Mental Health Integration: What's the Holdup?

Mental health integration is a term on top of many healthcare executives' minds today. It's a key strategy for healthcare cost reduction in the Patient Protection and Affordable Care Act and is often cited as one of the most effective ways to support preventative and primary care efforts.

While the link between mind and body has been largely ignored in the recent history of medical care, research clearly demonstrates the benefits of access to mental health care for both patients and providers. Patients who receive needed mental health care have better quality of life, lower hospital admissions and readmissions rates and better control of their chronic conditions than when they go without it. Institutions offering integrated mental health care can provide better quality treatment, ultimately at a lower overall cost.

Considering the stakes, integrating mental health into primary care seems like the obvious thing to do. Unfortunately, it was never going to be easy. Mental health care has long separated itself from settings for physical care. Examining the way appointments are scheduled and patients are handled in both arenas shows how completely separate the spheres of medicine of the mind and medicine of the body have become.

Traditionally, acute care providers have avoided the provision to dodge extra costs. Behavioral health providers are equally culpable in maintaining the split, concerned as they have been with maintaining a separate identity from acute-care providers. Now, with both sides aware of the dangers of shuttling patients around and between systems of care, that seems about to change. While the alchemy of bringing these two worlds together promises to be complex, the product it yields may be an integral part of the solution to a very difficult problem: keeping Americans healthy.

Primary care as a mental health system

Some health systems are ahead of the curve in terms of pursing this revelation. At Salt Lake City-based Intermountain Healthcare, the largest acute-care provider in the Intermountain West, mental health integration has spread from a pilot program to 90 of its clinics within just 15 years.

"Other countries fund their mental health services. [The United States has] a de-facto mental health system, and that is primary care. There's just no other place to go," says Brenda Reiss-Brennan, mental health integration leader at the system. "Our physicians asked for it. They made clear they wanted help with handling mental health issues."

Amanda Lucas, executive director of Columbus-based Ohio State University Harding Hospital, worries about the de-facto mental health system Ms. Reiss-Brennan describes. While Ms. Lucas believes healthcare and the U.S. government are on the right track, reform hasn't been fast or immediately effective, frustrating a system ready for change.

"Globally, we're at a point in healthcare where health is no longer a unitary concept. You can't parse out mental and physical health," says Ms. Lucas. "For example, for cardiac patients there are plenty of physical risk factors. Depression and anxiety are two of these factors, and patients are more likely to die with depression and anxiety. You can't just fix psychological issues with a one-time solution like antibiotics. Not dealing with mental health issues make all patient issues more complicated," Ms. Lucas says. She predicts academic medical centers will focus increasingly on integrating mental health in 2014, as it becomes more of an obvious value-added proposition.

The best scenario in Ms. Lucas' eyes is integration. Co-location is the logical next step; It's the shape mental health integration takes when it presents in its most sophisticated form. With co-location, having patients see a mental health provider may be a simple matter of sending that patient down the hall. Some believe this is the future toward which integration must travel in order to be maximally effective. Ms. Lucas can see the upside: "We need a situation in which the hallway conversation would be how to treat Mrs. Smith effectively in both directions. We need integrated electronic health records, and we need one front door," she says.

Co-location in practice

Elk Grove Village, Ill.-based Alexian Brothers Health System is headed in exactly this direction. They are seeking approval for their plans to co-locate mental health and acute care, hoping to open a 25-bed psychiatric ward on a floor of one of their medical-surgical hospitals. The endeavor began as a way to use space efficiently to accommodate demand at one of the system's two medical surgical facilities. Now the project is more than a matter of convenience.

"Co-location is efficient for psychiatric patients with medical conditions, especially geriatric patients," says Clay Ciha, CEO of Alexian Brothers Behavioral Health, noting the number of senior citizens is growing at the rate of 10,000 individuals per day in the U.S. "Their comorbidities can be better served with integration," he reiterates.

In addition, Alexian Brothers currently has mental health integrated into a small number of primary care physicians' offices and is looking to extend this service in the near future. "Working on integrating psychiatry and physicians offices breaks down the barrier," says Mr. Ciha of the system's plans. "Co-locating is a great opportunity to do a soft handoff."

However, Alexian Brothers' move is rare. In fact, while mental health integration is a budding facet of primary care, nationally it's being handled more like an intervention. The reason mental health integration is being treated like a temporary project — though the consensus is that it's a necessary part of care — is that it is not yet reliably funded.

Who pays?

The funding question is a real problem for patients and providers alike. There aren't yet enough resources for all patients to have equal access to care, and though parity rules have just been issued, for people who need care now there will be expensive medical bills to pay in the interim. These payment issues also affect acute-care providers. Though addressing mental health issues saves money on emergency department visits and hospital readmissions, to cash-strapped hospitals, implementing integration on a scale large enough to reap long-term benefits may be fiscally impossible in the short-run. The luckier health systems and hospitals have managed to obtain some funding. However, even systems in which mental health has been made a priority are taking full-scale integration one step at a time.

Burlington, Ma.-based Lahey Health has long placed an importance on its mental health services, following the Mayo Clinic and other integrated group practice models and funding its psychiatry department in lean years through other, higher paying specialties.

This strategy won't, however, cover the cost of Lahey's primary care-mental health integration project, which is occurring both in its facilities and in the communities in which they are located. The question of who will pay for the service in the long term is still a pressing one.

"We have one year's worth of social workers in primary care practices through a grateful patient grant and a grant from one of our insurers that covers a portion of an embedded clinican at three of our practices," says Mary Anna Sullivan, MD, chair of Lahey's department of psychiatry and behavioral medicine. "We're cobbling [funding] together at this point; our behavioral health integration project is grant driven." She says Lahey has applied for a major federal grant to continue expanding integration in the future. "Everyone knows from a triple aim point of view this is the way to go, we just have to figure out how to get the money to align," she says.

The upshot

Shifting entire systems from old to new models will be challenging. According to Dr. Sullivan, it will require retraining staff and reaching out to educational institutions to retool their programs. However, according to Kevin Norton, CEO of Lahey Behavioral Health, this shift is a great opportunity. "It's a hard transition to have social workers embedded in a practice, but the primary care physicians that have it are ecstatic and interested. We were surprised when it wasn't hard to convince primary care physicians about value added," he says, adding openness of schedule has been a key component for clinicians in integration. "We're not managing behavioral health staff on productivity: their role is to be present and respond to needs as they arise. It's a whole different way of thinking about care from a business perspective."

Mental healthcare provision is underfunded, fragmented and stigmatized. It has never been one of the most well-reimbursed services. There is a historical precedent to overcome of providers shuttling patients to mental health services in a way akin to washing their hands of the affair. Despite these hurdles, there is cause for optimism.

"[Integrating] is the most rewarding thing I've ever done. We've reached more families, had more people with access to equitable healthcare, treated equally and had their underlying problems addressed. Families feel taken care of and respected, and patients finally have the opportunity get well," says Ms. Reiss-Brennan of Intermountain. Even without in-house mental health services, all providers can still make opportunities to become involved in integration. Harding Hospital's Ms. Lucas recommends starting out by capitalizing on existing health systems to create partnerships. "If you figure out how to partner with someone in your community it's a win-win situation," she says.

More Articles on Mental Health:

Bill Introduced to Extend MU Incentives to Behavioral Health Providers

New Rules Treat Mental Illnesses Like Physician Illnesses

Primary Care Depression Diagnoses May Result in Unecessary Treatment

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