Behavioral Health Providers Can Take a Leading Role in Next Wave of Integration

The integration of physical and behavioral healthcare has produced an array of innovative clinical service models. These models, including collaborative care, health homes, and reverse co-location arrangements have been developed, modified, and disseminated through a variety of local, state, and federal programmatic funding pathways over the past 30 years. Such approaches have defined the first generation of integrated care by eliminating or reducing the largely arbitrary divide between physical and behavioral assessment, treatment, and recovery.

More recently, the healthcare field has entered a new phase of this evolution—“Integration 2.0”—characterized by a broadening embrace of the critical role played by social determinants of health (SDOH) in individuals’ overall wellbeing. Policy changes, including payment reform and regulatory flexibility to support innovative community partnerships, are creating fertile conditions for behavioral health providers to take a leading role in this new integration generation.

Building on a Foundation of Integration

The behavioral disciplines have long understood people in the context of the critical emotional, physical, and social dimensions of their lives as evidenced by foundational frameworks such as the biopsychosocial model in psychiatry, targeted case management service planning, and psychosocial rehabilitation assessment. However, regulatory policies and funding streams have not always aligned with person-centered approaches that incorporate domains outside of traditional healthcare such as housing, food security, employment, and participation in other aspects of community life. As both public and private healthcare payers recognize the powerful influences that these factors exert on the cost, quality, and outcomes of treatment, new investments are being made to support their incorporation into service delivery.

Case Study: Pennsylvania

Pennsylvania pioneered the integration of human services and behavioral health 25 years ago through the establishment of its Medicaid program called Behavioral HealthChoices. The program invests responsibility for behavioral health Medicaid funding at the county level where most human services are managed. Counties then partner with managed care organizations to support the clinical, network, quality, and payment operations. This model allows local stakeholders who are most familiar with their community’s needs to coordinate services such as behavioral healthcare, housing support, and child welfare based the priorities of the population.

For example, one large Pennsylvania county along with its managed care partner, Community Care Behavioral Health/UPMC, collaborated with providers and HealthChoices members to design a model of assertive community treatment that lowered hospitalization rates and incentivized engagement in competitive employment through a value-based payment (VBP) model. In another example, Community Care worked with counties across Pennsylvania to implement Community and School Based Behavioral Health (CSBBH) programs that support the emotional and social wellbeing of children through flexible, mobile treatment services that work with the child and family in school, at home, and in the community. While Pennsylvania created the platform to enable such innovative and effective approaches, it, like other states, still restricted the ability for payers to contract only with traditional behavioral health treatment providers. More recently, however, policy changes that widen the circle of organizations able to formally participate in coordinated care efforts have heralded the dawn of a new integration era.

Community Integration

Over the last several years, the Pennsylvania Medicaid program has established new funding for community-based care management to address SDOH and established requirements for physical and behavioral health managed care companies (MCOs) to implement VBPs that include community-based organizations (CBOs).

CBOs are defined as not-for-profit, non-clinical organizations that work to improve the life of residents. Community Care Behavioral Health collaborated with county behavioral health providers and a CBO that provides shelter services to develop an innovative model to address housing stability and reduce avoidable psychiatric hospitalizations. The approach funds care management services within the local CBO shelter provider and incentivizes the shelter along with inpatient and ambulatory mental health providers to improve linkage to community-based care and reduce hospital readmissions through coordination of care and housing support. While the interplay between housing and mental health recovery has long been understood by those in our field, models like this represent a shift in the regulatory and payment paradigm that not only permits but incentivizes partnership between healthcare, human services, and the people whose lives are so profoundly impacted by both.

Opportunity

Great progress has been made in the integration of physical and behavioral healthcare. It is now incumbent on behavioral health providers to take advantage of the growing awareness in our society of the beautiful and complex mosaic of wellness that includes SDOH.

Regardless of the funding source for their treatment, people with behavioral health conditions face myriad challenges and draw upon a rich array of strengths in their recovery that extend beyond diagnosis, symptoms, and treatment. The Substance Abuse and Mental Health Administration’s (SAMHSA) 8 Dimensions of Wellness based on the work of Peggy Swarbrick, et al, is a valuable framework for conceptualizing people and populations in the full context of their lives. These dimensions—emotional, physical, occupational, intellectual, financial, social, environmental and spiritual—are crucial to understanding and addressing the whole health needs of people with mental health and substance use disorders.

Our field was built upon such a dimensional framework. Behavioral health providers are uniquely positioned to take a leadership role in defining this next generation of integration that embraces the many drivers and determinants of health.

Matthew O. Hurford, MD, is president and CEO of Community Care Behavioral Health and vice president of Behavioral Health UPMC Insurance Services.