Measuring Integrated Care: “or trying to weigh a moving wave.”

About once a week I get a call from a colleague asking me if I could send them information and/or data as to how we measure the effectiveness of our integrated care project. First off, those of you who might have read previous posts on this site know what I think about the term “project” in relation to integrated care. For now, we’ll set that aside.

I’ll usually start by asking them what specifically are they looking for? A lot of times they aren’t really sure, but generally they want to see some comparative data as to the efficacy of the model versus those who have not received integrated care. In a vacuum where we can control for the dozens of variables involved, that might be possible. In practice, though, it’s like measuring the weight of a specific wave. How much of it exactly do you want to weigh? How do you define a wave? At what point in its development from just a surge to full-on surfable wave? Where does it start and stop? What about the debris and sealife that might be rolled up in the wave? Do we measure that too, or just the water? So the point is made – it’s a bit of a loaded question, and frankly one that in a truly integrated system is impossible to answer to the satisfaction of someone wanting that level of detail. Now, in theory, measuring a wave is really as simple as measuring its height times width and factoring it at a measure of one cubic meter of water weighing one ton. But we’re not talking about theory here, are we? We want to compare a specific patient versus another specific patient controlling for specific variables. Patient A received interventions from a behaviorist (BHC), Patient B didn’t. Who is better?

Clearly we see the problems with this. We have to control for a lot of variables, set some very clear definitions, and design some very specific measures and procedures to vet this with any degree of accuracy. This is why we choose to focus on population health measures. This is for a couple of reasons:

  • This is a population-based practice
  • Causality and correlation is impossible to identify
  • It’s not really a choice at all. It’s the only way to ethically and accurately measure its effectiveness

In a truly team based integrated setting, there are a number of connections, relationships, and communications that may benefit a particular patient. For example, Patient A comes in, scores high on her PHQ-9, and gets to chat with a BHC, and leaves with a few self-interventions she can apply in her life to decrease the impact of her depression (leaving out, of course, the medical interventions which may also play a significant role in the patient’s mental functioning – but we’ll control for that in this example). Patient B comes in, scores the exact measure on his PHQ-9, but does not see the BHC. Could we figure out some measures to track their outcome from that point? Maybe. But the scientists quickly start raising alarms about reliability, validity, distortion, bias, correlation, causality, etc. In a truly integrated setting, we need to ask a whole lot of questions about Patient B. Did the provider consult with a BHC (a “curbside consult”)? Did the provider use skills and protocols he might have learned from a BHC to assist the patient and his depression? Is the patient receiving counseling from an external therapist? Is he already on an anti-depressant and has suffered with depression for a long time? Quickly we’re trying to measure waves again, right?

In a behavioral enhanced patient centered medical home practice measuring specific patient outcomes in comparisons to others is a fool’s chase. It is a rabbit hole the size of the Holland Tunnel. And in the end its meaningless. This practice helped that patient. Great. So what? Are we prepared to transform an entire healthcare system based on isolated cases in statistically insignificant sample sizes? Is a grantor or payer going to be dazzled by that and commit to collaborate?

We measure our impact on populations and the unique challenges facing each particular practice. I always start with this graph based on data from an external payer that compares our practice with other local providers serving safety net patients:

Comparison Slide - Graph

In this graph you see that our practice produces more primary care encounters, and significantly decreases ER utilization, specialty care, and hospitalizations to the tune of an overall cost savings of 22 percent. We can dive deeper into this by looking at the factors that keep our patients out of the ERs 68 percent less than our peers. Better care coordination, accessibility to care, more targeted services, etc. This data, by the way, covers a very large sample size and time period, for those asking (and rightly so) about its context.

When stakeholders or payers ask about specific outcome data, it should not be a point of stress, but rather an opportunity to educate them on what integrated care truly is. As described by Parinda Khatri, Ph.D., our chief clinical officer, we need to also consider the common factors that tend to impact patient outcomes: Culture, family dynamics, habits, and health literacy. In the very least, the model helps mitigate barriers to care and does not contribute to the problems of access and the delivery system. In the ideal, we have some impact on keeping patients out of ERs and hospitals, and help with personal resiliency.

I know that is often an unsatisfactory answer to people who want simple measures and results. It would be far easier if we were segregating one population from another (for example, adult patients with a diagnosis of depression that all receive identical protocols from a trained team of specific providers that is responsive to this population). Sure, that’s an effective approach that will likely yield terrific results – but it is not what we think about in terms of integrated, population-based care.

So, surf’s up…who’s ready!?!



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Medical Expenses & Poverty, What We Now Know: Or, “The poop on MOOP.”

I had the opportunity this week to attend a panel presentation on poverty hosted by a local church. The event was billed as a discussion on poverty and “to help bring awareness of the all-too real problem of poverty and homelessness within our county.” I needn’t identify the county, because one could insert any county in the title and it would still apply. On the panel was an esteemed gathering of homeless shelter/housing directors, the sheriff, a charity that helps with small bills and expenses, a school superintendent, and an attorney who specializes in guardianship and poverty law.

Naturally the discussion initially focused on homelessness which is the all-to-visible face of poverty. The director from the small charity, though, asked that we also consider poverty in whole; while not that we ignore homelessness, but the epidemic of poverty is by-in-large unseen – hidden right in front of us in plain sight.

Earlier this week I participated in an all-day strategic planning session for a health center for which I’m honored to serve as a board member. There we had a consultant present on a series of data that she collected about our area including health disparities, penetration rates, demographics, and poverty. What quickly emerged is that in our area – despite news reports of declining unemployment and an improving economy – is that poverty rates increased, health disparities worsened, and that demographics radically changed in several markets. Community Health Centers, by their very mission, tend to go where the grass is browner, so the ground is fertile for expansion of services.

But I’m drawn again to the panel discussion. Who was missing on that panel? Many discussed mental health and substance abuse as a key indicator – not cause – of poverty. Yet there was no representative from any mental health and substance abuse providers. Who else was missing?

In 2013 the U.S. Census released a report on poverty related to medical expenses. Depending on where you look, the national rate of poverty hovers around 15% in the United States. In data from 2011-2012, the report found that medical out-of-pocket (MOOP) expenses alone added nearly 3.4% of all Americans to the poverty rolls – or more accurately, 10.6 million people.(1) Digging deeper, of those working age adults living in poverty, 50% of them spend ten percent of their income on MOOP, the single highest expense other than shelter and food – and at a rate that doubled since 2001.(2)

So who was missing on that panel?

We already understand that the people living in poverty often live in food deserts, lack access to exercise facilities, and often work long hours at multiple jobs, and tend to not have advanced degrees. All of these factors are indicators in poor overall health and where you find health disparities, you’ll often find these indicators. Yes, education, employment, shelter are all important factors in stemming the rise of poverty, but clearly, access to affordable medical services and coverage is also important – if not on equal weight.

I often think of a 3-legged stool in terms of community stability: Housing, employment and healthcare. If any of those legs fall out of balance, the stool is unstable. It rings true for individuals as much as a community. Strength in one positively impacts the other, as much as a depletion of one burdens the others. If you want to add a fourth leg of education, you’ll get no argument from me.

So there was a glaring gap on that panel – as strong and passionate as the speakers were. The lack of access to quality affordable healthcare and MOOP costs are every bit a factor of poverty as anything else that we already knew, and according to the data, it’s worsened in since 2001. Will the ACA and state expansion of Medicaid help curb this tide? The early data is promising. In the small sample size that is our local health center, due to the tireless work of healthcare navigators, a sizable percentage of previously uninsured patients became covered from 2014 into 2015. That conversion alone shifted the payer mix significantly and helped provide better access to healthcare for those individuals – healthcare that will now be at least partially covered.

Look around your own community – really look. It will be hard to see the poverty, but if you look, you’ll find it. Single parents who line up at Minute Clinics in the early mornings before school; the waitress at your favorite restaurant who also works at the nursing home on weekends; the grocery store check-out lady who worries about her job as her store adds four more self checkout kiosks. Encourage your community to have similar conversations and panels.

And who will YOU remember to include?

(1) Weissmann, J. Census: Medical Expenses Put 10.6 Million Americans in Poverty. The Atlantic. Nov 3, 2013.

(2) Collins, S. New Census Poverty Measure Shows Medical Expenses Push 10 Million Americans into Poverty. The Commonwealth Fund. Nov 10, 2011.


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The Value of True Integrated Care: Or “Vying for shelf space in a competitive market”

We all remember that time when our parents returned from the grocery store with a two liter of cola. Not Coke or Pepsi, but just some nondescript plastic bottle of something that on first glance sure looked like cola. The label said “Cola,” and it even fizzed like cola when you opened it. But then…you tasted it…and it wasn’t Coke or Pepsi. It was, I suppose, by definition cola, but you still felt gypped.

There will come a day when patients and payers feel the same way about healthcare. They will be sold something called “integrated care,” but once the product is served, they’ll soon realize they’ve been given the healthcare equivalent of cola when they were expecting Coke. So what’s the big deal? Buyer beware, right?

In the marketplace, inferior products soon find themselves relegated to the bottom shelves, if at all. They are replaced with the items in demand, the items that provide value, be it financial or satisfaction. And it tends not to take long. The difference in healthcare, with integrated care, specifically, is that the discovery period is much longer, much more expensive, and in the meantime, lives are affected. Maybe even lost.

Recently, the Agency for Healthcare Research and Quality took on the task of defining integrated care. A panel of experts from across the country was convened and this is what they developed:

“The care that results from a practice team of primary care and behavioral health clinicians, working together with patients and families, using a systemic and cost-effective approach to provide patient-centered care for a defined population. This care may address mental health and substance abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress related physical symptoms, and ineffective patterns of health care utilization” (Peek CJ & NIAC. Executive Summary: Lexicon for Behavioral Health and Primary Care Integration – Concepts and Definitions Developed by Expert Consensus. AHRQ Pub No. 13-IP001-1-EF. Rockville, MD. 2013).

While it certainly forms some boundaries around the concept of integrated care, it is hardly prescriptive and still leaves ambiguity. It clearly states that it is team-based care of behavioral and primary care clinicians working together, it may still lead some to believe that the clinicians are separate and only come together when indicated. In fact, what is fast becoming the gold standard – or best practice – is that the behaviorist is embedded on the primary care team and for all intents and purposes, functions much like a primary care provider in their delivery and scope. This is well described in Understanding the Behavioral Healthcare Crisis: The Promise of Integrated Care and Diagnostic Reform (Cummings, N., and O’Donohue, W., Routledge, New York. 2011).  Clear definitions between co-location of specialty care and primary care, and true integrated care are described. What many call “integrated care” is in actuality a co-location of services, care collaboration, care coordination, or something else. There is, in fact, nothing wrong with those approaches, but they are not by definition, integrated care. They will not produce the cost-effectiveness results, nor will they impact broad health disparities in a population-based healthcare model. These will be the value standards by which payers will seek to negotiate payment with providers. If you aren’t delivering the value – even if it seems to fizz when the bottle is opened – you will soon find yourself vying for shelf space with other inferior products in the clearance aisle.

It is vital that as payers and stakeholders become wiser to integrated care, that they are smart shoppers, and we as providers are beholden to some accountability of our labels and services. Only then can true value be recognized and extracted. The importance of this cannot be understated as we evolve through value-based payment reform.





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A Culture of Transformation: Or “Yogi and Aristotle walk into a bar…”

Those of us who have spent our lives writing college papers, news dispatches, reports, grants and articles all know that the best way to sound smart is to quote someone else. Especially if that person is dead. Death awards a few more credibility points to the quote, and more importantly that person can’t come back and tell you that you took their words out of context.

So, with that, I giggled a bit last week during our most recent Primary Behavioral Health Integrated Care Training Academy when Dr. Dennis Freeman, our CEO, quoted Aristotle on one of his slides when discussing culture. Come on, sing along – you know the one:

“The whole is greater than the sum of its parts.”

Dr. Freeman shifted it up a bit in his remarks, though, by inferring that a health center’s integrated care culture is greater than the sum of primary care plus behavioral health.

Now – let me clarify that Dr. Freeman is a wise man in his own right, and doesn’t need to be quoting Aristotle for any added credibility. He’s like the World’s Most Interesting Man – Aristotle would quote him in a presentation. I should also add my annual performance appraisal is due this month.

The inference is dead on, though. In the last couple of years while working with groups all over the country, we’ve probably spent as much time talking about culture and leadership as we have about H&B codes, the role of a behaviorist, or value-based contracting. You can pull up the website of any health center or mental health clinic in the country and read a darn fine mission statement. A group of executives, consultants and board members probably sat around a table and word-smithed that thing to a brilliant sheen over a couple of days and bottles of aspirin. What is impossible to ascertain over a website, though, is the culture – its texture, content, accessibility, breadth, depth, and temperature. It’s a living thing that requires nurturing and attention; when it’s starved, it will eat your mission for lunch all day, every day.

It’s why when Dr. Freeman talks about an integrated practice simply being more than the sum of primary care and behavioral health, he’s referring to the missing quotient. Culture. Without a culture of integration – of serving the underserved, of mission-minded providers, of inclusiveness, communication, cohesiveness and coordination – you simply have primary care and behavioral health. Or co-location. Or what well-meaning people sometimes call a “one stop shop.” Wal-Mart is a one-stop shop. You can buy a set of tires and a bag of frozen peas there. Is there any reason or ability to coordinate those services? Or is it just a matter of convenience? There’s nothing wrong with that concept – but it’s not an integrated service, is it?

Integrated care is transformative. It involves and/or impacts every department and person in the organization. The culture is really the sum of:

  • Mission and values
  • Leadership
  • Workforce development
  • Training and information sourcing
  • Strategic planning, operations/implementation
  • Financing and sustainability
  • State, payer, and policy advocacy
  • Data management

To underestimate the importance of culture is a fatal flaw in your transformation. It has to be led from the top. The recently deceased Theodore Hesburgh, the former president of the University of Notre Dame, said when discussing leadership “you can’t blow an uncertain trumpet.” (I get all kinds of credibility points for that one!)

As you begin or continue your journey to integrated care do yourself the favor of zooming out. Look at the landscape. Take a honest reading of the temperature of your culture – ask open questions of the staff, have critical conversations, talk to your patients. And then choose to take the right path. Do you want to sell frozen peas and tires, or do you want to offer well-coordinated, orchestrated, high-quality, efficient patient care?

After all, it was the great American philosopher Yogi Berra who said that “when you come to a fork in the road, take it.” And mind you – Yogi is still with us to certify that!


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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.



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