Orange County Mental Health
May 17, 2012
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The Importance of Pursuing Mental Health Integration
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Why Pursue Mental Health Integration ? – simple question to answer … Aha !
The Importance Of Pursuing Mental Health Integration … Orange County Mental Health
It’s right thing to do: The NCCBH vision statement provides foundation for our work: We’re co-mmitted to creating & sustaining healthy & secure co-mmunities – achieved through system – holds needs of co-nsumers paramount – regardless of their ability to pay.
Vital to this co-mmitment’s network of organizations & advocates promoting services of unparalleled value.
Orange County Mental Health … The Importance Of Pursuing Mental Health Integration
NCCBH members primarily serve public sector co-nsumers – those with severe & persistent mental illness / serious emotional dis-turbance-the needs of this population’re often overlooked in primary care & integration planning. We must assure – their needs as well as needs of broader co-mmunity’re appropriately addressed.
Many people in broader co-mmunity now receive their behavioral healthcare in primary care setting – & gap between medical & behavioral healthcare systems must be bridged: As noted by Robin Dea & lots of other co-mmentators – there is:
“evidence – lots of – if _NOT_ most – people co-ming into primary care’re being treated for psychosocial problems – _NOT_ organically based medical dis-ease . . . evidence of medical co-st offsets from treating behavioral health problems pre-senting as physical health problems in primary care setting . . . assumption – if adequate de-tection of early stage psychiatric illness took place in primary care – there would be some pre-vention of patients going to more severe episodes of major psychiatric illnesses . . . & primary care’s where most people who’ve behavioral health problems’re in fact seen.”
Some of important findings from research field include:
-The Epidemiologic Catchment Area (ECA) Study & articles based on this survey data – reported finding – about 50% of care for co-mmon mental dis-orders was de-livered in general medical settings. However – lots of subsequent studies’ve shown – these dis-orders may be undiagnosed / under-treated.
-Screening systems – treatment guidelines & provider education in primary care’re necessary _BUT_ _NOT_ sufficient steps to ensure difference in outcomes.
-Collaborative & stepped care has been shown to achieve outcomes -’re better than “usual care”.
There’s opportunity for quality improvement of care within primary care & specialty behavioral healthcare settings: Studies’ve shown – lots of people with de-pression stop taking their medications before mini-mal time required to effectively treat episode of de-pression. Patients @ Group Health Cooperative who initiated medications for de-pression with their primary care physician & received targeted stepped up care & relapse pre-vention support’re significantly more likely to adhere to adequate dosages of medication & to de-monstrate greater de-crease in de-pressive symptoms.
Application of research findings such as these through adoption of evidence-based practices in both primary care & specialty behavioral health (BH) settings shall result in better outcomes for co-nsumers.
With publication of Priority Areas for National Action: Transforming Health Care Quality – Institute of Medicine’s 2003 follow up to Crossing Quality Chasm: A New Health System for 21st Century – major opportunity & challenge has appeared for public mental health system.
The Quality Chasm recommended systematic identification of priority areas for national quality improvement; Priority Areas proposes twenty areas for trans-forming health care nationally. Included in this list’re major de-pression (screening & treatment) & severe & persistent mental illness (focus on treatment in public sector).
Their inclusion as priority areas – as well as findings in Interim Report from President’s New Freedom Commission on Mental Health – with its observation – system’s “fragmented & in dis-array-not from lack of co-mmitment & skill of those who de-liver care – _BUT_ from underlying structural – financing & organizational problems” suggests – time for new strategies’s @ hand.
Many people being served by public behavioral health services need better access to primary care: A rationale less frequently articulated for integration’s – specialty BH system – especially public sector focusing on severe & persistent mentally ill adult population (SPMI) & seriously emotionally dis-turbed (SED) children – serves dis-abled co-nsumer population with healthcare needs -’re frequently under-addressed due to difficulties in obtaining medical services.
Most state Medicaid waivers related to co-verage for physical healthcare’ve focused on enrollment of TANF population into Medicaid managed care plans – leaving dis-abled Medicaid population unable to adequately access care – / in better situations – reliant on “safety net” providers-community health centers (CHCs) / co-unty de-livered health services.
Community health centers serve people who need better access to behavioral healthcare. These “safety net” providers serve broader scope of patients than just Medicaid population. But lots of states’ve implemented mental health Medicaid waivers – focus public mental health system on SPMI/SED & Medicaid populations – with mini-mal levels of support for non-SPMI/SED / uninsured populations. Often there’s _NOT_ good match of target populations between two systems. If Medicaid mental health program also has highly managed service authorization & payment methodology – there may be additional barriers to reimbursement for mental health services.
This has led to frustration for “safety net” healthcare providers because they’ve difficulty obtaining behavioral health services for their non-SPMI/SED / uninsured patients. In recent survey of CHC medical directors – 80% indicated – co-st’s main barrier to behavioral health care for their uninsured populations. The recent financing & de-velopment of behavioral health services in CHCs addresses this frustration &’s just latest in series of efforts to acknowledge – large proportion of population gets their behavioral health services in primary care.
Because behavioral health clinicians’re resource for assisting people with all types of chronic health co-nditions: Yet another reason for integration’s potential co-ntribution of BH clinicians regarding behavioral & lifestyle change: providing interventions targeted @ better management of chronic dis-ease – supporting & “leveraging” time of primary care providers through dis-ease management programs.
Disease management activities focus on several areas: early identification of populations at-risk for co-stly chronic dis-ease (e.g. – asthma – diabetes) – care interventions – utilize evidence-based practices – education-intensive orientations – focus on both patient & provider – care management & co-ordinated approach across multidisciplinary treatment teams – & method for systematic data co-llection – measures clinical & co-st-effectiveness. Large organized healthcare systems – such as Northern California Kaiser-Permanente – implement their major dis-ease management programs with specifically assigned nurses as care managers & educators.
However – lots of physicians in individual / group practices do _NOT_’ve access to this level of support unless they’re in network of health plan with active dis-ease management programs. In markets where primary care & multi-specialty groups’ve accepted accelerated risk – dis-ease management approaches shall be especially value-added.
We’re in time of significant public policy activity regarding financing of national healthcare system & uninsured population. As all of us approach 40th anniversary of founding of co-mmunity mental health center movement – dialogue has returned us to our public health beginnings-serving needs of population.
The Health Resources & Services Administration (HRSA) Primary Care Integration Initiative’s currently being implemented across co-untry. The HRSA initiative includes: identification of system issues related to integration & de-velopment of related strategies; de-velopment of service manual for CHC behavioral health services; de-velopment of BH intervention models for CHCs; & grants for establishing BH services in existing CHCs.
Newly funded CHC sites shall be expected to provide de-ntal – mental health & substance abuse services – either directly / by subcontract arrangements. CHCs’re in process of de-cision making about building their own BH services / co-ntracting for BH services – as they pre-pare their grant applications. (The NCCBH website – www.nccbh.org – has Primary Care Integration Resource Center with more de-tails about HRSA process.)
At same time – HRSA’s putting new BH resources into CHCs – reports’re emerging from lots of states indicating – public mental health system’s funded @ somewhere around half level -’s needed. In private sector – relentless downward pre-ssure on behavioral health PMPMs has also reduced overall system resources – shifting co-st from private sector to public sector.
Reports such as these’re released prior to current fiscal crisis in state Medicaid programs; rather than addressing shortfalls – there’re significant new reductions in BH services in lots of states. And – implementation of managed care methods for Medicaid’ve made it difficult for some co-mmunity based BH providers to co-ntinue to enact their mis-sion of serving needs of population – regardless of ability to pay.
The implications for system-wide duplication & co-mpetition for scarce resources of BH staff & funding – as well as opportunity to improve co-nsumer access to both health & behavioral healthcare services – suggests – co-llaboration’s priority @ national – state & local levels. Good public policy shall work @ sustaining – supporting & requiring co-llaboration between two “safety net” systems of co-mmunity mental health centers & co-mmunity health centers.
The co-nceptual model proposed in this paper may become basis for HRSA grantees to work with their partners in public mental health system to fully de-fine working relationships & co-llaboration on behalf of co-nsumers of care.
In summary – reasons for integration’re grounded in de-sire to improve access to both primary care & behavioral health services; ensure – there’re evidence-based practices as well as co-nsistent co-mmunication & co-ordination of clinical activities (especially medication management-a key co-ncern of co-nsumers) among providers serving any single individual; wed skill sets of primary care physicians & BH clinicians in order to better manage chronic health issues; & – participate in & shape public policy de-bate regarding _HOW_ services should be organized – de-livered & financed in ways – ensure – needs of public sector SPMI/SED co-nsumers & broader co-mmunity alike’re met.
