People present in wholes, not pieces. Despite this irrefutable scientific fact, our health care delivery system has reinforced a false notion that mental health is separate from physical health. We further this fragmentation, whether or not we realize it, in how we pay for care, deliver care, train for care, and create policy. New approaches to integrate behavioral health with primary care have emerged as among the most promising solutions to decades of fragmented care.
Mental health, often referred to as behavioral health, needs this type of disruption.
What does this integration look like? One word: seamless.
Imagine as a patient you walk into your primary care practice—and here, engaging you and all your health care needs, is a team of clinicians working together with you. Instead of referring you to another setting for your mental health needs, the primary care clinician addresses these needs and possibly brings a psychologist or other behavioral health clinician into the exam room to talk with you. There is no break in your care—no disruption in your day—there is instantaneous access to a behavioral health clinician who can talk to you about a range of health needs. No waiting to have someone talk to you—no referral for weeks down the road. This is about you having help in the moment you may need it most.
“The care that results from a practice team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population. This care may address mental health and substance abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, and ineffective patterns of health care utilization.”
Addressing mental health in primary care has historical roots, all of which come back to the evidence that integrating care helps people. Integrating care is being seen in increasing frequency around the United States, and the concept is found in more and more pieces of federal legislation.
However, as with many innovations, these integrated approaches have started in local communities. Communities have created their own solutions to problems. And while there have been some missed opportunities, such as accountable care organizations, each day shows new and exciting approaches (for example, use of integrated approaches in Medicaid and CHIP).
Integrating care is no longer just a good idea—integrating care is a movement.
However, as with all movements, there is a half-life. How can we take advantage of this propitious moment in health care, in which all policies are focused on improving outcomes, decreasing costs, and enhancing everyone’s experiences, to do something that matters to people? How can we further the movement to transform care to be seamlessly built around the person? Integration of behavioral health and primary care—this is our moment in health care—how will we respond?
To answer this question, we, in partnership with the Robert Wood Johnson Foundation, started with the experts: more than seventy of them. We scheduled time with each of them on the phone and asked them several critical questions such as:
In your experience, what on-the-ground factors or issues pose a challenge to the success of integration?
In your experience, what systems- or policy-level issues pose a challenge to the success of integration?
Once these data were gathered, we organized the responses into a draft report making specific recommendations to help advance the integration movement. In Washington, D.C., we gathered national leaders from the field of integration to finalize these recommendations into an actionable framework.
The final report outlined six elements that are important to scaling integration efforts nationally. The elements were viewed as interdependent. The six elements of this framework are
- Organizing the Movement: To advance integrated behavioral health and primary care efforts, there needs to be a comprehensive and consistent definition used for integration that all, or at least the majority of, stakeholders can agree upon. Additionally, there is a profound need for accessible technical assistance to advance integrated care efforts in all their various permutations. Technical assistance needs to be available at multiple levels (at the practice level, community level, state level, and federal level).
- Workforce Training and Education: Reform in training and education is needed to prepare a workforce to deliver integrated care. In short, the current workforce needs re-training and professional development opportunities, the future workforce needs access to curricula that teach how to deliver integrated care, and communities need education and enhanced understanding of how integrated care improves access to services and improves health outcomes.
- Financing: The current fee-for-service payment system presents huge barriers to team-based, integrated care. Our health care system needs a framework for alternative payment methods, including per member per month and population-based payment strategies to pay for whole-person, team-based care. Also, a strategy to connect innovative practices with payers that are implementing alternative payment methodologies is needed to share lessons learned and to build a business case that presents the financial benefits of paying for integrated mental health and primary care in new ways.
- Technology: To allow primary care and behavioral health clinicians to deliver care together, technology needs to be used to allow for the seamless flow of information and for exchange of data. Better education around existing behavioral health data regulations, national learning collaboratives, and an examination of how technology can be used, could help address barriers to sharing data.
- Care Delivery: Scaling innovative, integrated care delivery requires curating and sharing evidence on integrating mental health and primary care and including prevention and health promotion. Rapid-cycle learning must be implemented for immediate application and spread of best practices for integrated care.
- Population and Community Health: Integrating behavioral health and primary care cannot be confined to the walls of a clinic, and so the effort must consider social determinants of health, such as housing, education, and employment, and environmental conditions. All members of the community should be involved in planning and implementing health programs; community data measuring wellness, rather than just illness, needs to be collected and used in real-time to inform interdisciplinary action; and the role of community to support and strengthen health needs to be reexamined and reinvigorated.
The full report, Creating a Culture of Whole Health: Recommendations for Integrating Behavioral Health and Primary Care, can be found here, and the brief report, “Integrating Behavioral Health and Primary Care: An Actionable Framework for Advancing Integrated Care,” here.
Having access to both behavioral health and primary care should be the new standard of care. If we are serious about treating the whole of health in such a way that can improve outcomes, decrease costs, and give people what they want, we must integrate care.
Communities are already advancing some approaches on integration. However, as is true with many innovations in health care, communities need help. This framework can do that. The framework can help prevent us from looking back on our history and saying, “We should have done more.” Now is the time for us to move our health care system to a place that sees no difference between a person’s mind and his or her body, to a place that is inclusive of the whole.
Related reading on Health Affairs Blog:
“State Licensing And Reimbursement Barriers To Behavioral Health And Primary Care Integration: Lessons From New Jersey,” by Joan Randell and John Jacobi, April 7.