The U.S. Department of Health and Human Services (HRSA) recently released a $50 million grant application to expand behavioral health services in existing federally qualified health centers. In reviewing the requirements listed on a technical assistance webinar, it listed this:
Applicants must propose a plan for achieving or enhancing a fully-integrated primary care and behavioral health services model of care. The plan must include:
- Use of screening, brief intervention, and referral to treatment (SBIRT) and other evidence-based practices.
- Use of a team-based integrated model of care.
I was reminded of bourbon. Not that the application caused me to knock back a heavily iced glass of nice smoky, caramely Four Roses single barrel select. But more accurately to think about the definition of bourbon in comparison to the definition of integrated care. A couple of the key distinctions that allow a certain whiskey to carry the designation of “straight bourbon” is that it must be reduced with water to less than 125-proof at the end of the distillation process and stored for at least two years in new oak barrels that have been charred on the inside. There are a few other distinctions, but the new charred barrels and proofing are the key features that give bourbon its unique flavoring, coloring and what separates it from the swill it has to share shelf space with in your local package store like “birthday cake vodka” and “coconut rum.”
You see, there are distinctive features that by law enforce the accurate labeling of a product. Unfortunately “integrated care” is not afforded such protections, and is often lumped as a generic commodity. It can mean anything. Like the “fish” in a Filet-o’-Fish. We think of the best practices of integrated care to include the following:
- Blended care team
- Shared support staff and physical space
- Well orchestrated clinical flow
- One clinical record, unified treatment plan
- Immediate communications
- Shared patient population
- Reimbursement mechanisms that support the model
- Expanded, behavior-focused Patient Centered Medical Home
- Blended and blurred professional roles
- Targeting high-risk, high-need populations
- Integration defines the corporate identity and mission
- Partnerships with payers
- In sync with the goals of healthcare reform (Triple Aim)
Beyond that, we have defined standards that we promise our payers in return for their support of integrated care payment methodologies. Think about bourbon again – that it is aged in new, oak, charred barrels. Those are three very distinct, specific standards. If any one of those three are not met, the end result might be a nice whiskey, but it will not be a bourbon. We think the same about our standards of integrated care:
- Weekly multidisciplinary care team meetings
- A BHC that is embedded on the primary care team
- Real-time psychiatric consultation is available
- Behavioral health screening of every primary care patient
- Integrated clinical record and treatment plan
- Teleconference capability to import providers as necessary
Further, we define the scope of work of that embedded BHC; that she is not just doing “case finds” of mental health diagnoses and treatment of only depression and anxiety. They are population-focused generalists whose caseload is that of the primary care clinic. Anything short of that might still be a beneficial service, such as the co-location of a traditional mental health provider in primary care. Like whiskey stored in used charred oak barrels (I’m looking at you Jack Daniels), it is not a bourbon, and neither is a co-located traditional therapist really doing integrated care.
So are we splitting hairs? Why is this important? There are about 50 million reasons why this is important. When the government puts out a mandate specifying “fully integrated,” it is important that we understand what that means and that there should be some measurable standards by which to assess the attainment of that distinction. We see a recent resurgence of this in consumer labeling, from what can be called “low fat,” all the way to what can be accurately labeled as a Greek yogurt, to whom can actually claim to make Brie cheese. Consumers have the right to know what they are buying, just like payers and patients have the right to be educated on what “fully integrated” really means.
I don’t know about you, but that $58 bottle of Four Roses single batch is doing no one any good just sitting on that shelf. Consumer products really only expel their value when actually consumed. So I guess I’ll take one for the team and do my part.