Reimagining Integrated Care: Why Social Interventions are Vital in Providing Support for People with Serious Mental Illness

The concept of “integrated healthcare” has been regarded as an optimal treatment approach for individuals experiencing co-occurring mental and physical illnesses. Twenty years ago, Fountain House – the most widely replicated evidence-based community model for people living with mental illness in the world – created the first integrated health home specifically for people with serious mental illness in the US, known today as the Brightpoint/Sidney R. Baer Jr. Health Center (Baer Center). The extraordinary health outcomes of Center patients (a re-hospitalization rate of 10% compared to re-hospitalization rates of 50% for people with schizophrenia in the general population; and a 21% decrease in cost of care to Medicaid [Solís-Román C, Knickman J. Project to evaluate the impact of Fountain House programs on Medicaid utilization and expenditures [Internet]. New York (NY): New York University Health Evaluation and Analytics Lab; 2017 May 9 [cited 2018 Jan 29]. Available from:]) result from a reimagined version of integrated care, which Fountain House calls a “Community System of Care.” This approach goes beyond primary and psychiatric care to include a vital, overlooked and unfunded third element – social interventions.

Social interventions address the Social Determinants of Health (SDOH) and empower people with serious mental illness – a population that often has weak social networks, lives in poverty, experiences precarious housing, are often caught in the revolving door of hospitalizations and incarceration, and lacks access to healthy lifestyle options – to form meaningful peer relationships, return to school and work, obtain and maintain housing and participate in wellness activities. These social interventions are delivered at Fountain House’s clubhouse – a nonclinical, strengths-based environment – while medical and psychiatric interventions take place at the Baer Center. In this way, individuals are related to comprehensively, beyond just their diagnosis.

Baer Center patients have their psychiatric and medical records in one location. The Center’s staff and treatment team – comprised of the patient, a Fountain House social practitioner (social worker), a Baer Center general practitioner and a psychiatrist – participate in a full continuum of primary and behavioral healthcare services. Together, they develop an individualized recovery plan. The social practitioner, based on an established relationship of confidence with the patient, brings an in-depth knowledge of the person that is shared (with permission) with doctors. The doctor, because of his/her close working relationships with the social practitioner, absorbs and utilizes this information in the treatment of patients. Doctors discuss the circumstances of patients’ lives and their goals such as employment, education, housing, as well as physical and psychiatric health. One of the first questions a patient is asked when seeking care at the Baer Center is what his/her life goals are, beyond the management of the illness (Aquila R, Santos G, Malamud TJ et al: The rehabilitation alliance in practice: The clubhouse connection, Psychiatric Rehabilitation Journal, Vol 23(1):19-23, 1999).

The Baer Center is able to include a focus on patients’ life goals and full medical, psychiatric and social recovery, because of its connection to and communication with Fountain House. An example of the complimentary support services Fountain House provides to Baer Center patients are the robust Wellness activities that take place every day at The Peter B. and Adam Lewis Wellness Center at the clubhouse. The Wellness Center supports a health-conscious culture in which members engage – at no financial cost – in fitness, nutrition and health education activities. For a population mostly unable to afford gym memberships, The Wellness Center offers state-of-the-art exercise equipment, running groups, and cooking classes. Fountain House members encourage and motivate each other to lose weight, eat healthier, reduce stress through yoga and meditation, stop smoking, stay sober and improve their overall wellness (Doyle A, Lanoil J, Dudek KJ (eds): Fountain House: Creating Community in Mental Health Practice. Chichester, West Sussex, New York: Columbia University Press, 2013).

To improve the lives of people with serious mental illness while also reducing costs, we must reimagine what we understand as integrated healthcare. Qualitative and quantitative outcomes of models that include social interventions have broad implications for the future of social programs. The current system of integrated care has not prevented homelessness, incarceration, and emergency room use for people with schizophrenia and bipolar disorder. It is time for upstream investment in models that go beyond the delivery pf psychiatric and primary care and consider the comprehensive needs and potential of this population.

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