Integrated Care

Applying Theory to Practice

Russ Curtis, Eric Christian, Russ Curtis, Eric Christian

• Publisher: Routledge
• Year: 2012
• ISBN:
  9781136789113
• Edition: 1
• Topic: Business
• Subtopic: Industria farmaceutica, biotecnologica e sanitaria
• Index: Business

This book provides pertinent and practical information about how to create, work, and thrive in an Integrated Care (IC) setting. Unlike other books on the subject, it focuses on the "nuts and bolts" of establishing an IC practice; it also covers material that is often missing from or insufficiently covered in the existing literature. Specific topics discussed include the basics of IC, such as different models and levels of IC and examples of IC initiatives; how to build an IC program, with guidelines for entering and working effectively in a practice, as well as managing the associated economic aspects; ethical issues involved in IC, given the discrepancies between medical and mental health ethical standards; assessment and intervention in IC; cross-cultural and diversity issues in IC; and leadership, consultation, and supervision.

PART I
Requisite Knowledge and Skills Needed to Begin Working in Integrated Care

CHAPTER 1
Introduction to Integrated Care

ERIC CHRISTIAN and RUSS CURTIS

Integrated systems, including Kaiser Permanente in California, Geisinger Health System in Pennsylvania, the public systems in Finland and New Zealand, and the Veterans Administration in the United States, can provide better care at 20% to 30% lower cost. Clearly, systemic problems require systemic solutions. (Christensen, 2010)

Introduction

Integrated care (IC), for the purposes of this text, can be described as the provision of behavioral heath services within primary care settings to attend to the overall health care needs and wide array of problems presented by patients to providers in these settings, which can vary in their degree of behavioral health programming. The inception of IC was at the grassroots level, implemented in primary care medical offices and hospitals throughout the country in an effort to address the escalating number of patients presenting in these settings with mental health, substance abuse, and other behavioral health issues (Gatchel & Oordt, 2003; Salovey, Rothman, Detweiler, & Steward, 2000). Four main reasons can be attributed to the rapid growth of integrated care: (a) the continuing struggle of the health care industry to identify effective treatments while curbing skyrocketing costs (Lubell & Sloan, 2007), (b) the increasing number of patients presenting to primary care offices and emergency rooms with mental health needs (Gatchel & Oordt, 2003), (c) the effectiveness of behavioral health care in treating patients with medical issues (Katon et al., 2002; Rasmussen et al., 2006; Sotile, 2005), and (d) research indicating the wide-scale efficacy of integrating medical and mental health care (Blount et al., 2007; Cummings, 2002).

Although countries with socialized medicine health care systems have long practiced IC as a way to control health care costs, the United States is just now embracing integrated care on a wider scale. The U.S. Air Force and Navy, for instance, inducted integrated care models, as did one of the largest health maintenance organizations in the country: Kaiser Permanente in northern California (Cummings, 2002; Strosahl, 2007). The integration of medical and mental health services dates back as far as 1979, as documented in the U.S. Surgeon General’s report, Healthy People: General’s Report on Health Promotion and Disease Prevention (U.S. Department of Health, Education, and Welfare, 1979), and more recently has been touted by the Substance Abuse and Mental Health Services Administration and the American Academy of Family Physicians, among other influential agencies (Blount et al., 2007). IC is gaining such national prominence that House Resolution 5176, the Community Mental Health Services Act, was introduced into the U.S. Congress in January 2008. Resolution 5176 not only encourages bolstering the mental health workforce but also supports the provision of more effective treatment for the mentally ill by increasing the number of primary care physicians (PCPs) working within mental health agencies (National Council for Community Behavioral Health, 2011). The primary care medical home (PCMH) movement is one in which primary care practices strive to meet core competencies which are considered to provide comprehensive, coordinated, patient-centered, accessible, and ongoing quality-based care, that involves input from the patient and all of their health care providers. In this way, the primary care clinic becomes the medical hub for each patient’s overall health care, which may mean coordinating the various types of providers and services (U.S. Department of Health and Human Services, 2011). The PCMH concepts are also in support of proven best practices in IC, and experts believe that behavioral health is an essential component of primary health care (Mauer, 2009).

It is clear there is growing popularity and adaptation of IC in U.S. health care. The purpose of this text is to explore the rising trend of IC health care, the role of behavioral health providers (BHPs) in IC settings (primarily in primary care settings), and the tools necessary for thriving within this budding and expanding system of care. Specifically, this text will assist BHPs in acquiring the fundamental and requisite knowledge and skills essential to working within integrated primary care medical settings. The reader will learn about considerations for working as a BHP in primary care with general and specific populations, and about issues related to the efficacy, operation, evolution, and the promising future of IC as a prominent health care treatment model.

Overview of Integrated Care

To conceptualize the various permutations in which IC is practiced, Doherty, McDaniel, and Baird (1996) created an IC hierarchy delineating the different levels of collaboration ranging from minimally to fully integrated care; Peek (2009) refined these concepts further (see Table 1.1). In minimal collaboration constructs, the PCP refers patients with mental health needs to BHPs located in separate facilities. Midlevel collaboration is typically characterized by the presence of a BHP in a medical office, commonly referred to as “co-located,” in which patients are referred back and forth between providers, but with consultation between the PCP and BHP maintained at a generally minimal level. A fully integrated care facility, which is considered optimal for providing comprehensive and effective health care (Strosahl, 2007), exists when the BHP and PCP consult frequently throughout the day, regularly see patients together in the examination room, and collaborate for optimal treatment.

Table 1.1 A Range of Goals for Collaborative Practice: Levels or Bands of Collaboration

Model	1	2	3	4	5
	Minimal Collaboration	Basic Collaboration From a Distance	Basic Collaboration On-Site	Close Collaboration in a Partly Integrated System	Close Collaboration in a Fully Integrated System
Doherty, McDaniel, and Baird (1995)*	Separate systems Separate facilities Communication is rare Little appreciation of each other’s culture; little influence sharing	Separate systems Separate facilities Periodic focused communication mostly by letter or phone View each other as outside resources Little understanding of each other’s culture or sharing of influence	Separate systems Same facilities Regular communication, sometimes face-to-face Some appreciation of each other’s roles and general sense of larger picture, but not in depth Medical side usually has more influence	Some shared systems Same facilities Face-to-face consultation, coordinated treatment plans Basic appreciation of each other’s role and culture; share biopsychosocial model Collaborative routines are difficult—times and operations barriers Influence sharing—but with some tensions	Shared systems and facilities in seamless biopsychosocial web Patients and providers have same expectation of a team Everyone committed to biopsychosocial; in-depth appreciation of roles and culture Collaborative routines are regular and smooth Conscious influence sharing based on situation and expertise
Handles adequately	Routine, with little biopsychosocial interplay and management challenges	Moderate biopsychosocial interplay (e.g., diabetes and depression with mgmt of each going reasonably well)	Moderate biopsychosocial interplay requiring some face-to-face interaction and coordination of tx plans	Cases with significant biopsychosocial interplay and management complications	Most difficult and complex biopsychosocial cases with challenging management problems
Handles inadequately	Cases refractory to tx or with significant biopsychosocial interplay	Significant biopsychosocial interplay; when care plan is not satisfactory to either MH or medical providers	Significant biopsychosocial interplay; those with ongoing and challenging management problems	Complex, with multiple providers and systems; tension, competing agendas, or triangulation	Team resources are insufficient or breakdowns occur in the collaboration with larger service systems
Seaburn et al. (1996)	Parallel deliver: clear division of labor not flowing into each other significantly	Informal consultation: MH professional helps physician deal with a clinical problem, but usually not contact with the patient	Formal consultation: MH professional has direct contact with pt. in typical relationship as a consulting specialist	Co-provision of care: patient care is shared and the professionals may see the patient or family together	Collaborative networking: provider team is extended to include family and other medical specialists, educators, and community resources
Strosahl (1998) and Peek (1998)	Traditional referral-between-specialties models		Co-location models	Organization integration or “primary care mental health” models
MH provider might say:	“Nobody knows my name.”	“I help your patients.”	“I am your consultant.”	“We are a team in the care of our patients.”	“Together, we also teach others how to be a team in care of patients and design of the care system.”
Medical prov. might say:	“Who are you?”	“You help my patients, but not me.”	“You help me as well as my patients.”

Source: Reproduced by permission from Peek, C.J. (2009). Collaborative Care: Aids to Navigation. White paper prepared for Creating a Research Agenda for Collaborative Care, a research agenda-setting conference of the Collaborative Care Research Network, Denver, CO, October.

* Also appears in Doherty, W. (1995). The why’s and levels of collaborative family healthcare. Family Systems Medicine, 13(3/4).

Integrated primary care clinics with co-located PCPs and BHPs can provide behavioral health services that are both nontargeted, called horizontally integrated, and targeted, called vertically integrated. Horizontal integration refers to the method a clinic follows for providing behavioral health services to patients who present with a range of concerns, to the degree of support needed. Horizontally integrated psychosocial services in primary care are population based, in that a wide net is cast to help all patients to improve their overall health (O’Donohue, Byrd, Cummings, & Henderson, 2005). Vertical integration employs the use of protocols for working with specific subpopulations of patients, such as those who have depression. Providers in integrated primary care settings serving large populations may decide to streamline care by defining treatment protocols to target a few key conditions that frequently affect subpopulations of their patients. Examples of vertical integration established to provide comprehensive treatment for two common conditions are the design of care protocols for depression and chronic pain (O’Donohue et al., 2005). This practice allows a clinic to address the special needs of patients with these conditions within the context of a fairly prescribed protocol based on best practices.

Specialty medical settings such as cardiology or oncology clinics can horizontally integrate behavioral health services to address the stress, anxiety, and depressive symptoms typically associated with conditions treated in these clinics, and to assist patients in achieving the health behaviors that best support the prescribed medical treatment regimen. In these example specialty settings, treatment for major depression might also be vertically integrated for a subpopulation in need of targeted services, with an identified protocol that involves the nursing staff for screening of depression, physicians who assess motivation for treatment, and a BHP who provides treatment. Each provider thereby fulfills optimal roles for treating patients based on his or her area of expertise.

Although most IC settings today consist of BHPs working within medical offices, another permutation of IC exists, called reverse co-location (Collins, Hewson, Munger, & Wade, 2010). In this arrangement, a PCP works within a mental health agency. Studies have shown that patients who suffer from severe and persistent mental illness die 25 years earlier on average than the general population. The unmet physical health needs of these patients are by and large cardiovascular and pulmonary disease management, with an occurrence rate of 60% (Moran, 2007). The provision of colocated primary medical care delivered in close collaboration with mental health services results in an increase in the number of recommended primary care interventions and health outcomes when compared to patients receiving usual care (Druss, Rohrbaugh, Levinson, & ...