The recent Health Resources and Services Administration (HRSA) mental health expansion grant award has spurred plenty of welcome dialogue about the inclusion of behavioral health in primary care. HRSA is to be congratulated for recognizing the need and providing provisions for health centers to treat their patients in more holistic, patient-centered approach. A cursory Google search turns up volumes of articles and documents alluding to this grant and practice, many trumpeting it as the “perfect opportunity” for collaborations between community mental health centers (CMHC) and Federally Qualified Health Centers (FQHC).
Whoa. As a nod to the late great Joan Rivers: “Can we talk?”
First, I am in no way discouraging or advocating against collaborations, partnerships and agreements between the CMHC and FQHC sectors. However, I think there is need for some balanced discussion about this. There really is nothing “perfect” about it, and it is only fair for all parties to understand that before forging ahead thinking it will be a “perfect fit.”
Adding to this is the encouragement in the grant for FQHCs to collaborate with “community partners,” notably CMHCs, and to onboard SBIRT (Screening, Brief Intervention, Referral to Treatment) as part of it. It is easy to see why applicants scurried about to secure new agreements or to revisit current ones in the rush to submit their proposals.
As a confession, in my previous career in a CMHC, I too aggressively sought out a relationship with a FQHC with the best of intentions; I clearly remember saying “they don’t know anything about mental health. Let us come in and provide the mental health services, and let them concentrate on primary care.” At the time with the limited knowledge and definitions about integrated care we had at our disposal, that seemed a perfectly logical summation. As we know now, though, that summation is fundamentally flawed, and if followed through to its logical conclusion will result in a failed collaboration. At least if the goal was to have an integrated care setting.
The relationship is not perfect.
We know that integrated care is not doing traditional mental health services in primary care. We know that the co-location of traditional mental health in the primary care milieu is not integrated care. We know that simply locating a nurse practitioner in the mental health setting is not integrated care. They might be swell collaborations, and yield positive selected outcomes, but they are fraught with incredible challenges including funding, documentation, workforce development, and patient flow issues. And, speaking frankly, there are often unspoken (and perhaps unrecognized) competing agendas. Bearing witness through observation and consultation in dozens of these efforts, the simple fact is that many mental health partners enter these partnerships with a case-find orientation. Already heavily burdened with incredible demand, workforce shortage, and ever increasing budget pressure, CMHCs often need to see a quick return on investment in these partnerships. And OF COURSE that’s a logical expectation. No one faults them for that. In several cases we’ve worked with, they’ve told us their very survival depends on it. This is not a critique, it is simply the reality of the matter for many.
But OF COURSE it won’t work, because it is not a perfect fit. The goal of integrated care is not to provide traditional mental health services in primary care, nor build a referral pipeline back to the CMHC. In fact, a truly effective integrated care practice keeps about 90-percent of its patients in primary care. I recently had a debate with a psychologist who openly and angrily challenged me on the efficacy and ethics of integrated care. He waved his credential and license in the air like a battle flag arguing that his profession DEMANDS he complete at least an hour-long comprehensive assessment and engage in testing and psychoanalysis in order to reach a diagnosis and effective treatment course of care. If we were doing traditional mental health, I’d agree. We’re not, though. I think what we did agree on, however, was that this model was not for him.
With a very small pool of experienced, well-trained primary care behaviorists at their disposal, CMHCs will often send newly licensed and inexperienced social workers over to primary care to work as behavioral health consultants (BHCs). Even when they have the right personality and desire to work in this completely different function, their traditional social work training and education did not adequately prepare them for this approach. The result is that while they may dabble in some behavioral health issues indicated by medical presentations, for the most part they function adjunct to the primary care team and skim off the depression and anxiety cases and plug those patients into a traditional model of care in the co-located setting. It won’t take long for access to their services to tighten and render them almost useless to the primary care provider. But they will use all the correct language of “warm handoffs,” “curbside consults” and “brief therapy.” And we have yet to even touch on the role of psychiatry, and the often confounding challenges defining that role presents when it is part of the collaboration.
Can these collaborations work? Sure they can. But it is important to be very clear and explicit about the expectations of the collaboration. It is not perfect. It will take considerable alignment, and the release of turf control. Can FQHCs go at it independently and create their own capacity to meet the need? Sure they can. But it will take considerable realignment of workflow, payment contracting and infrastructure and many other processes.