Care Integration is Imperative for County Service Systems

The Affordable Care Act (ACA) can be expected to foster a dramatic transformation in health service delivery systems operated and supported by counties, including mental health, substance use, and intellectual development/developmental disability (ID/DD) programs. A primary feature of this transformation will be the creation of integrated service systems that combine these separate services into medical homes operated by primary care entities or health homes operated by behavioral health entities. Here, we discuss these developments and how counties can prepare for them.

We have known for more than a decade that separation of primary and behavioral care can lead to very significant adverse consequences. Clients with severe mental illness and substance use conditions who are served by public systems die 25 years earlier than other people. Although lifestyle factors and the adverse effects of second-generation psychotropic medications can contribute to early mortality, lack of needed primary care services clearly is a key factor. At the same time, persons with serious medical conditions, like heart conditions or diabetes, also have  worse prognoses and die earlier when they suffer from untreated or poorly treated mental and substance use conditions, such as depression. Hence, service integration is not only advisable, it is absolutely essential for personal longevity and wellbeing. 

Stages of Service Integration 

Services integration has gone through several stages of development during the past decade. Early service integration efforts included behavioral treatment for mental or substance use conditions, followed by referral to a unrelated primary care practice. Generally, this approach worked very poorly because most clients never appeared at the site to which they were referred.

To solve the problems of referral, a co-location approach (also called bidirectional integration) has been adopted more recently. Behavioral healthcare service units are placed next to primary care service units, or vice versa. This second approach suffers from two problems: lack of sustainability because funding comes primarily from grants, and ineffective service coordination because primary care and behavioral health service units remain separated and do not constitute actual service teams. Since behavioral healthcare funds are “carved out” or separated from health care funds, payment mechanisms for integrated care are very complex, at best, and  ineffective, at worst. Grant funds provide a very unstable foundation for this work. Also, co-location does not assure close teamwork on complex cases, and primary care services are not likely to learn about whole health, recovery, trauma informed care, resilience, or peer support services. 

Because of the problems of treat-refer and co-location, a new approach to care integration is beginning to be implemented. Called simply full integration, this approach is based on an integrated service delivery team and integrated funding. Full integration  can be implemented in either a primary care or behavioral health setting.

At the present time, only about 30-35% of persons with behavioral health conditions are seen in behavioral care settings. The balance receive care from primary care physicians. We envision that this distribution with change even more with ACA implementation. By 2025, only 10% of behavioral care will occur in health homes operated by specialty providers. However, these dynamics are not likely to have much effect on the total number served, since insurance provided through the ACA will double the number seeking behavioral care from public and not-for-profit behavioral health service providers. Yet, a larger percentage of those who are served there will have more severe conditions.

Potential Responses by Counties

County service delivery systems will need to adapt to these changes by developing medical and health homes for the populations they serve. Although several different approaches to achieve this goal could be taken here, it is very important to keep in mind that these changes primarily need to occur at the point of service delivery. Several proposals have been provided below with this in mind.

Build County or Intercounty Health Collaboratives. A single county or several counties joined together could develop a health collaborative to serve the the health needs of public sector clients. County agencies participating in the collaborative could include health, mental health, substance use, ID/DD, and even public health. The agencies could contribute staff who would participate in service delivery teams or funding to purchase needed services. In this model, county agencies would exercise oversight on appropriate credentialing and quality assurance.

Supplement Local Federally-Qualified Health Centers (FQHCs) and Rural Health Centers (RHCs). For single counties or sets of counties that are small or that lack public service infrastructure, a formal relationship could be developed with local FQHCs/RHCs to configure medical homes using the infrastructure already provided by the federal government. Typically, these entities will lack sufficient mental health and substance use service resources. The formal agreement could provide either staff or funding to add these latter personnel and services. In addition, effort should be made to extend this work to include public health prevention and promotion services.

Combine Local Services and Virtual Services. For single counties or sets of counties that have some services but not others, it may be possible to configure the on-the-ground services with virtual services so that the minimum array of services neded for a medical or health home is available to public sector clients. Typically, this will mean use of telemedicine to add virtual mental health or substance use services, including the use of some related online services done without a provider.

Next Steps

It should be obvious that these three models could be combined in different ways depending upon county needs and capacities. The most important point is to begin planning now so that medical home and health home services can be made available to public clients in the short term future.

Some federal funding is available to help with service implementation. ACA Section 2703 provides 90% federal Medicaid funds for two years from the Centers for Medicare and Medicaid Services to develop medical and health homes for particular disability populations. Further, the Health Resources and Services Administration (HRSA) provides federal funds to FQHCs/RHCs to add necessary mental health and substance use services. These opportunities clearly ought to be explored.       

Full integration has tremendous implications for counties and for the programs they operate and fund. Counties should begin immediately to prepare for the landmark changes that are about to occur.