Partnerships between public health and behavioral health move self-management

We have long assumed that the next big advance for behavioral healthcare will be the addition of population health management to our traditional clinical interventions. Such a transition would permit us not only to treat disease while promoting self-determination and self-management, but also to move upstream to undertake the equally arduous task of preventing disease. What we have lacked is a field-wide strategy to make this transition practical.

Now, two fields, public health and behavioral health, are beginning to open up the possibilities of working together on population health management. In just a few days, on November 5, the Carter Center Behavioral Health Program and the American Public Health Association Mental Health Section will host a joint event for this purpose. Discussions will center on how behavioral health can incorporate public health interventions and practices, and how public health can add clinical interventions long-used by behavioral health.

The essence of population health management is to promote better self-determination and self-management for a population after subdividing it into groups based upon two factors: health and illness.

Here, health refers to one’s health practices and outlook, for example, exercise, stress management, and lifestyle factors, such as smoking, drinking, and obesity; illness refers to the presence of disease. It should be obvious that four population subsets can be defined by these two factors: Healthy-No Illness; Not Healthy-No Illness; Healthy-With Illness; Not Healthy-With Illness. When arrayed this way, the four groups reflect increased risk of intensive and costly care, with more intensive efforts to promote self-direction and self-management required in the latter groups. It also should be noted that each of these four groups could be subdivided further.

Public health seeks to promote better self-direction and self-management using community- and population-level interventions, such as campaigns that promote more exercise, better eating habits, and better personal and family wellbeing. This field also understands quite well the social and physical health determinants that underlie these issues in living. What it lacks currently are the behavioral health tools designed to address the personal trauma that plays such a huge role in generating lifestyle issues in the first place.   

Behavioral health is the mirror image. It has become expert at addressing personal trauma and its illness sequelae. Like public health, it seeks to promote self-determination and self-management, but through the critical lens of recovery. Yet, behavioral health is extremely weak in altering the negative effects of the social and physical health determinants before they become manifest in trauma, and it has virtually no community- or population-level interventions.

Clearly, public health and behavioral health really do need each other, much like the proverbial Jack Spratt and his wife.

What are some potential strategies that can be employed to develop a joint agenda? Several come immediately to mind and are summarized here.

City, county, and state behavioral health directors must become familiar with their public health counterparts. They also must become knowledgeable as well with the projects that these public health programs already have underway and be willing to engage in them.

Familiarity and ongoing interaction can foster joint projects that address the full spectrum of population health management. When these opportunities do present themselves, we from behavioral health must be prepared to engage, and we must invite public health colleagues to participate with us in joint ventures.

Together, we also must develop new training regimens. Future new hires in both fields will need the skills from both disciplines. This will require re-engineering of our university curricula and degrees. In the future, joint advanced degrees that span these fields must be available.

In all of this work, we also must have a crystal clear vision of our goal. Our efforts must support and promote self-determination and self-management in a very person-centric manner. We must help people who are healthy and who have no illness to remain fully healthy and independent for as long as possible. At the other end of the risk continuum, for those who are not healthy and who already have illnesses, we must promote full autonomy, self-determination, and self-management of disease.

To support these efforts, a move to fully integrated funding through value-based payments will permit the flexibility in interventions that simply would not be possible in a traditional fee-for-service framework. The outcome measures we associate with the new payment paradigm can serve as a powerful engine to promote self-determination, self-management, and a full life in the community for all.

Population health management is a foundational tool that can help us to achieve goals that have eluded behavioral health for decades. I hope that we will take full advantage of this new opportunity as it unfolds.