According to the Substance Abuse and Mental Health Services Administration (SAMHSA), integrated care is defined as “the systematic coordination of general and behavioral healthcare.” Integrated care management takes this one step further by creating a person-centered and evidence-based method of coordinating support across providers, payers, and more. In short it defines what it means for patients to receive holistic, health literate care.
To provide the best services possible, healthcare organizations of all kinds must understand how to implement integrated care management.
What does integrated care management mean?
Integrated care is a best practice model that combines evidence-based medical and behavioral healthcare services at one point of entry. This model of care takes place in a variety of settings and locations. The main purpose is to effectively address and treat co-occurring and chronic mental health, substance use, and medical disorders.
Integrated care came from the Triple Aim, which sets goals introduced by the Institute for Healthcare Improvement. The three goals of the Triple Aim are to:
- Improve the quality of healthcare
- Enhance the client’s experience of healthcare
- Reduce costs associated with healthcare services
Integrated models link behavioral health, substance use treatment, and medical care so that clients receive truly holistic treatment. In fact, the best models of integrated provide clients with access to a menu of services according to their needs. This should be the case regardless of whether the initial contact was with a behavioral health or medical provider.
Integrated care management is the set of processes that allow different facilities and professionals to provide holistic care as persons served make their way through the continuum of care. According to the National Library of Medicine, integrated care management:
“… views the multidisciplinary approaches to collaborating care delivery by activity, cost and quality, and using a process approach to problem- and outcome-based care delivery. Involving patients and their carers in determining the process and outcomes of care provides a route to better communication, patient and staff satisfaction, and the overall quality of care.”
Now that we have a better understanding of these processes, let’s explore how organizations can use integrated care management.
Successful examples of integrated care management
While primary care physicians (PCPs) are often bound to their 15-20 minute visits with a patient, innovative healthcare systems like Memorial Hermann have an in-house psychologist within the group practice.
This grant-funded program allowed PCPs to identify patients who may be in need of additional mental healthcare. Appointments are then scheduled one week later to focus on behavioral health with a mental health practitioner. This gives the mental health practitioner the opportunity for a longer conversation about the patient’s psychosocial history and can lay the groundwork for continued mental healthcare. The mental health practitioner and the PCP then connect after the visit to ensure coordinated care.
When asked about the role of the PCP in integrated care, Shayna Upchurch, MD, said:
“My role is twofold. One, to be cognizant and aware of how mental health and well-being is impacting the patient at the moment and if there is something to identify and, two, to be able to practice team-based care.”
She went on to outline situations when the patient’s mental health condition warrants a referral to a psychiatrist. For example, when a patient is not responding to first- or second-line treatments for bi-polar disorder.
Identifying social determinants of health
PCPs must be mindful of the social determinants of health in their referrals as well. This means considering things like:
- Referring working patients to clinics that offer extended hours
- Referring Medicaid patients to well-known psychiatric units that work well with their insurance
- And more
Building rapport and understanding the patient more fully can help PCPs direct patients to the appropriate resource and encourage follow-ups.
For example, an immigrant worker who typically works odd hours and speaks Spanish as a first language, may prove hesitant to follow up with an appointment during work hours or when providers conduct care conversations primarily in English. When initial screenings for depression indicate that this client needs a follow-up, PCPs and social workers can consider these social determinants of health.
If a physician builds rapport, arranging for a follow-up appointment – including a warm hand-off to a bi-lingual psychiatric professional during accessible hours – can facilitate this patient’s appointment compliance.
Additionally, something as simple as the physician saying, “I would like to follow up with you to discuss that you have been feeling down” can be disarming to patients who feel like spending time talking about “feelings” can be burdensome to others.
Understanding medical principles
The responsibility of integrating care management does not only call for physical health providers to understand more about mental health; it also places an onus on behavioral health providers to have a better awareness of physical health.
One example of a behavioral health provider who has worked toward bridging this gap is the Greater Nashua Mental Health Center, a community mental health center that brought a nurse practitioner from a federally qualified health center (FQHC) on site. They developed a physical health report card in conjunction with other wellness programs through a SAHMSA grant.
One way the community mental health center empowered patients was to give them a paper report card about their health including weight goals vs. current weight and normal blood pressure range vs. current blood pressure reading. By simply shifting the mindset of patients to consider that physical health should be part of the mental health conversation, Greater Nashua Mental Health Center connected with patients about physical wellness when many may not have attended an annual exam otherwise.
Challenges of integrated care management
The National Council for Mental Wellbeing anticipates that the amount of available psychiatrists will be less than 50% of what the healthcare system will demand by 2025. This makes it increasingly important for general and family medicine practitioners to be the frontline of behavioral health.
Final recommendations from the U.S. Preventative Services Task Force (USPSTF) recommend “screening for depression in the general adult population, including pregnant and postpartum women.” However, the recommendation also indicates the screening should be conducted when “adequate systems [are] in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up,” further underscoring the need for integrated and coordinated care.
The lack of patient follow-up emphasizes what healthcare systems are moving toward addressing creatively. Namely, transitions in care are the key inflection points that determine a patient’s trajectory through the healthcare system.
There is no health without integrated care management
The belief that there is no health without mental health has reverberated worldwide. In the United Kingdom, the Mental Health Five Year Forward View, outlines integrated mental and physical health pathways through integrated models, including Increasing Access to Psychological Therapies (IAPT).
Indeed, since April 2018, clinical commissioning groups have been required to offer IAPT services integrated with physical health pathways. This has increased access to psychological care through general practitioners who have a specific focus on those with chronic conditions. Plus, the innovative program has engaged the community to truly provide wrap-around care.
As part of Mersey Care Trust’s Zero Suicide Policy, the Trust has connected with the community to reduce suicides through community engagement in training. One example of this is the Trust training cab drivers to respond when passengers ask to go to locations that are common for suicide attempts. By engaging the community in mental health initiatives, promoting mental wellness spreads from beyond clinical settings and into the community.
By continuing to observe successful models of integrating care management, providers can consider community-specific ways to better integrate care. Integrated care calls for the active participation of all members of a care team and requires collaboration between the patient, clinicians and community resources to address the whole person.
Special thanks to Shayna Upchurch for contributing to this blog post and sharing innovative integrated care practices at Memorial Hermann. Upchurch practices general and family medicine resident physician practicing at Memorial Family Medicine in the Memorial Hermann healthcare system. She is passionate about the patient-physician relationship, coordinated care and women’s health. Her undergraduate and medical school education is from Texas A&M University.
Integrated Care and Care Coordination in a Value-Based World
As healthcare organizations search for ways to compete and thrive in this new world, the role of integrated care coordination has become a key component in improving health outcomes and lowering cost. In addition to care coordination, technology is another tool used to close the historic healthcare delivery system fragmentation. Watch this webinar to learn about the following topics:
- What value-based care is, how it works, and why it matters
- Integrated service delivery
- The role of care coordination in improving health outcomes and lowering costs
- The role of technology in using actionable data and analytics to assist with care coordination