Integrated Care Part 1: Securing Your Place at the Behavioral Healthcare Integration Table
"Things do not change, we change." ~ Henry David Thoreau
The change we've been talking about—integrated behavioral and primary health care--is upon us. It's been a long time coming, and the details are still emerging, but now is the time to position your program for a place at the table. Addiction counselors will encounter tremendous opportunities, but need to get ahead of the curve and start connecting themselves to newly developing health care systems. Linkage and preparation points may include additional education about models for integration, policies and billing related to parity and health care reform and developing skills in cross disciplinary communication and team work. This series will highlight some practical aspects of this process, starting with targeted outreach and marketing yourself, your program and your profession to the primary care world.
Of course, there are daunting challenges inherent in this process, including:
- Many primary care providers do not adequately understand addiction and mental health disorders; a recent article in the Annals of Internal Medicine notes "Despite the high prevalence of substance use and its consequences, physicians often do not recognize these conditions and, as a result, provide inadequate patient care." (1)
- You will need to educate primary care providers about what you and your team can offer.
- Addiction counselors may not understand or appreciate the pressures faced by medical providers, as noted here: "Behavioral health professionals used to spending long periods of time with clients may recoil when faced with fast-paced primary care settings in which they may have only a few minutes to assess a client"(2).
- You may want to shadow a physician or nurse practitioner or review the literature and learn more about the expectations for performance that they face.
- Primary care and behavioral health may speak different languages even when dealing with similar concepts (for example, referring to "motivational interviewing" (MI) techniques might be better phrased as "treatment based on stages of change" when talking to primary care providers).
- Ask about what providers in your area are familiar with and be prepared to provide brief descriptions, core concepts and evidence about the impact of the services you offer.
- Some addiction counselors are concerned about the possible "overmedicalization" of addiction treatment; if that's a concern for you, there is no better way to address it than to be an early and consistent part of a comprehensive treatment team where treatment decisions are discussed and made in collaboration with the client.
- Share your experience and wisdom with medical providers about engaging clients and helping to improve their commitment to change.
These challenges should not stop us from moving forward, but should inform how we proceed—the more you understand the system, your points of connection and what you offer in the redesign, the better your chances for a successful integration.
Perhaps the biggest challenge may come from the fact that addiction treatment and mental health treatment are not yet well integrated. It's likely that primary care will continue to be the driver of most of the health care transformation, so behavioral health providers are likely to experience greater success if they present a united front wherever possible, "selling" their services and expertise collaboratively. Most primary care providers may believe addiction and mental health are already integrated, so the field will need to double our efforts to make this a reality.
Sound overwhelming, or like something that is happening at such a big system level that you can't really influence it? Wrong! If you are an individual counselor in an agency, or an addictions educator, a peer recovery mentor working in a nonprofit, or a clinician in private practice, you play a key role in the system redesign and you have skills necessary for improved patient care and outcomes; but how do you start? First, educate yourself and then start actively encouraging colleagues, your employer and other partners to follow suit. Once conversant with the issues and mechanics of health care reform and behavioral health care integration, you can implement some of the following suggestions.
There are many comprehensive and practical information sources you can use to educate yourself. Review some and you'll quickly see recurrent themes -- models being explored, what has worked in situations similar to yours, key concepts and goals of health care transformation. The following are a few resources, and each will lead you to others:
- Introduction to Effective Behavioral Health in Primary Care, a SAMHSA webinar which provides a good overview can be found at http://www.integration.samhsa.gov/June_1_Webinar.pdf
- The Addiction Messenger has been highlighting this transformation for at least 5 years, including series on health care integration, health care reform, recovery-oriented systems of care and more: http://www.attcnetwork.org/regcenters/c1.asp?rcid=10&content=CUSTOM1
- Patient-Centered Primary Care Collaborative website http://www.pcpcc.net/ has an addiction medicine and a behavioral health section
- Evolving Models of Behavioral Health Integration in Primary Care, a report from the Milbank Foundation at www.milbank.org/reports/10430EvolvingCare/EvolvingCare.pdf
- Behavioral Health/Primary Care Integration and the Person-Centered Health Care Home report at http://www.thenationalcouncil.org/galleries/resources-services%20files/Integration%20and%20Healthcare%20Home.pdf.
Once you are more familiar with the "big picture," start doing some targeted outreach, perhaps using talking points provided later in this issue as a reference. Contact the mental health and addiction authority for your state (http://findtreatment.samhsa.gov/ufds/abusedirectors ) to find out how health care integration is happening in your area. Make appointments to talk to key players who might be the convenors of what are known as "medical care homes" (MCHs), "coordinated care organizations" (CCOs) or "accountable care organizations" (ACOs), as they will be the main focal point for coordinated services, including behavioral health care. Be prepared to tell them what you can offer; specifically:
- Describe your services and how they could benefit the primary care client (and primary care providers--realistically, the more you convince someone that your services will make their job easier or more effective, the better chance you have of becoming a partner). Use some of the keypoints provided in this AM to craft those messages.
- Have a mission that is aligned with health care reform principles such as the "triple aims" of "improve the health of the population; enhance the patient experience of care (including quality, access, and reliability); and reduce, or at least control, the per capita cost of care" (http://www.ihi.org/offerings/Initiatives/TripleAim/Pages/default.aspx ). Use those words and be able to provide examples of what you have achieved or what you can offer in relation to them.
- Consider where you could or would like to fit into new systems. Familiarize yourself with the models (see Addiction Messenger Jan/Mar 2011 http://www.attcnetwork.org/regcenters/c1.asp?rcid=10&content=CUSTOM1 ) and determine where you fit in: as a co-located service, as an offsite partner, etc. Begin to conceptualize yourself as a member of a holistic professional treatment team, rather than an isolated provider of publicly-funded services.
- Ask what the primary care providers' needs are and what difficulties they experience with clients who may have substance use or mental health disorders. What concerns do they have about a shift in their clientele? What beliefs or perspectives do they have – valid or not--about substance abuse and mental health? Similar to your clinical work, meet them where they are and take time to listen.
- Learn the terminology--speaking meaningfully about health care reform will add to your credibility. The Kaiser Family Foundation's glossary of health care reform terms can be found at http://www.kff.org/healthreform/upload/7909.pdf. The other websites and reports mentioned in this issue will also help.
- Stay abreast of trends in health care reform — to say it is rapidly evolving is an understatement. The more familiar you are with current developments, the better able you will be to seize opportunities and the more credibility you will have as you talk with others. Set up a keyword Google alert to bring relevant news and articles to your attention without having to search for them. Subscribing to e-newsletters from websites mentioned in this issue is also recommended.
- Step up efforts to collaborate with mental health partners. Where possible, make overtures to primary care providers together. Create your messages and marketing materials together, emphasizing the strengths you can bring as a behavioral health team.
Consider turning the information below, shaded in grey, into a factsheet—add your own information, logo and contact information. Familiarize yourself with these ideas so you can help medical providers understand what you have to offer and why it is so important to their ultimate success. Pick the facts that resonate with you the most and have a "2-minute elevator speech" ready so you can take advantage of even casual opportunities to promote the value of addiction treatment in primary care. Another good resource you could use for ideas is a powerpoint presentation at PCPCC:Behavioral Health and the PCHM-10.12.09).
Behavioral health: an important part of the health care team
Here are a few facts about why having a strong behavioral health component on the health care team is vital to positive outcomes and cost containment:
Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry (American Society of Addiction Medicine ASAM http://www.asam.org/for-the-public/definition-of-addiction). Addiction is a chronic disease just as diabetes and heart disease and should be treated as such.
People with addictions and mental health issues are in the primary care/medical home client base. ASAM's policy statement supporting medical homes (http://www.asam.org/advocacy/find-a-policy-statement/view-policy-statement/public-policy-statements/2011/12/16/patient-centered-medical-home) notes that tobacco use/addiction is the number two and alcohol use/addiction the number three cause of death in the United States. Use of and addiction to tobacco, alcohol, and other drugs, and injection use of a variety of substances, underlie many other medical diseases. Alcohol and drug addiction can compromise the ability of patients to properly take care of themselves and their families. Further, increased rates of depression are found in patients with congestive heart failure, diabetes, COPD (4); patients with chronic illness and depression had 2-5 times the healthcare cost of patients with chronic illness alone (4); depression is the common factor in patients disabled by hypertension, asthma, arthritis, ulcers (compared with patients equally sick but not disabled) (4).
Untreated addiction drives up costs. Research support: Patients with chronic medical and behavioral health conditions combined cost 46% more than those with only a chronic medical condition (3); the top 5 conditions driving overall health costs (work related productivity + medical+ pharmacy cost) are depression, obesity, arthritis, back/ neck pain, and anxiety (3); health care costs and utilization of services were twice as high in diabetes and heart disease patients with depression (3). Addiction is a treatable chronic disease which needs to be addressed if medical care homes are going to succeed in achieving improved outcomes and containing costs.
The choice, for patients with underlying addiction or mental health issues, is this: does the medical care home continue to treat ever-escalating physical and emotional symptoms, or instead focus on and treat the root cause? Research support: Primary care service utilization decreased by nearly 16% for those receiving behavioral health care treatment while controls who did not receive behavioral health care had an increase of approximately 12% in primary care service utilization (3).
Addiction treatment is a specialty area that most primary care providers are not well trained in, nor even comfortable dealing with. Fortunately, addiction treatment counselors have the special training and experience which assists primary care teams with screening, referral and case management. Treatment counselors also have the necessary skills to address substance dependence and life long recovery. For the growing number of primary care physicians who are attending to this issue by using an evidence-based screening, brief intervention and referral protocol known as SBIRT, having addiction counselors to whom you can refer patients is a key to success.
Addiction treatment experts share many common beliefs/structures with medical providers and this can be a strength for the medical care home. Commonalities include: a professional norm emphasizing the use of evidence-based treatment practices (the Substance Abuse and Mental Health Services Administration, or SAMHSA, maintains a database of such practices at https://www.samhsa.gov/ebp-resource-center), the use of a stepped care approach to treatment based on the severity of the presenting problem, using treatments that are based on diagnostic criteria that are clearly defined and developed by expert panels, development of treatment plans as part of the treatment process, ongoing documentation is part of the treatment process, and both disciplines bring years of experience working with clients with complex chronic diseases.
Addiction treatment experts have additional strengths and benefits to bring to the primary care setting, some of which may be unique or lacking without their inclusion in a treatment team:
- expertise in treating addiction and mental health disorders, which often co-occur and need to be treated in a coordinated manner
- significant experience in supporting family involvement in treatment
- good connections to community support resources (housing, employment, social services, etc.)
- significant experience dealing with clients who can be difficult and challenging to work with
- connections to community-based prevention partners
- deep understanding of and experience with recovery support as important aspect of successful chronic disease management; primary care patients with chronic conditions could benefit from more of this approach— counselors know how to help clients anticipate and manage relapse, how to develop and follow wellness plans, etc.
The primary care team that includes behavioral health will have a competitive advantage. Behavioral health specialists work well with clients that others consider difficult to manage. Behavioral health clinicians also free up time for primary care physicians to spend with other patients, while enhancing patient satisfaction and self-efficacy (4). Anecdotal reports indicate that physicians with behavioral health specialists on their team feel less isolated, enjoy treating "complex" patients more, report better job satisfaction and better provider retention (4).
Addiction counselors are ready and willing to partner with primary care and bring their specialized skills and experience into the mix.
Behavioral health integration and health reform is here to stay. Despite abundant challenges and concerns, the benefits of being at the table early and consistently far outweigh the obstacles. You can help shape the system and participate in an exciting new era of integrated care, but you need to take an active role in making that happen.
Series Author: Wendy Hausotter, MPH
Series Editor: Traci Rieckmann, PhD, NFATTC Principal Investigator, is editing this series.
The Addiction Messenger's monthly article is a publication from Northwest Frontier ATTC that communicates tips and information on best practices in a brief format.
Northwest Frontier Addiction Technology Transfer Center
3181 Sam Jackson Park Rd. CB669
Portland, OR 97239
Phone: (503) 494-9611
FAX: (503) 494-0183
A project of OHSU Department of Public Health & Preventive Medicine.