Headline 2014: Full Service Integration has Arrived

Today, the leading edge of a new form of service integration is almost upon us. We need to recognize this very important fact. We also need to prepare for the very dramatic changes that will ensue in its wake. I and my colleague, Roger Kathol, M.D., just have chronicled this development in Annals of Internal Medicine (Volume 160, Number 1, Pages 61-65) in our article, “Fostering Sustainable, Integrated Medical and Behavioral Health Services in Medical Settings” . Here, I will provide a brief overview.

To restate a very well-known point, service integration not only is needed, it is absolutely essential: Mental health and substance use clients die at least 25 years younger than other Americans because they lack the basic primary care that we all take for granted. Similarly, persons with long-term health problems, such as diabetes or heart conditions, fare more poorly and die younger when they also experience untreated mental and substance use conditions. The case for integration is very, very clear.

What have we done to foster integration of primary care, mental health, and substance use services?

Treat and Refer. Our earliest efforts at service integration simply involved treatment for a behavioral health condition, followed by referral to a primary care physician. No working relationship existed between these treatment providers. A considerable literature has developed which documents that Treat and Refer simply does not work well. The client hardly ever arrives at the second treatment site.

Co-Location/Bidirectional Integration.  Partly to resolve the problems of Treat and Refer, Co-Location has been adopted more recently. This involves placing a behavioral health service unit next to a primary care unit at the same site, or vice versa. Hence, this model also is called Bidirectional Integration. Although Co-Location has had somewhat greater success for clients that Treat and Refer, it has not solved the fundamental issue of sustainability. First, because behavioral healthcare funds are carved out, or separated, from health care funds, payment mechanisms in such services are complex and difficult. Second, because the system itself is sustained by grant funds rather than service funds, Co-Location is an unstable arrangement.

An equally important issue also arises with Co-Location. Because behavioral healthcare and primary care treatment providers  actually do not function together as a team, complex case are very difficult to serve successfully, and primary care services are not infused with key behavioral healthcare concepts, such as whole health, shared decision making, and recovery.

Full Integration.  Because of the problems with co-Location, we are on the cusp of a third model, which we simply call Full Integration. In this model, primary care and behavioral healthcare providers function together as an integrated team. Further, behavioral healthcare funds are either carved in or fully integrated with primary care funds, thus making it much easier to pay for needed care.

Full Integration can occur in a Primary Care Medical Home or in a Behavioral Healthcare Health Home. This model does not imply that behavioral healthcare will disappear in either setting, since performance measures will be required to assure that behavioral healthcare services are actually delivered when needed.

Currently, about 70% of persons with behavioral health conditions actually are seen in primary care settings, and 30% are seen in specialty behavioral healthcare settings. With full-scale implementation of Full Integration, we envision this distribution changing to 90% in primary care settings and 10% in behavioral healthcare settings, with the more severe behavioral healthcare clients being seen in behavioral healthcare settings. Because the Affordable Care Act (ACA) can be expected to approximately double the number of clients with behavioral health conditions seeking care, these changes can be expected to have little effect on the number of clients seen in behavioral healthcare settings.

Clearly, Full Integration has tremendous implications for our field and our service programs. Implementation of the ACA has accelerated the arrival of Full Integration. Collectively, we need to begin immediately to prepare for the monumental changes that are about to unfold.