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Better Operating Models are Needed to Fulfill the Integrated Care Concept
Integrated care is a major focus in healthcare. In the most basic sense, it involves collaboration among clinicians. Yet the term “integrated” may be a misnomer. Behavioral and medical (or mind and body) domains are better seen as “inseparable.” The practical challenge is that we need clinical models that embody this inseparability. We are not there yet. This important concept lacks robust models for executing it in practice.
Hope for integration is higher than ever. Consider the government’s current strategy for addressing our mental health crisis by building an “integrated and equitable” healthcare system. The general plan is to train clinicians and incentivize coordination with value-based financing. Aspirations for integration are high, but it may be time to acknowledge the shortcomings of our current strategies.
Limitations of Current Strategies
Our 3 most common approaches might be categorized as psychiatric, psychotherapeutic, and supportive. Psychiatrists consult on medications under the collaborative care model, psychotherapists co-locate with primary care physicians (PCPs), and non-professional coaches offer supportive services on multidisciplinary teams. Each has value, but no model does justice to the concept.
The collaborative care model is the most prominent. It focuses primarily on effective medication management, and psychiatrists rightly tout the many studies supporting its clinical value. PCPs have generally responded with a shrug. First, this collaboration relies on intermediaries (psychiatrists rarely talk with PCPs), and improved use of psychotropics is not a top priority for PCPs.
PCPs are increasingly focused on survival. Alternatives to the traditional primary care setting are growing, and competition from advanced practice providers like nurse practitioners (NPs) and physician assistants (PAs) is rising. Ironically, as collaborative care aims to improve PCP prescribing practices, the expanded primary care workforce is becoming less educated and well-trained. This hardly seems the zenith of integration.
Placing therapists in primary care is seen by many as the epitome of integration. Working inside the setting rather than in separate offices is a big advancement, but the drawback is that this model usually depends on PCP referrals for therapy. Sophisticated detection systems (e.g., with psychometrics) are lacking, and group-based services are rare. The model also relies on 50-minute sessions.
Therapists can help those with early- to late-stage behavioral disorders, comorbid medical-behavioral conditions, and the many issues complicating PCP interventions and impairing health. Yet the scale of need far exceeds a traditional therapy model. Visits for 20 minutes or less are still rare, partly because research has not explicitly validated brief visits. Yet the data support trusting the therapist’s judgment.
Another popular approach today is team-based care. This solution involves a behavioral health member (unlicensed) who is often called a coach. Descriptions of coaching can seem dishonest. They start by insisting that coaching is not therapy, and then proceed to describe services nearly identical to therapy. Coaches can be wonderful (and lower cost) despite these misgivings, but is this an exemplary model?
Breaking with Tradition in Thought and Action
The only way to achieve a strong operating model for mind-body inseparability is for the experts in each domain to depart from their traditional siloed approaches. PCPs must become attuned to how behavior plays a role in every diagnosis they make. Behavioral specialists must adapt their therapeutic approach to achieve optimal results in a new context.
Psychiatrists are rightly proud of their consultation and liaison tradition, but it endorses division. MDs collaborate across disciplines. Therapists mistakenly believe techniques drive results more than the people using them. Research shows the reverse. Delivering mini-cognitive behavioral therapy (CBT) is the wrong goal. A better one is to unencumber effective change agents and let therapists meet new challenges less tied to techniques.
Formal therapy cannot scale to meet population need. However, traditional sessions are often not necessary. Many people can benefit from brief discussions about personal issues impacting their health. Fifty minutes is arbitrary. Additionally, the timeframe for primary care is longitudinal, extending over many years. There is time to plant seeds and wait. Timing is more powerful than clinical tips and tools.
Designing new models for integrated care may be a bit premature. We may first need to acknowledge being far from our goal due to weak strategies. For example, value-based care (VBC) has high expectations. It may bend the cost curve, but its contribution to integration is likely to be minimal.
VBC’s weakness is the same as that for collaborative care and co-location. Placing clinicians together is merely a first step, and funding arrangements cannot guarantee meaningful integration. We cannot fulfill the promise of integration until we change how clinicians think and act. New thinking starts by embracing the biopsychosocial view and then focusing on the inseparability of each domain.
The popularity of integrated care today fosters the illusion it is successful. Yet the idea may eventually fade away if we cannot improve upon its mediocre operating models. This important yet challenging concept demands we abandon some traditional practices and find the audacity to try new things.
Ed Jones, PhD is currently with ERJ Consulting, LLC and previously served as president at ValueOptions and chief clinical officer at PacifiCare Behavioral Health.
The views expressed in Perspectives are solely those of the author and do not necessarily reflect the views of Behavioral Healthcare Executive, Addiction Professional, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.
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