In the United States, healthcare facilities are largely privately owned and operated, with 58% of US hospitals being non-profit, 21% being governmentally owned, and 21% being investor-owned. The US spends more per capita ($9,267), and a greater percentage of its GDP (17.4%) on healthcare than any other nation. In addition to being the most expensive, the US healthcare system was found to be the worst performing out of 11 developed countries in terms of health access, efficiency, and equity. Equity includes issues related to insurance coverage (being uninsured or underinsured), as well as proper coverage for behavioral health and psychiatric conditions, and demographic health disparities (racial/ethnic, sex, age, disability status, socioeconomic status). Efficiency of healthcare delivery has also been found to relate directly to outcome for patients. Equity and efficiency with respect to healthcare delivery of course impact healthcare access for a given individual.
Although geographical access to primary care providers and insurance coverage is critical to one’s physical health needs, health disparities with respect to behavioral health access and treatment are arguably even more complex and problematic. Although 1 in 5 adults in the US experience one or more mental health condition, access to treatment is relatively rare. Among individuals with psychiatric conditions, nearly 60% did not receive treatment services in the past year, with the average delay in getting treatment being nearly a decade.
Other barriers to treatment include stigmatization of mental health treatment and difficulty navigating complex healthcare systems. A confluence of these factors lead individuals to most commonly disclose behavioral health problems like depression and substance use to their primary care providers, whom they know and trust. In fact, 52% of behavioral health services are provided by primary care and other medical providers (i.e., non-mental health professionals), and 70% of primary care visits are related to behavioral health issues.
However, generalist providers are largely ill-equipped to assess, diagnose, manage, and/or make appropriate referrals for behavioral health issues due to reasonable limitations in their own familiarity and comfort with diagnosing and treating these conditions (after all, behavioral health is not their specialty), as well as the resources and time they have at their disposal in which to do so. How do we solve these complex problems? According to the Substance Abuse and Mental Health Services Administration (SAMHSA), the solution lies in integrated healthcare for medical and behavioral health conditions, an approach that can mitigate the impact of these complex issues of access, knowledge, resources, efficiency, and equity.
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SAMHSA defines integrated healthcare as “the systematic coordination of general and behavioral healthcare.” The Agency for Healthcare Research and Quality (AHRQ) defines behavioral health integration as “care resulting from a practice team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population. This care may address mental health, substance use conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related, physical symptoms, and ineffective patterns of healthcare utilization.” This holistic approach to treating physical and psychological symptoms considers medical and behavioral health issues to be interrelated and provides patients with improved access to diagnosis, assessment and treatment by increasing resources and access at their entry point into the behavioral healthcare system – that is, primary care.
However, two-thirds of primary care providers report they are not currently able to access behavioral health treatments for their patients, another problem that can be solved through integration. Methods for integrating care include training primary care providers to identify and treat behavioral health conditions, screening for behavioral health issues in primary care settings, providing consultation services to primary care providers, co-locating behavioral health and primary care services, and delivering integrated team-based behavioral health and primary care treatment.
Healthcare plans and provider systems are increasingly developing and implementing such strategies to better integrate medical and behavioral health services. Integrated healthcare systems are increasing in popularity and prevalence in the US and internationally. As of 2000, approximately 850 integrated healthcare delivery systems existed in the US, and integration continues to grow.
Why integrated care? The importance of psychological factors in the field of medicine is increasingly widely recognized, and this has contributed to increased prevalence in integrated healthcare. The notion of dualism – that is, that the mind and the body are separate entities – has been debunked by advances in psychology and neuroscience indicating that cognitive processes like thoughts and feelings have physical instantiations in the brain. The mind – one’s thoughts, feelings, and beliefs – is widely recognized to have an enormous impact on one’s physical state and even real physical symptoms such as chronic pain. The converse is also true – one’s physical state in turn affects one’s thoughts, feelings and beliefs.
This holistic view of the individual involves viewing one’s health as involving dynamic, integrated systems, rather than a sum of independent body systems. In other words, the whole is greater than the sum of its parts. Therefore, a primary initial goal in integrated healthcare is proper assessment of patients for common conditions as well as those for which they may be at elevated risk to identify all patient health needs. To accomplish this, providers need appropriate tools to screen for these conditions. Substantial empirical evidence demonstrates the effectiveness of screening for behavioral health conditions in primary care; quick, evidence-based tools can enable providers to screen for conditions like depression, anxiety, post-traumatic stress disorder, and substance use disorders. For example, Screening, Brief Intervention, Referral to Treatment (SBIRT) is an evidence-based screening, brief intervention, and referral tool for health risk behaviors like substance use that has been found to be clinically and cost-effective. Assessment is beneficial not just for detection of behavioral issues, but for prevention as well. Screening adolescents for behavioral health issues is especially important for prevention. For example, the earlier depression is detected and treated, the more effective treatment is likely to be, and the lower the risk of relapse. Another related goal of integrated care is facilitating appropriate referrals to behavioral health treatment when issues are detected. Broadly, the overarching goal of integrated healthcare is providing person-centered care and in order to achieve this, coordinating care to better serve the patient.
According to SAMHSA, “Integrating mental health, substance abuse, and primary care services produces the best outcome and proves the most effective approach to caring for people with multiple health care needs.” Benefits of integrated healthcare for patients include reduced homelessness, fewer psychiatric hospitalizations, reduced need for alcohol and/or drug detoxification, and fewer emergency room visits.
In addition to increasing access to healthcare services and improving quality of care for patients, integrated healthcare has also been found to lower overall healthcare costs for healthcare administrators. Research conducted by SAMHSA suggests that integrated healthcare programs can save as much as $2.5 million per year.
The largest integrated healthcare system in the US is the Department of Veterans Affairs (VA), which serves over 22 million Veterans annually. The VA system provides primary care patients with integrated services via evidence-based mental healthcare on-site or remotely in primary care settings. Their Primary Care – Mental Health Integrated Care Program lists among its goals to promote effective treatment of common mental health conditions in the primary care environment (depression, problem drinking, anxiety, PTSD screening), integrate care for physical and mental health in one setting, promote patient engagement and adherence, avoid stigmatization and fragmentation of care, and decrease risk of suicide attempts and death. In fact, one of the VA’s Mental Illness Research Education and Clinical Centers is devoted to researching integrated healthcare in order to understand and improve VA’s initiative to integrate mental health and primary care services (VA Center for Integrated Healthcare, Center for Excellence, VISN 2). The VA is also known for its award-winning integrated electronic medical record, which is shared across hundreds of VA sites so that the entire medical record is readily available. This facilitates VA providers to deliver quality care to Veterans, easily consult with and make referrals for specialty care, and follow their patients’ other health issues.
Another prime example of a successful integrated healthcare system is Kaiser Permanente, which represents the largest nonprofit integrated healthcare system in the US, and serves nearly 10 million members. The Kaiser Permanente system utilizes technology and integrated care to improve care, increase patient safety, and closely monitor costs and performance. Specifically, Kaiser Permanente uses of a plan-wide electronic medical record, diagnostic tools and consultations to determine clinically appropriate dispositions, aims to reduce time pressures on physicians so they can devote the necessary time to address patient concerns, and these attributes have been found to contribute to cost-effective treatment.
In integrated healthcare systems, the ultimate goal is providing the best possible care to patients, and treating the whole person simultaneously, across integrated systems within the individual. Traditional healthcare has utilized fee-for-service, which has been criticized as partly responsible for sky-rocketing healthcare costs, since seeing as many patients as possible, ordering expensive procedures, and growing one’s business are incentivized.
Within integrated healthcare systems, risks are mitigated; primary care providers perform the functions their patients need, and have the resources available so that they know where to turn when their patients’ needs fall outside their realm of expertise. From a risk management perspective, the main challenge in integrated healthcare is to institute an integrated risk management plan. As noted earlier, in traditional healthcare, primary care providers have had to attempt to provide the care their patients needed, diagnosing and treating patients in areas outside their expertise to the best of their ability – with less than ideal results.
In integrated healthcare systems, there is close alignment between primary care, patients, and specialty care provider. This in turn relates to quicker resolutions of patient concerns and improved outcomes for patients. However effective treatment requires trust, credibility, and transparency between entities in order to be effective. In contrast, in traditional healthcare, information and treatment has been siloed; individual providers (primary care, specialists, mental health providers) each have unique areas of knowledge regarding the patients. Poor communication between primary care providers and specialists can hinder chronic disease management, and often leaves primary care providers unaware whether patients have followed-up with specialists, and patients are left bearing the responsibility of bridging gaps in knowledge to different providers (for example, telling their mental health provider about their diabetes, which is contributing to their depression).
As noted earlier, integrated healthcare is associated with higher quality of care. In contrast, traditional healthcare is more time-consuming, with greater delays in patients getting treatment and less efficiency.
Integrated healthcare can be more expensive – if not implemented correctly. Admittedly, the systems that must be in place in order for integrated healthcare to operate efficiently and cost-effectively are expensive. In contrast, traditional healthcare involves the costs to which consumers and healthcare administrators are already accustomed. SAMHSA’s Center for Integrated Health Solutions has tools to help health organizations to identify where they are on the integration continuum; this six-level framework can be used for planning, financing, assessing, and elucidating goals regarding integration of care. In budgeting for integration, the historical financial expenditures for each component of the integrated system should be taken into consideration.
It depends on the integrated healthcare network and providers involved, but typically, patients within integrated healthcare systems experience improved access to the appropriate specialists. Because concerns are detected earlier and because primary care providers have increased access to consultation and referral services, patients receive specialty care much quicker than in traditional healthcare systems, where long waits are typical and patients are accustomed to waiting several months to see specialists.