Back in the height of what was called the “Humane Care” period, state hospital institutions took care, to the limits of their abilities, of the full spectrum of people’s needs. While one can certainly look back and question the quality of the care and the enormous personal consequences of long-term hospitalization, it is also true that mental healthcare, physical medical care, nutrition and work were part of the tapestry of better institutions.
As our field evolved and we came to realize the terrible personal costs people paid by spending such long periods of time in institutional settings and with the advent of Medicaid and Medicare, government began to organize itself differently. Over time silos of disability-specific agencies emerged to create, fund, regulate and monitor select portions of the human experience. Those of us who have been in the human services world for a while have decried this artificial segmentation of the service system. Phrases like “cross systems kids” or “multiply dually diagnosed” became common place. Our inability to address individual needs in a more comprehensive way had dire consequences for many.
Unfortunately, many of those discharged from mental institutions during deinstitutionalization did not receive proper access to the medication and rehabilitation services they needed and, instead, ended up on the streets, homeless. Even to this day, an estimated 30 to 50 percent of homeless people in the U.S. suffer from mental illness.
Deinstitutionalization brought with it the promise that individuals with mental illness could adjust to everyday life and live without stigma in their communities, albeit with the assistance of dedicated social workers, psychiatric rehabilitation, and other forms of support. Recent changes in mental health policies that promote managed care and Whole Health programs live up to that promise and will benefit not only those with mental and behavioral problems, but society as a whole (http://www.pbs.org/wgbh/pages/frontline/shows/asylums/special/excerpt.html).
The Whole Health Model
There has been a paradigm shift in the way we think about and treat those with mental health-related issues. In the past, if an individual was a substance abuser, then treat their addiction. If a person was homeless, find them a place to stay. Each issue was dealt with separately, through various agencies that often did not coordinate or communicate with one other. Navigating the maze of departments and resources was hard enough for those without mental health issues and extremely difficult for those with them. The system was both inefficient and ineffective as many of the people who most needed help didn’t get it and simply gave up, resulting in high mortality rates and a high instance of chronic illness among them.
Today, the trend is shifting from treating mental health issues in separate “silos” to a more integrative Whole Health approach that focuses on treating all aspects of an individual’s life—mental, physical health and substance abuse.
This Whole Health approach demonstrates that problems—and their solutions—are interrelated. Drug addiction, joblessness and homelessness often go hand-in-hand. Rather than treating each issue separately, treat them simultaneously. Instead of going to different departments for different resources, coordinate all efforts through a central source. For example, while working on a person’s addiction, help them find suitable accommodations, get them job skills training, and, when ready, help them find employment. If they have a family, help them get public assistance or find them a free children’s lunch program to ensure proper nutrition.
The Whole Health approach goes beyond recovery to empowering individuals to learn more healthy behaviors, make better choices, and to lead a fulfilling life. Programs like ICL’s Healthy Living that teach individuals how to follow and lead more healthy lifestyles, develop a skill, or tap into a hidden talent, provide the positive reinforcement that is needed to improve lives.
Also integral to the Whole Health approach is to address the underlying causes of recurring behavioral problems and identifying the strong connection between a person’s upbringing, their behavior, and their physical well-being.
The ACE Study: The Consequences of Adverse Child Trauma
Often, those who experience mental and social disorders have also been affected by adverse childhood experiences or (ACE). A groundbreaking study of 17,421 individuals over a 17-year period by Dr. Vincent Felitti, of the Kaiser Permanente Department of Preventive Medicine in San Diego, CA, found that adverse childhood experiences were linked to every major chronic illness and social problem in the U.S. ACEs can include: sexual, verbal and physical abuse, one or both parents who are mentally ill, alcoholics, incarcerated, or victims of domestic violence, the loss of a parent through divorce or abandonment, and or emotional and physical neglect.
Children who experience ACE often mask their feelings of fear, shame, and anxiety by turning to drugs, alcohol, violence or other seemingly self-destructive behaviors for solace. Understood in the context of their trauma, these behaviors can often be explained and seen as strengths; and the individual recognized as a survivor rather than a victim. The more adverse the childhood experiences, the greater the risk of medical, mental, substance and social problems as an adult.
“The biological impact of ACEs transcends the traditional boundaries of our siloed health and human services systems,” says Dr. Robert Anda, a researcher at the CDC who participated in the ACE study. “Children affected by ACEs are more likely to become adults with behavioral, learning, social, criminal, and chronic health problems.”
With proper training and support, individuals can learn to break the continuum of emotional distress and develop positive mental and health behaviors. This is especially true for children where early intervention, or the lack thereof, can have an enormous impact on that person as an adult.
What’s needed is an integration of the educational, mental health, and other public systems to share knowledge and resources and replace past fragmented approaches. By identifying and breaking the cycle of ACEs, behavioral health professionals can help individuals and families turn their lives around, and help reduce the costs of healthcare, social services, and other support areas significantly (Stevens, Jane, “The Adverse Childhood Experiences Study—the largest public health study you never heard of,” Huffington Post, October 4, 2012).
Managed Care Organizations: Improving Care, Reducing Costs
It is estimated that the top one percent of patients consume one-fifth of all healthcare costs and the top five percent consume one-half. However, recent initiatives have shown that improving the quality of care through managed care programs is actually a very effective way to reduce health care costs, especially for high-need, high-cost individuals with complex behavioral issues and chronic conditions. One such effort is the New York State Medicaid Redesign Team (MRT). Launched in 2011, MRT is a collaborative effort to reduce the state’s Medicaid costs while enhancing the health of participants, and has broad support among the healthcare stakeholder community. So far, the state has cut $4 billion in Medicaid expenditures while adding 154,000 to the Medicaid rolls and getting high marks for the quality of its managed care programs (http://www.health.ny.gov/health_care/medicaid/redesign).
Nationally, the Affordable Care Act (ACA) provides funding for care management programs for high-need, high-cost Medicaid beneficiaries. In New York State, this funding was used to help launch a three-year Chronic Illness Demonstration Project (CIDP) to test new strategies to improve health care quality and control spending for Medicaid’s highest-need, highest-cost populations. Six providers throughout New York State were selected to participate, among them the Institute for Community Living.
Using a Whole Health “managed care” approach (not just managed costs) consisting of nurses, social workers, and peer specialists (who experienced issues similar to those whom the program attempts to help) searching the streets, homeless shelters, veterans fairs, and drug clinics for targeted high-need, high-cost individuals. Once enrolled, a “care manager” coordinated with a team of physicians, social workers, behavioral health providers, and others all with the goal of ensuring that each participant was given access to all the services needed to stay healthy, out of the hospital, and off the streets, and the reduced cost of such should be viewed as an added bonus that allows for wider distribution of services to a greater population in need.
This managed care model has not only improved the quality of care for participants—who account for about half of the state’s $54 billion annual Medicaid expenditures—but lowered costs by reducing preventable hospitalization and emergency department use. Best practices from New York’s CIDP initiative offer valuable lessons to other cities and states across the country. In December 2012, with additional funding available from the Affordable Care Act, New York launched plans to extend case management services to nearly one million of its five million Medicaid beneficiaries, using the CIDP as a model.
Furthermore, as the Institute for Healthcare Improvement (IHI) notes, new designs must be developed to simultaneously pursue three dimensions, which they call the “Triple Aim”: improving the patient experience of care (including quality and satisfaction); improving the health of populations; and reducing the per capita cost of health care.
Organizations and communities that attain the Triple Aim will have healthier populations, in part because of new designs that better identify problems and solutions further upstream and outside of acute health care (http://www.ihi.org/offerings/Initiatives/TripleAim/Pages/default.aspx).
Recently, I became the President and CEO of the Institute for Community Living (ICL), one of the six providers who participated in the New York CIDP pilot program, and I have seen first-hand how the application of integrative Whole Health, managed care initiatives can have a tremendous impact for individuals who suffer from mental, physical or substance abuse problems; the homeless; and returning veterans and their families.
I know it’s an overused phrase these days, but there really are opportunities in the crises that seem upon us; opportunities to do some of the kinds of care some of us have hoped for for decades. It certainly won’t be without its challenges, but let’s all keep our eyes on the prize.
There are a growing number of innovative managed care programs that are showing positive results on the local, state and national level. Their success is a fulfillment of the principle espoused in 1979 when President Jimmy Carter’s Commission on Mental Health sought to maintain “the greatest degree of freedom, self-determination, autonomy, dignity, and integrity of body, mind and spirit” for those with behavioral health issues. And it’s about time!