The integration of everything has begun

The cusp of a new phase is just dawning in the integration revolution. Not only are we integrating the different components of health service delivery, we also now are beginning to encompass social services. This latest phase could be dubbed “the integration of everything.”

Since the passage of the Affordable Care Act (ACA), giant strides have been made in developing and implementing service systems that integrate primary and behavioral health care services. This innovation has been very long in coming, yet very badly needed by the large number of persons with co-morbid behavioral and physical illnesses. The absence of such systems in the past contributed significantly to the 25 year disparity in length of life experienced by public mental health clients, which still exists today.

But how well do these new systems actually function? On better access and better care, their grades are probably quite high. On outcomes, they probably are not so good. Many persons served by these systems are high need individuals with complex behavioral conditions and serious chronic physical illnesses. Although the new systems are equipped to address these conditions, they are not equipped at all to fulfill the very significant social needs that almost always co-occur in this population.

Take as an example a middle age homeless person with schizophrenia and heart disease. It should be obvious that failure to address the problem of homelessness will significantly impair the effectiveness with which the other conditions are treated. Hence, the new question is how to add housing, job, and social supports to these integrated health delivery systems so that the effectiveness of their health services can be optimized.

Since the early 1980s, our behavioral healthcare systems have supported case managers whose primary task was to coordinate health, behavioral, and social services. Because the case manager was required to reach across large-scale systems to achieve this coordination, the effectiveness of the result always was tenuous at best. The difference now is that the social services actually are becoming part of the health service system configuration.

A recent landmark event signaling this transition is the new grant announcement from the CMS Innovation Center that extends Medicaid federal financial participation to the integration of social services. CMS calls this new approach the Accountable Health Communities Model. Although Medicaid funds cannot be spent on social services per se, they can be spent on the formal coordination of these services with the healthcare entity. The model aims to identify and address beneficiaries’ health-related social needs with respect to housing instability and quality; food insecurity; utility needs; interpersonal violence; and transportation needs.

To quote from CMS:

“The Accountable Health Communities (AHC) model addresses a critical gap between clinical care and community services in the current health care delivery system by testing whether systematically identifying and addressing the health-related social needs of beneficiaries’ impacts total health care costs, improves health, and quality of care. In taking this approach, the AHC model supports… [CMS’s]… 'better care, smarter spending, and healthier people' approach to improving health care delivery.”

CMS will award 44 cooperative agreements ranging from $1 million to $4.5 million to implement the AHC model. Entities receiving awards will partner with state Medicaid agencies, clinical delivery sites, and community service providers. They will be responsible for coordinating community efforts to improve linkage between clinical care and community services. Award recipients must use their awards to fund interventions intended to connect community-dwelling beneficiaries with entities offering such community services.

Clearly, this is a revolutionary step never before taken in the 51 year history of the Medicaid Program. We applaud this new effort, and we look forward to the results from this new program.

The integration of everything has begun!