“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.