The Value of Leadership in Practice Transformation: Or “How Ellie, Cesar, and a Shark see it.”

After a busy month of traveling and work, I had a chance to sit lazily on the couch and plow through some mindless television on a recent Sunday evening. But I soon found myself flipping back-and-forth between Cesar Millan’s “Dog Whisperer” on NatGeo and “Beyond the Tank” on ABC – a spinoff of the popular “Shark Tank.” As the proud – if not exasperated – owner of Ellie, a 14-week-old Vizsla, I was intrigued with Cesar’s strategies. I also found it interesting listening to the “Sharks” work with the people with whom they’ve invested.

Ellie, well, she could care less.

Several of the visits we made in April to different sites and trainings across the country talking about integrated care implementation were really workshops on leadership. As we’ve discussed in this forum previously, a common misstep organizations make is treating the transformation to an integrated practice as a project, rather than a process. As such, very little planning and strategy is developed to support the transformation. Typically a few key staff, perhaps a few bucks for training, and the services of some consultant are allocated for the project. Someone might even be promoted (vertically or horizontally) to the title of “Director of Integrated Care” and off and running they go. It’s usually around the 90-120 day point when the first real frustration pangs are felt as progress has slowed. It seems impossible to engage providers, available trainings and grants are few and far between, and the task of collecting data seems daunting – especially with an EMR that doesn’t seem to support integrated care. Not to mention the head scratches you get when talking to payers about this. So usually around day 120, the air leaks out of the motivational balloon and what was once a great idea starts to decay on the branch before it is even given a chance to bloom. Excuses are made – “Well, the timing just isn’t right to do this right now,” or “We have too many other things going like PCMH to focus on this at this point,” or “the state environment isn’t friendly to this, we need to wait until after the next election.”

It occurred to me while watching Cesar is that he would probably have a very interesting take on this. We’re making this the dog’s problem; or more specifically, we’re letting the project wag the dog. When he works with “problem dogs,” Cesar almost never initially focuses on the dog, but rather the owner. Usually within a few minutes of his introduction to the dog, he has the dog in a submissive, calm state – and it’s done with nothing else but his confidence, awareness, and presence. Or leadership. Author Malcom Gladwell recognized this in Millan and wrote about him in What the Dog Saw. Please understand I’m not making the leap of comparison of employees to dogs, or that staff need to be calm and submissive. This is in reference to leadership, and the lack of it in failed transformations. Dogs are packs animals, and they desire to be lead – even “alpha dogs” can be lead. Processes require strong, consistent, confident leadership – or some alpha force such as frustration, apathy, or “this is the way we’ve always done it” will invariably take over.

Ellie shrugs and says “that’s about right.”

Over on “Beyond the Tank,” one of the Sharks was working with a mother and son duo who, coincidentally, were selling all-natural dog treats. The Shark investor saw something in them and invested, and as part of her partnership negotiated a deal with a national chain retailer to sell the product from coast-to-coast. This would require significant increases in production, distribution, and infrastructure – and exactly what the Shark had in mind when she invested. However, she had serious reservations in the mother’s ability to lead this transformation. Mom was a great baker and could manage the regional sales using QuickBooks, but recognized that she was about to be batting much higher in the order than what she was prepared for. In order to see through the transformation, they needed to hire an experienced operations expert to handle the specific tasks of expansion. This new alpha dog, though, still needed leadership and to understand the vision – which now became mom’s job. She became a talent scout and guardian of the mission and vision.

The value of leadership and planning when taking on practice transformation cannot be understated. Likewise, it is as important to understand that when you’re talking about an integrated care practice, you are really talking about practice transformation, and it’s the practice in whole – administration, financing, operations, and clinical.

Ellie shrugs, yawns. “Yeah, that’s about right.”

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Practice Transformation and Process Management: Or “Trying to make pizzas in primary care.”

“What is the biggest mistake organizations make when trying to integrate primary and behavioral health care?”

Great question! Thanks for asking. At the risk of replowing upturned ground, here are what we think are the two biggest errors organizations make:

1. Trying to offer traditional mental health services in primary care, and

2. Not understanding the difference between process management and project management.

We’ve covered the first point a number of times on this blog, and will no doubt address it again. Not today, however. Let’s take a look at process management vs. project management. I know we talked about it in a recent blog, but its an important enough issue to discuss again.

When thinking about project vs. process management, it’s the difference between Dominoes and Deming. Building a pizza is a project. It has a beginning, an action, and an end. It tends to have a series of prescribed steps, is easily measured, defined roles, and generally simple to assess the success of effort. A process is far more complicated.

To begin, implementing an integrated care practice is most certainly a process. Creating a co-located specialty mental health partnership is a project. Integrated care is a game changer, it changes almost everything – and that what it doesn’t change, it in the very least impacts. In his 14 Points for Management, Dr. W. Edwards Deming lays out the key principles for process management. You can click the link to see them, but I want to concentrate on a just a few:

Constant Purpose Toward Improvement – We are all well-versed on quality improvement and basic QA practices. Deming urges us to move beyond what most of us think in terms of QI; just managing quality isn’t enough. And really, what is quality anyway? In terms of an integrated practice what we think about when it comes to constantly chasing improvement is to not just do the same things better, but rather find better things to do. This strikes at the core of integrated care. This isn’t doing “mental health” better or in a different place or offering it to different people. This is doing something better altogether. Embedding a uniquely skilled and well-trained behaviorist on the primary care team that functions at the speed and responsiveness of a primary care provider is different. This is not an adjunct to, or specialist on the team. She is a visible, active, valuable part of the team – and is available to the entire panel. Not just the patients with DSM-V diagnoses or the “worried-well.” When you think about that one position, you also then need to think about the ripples it creates: communication flows, screenings, patient flows, documentation, scheduling, cycle times, etc. Very quickly you see how this changes (or at least impacts) everything.

Implement Leadership – This also goes with another point about eliminating unclear language. Implementing an integrated practice is a seismic shift in the way your organization operates. It is not driven by a VP of Clinical Services, or a mid-manager appointed to head-up a task force, or a nurse manager assigned to “get us integrated.” It is led by the mission, and the CEO who’s job is to be guardian of that mission, and seeker of talent to fulfill it. The goal is for the organization to reach its full potential, not just focusing on a spreadsheet of targets and quotas. We’re certainly not suggesting you don’t measure your progress and have goals – but to not ever lose sight of the bigger picture. The unrelenting, hard-headed, committed artist behind that picture is the CEO. If the troops in the back can’t hear her trumpet from the front, the charge stalls.

Make Transformation Everyone’s Job – The most recent trend in the industry seems to be to hire a “director of integrated care.” Often this will be an administrative position of someone who is responsible to, well, integrate everything. Make no mistake, the “director of integrated care” is the CEO. Surely there can be a provider or clinician who is the champion, often times it will be the BHC. Our experience has shown that the most successful champion, or person who is given the chief responsibility of implementation is typically a provider. Often this is the chief medical officer, chief clinical officer, a BHC, or a provider. It is someone influential who has the respect of the medical providers, as well as the respect of the support staff. It’s a tough job, no doubt. It requires significant time, development, and training. But when it is led and supported by the CEO, and introduced as not just a part of the mission, but the essence of how your organization functions, it becomes everyone’s responsibility as well.

Many organizations will appoint or hire a director of integrated care, give her an office, send to her a national workshop, and expect that some binder somewhere will be a “plan to integrate.” If this were a project to expand the lunchroom or purchase a new EHR, that seems a very rational, logical approach. Integrating primary and behavioral health is practice transformation. It has no end. It is a process, and thus needs to be managed as such.

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Collaborating to Provide Behavioral Health: Or “The Imperfect Fit.”

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.

 

 

Posted in Behavioral Health, Behavioral Health Consultant, Billing Claims, Care Coordinator, Cherokee Health Systems, Federally Qualified Healthcare Center, healthcare, healthcare management, healthcare practice, Healthcare Reform, Integrated Care, Integrated Care Assessment, integrated primary behavioral health, Warm handoff | Tagged , , , , , , , , , , , | 1 Comment

Diagnosing Patients in an Integrated Care Model: Or “DONGDONG, I hereby sentence you to…”

Of the many obstacles individuals and organizations face in the transition to an integrated model of care – be them systemic, workforce related, or issues with the electronic record – the one that often seems insurmountable to some is The Diagnosis. I feel like it would be appropriate if we made the DONGDONG noise from Law & Order every time we mention The Diagnosis.

At a recent training academy for behaviorists, a participant struggled with the idea that she could stamp a patient with a diagnosis in such a short abbreviated time as related to the brief intervention model that supports integrated care. “It’s such an important process,” she said. “I can’t wrap my mind around how we can just diagnosis someone with something in such a short period and have that diagnosis stuck to that person forever.” Another explained that she works with teens who often go into the military or police academies and is troubled with the idea that her diagnosis could interfere with their futures.

Certainly no one would debate those concerns. Any mental health expert understands the importance of a diagnosis, but also the weight of it in terms of stigma. But like many issues when it comes to an integrated care model, there needs to be considerations and new perspectives to the methods we use.

First off, we need to think about the purpose of the diagnosis. As explained by Suzanne Bailey, Psy.D., a behavioral health consultant (BHC), the diagnosis is gateway to a path of care. It triggers certain interventions, best practices and options for the patient. And, in this model, explained Parinda Khatri, Ph.D., Cherokee Health Systems’ chief clinical officer, the diagnosis is typically a working diagnosis. “We’re not issuing a life sentence,” she said. “Diagnoses change all the time, especially in primary care.” Dr. Khatri explained that we are presented with an array of signs, symptoms, observations, and other data that we start with. It is also important to understand that a BHC rarely – if ever – walks into an exam room cold, devoid of any information at all. “The patient record is rich with information and data,” she said. BHCs will take time to briefly review the patient’s record looking at recent screenings, the doctors’ notes, and any history that can be quickly gleaned. “It’s not unusual that I walk into the room with a working diagnosis already in mind,” Dr. Khatri said.

In the case of the teens who’s futures can be impacted with a diagnosis it is clear that the issuing of a diagnosis is no less important in primary care than it is traditional mental health. It is important to remember that a patient presents with a diagnosis already; the mental health expert only uncovers it and labels it. It is like the fable of the boy watching a great sculptor carve out a noble statesman from a block of marble. “Hey mister, how’d you know that guy was in there?” the lad asks. Granted, it can often take a great deal of time to appropriately identify and label a syndrome or disorder, as it can with a primary care diagnosis. If a youth presents with a spectrum of symptoms, complaints and reports from others that might indicate some sort of severe disorder, number one it is our job as a mental health expert to appropriately process that information and objectively diagnosis it. Number two, we understand that we may need more time to do this, so a referral to a more structured, traditional setting would be an appropriate intervention in the case where you suspect there are heavier issues in play. In the meantime, for the services you need to provide in the integrated setting, you can issue a working diagnosis knowing that on the plan of care you are going to build a referral to specialty care for a more thorough assessment if you deem it necessary. It would be rare even in a traditional setting for a therapist to level a “life sentence” diagnosis on the first visit anyway. Often we will “rule out” several other options before settling on a diagnosis.

“True, but we all know the stigma related to a diagnosis and that people will see it and even if it was discharged, still think of that person as having it,” said one of the other participants. We can debate about the legitimacy of that statement, some scholars will support it, while others will present data to dismiss or negate it. The fact remains that the process of diagnosing is important. That is why at Cherokee Health Systems we use highly skilled, well-trained individuals in the role of the behaviorist; they are typically psychologist level providers. However, well-seasoned, highly skilled social workers can – and do – function effectively in this role. It is difficult – and dare we say unfair – to throw a brand new professional in this role and ask them to depend on their limited experiences and training to process all of this in the fast paced world of primary care. It is also important to remember that you are not operating in isolation; you are part of a larger, dynamic team. You have a physician, team of nurses, clinical supervisor, and consulting psychiatrist with which to consult; and most importantly – the patient. You are part of a behavioral enhanced patient centered medical home model.

Through this peep hole of The Diagnosis, you can see the inner workings of an effective, efficient integrated care model. You see the communication channels, the importance of a robust EMR, the workforce development and construction of an integrated team, the screening mechanisms, patient flow and cohesion of an overall plan of care; and if you look even deeper you can see the back office mechanisms of billing, coding and contract negotiations to support the model. If any one of those facets are missing or broken, the model struggles.

 

 

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Foundations for Success in Integrated Care: Or “System transformation in three PPT slides.”

A few days ago I had the pleasure of hosting a call between two of my colleagues from separate private foundations from different states. Both are well-capitalized organizations and have exceptional leadership, and both have taken a keen interest in the transformation of their states’ safety net provider system through practice improvement measures. Specifically they have identified the integration between primary and behavioral health as a key concept to the transformation.

While they both came to the table with some knowledge the basics, they each quickly learned a lot about the challenges of change management and workforce development at the provider level, but also about the obstacles and logjams at the systems level – specifically at the policy and payer level.

Our small brief summit focused much on the systems level challenges. Two key points emerged:

  • We identified that there is a constant “bleeding of institutional knowledge” in stakeholders, policy makers and often payers. This is through administration changes in the governor’s office, shifts in healthcare priorities and usually some other political wrangling.
  • States often claim that certain potential policy shifts are not their priority at this time. For example, many states continue to prohibit the allowance of billing for two services in one day, and restrict the use of certain code sets that would promote integrated services. “(State Medicaid officials) don’t see this is a priority right now because they’re focused health homes,” is what we typically hear.

We brainstormed about these issues for a while. We talked about strategies on how to counter or adjust to the fairly constant changing of personnel in key positions; while there are certainly challenges in that, there are also opportunities. How can leverage that known variable to our advantage? Are there workarounds we can utilize to lessen the impact of political changes? We also talked about the priorities of policy makers and the perceived stalling or avoidance of dealing with the same-day billing and code modification issues. What we’re talking about in these modifications aren’t tectonic shifts; in fact in states where they have been applied, the process was rather simple and impact on the state rather minor (yet significant for the providers). How can we demystify these issues? What is our best advocacy steps to educate a rather disinterested and avoidant group of people on this important topic?

Certainly some foundations come to the table with significant financial and political equity. Leveraging their influence is a powerful arrow in the quiver – but it has to be used at the right time, at the right target, and with the most impact – otherwise you risk diminishing returns every time you fire it. Understanding the political landscapes and relationships between payers and policymakers is vital, and making sure you have access to the people who can navigate you through those potentially dangerous waters is necessary. Knowing that certain positions in some state or payer departments wield more influence than others is also important; for example, we know when pitching out-of-the-box contractual agreements with payers our best tack is to deal directly first with the plans’ medical directors, not the contract specialists. And most importantly coming to the discussion armed with data; but not just raw spreadsheets full of statistics and outcomes. It has to be scoured and polished, refined and processed, and presented in a simple uncomplicated form that tells a story in, ideally, 3-4 slides of a Powerpoint presentation. This is where a good data analytics professional is a great investment.

Do we have a story to tell at Cherokee Health Systems and how our behavioral-enhanced patient centered medical home model is effective for populations and efficient for payers? You bet we do. Figuring out the best way to tell that story is a new challenge in every state where we provide technical assistance to our safety net colleagues, but through the support of some terrific foundations, that process takes on a whole new life.

 

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Lessons from a Harsh Winter: Or “A lawyer, banker and butcher walk into mission control…”

Looking out of the window in my home office today I see a beautiful spring morning; the kind of colors and contrasts that would send Thomas Cole to the easel with canvas and paints in hand. It’s a very different view from even 30 days ago when The Winter That Would Not Die was still lingering outside like a group of huddled chain smokers in a haze of smoke and anguish.

In the warmth and promise of most springs we’re able to shed the bitter memories of gray icy mornings, or piles of snow narrowing our driveways, or car floor mats caked with a sloppy stew of muck, water, ice, snow, and whatever else. This spring is different, though, isn’t it? While the weather has finally changed, we’re still left to deal with the lessons of a historically severe winter. As both an employee of one health center, and a board member of another, I’ve learned some valuable lessons about communication, tension and planning.

Throughout the Midwest and East Coast, this winter was accumulatively catastrophic. The economic impact was realized instantly, but then also gradually worsened. In our area, on three different occasions, the county police issued orders for people to stay off of the roads. The conditions were so poor that snow removal equipment were getting bogged down, and emergency vehicles found roads impassible. Many community health centers were forced to close for 3, 4 and some for 5 days over a 45 day period. The budgetary consequences were severe. It was not uncommon to hear about budgets that quickly fell $200,000-$400,000 behind due to lost production, shaky policies about paying staff in those situations, and other weather-related expenses (snow removal, building damage, excessive heating costs, overtime, etc).

They were challenging times for sure. From the perspective of governance boards, listening to worsening financial positions from month-to-month created instant tension. The natural inclination for many was to react very operationally – to want to wade deep into the finances and rustle through data and reports, asking a lot of questions and making recommendations. Certainly, part of that is the obligation of high-functioning boards; to be keenly aware of finances and the challenges experienced by the organization. The enormity of the situation, though, likely caused many boards to act out of character; perhaps out of panic especially when they were used to favorable financials supported by expansion grants, Medicaid expansions, and the promise of a surge in new patients through the ACA.

From the staff perspective, the pressure to recover that lost revenue created anxiety and frustration with visions of triple booking, productivity meetings, layoffs, hiring freezes. Those were a reality in many places. The pressure was crushing, and in some cases created chasms between staff and management; between management and boards. Perhaps some of that resentment still lingers in some.

After hearing about this from all over the most severely impacted areas of the country, it seems like we can now take a second to breathe, and look back on some things.

The role of a FQHC board – especially one that is high-functioning, governance-oriented, and supportive of its CEO – is a delicate balance between operations and governance. The board needs only to be aware of the operational functions, but not intrusive in them. Our job is hire, support and if need be, replace the CEO. We need to be supportive of him or her, offer whatever support and guidance we can, and develop sound and fair measures on which to assess their performance. This winter invited the temptation for us to wander into the operations shop. The imagery I have of that is like a Mission Control setting, where lots of red lights were flashing, alarms sounding, and nervous people in short-sleeved white shirts shouted over each other and chain-smoked, but all the while kept a laser-focus on solving the problem. Then in came wandering a banker, lawyer, minister and butcher from the board asking “What is that button for?” “What does that alarm mean?” “Have you tried turning that knob?” “Why didn’t we see this coming?” In the breakroom the staff slammed cups of coffee and wondered aloud who the hell those people were and what did they know about healthcare? In the midst of a crisis, tensions and misunderstandings grow. Obviously the key lesson here is about not panicking. The extra effort to remain calm, take deep breaths, and talk calmly and stay in our lanes is vital. Staff also has to understand the pressures and obligations of a board to monitor finances and learn as much about the situation as possible in order to better understand the problem. Finance committees play an important role; that’s where the tough questions can be asked and the data scoured, so that the general board can stay focused on the big picture and not fall into the trap of operations.

How we communicate is key. We need to understand that when tensions are cranked, human nature is often to feel attacked by even the most benign of questioning. However, when that line of questioning is in the context of accusation or steeped in potential consequences, we get misaligned quickly. It’s important that on one hand we do our best to filter out emotion and depersonalize our communications, but at the same time understand the very human pressures and natural reactionary traits we all have. My dad often offered up the best advice in situations were impulse is better replaced with thought: “Sleep on it” he’d say. I thought about that many times this winter; instead of firing off a probing email or calling an emergency meeting, sleeping on it often allowed for additional thought, new perspectives, and time for the problem to work itself out a bit.

With that, I think I’ll go out and dig out a few shrubs I lost under the enormous piles of ice and snow. Then fire off an appreciative “thank you” to the team for not panicking and for steering us through that rough patch.

 

 

 

Posted in Behavioral Health, Behavioral Health Consultant, Billing Claims, Care Coordinator, Cherokee Health Systems, Federally Qualified Healthcare Center, healthcare, healthcare management, Integrated Care, integrated primary behavioral health, Process management, Warm handoff | Tagged , , , , , , , , , , | Leave a comment

The One-Stop-Shop Myth: Or “The phrase that frays.”

I suspect we all have one particular phrase that when we hear it, it’s like nails on a chalkboard. Usually its the dumb phrase-de-jour conjured up by a commercial (“what’sssupppp?”) or some annoying thing that spreads through the simpletons like head lice (“Awesome Sauce!”). You hear them and you start reaching for your imaginary sledgehammer – or if you hear them enough – the real sledgehammer. With the recent HRSA grant announcement to expand mental health services in primary care, I realized there’s another phrase that causes a twitch in my trigger finger – but only in the context of integrated care. Over and over I saw a reference to “one-stop shop” in descriptions of a primary behavioral health integrated care practice.

It’s an innocuous enough of a phrase; most likely expressed with the best of intentions. It’s most certainly meant to relay a sense of convenience and ease for the patient to access both behavioral and primary care services. I’ve heard the phrase before in this context and its always caused me to bristle somewhat – but for the life of me I couldn’t figure out why. After talking with Dr. Parinda Khatri about this issue was I able to shed light on my discomfort with the phrase.

Wal-Mart is a one-stop shop. Dr. Khatri explained you can go to Wal-Mart and purchase a pair of socks and a gallon of milk. Before “super centers,” to purchase socks and milk would have required stops at two stores. So it’s a matter of convenience that you have only one stop to make now. However, the rub with calling integrated care a “one-stop shop” is in the relation of those items. Socks and dairy products have absolutely no relation. Purchasing them in the same market does not enhance either. Where I suspect some people who refer to the convenience of one-stop shopping in regard to integrated care error is in discounting the relationship between primary and behavioral health care. Very often they’ll even refer to patients getting their mental health and primary care in the same setting.

Lets be clear. If that’s really what they’re referring to, we’re not talking about integrated care. We’re talking about a co-location. And I suppose where my irritation with that lies is that too often I’ve seen organizations open up a one-stop co-located shop, and call it “integrated care” and rail on about the convenience they’ve created.

Convenience for whom? Sure, a certain groups of patients may find some convenience, but the cynical side of me can’t help believe that the true essence of convenience is for the benefit of the organization. And if that’s the case, we’re not really talking about convenience – we’re talking about containment.  I thought about that the last time I took my kids to Disney and utilized the ultra-convenient service of the Magical Express; a well-orchestrated shuttle service that swoops you up at the airport before you can get to the car rental desks, and whisks you to your on-property resort. If you had no intention of ever leaving the property, that is convenient. However, Disney is more interested in containing you within the warm embrace of those big gloved hands. The difference is, of course, is that Disney dresses that containment up very well; almost nothing that you would hope to find outside of the compound can also be found just as big and glitzy inside the park. Your money never escapes. In these co-located models there is certainly some room to be concerned about the effectiveness of the contained services. The Rand Corporation recently completed a study of a large integrated care project (that in reality has mostly borne colocated projects) and drew several disappointing conclusions including no evidence that that outcomes were any different than control groups, and difficulty with sustainability. Can those results be improved over time? Time will tell.

Back to socks and milk. Those are just as different as traditional mental health care and primary care. Those are services that just like socks and milk, are best individually packaged. If we really want to talk about a truly integrated one-stop shop, then we need to offer products/services that can be blended. Such as biopsychosocial brief interventions that can be blended into the primary care practice through the utilization of highly skilled behaviorists working within the confines of primary care. Let Wal-Mart handle the milk and socks and keep on selling them in different sections of the store. None of us are interested in Milksocks.

This is not an attack on co-located approaches. This is just another example of why language is important. If you set the vision to be a “one-stop shop” with the idea of convenience over the idea of offering an innovative, efficient and effective practice, yours is likely a model that will struggle reaching any level of true integrated care. I recently heard a CMHC CEO talk about his new FQHC status and referred to it as a “one-stop shop,” and how he has simply created a cost-center in the budget of the CMHC. From my perspective he seems much more concerned about containment (preventing the leaking away of patients away to primary care) versus truly integrating. Maybe I’m wrong. For his patients and his community, I certainly hope so.

 

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