and mental health treatment can occur in one location and making a single treating professional within the integrated site responsible for the integration process. This approach can be found in medical homes and mental health clinics with medical monitoring and assessment capacity. Finally, collaborative care is best exemplified by the Health Home (HH) networks that have been developed pursuant to the ACA and with federal subsidy. New York Department of Health has implemented HH development enabling multi-disciplinary teams to emerge to attend to the complex needs of eligible people within these networks. Care navigation is provided by individuals through network-based case management services. These virtual service systems are inter-connected by hi-tech electronic record systems (EHR) and regional health information exchanges (RHIO).
While we have developed a sophisticated array of community-based treatment and support programs for people with SMI and in some instances have empirically proven their efficacy on a pilot basis, an “array” of services and an integrated system with common standardized approaches are quite different in their impact and outcome. It could be argued that what is lacking from the current discourse on integrated care is a common organizing philosophy that can transcend programmatic boundaries and provide a common organizing principle. Prevention methodology may very well provide the common platform upon which the concept of integrated health could come to rest.
Prevention activities have never been a reimbursable service by Medicare or Medicaid insurance in the past. The gold standard was always that the treatment rendered must be “medically necessary” in order to be reimbursable. However, it has become clear that waiting for a person who is at risk for serious medical complications to become sick is simply not the best way of improving medical outcomes or avoiding costly emergency care.
Prevention is a concept that the Center for Medicaid Services (CMS) has become very comfortable with in the wake of the passage of the ACA. In fact, the previous Secretary of Health is on record as endorsing prevention efforts and CMS has established a rapid evaluation system for examining innovative cost-effective prevention strategies. Providers are less comfortable with prevention because of the previously held standard that only permitted Medicaid reimbursable services for the treatment of disease that was deemed of “medical necessity”. However, developing an understanding of a tiered prevention-based approach to population management would be very helpful from the perspective of primary, secondary and tertiary prevention efforts that are both clinically and educationally based and imbedded within various programmatic assets that exist to serve people with SMI.
Diabetes is perhaps the best disease profile to illustrate the point. The type II diabetes rate has been climbing at an alarming rate within the US population and nowhere is that more the case than among people with SMI. An integrated primary prevention approach to this disorder among adults with SMI would involve standardize screening procedures in clinics, housing, ACT teams, school based mental health programs etc. Early identification, especially for pre-diabetic conditions, nutritional and life style counseling within program environments such as housing, and primary, secondary, and tertiary preventive education protocols with a person centered focus as well as within the individuals living environment that addresses warning signs and symptoms, teaches frequent monitoring and medical management and targeted consultation with one’s physician could go a long way toward integrating health care. Important elements of the educational approach for people with SMI could include evidenced based strategies that have been shown to be effective when applied by peers such as motivational interviewing (MI). The goal of a tiered prevention approach would be to prevent the onset of the disease or more serious complications once the disease is diagnosed. Specific standardized prevention-based approaches could be structured for people who have already acquired the disease (secondary prevention) and people who have the disease as a chronic condition with secondary damage (tertiary prevention). Further, a prevention approach offers a metric methodology to measure effectiveness of comprehensive protocol driven integration efforts from a disease measurement standpoint. Indeed, Druss (2010) and colleagues report on preliminary pilot results that are hopeful in this area.
Conclusion
The concept of a competent community was developed decades ago to characterize the positive synergistic impact that can be harnessed when various support elements of a community have a common understanding and support a common intervention plan in support of a community member in need. Primary, secondary, and tertiary prevention may provide the common platform around which integrated health care competence can be organized.
Dr. McKay is Professor of Poverty Studies and Director of the McSilver Institute of Poverty, Policy, & Research, NYU Silver School of Social Work. Dr. Campanelli is Senior Scholar, Organizational & Community Services, McSilver Institute. Both are co-directing a new Advanced Certificate Program in Integrated Health within the NYU Silver School of Social Work.
