One of the most talked about issues in both the behavioral health and medical field is the integration of behavioral and physical health services. In fact, SAMHSA has reworked their definition of recovery to include physical health: A process through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential. This shows that recovery is no longer just about achieving abstinence or taking your psychotropic medications. It is about the person as a whole.
To understand and best provide services under this new model of recovery, it is important to understand the history and the challenges facing individuals with mental health and substance use disorders. Research conducted in the last decade indicates this population dies 15-25 years earlier than the rest of the population (Approaches to Integrating Physical Health Services into Behavioral Health Services, Lewin Group, 2012 (1)).
Individuals with behavioral health needs often don’t access traditional healthcare. They cite feeling uncomfortable and judged and many feel the service maze is large and complicated. In addition, many primary care physicians struggle to understand how to treat this population as they may not identify the behavioral health as a medical disorder creating a relationship of distrust for both sides (Merrill, Joseph O et al, Mutual Mistrust in Medical Care of Drug Users, J Gen Internal Medicine, May 2002 17(5) 327-333).
Further complicating matters are that many individuals struggling with mental health and substance use disorders have histories of trauma. The very act of going to the doctor and being asked to undress or being touched can recreate trauma. In addition, many providers are not trained in managing trauma and through the best of intentions may cause additional trauma (National Council, Linda Ligenza, Trauma Informed Care in an Integrated World, 2012).
Finally, most that have behavioral health issues lack many basic Activities of Daily Living (ADLs) such as making appointments, managing a schedule, and interpersonal communication. All of these deficits can create serious challenges for individuals to make and keep medical appointments. Often compounded with this is that these individuals do have real struggles to meet basic needs and thus medical care falls low on the priority of survival.
As a result of these many challenges, it has become critical that all medical and behavioral health services become integrated in order to provide individuals with high quality services to improve health outcomes and reduce healthcare spending.
Like any major shift in business, the integration of health care will encounter some fundamental challenges. For years, the areas of health, mental health and substance use treatment have practiced in their own silos. It can be understood that a client can have a physician in all three entities; however, the sharing of information and the collaborative effort to treat the client never structurally existed. Each profession has functioned and operated within their rights of their respective practice. Now with the integration of health care system, breaking down those dividers which section off each practice can pose some challenges.
One of the simplest barriers to this shift in health care is the lack of understanding amongst the disciplines. This integration will require practitioners from all areas to learn the core fundamentals of their new cohorts. A learning curve must be anticipated, as these practices have never shared or traded information in the realm that is to come. For health care providers, they must now understand all the nuances of addiction and treatment. Unlike the common cold, there is no prescription to be written to cure addiction. Healthcare providers will have to learn the elements of counseling and group therapy. On the reverse, behavioral health providers will now have to broaden their scope of treatment to include monitoring of any health-related issues that can conflict with a client’s treatment.
With sharing information, there comes the question of “how” do we go about doing this? Today, the use of electronic health records (EHR) is now a best practice in most fields. The use of technology to share information might seem to be the most practical way to co-treat a client; however, it can be the very exigent. Most fields have tailored their EHR systems to fit their needs, and it can be problematic to get systems, with different purposes to talk to one another.
When we start to talk about sharing information through the use of technology, we expand our list of collaborators to include our technology vendors. Technology vendors emphatically function in their own silos within the technology world, so there will be multiple layers of collaboration to consider. Additionally, we must consider each integrated entity’s governing source. Each field has their own local, state and governmental responsibilities that are often not transparent to their counterparts.
While the list of challenges might seem difficult, the solutions to combat these barriers pose some relief. With any change, there will be hurdles, however, with a well-thought-out strategic plan; there will be minimal ripples in the current. A starting point would be to cross train practitioners in evidence-based practices that have proven to be effective within each discipline. A unified understanding of all practices allows for a seamless integration. Developing linkages and co-locating programs between disciplines is another way to foster a more cohesive health care system. The collective goal of all areas of treatment is to treat the client’s basic needs which will then allow the client to focus on their health, be it general health, mental health or substance abuse disorders. The ultimate goal of an integrated health system is to treat the client from a holistic approach.